Namibia - Demographic and Health Survey - 2008

Publication date: 2008

Namibia N am ibia 2006-07 Demographic and Health Survey 2006-07 D em ographic and H ealth Survey Namibia Demographic and Health Survey 2006-07 Ministry of Health and Social Services Windhoek, Namibia Macro International Inc. Calverton, Maryland USA August 2008 The Global Fund – To Fight AIDS, Tuberculosis, and Malaria The report presents the findings from the 2006-07 Namibia Demographic and Health Survey (NDHS) conducted by the Ministry of Health and Social Services (MoHSS). Macro International Inc. provided technical assistance through the MEASURE DHS project, which is funded by the United States Agency for International Development (USAID). Most of the funds for the local costs of the survey were provided by the Government of Namibia, with assistance from the Global Fund, UNICEF, and DFID through a SADC project. Additional support was provided by UNFPA and the World Health Organization. USAID funding was provided under contract number GPO-C-00-03-00002-00. The views expressed in this report are those of the authors and do not necessarily reflect the views of the United States Agency for International Development or the United States Government or the Government of Namibia. The 2006-07 NDHS is part of the worldwide Demographic and Health Surveys program, which is designed to assist developing countries to collect data on fertility, family planning, maternal and child health, nutrition, and HIV/AIDS. Additional information about the survey may be obtained from the Ministry of Health and Social Services (MoHSS), Private Bag 13198, Windhoek, Namibia, Telephone: (264-61) 203-2544/5; Fax: (264-61) 272-286; Email: doccentre@mhss.gov.na; Internet: www.healthnet.org.na. Additional information about the DHS programme may be obtained by contacting MEASURE DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200; Fax: 301-572-0999; Email: reports@macrointernational.com; Internet: http://www.measuredhs.com. Suggested citation: Ministry of Health and Social Services (MoHSS) [Namibia] and Macro International Inc. 2008. Namibia Demographic and Health Survey 2006-07. Windhoek, Namibia and Calverton, Maryland, USA: MoHSS and Macro International Inc. Contents | iii CONTENTS Page TABLES AND FIGURES . ix FOREWORD . xvii PREFACE. xix SUMMARY OF FINDINGS . xxi MAP OF NAMIBIA . xxvi CHAPTER 1 INTRODUCTION 1.1 Geography, History, and Economy.1 1.1.1 Geography.1 1.1.2 History.1 1.1.3 Economy .1 1.2 Population .2 1.3 Health Services and Programmes .3 1.4 Survey Objectives and Implementation .4 1.4.1 Organisation .4 1.4.2 Questionnaires .4 1.4.3 Pilot Survey .5 1.4.4 Advocacy and Publicity.5 1.4.5 Training for Fieldworkers .5 1.4.6 Household Listing .6 1.4.7 Data Collection.6 1.4.8 Data Processing .6 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Population by Age and Sex.7 2.2 Household Composition .8 2.3 Education of the Household Population .9 2.3.1 Educational Attainment.10 2.3.2 School Attendance Rates .12 2.3.3 Grade Repetition and Dropout Rates .14 2.4 Household Environment .16 2.4.1 Drinking Water.16 2.4.2 Household Sanitation Facilities .18 2.4.3 Housing Characteristics.19 2.5 Household Possessions.21 2.6 Wealth Index .22 2.7 Birth Registration.23 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Characteristics of Survey Respondents.25 iv │ Contents 3.2 Educational Attainment by Background Characteristics.27 3.3 Literacy .29 3.4 Access to Mass Media .31 3.5 Employment .33 3.6 Occupation.36 3.7 Earnings and Type of Employment .39 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4.1 Current Fertility.41 4.2 Fertility Differentials by Background Characteristics.43 4.3 Fertility Trends .44 4.4 Children Ever Born and Living.46 4.5 Birth Intervals.47 4.6 Age at First Birth.49 4.7 Teenage Pregnancy and Motherhood.50 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods.53 5.2 Ever Use of Contraception .55 5.3 Current Use of Contraceptive Methods .57 5.4 Differentials in Contraceptive Use by Background Characteristics.59 5.5 Number of Children at First Use of Contraception.61 5.6 Knowledge of the Fertile Period .62 5.7 Timing of Sterilization .63 5.8 Source of Contraception .63 5.9 Cost of Contraception .64 5.10 Informed Choice.65 5.11 Future Use of Contraception .67 5.12 Reasons for Not Intending To Use .67 5.13 Preferred Method for Future Use .68 5.14 Exposure to Family Planning Messages .69 5.15 Contact of Nonusers with Family Planning Providers .70 5.16 Husband/Partner’s Knowledge of Women’s Contraceptive Use .72 5.17 Men's Attitude Towards Contraception.73 5.18 Men's Attitude Towards Childbearing .74 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status .75 6.2 Polygyny .76 6.3 Age at First Marriage .77 6.4 Age at First Sexual Intercourse.79 6.5 Recent Sexual Intercourse .81 6.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility.84 6.7 Menopause.86 Contents | v CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children .87 7.2 Desire to Limit Childbearing.89 7.3 Unmet Need for Family Planning .92 7.4 Ideal Number of Children .94 7.5 Mean Ideal Number of Children by Background Characteristics .95 7.6 Fertility Planning Status .95 7.7 Wanted Fertility Rates .96 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Levels and Trends in Infant and Child Mortality.99 8.3 Socioeconomic Differentials in Infant and Child Mortality . 101 8.4 Demographic Differentials in Infant and Child Mortality. 102 8.5 Differentials in Infant and Child Mortality by Women’s Status . 103 8.6 Perinatal Mortality. 104 8.7 High-Risk Fertility Behaviour . 106 CHAPTER 9 ADULT AND MATERNAL MORTALITY 9.1 Data. 109 9.2 Direct Estimates of Adult Mortality . 110 9.3 Estimates of Maternal Mortality . 112 CHAPTER 10 MATERNAL HEALTH 10.1 Antenatal Care . 115 10.2 Place of Antenatal Care. 117 10.3 Number and Timing of ANC Visits. 118 10.4 Components of Antenatal Care . 119 10.5 Tetanus Toxoid Injections . 121 10.6 Place of Delivery. 122 10.7 Assistance During Delivery . 123 10.8 Postnatal Care. 125 10.9 Problems in Accessing Health Care . 127 10.10 Participation of Men in Family Health Care . 129 10.11 Payment for Delivery . 131 CHAPTER 11 CHILD HEALTH 11.1 Child’s Size at Birth . 133 11.2 Vaccination Coverage . 135 11.3 Trends in Vaccination Coverage . 137 11.4 Acute Respiratory Infection . 137 11.5 Fever. 138 11.6 Prevalence of Diarrhoea. 140 11.7 Diarrhoea Treatment. 141 11.8 Feeding Practices . 142 11.9 Knowledge of ORS Packets . 144 vi │ Contents 11.10 Disposal of Children’s Stools . 145 CHAPTER 12 NUTRITION OF CHILDREN AND WOMEN 12.1 Nutritional Status of Children . 147 12.2 Initiation of Breastfeeding. 151 12.3 Breastfeeding Status by Age. 153 12.4 Duration and Frequency of Breastfeeding . 155 12.5 Types of Supplemental Foods. 156 12.6 Micronutrient Intake among Children. 159 12.7 Nutritional Status of Women. 162 12.8 Foods Consumed by Mothers. 163 12.9 Micronutrient Intake among Mothers . 165 CHAPTER 13 MALARIA AND OTHER HEALTH ISSUES 13.1 Ownership of Mosquito Nets . 167 13.2 Use of Mosquito Nets by Children . 168 13.3 Use of Mosquito Nets by Pregnant Women. 169 13.4 Malaria Prophylaxis in Pregnancy . 170 13.5 Malaria Diagnosis and Treatment . 172 13.6 Treatment of Fever. 173 13.7 Knowledge and Signs of Malaria. 175 13.8 Knowledge of Causes of Malaria. 176 13.9 Action Taken in Case of Malaria. 178 13.10 Action Taken to Prevent Malaria . 180 13.11 Health Insurance Coverage . 182 13.12 Knowledge and Attitudes Concerning Tuberculosis . 185 13.13 Use of Tobacco. 187 CHAPTER 14 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 14.1 Knowledge of HIV/AIDS Transmission and Prevention Methods . 192 14.1.1 Knowledge of AIDS. 192 14.1.2 Knowledge of HIV Prevention. 193 14.2 Comprehensive Knowledge about HIV/AIDS. 195 14.3 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 197 14.4 Accepting Attitudes towards People Living with AIDS. 199 14.5 Attitudes towards Negotiating Safer Sex. 202 14.6 Attitudes towards Condom Education for Youth and Beliefs about Abstinence and Faithfulness . 203 14.7 Higher-Risk Sex. 205 14.7.1 Multiple Partners and Condom Use . 205 14.7.2 Transactional Sex. 209 14.8 Coverage of HIV Counselling and Testing. 210 14.8.1 HIV Testing and Counselling for Pregnant Women. 212 14.8.2 Male Circumcision. 214 14.8.3 Self-Reporting of Sexually Transmitted Infections (STI) . 215 14.8.4 Prevalence of Medical Injections. 217 14.9 HIV Knowledge and Sexual Behaviour among Youth. 220 Contents | vii 14.9.1 Comprehensive HIV/AIDS Knowledge and Source of Condoms among Youth . 220 14.9.2 Age at First Sex . 222 14.9.3 Condom Use at First Sex. 223 14.9.4 Abstinence and Premarital Sex. 225 14.9.5 Higher-Risk Sex and Condom Use among Young Adults . 226 14.9.6 Cross-generational Sexual Partners. 229 14.9.7 Drunkenness during Sex among Young Adults . 230 14.9.8 Voluntary HIV Counselling and Testing among Young Adults . 232 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Employment and Form of Earnings. 233 15.2 Women’s Control over Their Own Earnings and the Relative Magnitude of Women’s Earnings. 235 15.3 Control over Husband’s Earnings . 237 15.4 Women’s Participation in Decision-Making. 239 15.5 Attitudes towards Wife Beating . 243 15.6 Attitudes towards Refusing Sex with Husband . 246 15.7 Women’s Empowerment Indicators . 251 15.8 Current Use of Contraception by Women’s Empowerment Status. 252 15.9 Ideal Family Size and Unmet Need by Women’s Status . 253 15.10 Women’s Status and Reproductive Health Care . 253 CHAPTER 16 ORPHANS AND VULNERABLE CHILDREN 16.1 Orphans and Vulnerable Children. 255 16.1.1 Children’s Living Arrangements and Orphanhood. 255 16.1.2 Orphaned and Vulnerable Children. 256 16.2 Social and Economic Situation of Orphaned and Vulnerable Children . 258 16.2.1 School Attendance. 259 16.2.2 Basic Material Needs . 260 16.2.3 Orphans Living with Siblings . 261 16.2.4 Nutritional Status . 261 16.2.5 Sex before Age 15 . 262 16.3 Care and Support for OVCs . 263 16.3.1 Succession Planning. 263 16.3.2 Widows Dispossessed of Property. 265 16.3.3 External Support for Households with OVCs . 265 CHAPTER 17 ACCESS TO HEALTH CARE 17.1 Proximity to Government Health Facilities . 269 17.2 Type of Transport to Government Health Facilities. 270 17.3 Type of Transport to Government Hospitals . 271 17.4 Time to Government Health Facilities . 271 REFERENCES . 273 viii │ Contents APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION . 277 A.1 Sample Design . 277 A.2 Sample Implementation . 279 APPENDIX B ESTIMATES OF SAMPLING ERRORS. 281 APPENDIX C DATA QUALITY TABLES . 301 APPENDIX D PERSONS INVOLVED IN THE 2006-07 NAMIBIA DEMOGRAPHIC AND HEALTH SURVEY. 305 APPENDIX E QUESTIONNAIRES . 311 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators,, Namibia 1991 and 2001. 2 Table 1.2 Results of the household and individual interviews. 6 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence. 7 Table 2.2 Household composition. 9 Table 2.3.1 Educational attainment of the female household population . 10 Table 2.3.2 Educational attainment of the male household population . 11 Table 2.4 School attendance ratios . 13 Table 2.5 Grade repetition and dropout rates. 15 Table 2.6 Household drinking water. 17 Table 2.7 Household drinking water by region . 18 Table 2.8 Household sanitation facilities. 18 Table 2.9 Household sanitation by region. 19 Table 2.10 Housing characteristics. 20 Table 2.11 Household durable goods . 21 Table 2.12 Wealth quintiles. 23 Table 2.13 Birth registration of children under age five . 24 Figure 2.1 Population Pyramid . 8 Figure 2.2 Age-Specific School Attendance Rates. 14 Figure 2.5 Percentage of Households Owning Various Durable Goods . 22 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents .26 Table 3.2.1 Educational attainment: Women.27 Table 3.2.2 Educational attainment: Men .28 Table 3.3.1 Literacy: Women .29 Table 3.3.2 Literacy: Men .30 Table 3.4.1 Exposure to mass media: Women.31 Table 3.4.2 Exposure to mass media: Men .32 Table 3.5.1 Employment status: Women .34 Table 3.5.2 Employment status: Men.35 Table 3.6.1 Occupation: Women.37 Table 3.6.2 Occupation: Men .38 Table 3.7 Type of employment: Women.39 Figure 3.1 Women’s Employment Status in the Past 12 Months.36 x | Tables and Figures CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS Table 4.1 Current fertility .42 Table 4.2 Current fertility by region .43 Table 4.3 Fertility by background characteristics .44 Table 4.4 Trends in age-specific fertility rates.45 Table 4.5 Trends in age-specific and total fertility rates .45 Table 4.6 Children ever born and living.46 Table 4.7 Birth intervals.48 Table 4.8 Age at first birth .49 Table 4.9 Median age at first birth .50 Table 4.10 Teenage pregnancy and motherhood.51 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence.42 Figure 4.2 Total Fertility Rates for Selected Countries .43 Figure 4.3 Trends in Age-specific Fertility Rates, Namibia 1992-2007.45 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods .54 Table 5.2 Knowledge of contraceptive methods by background characteristics .55 Table 5.3.1 Ever use of contraception: Women .56 Table 5.3.2 Ever use of contraception: Men .57 Table 5.4 Current use of contraception by age .58 Table 5.5 Trends in contraceptive use .59 Table 5.6 Current use of contraception among sexually active women by background characteristics .60 Table 5.7 Current use of contraception among all women by background characteristics .61 Table 5.8 Number of children at first use of contraception .62 Table 5.9 Knowledge of fertile period.62 Table 5.10 Timing of sterilization.63 Table 5.11 Source of modern contraception methods .64 Table 5.12 Cost of modern contraceptive methods.65 Table 5.13 Informed choice .66 Table 5.14 Future use of contraception .67 Table 5.15 Reason for not intending to use contraception in the future .68 Table 5.16 Preferred method of contraception for future use.69 Table 5.17 Exposure to family planning messages .70 Table 5.18 Contact of nonusers with family planning providers .71 Table 5.19 Husband/partner's knowledge of women's use of contraception .72 Table 5.20 Male attitudes about the use of contraception.73 Table 5.21 Male attitudes about childbearing .74 Figure 5.1 Trends in Contraceptive Use among All Women Age 15-49, Namibia 1992-2006-07 .59 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status .75 Tables and Figures | xi Table 6.2 Number of women's co-wives and men’s wives.77 Table 6.3 Age at first marriage .78 Table 6.4 Median age at first marriage: Women .79 Table 6.5 Age at first sexual intercourse .80 Table 6.6 Median age at first intercourse .81 Table 6.7.1 Recent sexual activity: Women .82 Table 6.7.2 Recent sexual activity: Men .83 Table 6.8 Postpartum amenorrhoea, abstinence and insusceptibility.84 Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility.85 Table 6.10 Menopause.86 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children: all women.87 Table 7.2 Fertility preferences by number of living children: currently married women and men .89 Table 7.3 Desire to limit childbearing: All women and men.90 Table 7.4 Desire to limit childbearing: Currently married women and men .91 Table 7.5 Unmet need and the demand for family planning among all women .92 Table 7.6 Ideal number of children .94 Table 7.7 Mean ideal number of children.95 Table 7.8 Fertility planning status.96 Table 7.9 Wanted fertility rates.97 Figure 7.1 Fertility Preferences of Women Age 15-49.88 Figure 7.2 Desire to Limit Childbearing Among Women 15-49 and Men 15-49, by Number of Living Children.91 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 100 Table 8.2 Early childhood mortality rates by socioeconomic characteristics. 102 Table 8.3 Early childhood mortality rates by demographic characteristics. 103 Table 8.4 Early childhood mortality rates by women's status . 104 Table 8.5 Perinatal mortality. 105 Table 8.6 High-risk fertility behaviour . 107 Figure 8.1 Trends in Infant and Childhood Mortality, Namibia 1992 to 2006-07 . 100 CHAPTER 9 ADULT AND MATERNAL MORTALITY Table 9.1 Data on siblings . 110 Table 9.2 Adult mortality rates. 111 Table 9.3 Direct estimates of maternal mortality . 113 Figure 9.1 Adult Mortality Rates in Namibia by Age and Sex 1998-2007 . 111 Figure 9.2 Female Mortality Rates in Namibia by Age, 2000 NDHS and 2006-07 NDHS . 112 xii | Tables and Figures Figure 9.3 Male Mortality Rates in Namibia by Age, 2000 NDHS and 2006-07 NDHS . 112 CHAPTER 10 MATERNAL HEALTH Table 10.1 Antenatal care provider. 116 Table 10.2 Place of antenatal care. 118 Table 10.3 Number of antenatal care visits and timing of first visit . 119 Table 10.4 Components of antenatal care . 120 Table 10.5 Tetanus toxoid injections . 121 Table 10.6 Place of delivery . 122 Table 10.7 Assistance during delivery . 124 Table 10.8 Timing of first postnatal check-up . 125 Table 10.9 Postnatal care provider . 126 Table 10.10 Problems accessing health care . 128 Table 10.11 Participation of men in antenatal care visit . 129 Table 10.12 Knowledge about diarrhoea treatment . 130 Table 10.13 Payment for delivery . 131 CHAPTER 11 CHILD HEALTH Table 11.1 Child's weight and size at birth. 134 Table 11.2 Vaccinations by source of information. 135 Table 11.3 Vaccinations by background characteristics . 136 Table 11.4 Vaccinations in first year of life. 137 Table 11.5 Prevalence of symptoms of ARI . 138 Table 11.6 Prevalence and treatment of fever. 139 Table 11.7 Prevalence of diarrhoea . 140 Table 11.8 Diarrhoea treatment . 141 Table 11.9.1 Feeding practices during diarrhoea: liquids . 143 Table 11.9.2 Feeding practices during diarrhoea: solid food . 144 Table 11.10 Knowledge of ORS packets or pre-packaged liquids. 145 Table 11.11 Disposal of children's stools. 146 CHAPTER 12 NUTRITION OF CHILDREN AND WOMEN Table 12.1 Nutritional status of children . 149 Table 12.2 Initial breastfeeding. 152 Table 12.3 Breastfeeding status by age . 154 Table 12.4 Median duration and frequency of breastfeeding . 156 Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview . 157 Table 12.6 Infant and young child feeding (IYCF) practices . 158 Table 12.7 Micronutrient intake among children . 161 Table 12.8 Nutritional status of women . 163 Table 12.9 Foods consumed by mothers in the day or night preceding the interview. 164 Table 12.10 Micronutrient intake among mothers . 166 Figure 12.1 Nutritional Status of Children by Age . 151 Tables and Figures | xiii Figure 12.2 Infant Feeding Practices by Age. 154 Figure 12.3 Infant and Young Child Feeding Practices 2000 NDHS and 2006-07 NDHS . 155 Figure 12.4 Infant and Young Child Feeding Practices . 159 CHAPTER 13 MALARIA AND OTHER HEALTH ISSUES Table 13.1 Ownership of mosquito nets . 168 Table 13.2 Use of mosquito nets by children. 169 Table 13.3 Use of mosquito nets by pregnant women . 170 Table 13.4 Prophylactic use of anti-malarial drugs and use of intermittent preventive treatment (IPT) by women during pregnancy . 171 Table 13.5 Prevalence of fever and treatment with anti-malarial drugs. 173 Table 13.6 Anti-malarial drugs received by children . 174 Table 13.7.1 Knowledge of signs of malaria: Women . 175 Table 13.7.2 Knowledge of signs of malaria: Men. 176 Table 13.8.1 Knowledge of causes of malaria: Women. 177 Table 13.8.2 Knowledge of causes of malaria: Men . 178 Table 13.9.1 Action taken in case of malaria: Women. 179 Table 13.9.2 Action taken in case of malaria: Men . 180 Table 13.10.1 Action taken to prevent malaria: Women. 181 Table 13.10.2 Action taken to prevent malaria: Men . 182 Table 13.11.1 Health insurance coverage: Women . 183 Table 13.11.2 Health insurance coverage: Men. 184 Table 13.12.1 Knowledge and attitude concerning tuberculosis: Women . 186 Table 13.12.2 Knowledge and attitude concerning tuberculosis: Men . 187 Table 13.13.1 Use of tobacco: Women. 188 Table 13.13.2 Use of tobacco: Men . 189 CHAPTER 14 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 14.1 Knowledge of AIDS. 193 Table 14.2 Knowledge of HIV prevention methods. 194 Table 14.3.1 Comprehensive knowledge about AIDS: Women . 196 Table 14.3.2 Comprehensive knowledge about AIDS: Men. 197 Table 14.5.1 Accepting attitudes towards people living with HIV/AIDS: Women . 200 Table 14.5.2 Accepting attitudes towards people living with HIV/AIDS: Men. 201 Table 14.6 Attitudes towards negotiating safer sexual relations with husband. 202 Table 14.7 Adult support of education about condom use to prevent AIDS . 204 Table 14.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women . 206 Table 14.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men. 208 Table 14.9 Payment for sexual intercourse among men . 209 Table 14.10.1 Coverage of prior HIV testing: Women . 211 Table 14.10.2 Coverage of prior HIV testing: Men. 212 Table 14.11 Pregnant women counselled and tested for HIV. 213 Table 14.12 Male circumcision. 215 Table 14.13 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms. 216 xiv | Tables and Figures Table 14.14 Prevalence of medical injections . 218 Table 14.15 Comprehensive knowledge about AIDS and of a source of condoms among youth . 221 Table 14.16 Age at first sexual intercourse among youth. 222 Table 14.17 Condom use at first sexual intercourse among youth. 224 Table 14.18 Premarital sexual intercourse and condom use among youth . 225 Table 14.19.1 Higher-risk sexual intercourse and condom use among youth: Women . 227 Table 14.19.2 Higher-risk sexual intercourse and condom use among youth: Men. 228 Table 14.20 Age-mixing in sexual relationships among women age 15-19 . 230 Table 14.21 Drunkenness during sexual intercourse among youth. 231 Table 14.22 Recent HIV tests among youth . 232 Figure 14.1 HIV Prevalence by Year of Survey . 191 Figure 14.2 Perceptions and Beliefs about Abstinence and Faithfulness . 205 Figure 14.3 Women and Men Seeking Treatment for STIs . 217 Figure 14.4 Type of Facility Where Last Medical Injection Was Received . 219 Figure 14.5 Percentage of Men and Women Whose Last Injection Was Given with a Syringe and Needle Taken From a New, Unopened Package, by Type of Facility Where Last Injection Was Received . 220 Figure 14.6 Trends in Age at First Sexual Intercourse, Namibia 2000 and 2006-07. 223 Figure 14.7 Abstinence, Being Faithful, and Condom Use (ABC) among Young Women and Men . 229 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings: All women and men . 234 Table 15.2 Employment and cash earnings: Currently married women and men . 235 Table 15.3 Control over women's cash earnings and relative magnitude of women's earnings: Women. 236 Table 15.4 Control over men's cash earnings . 238 Table 15.5 Women's perceptions of who controls earnings and the relative size of earnings . 239 Table 15.6 Women's participation in decision-making . 240 Table 15.7 Women's participation in decision-making according to men . 240 Table 15.8.1 Women's participation in decision-making by background characteristics. 241 Table 15.8.2 Men's attitude towards wives' participation in decision-making. 243 Table 15.9.1 Attitudes towards wife beating: Women. 244 Table 15.9.2 Attitudes towards wife beating: Men . 246 Table 15.10.1 Attitudes towards refusing sexual intercourse with husband: Women. 247 Table 15.10.2 Attitudes towards refusing sexual intercourse with husband: Men . 249 Table 15.11 Men's attitudes towards a husband's rights when his wife refuses to have sexual intercourse. 250 Table 15.12 Indicators of women's empowerment. 251 Table 15.13 Current use of contraception by women's status. 252 Table 15.14 Women's empowerment and ideal number of children and unmet need for family planning . 253 Table 15.15 Reproductive health care and women's empowerment . 254 Figure 15.1 Number of Decisions in Which Women Participate . 242 Tables and Figures | xv CHAPTER 16 ORPHANS AND VULNERABLE CHILDREN Table 16.1 Children's living arrangements and orphanhood. 256 Table 16.2 Orphans and vulnerable children (OVC) . 257 Table 16.3 School attendance by survivorship of parents and by OVC status . 259 Table 16.4 Possession of basic material needs by orphans and vulnerable children. 260 Table 16.5 Orphans not living with siblings. 261 Table 16.6 Underweight orphans and vulnerable children. 262 Table 16.7 Sexual intercourse before age 15 among orphans and vulnerable children . 263 Table 16.8 Succession planning. 264 Table 16.9 Widows dispossessed of property. 265 Table 16.10 External support for very sick persons. 266 Table 16.11 External support for orphans and vulnerable children. 267 Figure 16.1 OVC Population, Namibia 2006-07. 258 CHAPTER 17 ACCESS TO HEALTH CARE Table 17.1 Nearest government health facility . 269 Table 17.2 Means of transport to government health facility . 270 Table 17.3 Means of transport to government hospital. 271 Table 17.4 Time to reach government health facility and means of transport . 272 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Sample allocation by region . 278 Table A.2 Sample implementation: Women . 279 Table A.2 Sample implementation: Women . 280 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 274 Table B.2 Sampling errors for National sample. 285 Table B.3 Sampling errors for Urban sample . 286 Table B.4 Sampling errors for Rural sample. 287 Table B.5 Sampling errors for Caprivi sample. 288 Table B.6 Sampling errors for Erongo sample . 289 Table B.7 Sampling errors for Hardap sample . 290 Table B.8 Sampling errors for Karas sample. 291 Table B.9 Sampling errors for Kavango sample. 292 Table B.10 Sampling errors for Khomas sample. 293 Table B.11 Sampling errors for Kunene sample . 294 Table B.12 Sampling errors for Ohangwena sample . 295 Table B.13 Sampling errors for Omaheke sample . 296 Table B.14 Sampling errors for Omusati sample. 297 Table B.15 Sampling errors for Oshana sample . 298 Table B.16 Sampling errors for Oshikoto sample. 299 Table B.17 Sampling errors for Otjozondjupa sample . 300 xvi | Tables and Figures APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 301 Table C.2.1 Age distribution of eligible and interviewed women . 302 Table C.2.2 Age distribution of eligible and interviewed men. 302 Table C.3 Completeness of reporting . 303 Table C.4 Births by calendar years . 303 Table C.5 Reporting of age at death in days . 304 Table C.6 Reporting of age at death in months. 304 Foreword | xvii FOREWORD This report presents the results of the 2006-07 Namibia Demographic and Health Survey (NDHS) that was carried out from November 2006 through March 2007. The survey is the latest in a series of periodic surveys that are conducted in collaboration with various stakeholders led by the Ministry of Health and Social Services. The main objective of this survey was to measure levels, patterns, and trends in demographic and health indicators in Namibia. Specifically, the 2006-07 NDHS collected information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood and maternal mortality, maternal and child health, and awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections (STIs). In addition, it collected information on the use of mosquito nets, women’s empowerment and demographic and health outcomes as well as information on orphans and vulnerable children care and support. This survey was designed to produce estimates at the regional level for most indicators. The tables, figures, and text are related to the most important indicators consistent with the objectives of the survey. They are targeted for use by policymakers, planners, and researchers, especially in the health sector. I believe that the 2006-07 NDHS report will be widely read and utilized by communities, health and social workers, the relevant line ministries and civil society organisations, regional councils, local authorities as well as our development partners, with the vision of improving the health status of all Namibians at large. One of the key result areas in the third National Development Plan (NDP 3) is the Quality of Life. This key result area has three goals: 1) Affordable and Quality Health Care, 2) Reduce Spread of HIV/AIDS and its effects, and 3) the Eradication of Extreme Poverty and Hunger. In order for the Ministry of Health and Social Services and other stakeholders responsible for the implementation of programmes to realize the goals under this key result area, I urge them all to make use of the 2006-07 NDHS report to assist in the programming of health interventions. Together we can make a difference! DR RICHARD NCHABI KAMWI (MP) MINISTER FOR HEALTH AND SOCIAL SERVICES Preface | xix PREFACE The 2006-07 Namibia Demographic and Health Survey (NDHS) marks yet another milestone in the history of the Ministry of Health and Social Services. It provides a comprehensive source of information on health and demographic indicators at a point in time when the Ministry evaluates its implemented programmes and interventions over the five years period. The 2006-07 NDHS has been a large-scale research project. Twenty-eight field teams interviewed about 9,200 households, 9,800 women and 3,900 men age 15-49. The interviews were conducted between November 2006 and March 2007. The survey covered about 500 primary sampling units in all regions. This report presents findings of the 2006-07 NDHS. The 2006-07 NDHS is the third survey of its kind to be undertaken in Namibia, others being in 1992 and 2000. The 2006-07 NDHS differed in three aspects from the 2000 NDHS survey: it included a module on malaria indicators, women’s empowerment, and orphans and vulnerable children. The MoHSS would like to acknowledge organizations that contributed to the successful completion of the 2006-07 NDHS. The Ministry is grateful for the financial, technical and other assistance provided by the United States Agency for International Development (USAID), the Global Fund, the Chinese Government, and the United Nations Children’s Fund (UNICEF). Furthermore, the Ministry appreciates technical support from the United Nations Population Fund (UNFPA), World Health Organization (WHO), Macro International Inc., National Planning Commission Secretariat and others. Sincere thanks are also extended to members of the 2006-07 NDHS Steering Committee and stakeholders who contributed to the successful completion of the survey. The Ministry acknowledges the valuable support in raising awareness about the survey and generating cooperation from communities that was provided by all regional councillors, governors, various town and city councils; and the Namibia Agricultural Union and local farmers associations. Special thanks go to the staff who participated in various aspects of the survey and the respondents, who generously gave their time to provide the information that forms the basis of this report. Finally, I would like to express my sincere gratitude to the overall 2006-07 NDHS project coordinating team at the Directorate of Policy, Planning and Human Resource Development for their tireless work during the survey and for ensuring that the project was completed successfully. KAHIJORO KAHUURE PERMANENT SECRETARY Summary of Findings | xxi SUMMARY OF FINDINGS The 2006-07 Namibia Demographic and Health Survey (NDHS) is a nationally representative survey of 9,804 women age 15-49 and 3,915 men age 15-49. The 2006-07 NDHS is the third com- prehensive survey conducted in Namibia as part of the Demographic and Health Surveys (DHS) programme. The data are intended to provide programme managers and policymakers with detailed information on levels and trends in fer- tility; nuptiality; sexual activity; fertility prefer- ences; awareness and use of family planning methods; breastfeeding practices; nutritional status of mothers and young children; early childhood mortality, adult and maternal mortal- ity; maternal and child health; and awareness and behaviour regarding HIV/AIDS and other sexu- ally transmitted infections. The 2006-07 NDHS is the first NDHS survey to collect information on malaria prevention and treatment. HOUSEHOLD CHARACTERISTICS The 2006-07 NDHS collected information on the availability of various amenities in the surveyed households. The survey found that almost 90 percent of households have access to an im- proved water source. Nationally, one in three households has an im- proved, unshared toilet facility. There are large disparities by residence, with 60 percent of households in urban areas having sanitary toilets, compared with only 14 percent of rural house- holds. FERTILITY The survey results show that Namibia has ex- perienced a decline in fertility of almost two births over the past 15 years, with the fertility rate falling from 5.4 births per woman in 1990- 1992 to 3.6 births in 2005-07. On average, rural women have 1.5 children more than urban wom- en (4.3 and 2.8, respectively). The low level of fertility among urban women is also reflected in the lower fertility among women in the urban region of Khomas, where women on average are having 2.6 children compared with 2.8 to 5.1 children in the other regions. Fertility differen- tials by education and wealth are substantial. Women with no formal education have an aver- age of more than six children (6.3), while women with completed secondary education have less than three children (2.8). Similarly, women in the lowest wealth quintile have an average of five children (5.1), while women in the highest wealth quintile have between two and three chil- dren (2.4). Despite the decline in fertility, unplanned preg- nancies are common in Namibia. Overall, two in three births are either unwanted (41 percent) or mistimed, i.e., wanted later (22 percent). If all unwanted births were avoided, women would have an average of 2.7 children, compared with the actual average of 3.6 children. While marriage and cohabitation are generally considered primary indicators of exposure to the risk of pregnancy, many women in Namibia bear children outside of a stable union. Visiting rela- tionships are common and many women have children in the context of such unions. The me- dian age at first marriage in Namibia is relatively high, 28.2 years among women age 30-49. Urban women marry more than one year later than rural women (29.1 and 27.4 years, respectively). The median age at first marriage for women age 30- 49 with no education is 24.3 years compared with 27.9 years for women with more than sec- ondary education. Typically, men and women in Namibia begin sexual activity before marriage. Among the pop- ulation age 25-49, the median age at first sexual intercourse is 19.3 years for women and 18.2 years for men. The 2006-07 NDHS indicates that about 6 per- cent of currently married women are in a poly- gynous union (i.e., they have one or more co- wives). Three percent of men reported having two or more wives. This is a decline from the 2000 NDHS, in which 12 percent of women were in a polygynous union and 4 percent of men had more than two wives. Older women, women who live in rural areas, women with no education, and xxii * Summary of Findings women in the lowest wealth quintiles are more likely than other women to have co-wives. The prevalence of polygyny varies across regions. Hardap and Karas have the lowest level (less than 2 percent) and Kunene has the highest levels (17 percent). FAMILY PLANNING Knowledge of family planning in Namibia has been nearly universal since 1992. In the 2006-07 NDHS, 98 percent of all women reported know- ing about a contraceptive method. Male con- doms, injectables, and the pill are the most wide- ly known methods. Ninety-three percent of sexually active women and men age 15-49 have used a family planning method at least once in their lifetime. Two in three of these women are currently using any contraceptive method and 66 percent use a mod- ern method. The most popular methods are in- jectables and male condoms, used by 24 percent and 23 percent, respectively, of sexually active women. Nine percent of sexually active women use the pill and 8 percent have been sterilized. Government-sponsored facilities remain the chief providers of contraceptive methods in Namibia. The distribution of sources of modern methods for current users shows that three in four users obtained their method from the public sector. While the participation of the private medical sector in family planning service delivery has remained the same (10 percent), use of retail out- lets has increased fourfold since 2000 (3 percent to 13 percent). Unmet need for family planning has declined from 5 percent in 2000 to 3 percent in 2006-07. If all women with an unmet need for family planning were to use a contraceptive method, the contraceptive prevalence rate in Namibia would increase from 47 to 50 percent. CHILD HEALTH Data from the 2006-07 NDHS indicate that the under-five mortality rate in Namibia is 69 deaths per 1,000 live births (based on the five-year pe- riod preceding the survey). This means that one in every fourteen children born in Namibia dies before attaining his or her fifth birthday. The in- fant mortality rate is 46 deaths per 1,000 live births. About half of these infant deaths take place in the neonatal period, that is, during the first month of life. Child mortality is consistently lower in urban areas than in rural areas. There is substantial var- iation in mortality rates across regions. Under- five and infant mortality rates are highest in Ohangwena and Caprivi and lowest in Kunene. Children whose mothers have more than secon- dary education have much lower mortality than children whose mothers have less education. Si- milarly, children whose mothers are in the high- est wealth quintile have much lower mortality than children whose mothers are in the lowest quintile. Children are considered fully vaccinated when they receive one dose of BCG vaccine, three doses each of DPT and polio vaccines, and one dose of measles vaccine. Overall, 69 percent of children age 12-23 months have received all vac- cinations. Ninety-five percent of children have received the BCG vaccination, and 84 percent have been vaccinated against measles. Coverage for the first dose of DPT and polio is relatively high (95 percent each). However, only 83 percent of children received the third dose of DPT and 79 percent received the third dose of polio. Com- parison of the 2006-07 NDHS results with those of the earlier surveys shows that vaccination coverage in Namibia has increased from 65 per- cent in 1992 to the current rate of 69 percent. Four percent of children under age five experi- enced symptoms of acute respiratory infection (ARI) in the two weeks before the survey, and 17 percent of children under five were reported to have had fever—a major manifestation of ma- laria—during the same time period. More than half of the children (56 percent) were taken to a health facility or provider of treatment. Ten per- cent of children with fever received antimalarial drugs, while 15 percent received antibiotics. At the time of the survey, diarrhoea was a less prevalent problem among young children than fever; 12 percent of children under age five had diarrhoea at some time in the two weeks before the survey. Two-thirds of children with diarrhoea were taken to a health provider. Seven in ten children with diarrhoea were treated with some type of oral rehydration therapy (ORT): 63 per- cent were treated with solution prepared from a Summary of Findings | xxiii packet of oral rehydration salts (ORS), 21 per- cent were given recommended salt-sugar solution (SSS) prepared at home, and 16 percent were given increased fluids. Seventeen percent of children with diarrhoea did not receive any treatment at all. MATERNAL HEALTH In Namibia, almost all women who had a live birth in the five years preceding the survey re- ceived antenatal care from health professionals (95 percent): 16 percent from a doctor and 79 percent from a nurse or midwife. Only 4 percent of mothers did not receive any antenatal care. Tetanus toxoid injections are given during preg- nancy to prevent neonatal tetanus. Nearly six in ten women (57 percent) with a live birth in the five years before the survey had sufficient teta- nus toxoid coverage to ensure that their last (most recent) birth was protected against neona- tal tetanus; one in three women received two or more injections. The majority of births in the five years before the survey were delivered in a health facility (81 percent). This figure is higher than that reported in the 2000 NDHS (75 percent) and the 1992 NDHS (67 percent). Seventy-six percent of births took place in public health facilities and 5 per- cent occurred in private health facilities. Nine- teen percent of births were assisted by a doctor, 63 percent by a nurse or midwife, 7 percent by a trained traditional birth attendant, and 11 percent by a relative or other person. Thirteen percent of births were delivered by a caesarean section. Overall, 78 percent of mothers received a postna- tal checkup for the most recent birth in the past five years, with 34 percent having the checkup within the critical 48 hours after delivery. Adult mortality rates derived from the 2006-07 NDHS data are higher for males than females (10.4 and 8.3 deaths per 1,000 population, re- spectively). A comparison of the 2006-07 NDHS and the 2000 NDHS rates indicates that there has been a substantial increase in adult mortality in Namibia. The rate for females almost doubled between the two surveys and the rate for males is 65 percent higher than it was in 2000. The maternal mortality ratio during the 10-year period before the survey is estimated at 449 ma- ternal deaths per 100,000 live births. This figure should be viewed with caution because the num- ber of female deaths occurring during pregnancy, at delivery, or within two months of delivery is small (86). As a result, the maternal mortality estimates are subject to larger sampling errors than the adult mortality estimates; the 95 percent confidence intervals indicate that the maternal mortality ratio varies from about 390 to 560. BREASTFEEDING AND NUTRITION Breastfeeding is common in Namibia, with 94 percent of children breastfed at some point dur- ing childhood. The median breastfeeding dura- tion in Namibia is 16.8 months. Exclusive breast- feeding, on the other hand, is relatively short, with a median duration of less than one month. About one-quarter of babies are exclusively breastfed throughout the first six months of life. By age 6-9 months, 72 percent of children are receiving complementary foods. Two in three children age 18-23 months have been weaned. Bottle-feeding is common; 38 percent of babies less than six months of age are fed with a bottle. The proportion bottle-fed peaks at 50 percent among children age 6-8 months. Overall, 29 percent of children are stunted (short for their age), 8 percent are wasted (thin for their height), and 17 percent are underweight (thin for their age). All of the indices indicate that malnu- trition increases with age, prevalence peaking at age 12-23 months and declining as children ap- proach their fifth birthday. For example, stunting affects 38 percent of children age 18-23 months; 14 percent are severely stunted. Nine to 10 per- cent of children age 12-23 months are wasted; the highest rate of severe acute malnutrition is found among children age 18-23 months (3 per- cent). More than half of women (56 percent) have a body mass index (BMI) in the normal range (BMI 18.5-24.9). In Namibia, overweight and obesity are more common than underweight. A total of 28 percent of women are overweight or obese (BMI ≥25.0), including 12 percent classi- fied as obese (BMI ≥30.0). At the other extreme, 16 percent are considered thin (BMI <18.5), in- cluding 6 percent who are moderately or severely thin (BMI <17). xxiv * Summary of Findings MALARIA One in four households interviewed in the survey has at least one mosquito net, and most of these households have a net that has been treated at some time with an insecticide (20 percent). Al- most all of the households owning an ever- treated net have at least one net meeting one of the insecticide-treated net (ITN) criteria, i.e., it was a factory-treated net that did not require re- treatment, a pre-treated net obtained within the past year, or a net soaked in insecticide at some time during the past year. Eleven percent of children under age five slept under an ever-treated net the night before the survey, almost all of which were ITNs. Nine per- cent of pregnant women slept under an ITN. Among women who had their last birth in the two years before the survey, 30 percent took an antimalarial drug during their pregnancy. Twen- ty-eight percent of all pregnant women took at least one dose of SP/Fansidar during their preg- nancy. Eleven percent reported taking two or more doses of SP/Fansidar. The majority of women who took SP/Fansidar were given the drug during an antenatal care visit, and thus are considered to have received intermittent preven- tive treatment (IPT). HIV/AIDS AND STIS Knowledge of HIV and AIDS is universal in Namibia; 99 percent of women age 15-49 and 99 percent of men age 15-49 have heard of AIDS. However, among both women and men, only two in three have what can be considered comprehen- sive knowledge about the modes of HIV trans- mission and prevention. Comprehensive knowl- edge means, a) knowing that use of condoms and having just one uninfected, faithful partner can reduce the chances of getting HIV, b) knowing that a healthy-looking person can have HIV, and c) rejecting the two most common local miscon- ceptions about HIV transmission or prevention. Most women and men know that HIV can be transmitted by breastfeeding, and about three- quarters know that the risk of mother-to-child transmission can be reduced by taking drugs dur- ing pregnancy. Given that most HIV infections in Namibia are contracted through heterosexual contact, infor- mation about higher-risk sex (i.e., sexual inter- course with a non-marital, non-cohabiting part- ner) is important for planning HIV-prevention programmes. The 2006-07 NDHS measured higher-risk sex in the past 12 months. Overall, 49 percent of wom- en and 60 percent of men engaged in higher-risk sex in the year before the survey. About half of these women and two-thirds of the men reported using a condom consistently with their last high- er-risk partner. Among the adult population age 15-49, more than half of women and one in three men have been tested for HIV and received the results at some point in time. ORPHANS AND VULNERABLE CHILDREN One-quarter of Namibian children under age 18 in the households sampled for the 2006-07 NDHS live with both parents, while one in three does not live with either parent. Seventeen per- cent of children under age 18 are orphaned, that is, one or both parents is dead. A comparison of the results from the 2000 NDHS and 2006-07 NDHS for this age group indicates that there has been a dramatic increase in orphanhood in Na- mibia. The proportion of children orphaned, i.e., with one or both parents dead, more than doubled between the two surveys, from 11 percent to 17 percent. The proportion of paternal orphans, i.e., those whose fathers have died, increased from 7 percent to 13 percent, while the proportion of maternal orphans increased from 4 percent to 7 percent between two surveys. The proportion of children under age 18 with both parents dead tripled, from 1 percent in 2000 to 3 percent in 2006-07. Overall, 14 percent of children under age 18 are considered vulnerable, i.e., they live in a house- hold in which at least one adult has been chroni- cally ill during the past year or at least one parent living in the household or elsewhere has suffered from a chronic illness. In total, three in ten chil- dren are either orphaned and/or vulnerable. Summary of Findings | xxv ACCESS TO HEALTH FACILITIES Households interviewed in the 2006-07 NDHS were asked to name the nearest government health facility, the mode of transport they would use to visit the facility, and how long it takes to get to the facility using the transport of choice. The same questions were asked about the gov- ernment hospital. Rural households are more likely to be nearest to a clinic than urban households, and urban house- holds are more likely to be nearest to a govern- ment hospital than rural households. Two in three households access to the nearest government health facility by foot. Urban house- holds are more likely to use a car or motorcycle while rural households are more likely to use public transport. There are substantial regional differences in mode of transport to health facili- ties. About three in ten households in Hardap, Karas, Khomas, Kunene, Omaheke, and Otjo- zondjupa use car or motorcycle, while in Kavango more than nine in ten households walk to health facilities. The type of transport used to access the nearest government hospital is different from the type of transport used to access the nearest government health facility. Because of the greater distance, on average, to hospitals, fewer households (17 percent) reported that they would walk to the nearest government hospital, and two in three said they would use public transport. One in five households is within 15 minutes of a government health facility and three in five are within one hour of a facility. On the other hand, 10 percent of households are more than 3 hours from the nearest government health facility. Overall, it takes on average 74 minutes to reach the nearest facility and 99 minutes to reach a government hospital. Six in ten households in both urban and rural areas indicated that they would walk to the nearest government health facility. xxvi | Map of Namibia Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY, HISTORY AND ECONOMY 1.1.1 Geography Namibia is situated in South-Western Africa and covers approximately 824,000 square kilo- metres. It is bordered by the Atlantic Ocean in the west, Botswana and Zimbabwe in the east, South Africa in the south, and Angola and Zambia in the north. The Namib Desert, the oldest desert in the world, stretches along the whole west coast of the country, while the Kalahari Desert runs along the southeastern border with Botswana. Namibia’s name is derived from the Namib Desert, a unique geological feature renowned for the pristine and haunting quality of its landscape. The Namibian climate varies from arid and semi-arid to subtropical with temperatures between 5°C and 20°C. Fog sometimes occurs along the temperate desert coast. The central, southern, and coastal areas constitute some of the most arid landscapes south of the Sahara. The hottest months of the year are January and February, with average daytime temperatures varying between 9°C and 30°C. During the winter months, May to September, temperatures can fluctuate between -6°C and 10°C at night to 20°C in the day. Frost occurs over large areas of the country during winter, but in general, winter days are clear, cloudless and sunny. Overall, Namibia is a summer rainfall area with limited showers beginning in October and continuing until April. 1.1.2 History On March 21, 1990 Namibia achieved its independence after a century of colonial rule, first by Germany and then by South Africa, following the successful implementation of United Nations Resolution 435. With a constitution based on Roman-Dutch law, the country has a multi-party system and holds general elections every five years. A bicameral legislature consists of the National Council (two members chosen from each regional council) and the National Assembly. Administratively, the country is divided into 13 regions, namely: Caprivi, Kavango, Kunene, Ohangwena, Omusati, Oshana, and Oshikoto regions in the north; Omaheke, Otjozondjupa, Erongo, and Khomas regions in the central areas; and the Hardap and Karas regions in the south. 1.1.3 Economy The positive global economic performance between 2002 and 2006 had a favourable impact on the Namibian economy mainly through high commodity prices and strong demand from the rest of the world. In real terms, the economy recorded a growth rate of 6 percent in 2004, above the 4.4 percent projected earlier. On average, the economy grew by 4.6 percent between 2001 and 2004, just above the target rate of 4.3 percent set in National Development Plan 2 (NDP2). Taking into account the prospects of the world economy and that of Namibia’s main trading partners, the outlook for the Namibian economy for the coming years points to moderate economic performance with a projected average annual growth rate of 3.7 percent (Ministry of Finance, 2007). 2 | Introduction The economy of Namibia, which was formerly based on natural resources, is slowly becoming more diversified. This change is partly a result of the increased processing of minerals such as diamonds, zinc, copper, and marble. In addition, tourism sector has been expanding very rapidly in the past decade, e.g., preliminary amounts indicate that travel and tourism’s contribution to GDP increased by 9.3 percent (real growth) in 2007 alone. Agricultural growth has a disproportionate effect on reducing poverty because 70 percent of the poor in developing countries, including Namibia, live in rural areas. Namibia, along with its developing-country partners, has long championed the reduction of trade barriers for agricultural products as one of the most important actions to reduce poverty (Gaomab, 2007). The manufacturing sector in Namibia remains small, with fish and meat processing being the largest individual sub-sectors. Beverages, other food products, metal and pre-cast concrete products, furniture, paints, detergents, and leather goods are also produced. Namibia is ranked as a middle-income country but has one of the most skewed incomes per capita in the world. The disparities in per capita income among the population are as a result of lopsided development, which characterised the Namibian economy in the past. The country also has a high unemployment rate, which is estimated at 37 percent (Ministry of Labour and Social Welfare, 2004). 1.2 POPULATION According to the 2001 Population and Housing Census, the Namibian population consists of 1,830,330 people, of which 942,572 are female and 887,721 are male (Table 1.1). The country has a relatively young population, with 43 percent under 15 years of age and less than 4 percent over age 65. Despite rapid urbanisation, Namibia is still mainly rural, with one in three living in urban areas. Overall, the population density is low (2 persons per square kilometre). Regional population densities vary substantially, with almost two-thirds of the population living in the four northern regions and less than one-tenth living in the south. Despite its small population, Namibia has a rich diversity of ethnic groups, including Afrikaners, Basters, Caprivians, Coloureds, Damaras, Germans, Hereros, Kavangos, Namas, Owambos, Sans, and Tswanas. Table 1.1 Basic demographic indicators,, Namibia 1991 and 2001 Indicator 1991 Census 2001 Census Population 1,409,920 1,830,330 Intercensal growth rate (percent) 3.1 2.6 Density (population/km2) 1.7 2.1 Percent urban 28 33 Life expectancy at birth (years) Male 59 48 Female 63 50 Source: http://www.npc.gov.na/census/census_indicators English is the official language but there are more than 11 indigenous languages in Namibia. People commonly speak two or three languages and more than 50 percent of the population speaks Oshiwambo. Introduction | 3 1.3 HEALTH SERVICES AND PROGRAMMES The Ministry of Health and Social Services has adopted a primary health care (PHC) approach for the delivery of health services to the Namibian population. The PHC programmes established were to reflect the eight elements of PHC: • Promotion of proper nutrition and adequate supply of safe water; • Maternal and child care, including family spacing; • Immunisation against the major infectious diseases; • Basic housing and basic sanitation; • Prevention and control of locally endemic diseases; • Education and training in the prevention and control of prevailing community health problems; • Appropriate treatment for common diseases and injuries; and • Community participation in health and social matters. To implement the PHC strategy, programmes have been organised into functional directorates at the national and regional level. These include the following: • Primary Health Care, • Special Programmes, • Developmental Social Welfare Services, • Tertiary Health Care and Clinical Support Services, • Policy, Planning and Human Resource Development, • Human Resource Management and General Services, • Finance and Logistics, and • 13 Regional Directorates (MOHSS, 2007). Secondary and tertiary curative (care) services are maintained and strengthened to provide an integral national system of referral support for PHC services. The three intermediate/referral hospitals are Oshakati Hospital in Oshana Region, Rundu Hospital in Kavango Region, and Katutura Hospital in Khomas Region. Windhoek Central Hospital serves as the overall national referral hospital. As part of the health sector reform, restructuring has meant that authority is decentralised to the 13 Regional Management Teams (RMT) and their respective districts at the operational level. The 13 regional directorates oversee service delivery in 34 health districts. The role of the district is to ensure efficient and effective implementation of the regionally directed programmes and projects. Public health services are provided through 30 public district hospitals, 44 health centres, and 265 clinics. Three intermediate hospitals and one national referral hospital provide support to the district hospitals. Because of the vastness of the country, the sparse distribution of the population, and lack of access to permanent health facilities in some communities, outreach (mobile clinic) services are provided at about 1,150 outreach points across the country. As PHC includes diverse interventions, intersectoral collaboration has been recognised as an important aspect in health and social care delivery. Many partners in health and social care play a major role in this sector. Although the government is the main service provider, private and mission facilities continue to make important contributions, the latter is being totally subsidised by the government. The private sector is mainly urban, providing health care through medium-sized hospitals, as well as through private pharmacies, doctors’ surgeries, and nursing homes. 4 | Introduction 1.4 SURVEY OBJECTIVES AND IMPLEMENTATION The 2006-07 Namibia Demographic and Health Survey is designed to: • Determine key demographic rates, particularly fertility, under-five mortality, and adult mortality rates; • Investigate the direct and indirect factors that determine the level and trends of fertility; • Measure the level of contraceptive knowledge and practice among women and men by method; • Determine immunisation coverage and prevalence and treatment of diarrhoea and acute respiratory diseases among children under five; identify infant and young child feeding practices and assess the nutritional status of children age 6–59 months and women age 15–49 years; • Assess knowledge and attitudes of women and men regarding sexually transmitted infections and HIV/AIDS, and evaluate patterns of recent behaviour regarding condom use; • Identify behaviours that protect or predispose people to HIV infection and examine social, economic, and cultural determinants of HIV; • Determine the proportion of households with orphans and vulnerable children (OVCs); and • Determine the proportion of households with sick people taken care of at household level. The 2006-07 NDHS is part of the worldwide Demographic and Health Surveys (DHS) programme funded by the United States Agency for International Development (USAID). DHS surveys are designed to collect data on fertility, family planning, and maternal and child health; assist countries in conducting periodic surveys to monitor changes in population, health, and nutrition; and provide an international database that can be used by researchers investigating topics related to population, health, and nutrition. 1.4.1 Organisation The 2006-07 NDHS was conducted by the Ministry of Health and Social Services (MOHSS). Macro International Inc. of Calverton, Maryland provided technical assistance through the MEASURE DHS project of USAID. Most of the funds for local costs of the survey were provided by the Government of Namibia, with assistance from the Global Fund, UNICEF, and DFID, through a SADC project. USAID provided additional funds for the implementation of the survey and technical assistance provided by Macro International. 1.4.2 Questionnaires The 2006-07 NDHS used three questionnaires: the Household Questionnaire, the Women’s Questionnaire (women age 15-49), and the Men’s Questionnaire (men age 15-49). These field instruments were based on the model questionnaires developed for the DHS programme—and adapted to the situation and needs of Namibia—as well as the questionnaires used in the 2000 NDHS. The survey instruments included the expanded HIV/AIDS module developed to assist countries in obtaining UNAIDS core Monitoring & Evaluation indicators. During the adaptation of the questionnaires, input was sought from a variety of organisations that will be using the data. The completed questionnaires were translated from English into six local languages, namely Afrikaans, Damara/Nama, Oshiwambo, Otjiherero, Rukwangali, and Silozi. The main purpose of the Household Questionnaire was to collect information on demographic and socio-economic characteristics of the population and information about respondents’ dwellings. In addition, the Household Questionnaire was used to identify women and men eligible for the individual interview. The Household Questionnaire listed all persons who spent the night preceding Introduction | 5 the interview in the household, including usual household members and visitors. The Household Questionnaire also recorded the height and weight of women and children under 6 years of age. The Women’s Questionnaire was used to collect information on the following topics: ● Background characteristics (age, education, religion, etc.), ● Reproductive history (to arrive at fertility and childhood mortality rates), ● Knowledge and use of family planning methods, ● Antenatal and delivery care, ● Infant feeding practices including patterns of breastfeeding, ● Vaccinations, ● Episodes of childhood illness and responses to illness, with a focus on treatment of fevers in the past two weeks, ● Marriage and sexual activity, ● Fertility preferences, ● Husband’s background and the woman’s work status, ● Adult mortality, including maternal mortality, and ● HIV/AIDS-related knowledge, attitudes, and behaviour. Men were asked about their participation in the health care of their family and their attitudes on gender roles. Eligible men age 15-49 in selected households were interviewed using the Men’s Questionnaire. In addition to the questionnaires, other technical documents were prepared by MOHSS in collaboration with Macro International, including interviewers' and supervisors' training manuals; and interviewer and supervisor assignment sheets for fieldwork control. 1.4.3 Pilot Survey The survey instruments were piloted in Hardap, Omaheke, and Otjozondjupa regions from 16 September to 23 September 2006. In each region, the pilot survey was conducted by two teams that included six interviewers and one supervisor. The questionnaires were pretested in both urban and rural clusters. About 150 women and 150 men were interviewed during the pilot survey and the results of the pilot survey were used to modify the survey instruments as necessary. 1.4.4 Advocacy and Publicity A publicity campaign was implemented between September 5 and 23, 2006 to sensitize the communities about the survey and its objectives. The campaign was carried out by two teams that visited all 13 regions. Information about the survey was announced in the print media and on television, including the official launch of the survey by the MOHSS. T-shirts and leaflets were also prepared for this purpose. 1.4.5 Training for Fieldworkers A training programme was conducted for all NDHS field staff from 10 October 2006 to 10 November 2006. Approximately 230 persons representing all the major language groups in Namibia were trained. The trainers were from MOHSS, Macro International, and the Central Bureau of Statistics (CBS). The topics included sampling and use of the global positioning system. The training consisted of classroom lectures, mock interviews, and practical interviews in the field. Based on the performance during training, 170 persons were recruited to work as supervisors, field editors, enumerators, and data entry personnel. Among this group, about 100 were trained to 6 | Introduction carry out household listing. Because there was a break for Christmas and New Year’s Day, refresher training was conducted from 12 January to 3 February 2007. 1.4.6 Household Listing Prior to the main survey, a complete list of households in the selected primary sampling units (PSUs) was carried out. This provided a sampling frame from which 20 households in each PSU were selected for the survey. The listing exercise was carried out by CBS and assisted by MOHSS. 1.4.7 Data Collection The 2006-07 NDHS data were collected by 28 teams, each consisting of a team supervisor, a field editor, three female interviewers, one male interviewer, and a driver. The majority of team supervisors and editors were MOHSS staff. The assignment of field took into consideration the person’s proficiency in the major languages spoken in Namibia. Quality assurance was maintained by national and regional supervisors through close supervision and monitoring during fieldwork. The questionnaires were edited by the field editors in the field and verified by the team supervisor before being transported to the MOHSS central office. National and regional supervisors ensured quality control through editing of questionnaires and observation of interviewers. Common mistakes were communicated and discussed with all team members. 1.4.8 Data Processing Data entry commenced on 10 December 2006 and ended the third week of May 2007. CSPro—a Windows-based integrated Census and the Survey Processing package that combines and replaces the ISSA and IMPS packages, which was developed by the MEASURE DHS+ project in collaboration with the U.S. Census Bureau—was used for entry, editing, and tabulation of the NDHS data. Prior to data entry, a practical training was provided by Macro International to all data entry staff including the data manager, data entry supervisors, secondary data editors and data entry clerks. The data entry software was installed on 19 computers with one computer used as the central command or server unit for the data administrator. Data processing was performed by a team of 21 data entry operators, 2 data entry supervisors, 3 administrators/coders, and 3 secondary editors. Table 1.2 presents information on the number of households selected and interviewed and the number of eligible women and of eligible men identified and interviewed. A total of 9,970 households were selected for the sample, of which 9,410 were found and eligible for inter- view. Of the eligible households, 9,200 were suc- cessfully interviewed yielding a response rate of 98 percent. In the interviewed households, 10,352 women age 15-49 were identified as eligible for the women’s questionnaire. Interviews were com- pleted for 9,804 (95 percent) of these women. Of the 4,446 men age 15-49 identified as eligible for the men’s questionnaire, 3,915 (88 percent) were successfully interviewed. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Namibia 2006-07 Residence Result Urban Rural Total Household interviews Households selected 4,250 5,720 9,970 Households occupied 4,020 5,390 9,410 Households interviewed 3,893 5,307 9,200 Household response rate1 96.8 98.5 97.8 Interviews with women age 15-49 Number of eligible women 4,742 5,610 10,352 Number of eligible women interviewed 4,405 5,399 9,804 Eligible women response rate2 92.9 96.2 94.7 Interviews with men age 15-49 Number of eligible men 1,995 2,451 4,446 Number of eligible men interviewed 1,673 2,242 3,915 Eligible men response rate2 83.9 91.5 88.1 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 7 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 The purpose of this chapter is to provide a descriptive summary of some demographic and socio-economic characteristics of the population in the households sampled in the 2006-07 Namibia Demographic and Health Survey (NDHS). For the purpose of the 2006-07 NDHS, a household was defined as a person or a group of persons, related or unrelated, who live together and share a common source of food. The Household Questionnaire (see Appendix E) collected basic demographic and socio-economic information (e.g., age, sex, education attainment, and current school attendance) on all usual residents and visitors who spent the night preceding the interview in the household. This method of data collection allows analysis of results for either the de jure (usual residents) or de facto (those who were present at the time of the survey) populations. The Household Questionnaire also collected information on housing facilities (e.g., source of water supply and sanitation facilities) and household possessions. The information presented in this chapter is intended to facilitate interpretation of the key demographic, socio-economic, and health indices presented later in the report. It is also intended to assist in the assessment of the representativeness of the survey sample. 2.1 POPULATION BY AGE AND SEX Age and sex are important demographic variables and are the primary basis of demographic classification. The distribution of the de facto household population in the 2006-07 NDHS is shown in Table 2.1 by five-year age groups, according to sex and residence. Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Namibia 2006-07 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 11.0 10.8 10.9 16.0 13.8 14.8 13.9 12.6 13.2 5-9 11.2 10.2 10.7 14.9 13.1 14.0 13.4 11.9 12.6 10-14 10.8 10.2 10.5 15.7 14.3 14.9 13.7 12.6 13.1 15-19 9.2 10.9 10.1 12.3 11.0 11.6 11.0 11.0 11.0 20-24 10.7 11.6 11.2 8.5 7.9 8.2 9.4 9.4 9.4 25-29 11.4 11.1 11.2 6.1 6.0 6.0 8.3 8.1 8.2 30-34 9.9 9.7 9.8 5.1 5.3 5.2 7.1 7.1 7.1 35-39 6.8 6.4 6.6 3.9 4.6 4.3 5.1 5.3 5.2 40-44 6.0 5.4 5.7 3.2 4.2 3.7 4.4 4.7 4.5 45-49 3.8 3.9 3.9 2.6 3.2 2.9 3.1 3.5 3.3 50-54 3.4 3.1 3.3 2.5 3.4 2.9 2.9 3.3 3.1 55-59 2.6 2.0 2.3 1.9 2.7 2.3 2.2 2.4 2.3 60-64 1.2 1.6 1.4 1.8 2.4 2.1 1.5 2.1 1.8 65-69 0.9 1.1 1.0 1.6 2.1 1.9 1.3 1.7 1.5 70-74 0.4 0.8 0.6 1.3 1.6 1.5 0.9 1.3 1.1 75-79 0.3 0.4 0.4 1.1 1.6 1.4 0.8 1.1 1.0 80 + 0.2 0.7 0.5 1.5 2.6 2.1 1.0 1.8 1.4 Don't know/missing 0.1 0.1 0.1 0.1 0.2 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 8,126 8,773 16,900 11,498 12,916 24,414 19,624 21,688 41,314 | Household Population and Housing Characteristics 8 In Table 2.1, younger age groups (those under age 35) represent a higher proportion of the population than older age groups, reflecting a distribution pattern similar to that seen in the 1992 and 2000 NDHS surveys. The proportion of the population age 0-5 has declined steadily from 16 percent in 1992 to 14 percent in 2000 and 13 percent in 2006-07. Another indicator of declining fertility is the decline in the proportion of the population under age 15, from 43 percent in 2000 to 39 percent in 2006-07 (see discussion in Chapter 4). Table 2.1 shows that 53 percent of the population are females and 47 percent are males. The excess of females over males has been observed since the 1992 NDHS survey. This is true in urban and rural areas. 2.2 HOUSEHOLD COMPOSITION Information on key aspects of the composition of households, including the sex of the head of the household and the size of the household, is presented in Table 2.2. These characteristics are important because they are associated with the welfare of the household. Female-headed households are, for example, typically poorer than male-headed households. Economic resources are often more limited in larger households. Moreover, where the size of the household is large, crowding can lead to health problems. In general, household size has a negative correlation with the socio-economic status. While this is generally the case, it has also been found that sometimes there are significant benefits in having other members in a household. The 2006-07 NDHS data indicate that 56 percent of households are headed by men, a decline of three percentage points from 2000 compared with a decline of ten percentage points between 1992 and 2000. In contrast, female-headed households increased from 31 percent in 1992 to 44 percent in 2006-07. Rural households are more likely than urban households to be headed by women (47 percent compared with 40 percent). There are marked differences in size between rural and urban households. In rural areas, 13 percent of households have nine or more members compared with only 6 percent in urban areas. Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 NDHS 2006-07 Male Percent Female Age Household Population and Housing Characteristics | 9 Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18, according to residence, Namibia 2006-07 Residence Characteristic Urban Rural Total Household headship Male 59.9 52.6 56.0 Female 40.1 47.4 44.0 Total 100.0 100.0 100.0 Number of usual members 0 0.5 0.3 0.4 1 16.2 12.8 14.4 2 16.1 12.3 14.1 3 16.1 13.4 14.7 4 17.7 13.3 15.3 5 10.6 11.5 11.1 6 7.7 10.1 9.0 7 5.6 7.2 6.4 8 3.8 5.9 5.0 9+ 5.7 13.2 9.7 Total 100.0 100.0 100.0 Mean size of households 4.0 4.9 4.5 Percentage of households with orphans and foster children under age 18 Foster children1 19.9 46.1 33.9 Double orphans 2.5 5.5 4.1 Single orphans 10.7 25.0 18.4 Foster and/or orphan children 23.5 51.0 38.3 Number of households 4,260 4,940 9,200 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. The average household size in Namibia declined from 5.1 in 2000 to 4.5 persons at the time of the 2006-07 NDHS. The mean household size in rural areas is larger than in urban areas (4.9 compared with 4.0, respectively). Overall, 38 percent of households have orphans and fostered children. Orphans and fostered children are more likely to be found in rural households than in urban households (51 percent and 24 percent, respectively). 2.3 EDUCATION OF THE HOUSEHOLD POPULATION Education is a key determinant of the lifestyle and status an individual enjoys in society. Studies have consistently shown that educational attainment has a strong effect on health behaviours and attitudes (Gwatkin et al., 2000). Results from the 2006-07 NDHS can be used to look at educational attainment among household members and school attendance, repetition, and drop-out rates among youth. For the purposes of this analysis, the official age for entry into the primary level is age 6. The official primary level of schooling consists of 7 years (grades 1 to 7). The number of years assumed for completion of secondary school is five years. | Household Population and Housing Characteristics 10 2.3.1 Educational Attainment Tables 2.3.1 and 2.3.2 present data on the educational attainment of household members age six and over by sex. Overall, 15 percent of the female population and 16 percent of the male population have no education. These proportions are lower than those reported in the 2000 NDHS; 21 percent for females and 22 percent for males. There is a negative relationship between age and educational attainment, older persons are less likely than younger persons to have received education. Women and men living in rural areas are more likely than those in urban areas to have no education. For example, 19 percent of women living in rural areas have no education compared with 8 percent of those in urban areas. Table 2.3.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Namibia 2006-07 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 37.9 60.8 0.2 0.0 0.0 0.0 1.0 100.0 2,073 0.3 10-14 3.1 78.5 10.4 7.1 0.1 0.0 0.6 100.0 2,740 4.1 15-19 2.8 15.9 12.5 62.2 5.1 0.8 0.8 100.0 2,382 8.1 20-24 4.5 11.4 5.5 54.0 16.9 6.6 1.0 100.0 2,041 8.9 25-29 5.5 13.1 6.6 45.4 20.1 7.7 1.6 100.0 1,748 9.0 30-34 7.4 18.3 5.7 39.0 17.2 11.0 1.5 100.0 1,533 8.8 35-39 9.8 24.7 7.3 33.0 14.6 8.9 1.7 100.0 1,150 8.1 40-44 11.5 26.4 8.3 32.8 9.4 9.7 1.9 100.0 1,016 7.3 45-49 17.5 30.5 5.9 23.7 8.7 12.8 0.9 100.0 755 6.3 50-54 21.2 38.0 7.2 20.6 5.3 6.4 1.4 100.0 711 4.6 55-59 24.1 43.0 6.7 12.4 3.8 6.3 3.8 100.0 525 3.6 60-64 34.1 36.3 7.0 10.2 4.1 3.0 5.4 100.0 449 2.2 65+ 49.7 32.6 2.6 5.6 3.5 1.4 4.6 100.0 1,291 0.0 Residence Urban 8.3 23.8 5.8 35.8 16.0 8.5 1.9 100.0 7,653 8.3 Rural 19.1 42.5 7.7 24.6 2.9 2.0 1.3 100.0 10,792 4.4 Region Caprivi 16.0 37.6 7.1 34.2 1.7 2.9 0.6 100.0 922 5.4 Erongo 7.9 21.7 7.4 36.9 16.3 6.1 3.7 100.0 1,137 8.2 Hardap 13.0 36.6 7.8 30.3 8.2 2.7 1.4 100.0 612 5.9 Karas 6.4 31.4 11.1 33.2 12.6 4.4 0.9 100.0 603 7.1 Kavango 21.7 45.9 6.1 19.7 2.0 1.6 2.9 100.0 1,939 3.4 Khomas 6.2 19.0 4.7 35.5 20.6 12.8 1.3 100.0 3,363 9.1 Kunene 38.3 27.7 5.2 17.4 5.8 1.9 3.8 100.0 528 2.3 Ohangwena 18.0 44.1 8.8 22.3 2.5 1.8 2.5 100.0 2,250 4.2 Omaheke 26.4 31.0 6.5 25.4 5.5 3.6 1.6 100.0 726 4.3 Omusati 13.8 42.2 7.6 29.5 3.7 2.3 0.8 100.0 2,154 5.2 Oshana 9.9 37.1 6.8 34.2 8.1 3.4 0.5 100.0 1,554 6.4 Oshikoto 14.3 41.9 7.3 29.0 4.1 2.8 0.5 100.0 1,695 5.1 Otjozondjupa 22.3 32.2 6.1 27.0 8.1 3.9 0.3 100.0 962 5.1 Wealth quintile Lowest 24.6 48.2 6.9 18.0 0.6 0.1 1.7 100.0 3,759 3.1 Second 19.5 44.3 7.7 24.5 1.8 0.5 1.7 100.0 3,691 4.2 Middle 16.5 36.6 8.3 31.5 4.0 1.9 1.3 100.0 3,474 5.4 Fourth 8.2 27.5 7.1 40.6 11.0 4.2 1.4 100.0 3,644 7.7 Highest 4.4 17.8 4.5 31.9 23.4 16.2 1.7 100.0 3,878 9.6 Total 14.6 34.7 6.9 29.2 8.3 4.7 1.6 100.0 18,445 6.0 Note: Total includes 27 unweighted women with information missing on age. 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level Household Population and Housing Characteristics | 11 Observation of education level across regions show that women and men in Kavango, Kunene, Omaheke, Otjozondjupa, and regions are the least likely to have gone to school. On the other hand, women and men in Caprivi, Erongo, Karas, and Khomas regions have the highest levels of education. Table 2.3.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Namibia 2006-07 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 38.0 60.3 0.1 0.1 0.0 0.0 1.4 100.0 2,173 0.3 10-14 4.8 82.9 6.3 5.4 0.2 0.0 0.4 100.0 2,683 3.7 15-19 5.0 28.5 13.5 48.7 3.6 0.3 0.5 100.0 2,156 7.2 20-24 7.8 17.8 6.4 46.7 14.6 5.5 1.3 100.0 1,853 8.5 25-29 9.4 18.9 5.8 37.0 18.8 8.1 2.1 100.0 1,621 8.7 30-34 10.6 18.4 4.9 34.6 19.4 10.2 1.9 100.0 1,395 8.7 35-39 12.7 23.6 5.9 28.1 18.7 10.4 0.7 100.0 1,002 8.1 40-44 14.8 25.6 5.0 25.7 15.0 12.1 1.8 100.0 856 7.6 45-49 22.7 27.5 5.4 20.9 8.5 13.0 1.9 100.0 610 5.8 50-54 20.6 31.3 7.6 19.9 8.6 10.1 1.9 100.0 561 5.5 55-59 24.2 33.1 5.9 15.7 7.3 12.8 1.1 100.0 427 4.6 60-64 36.2 36.0 5.6 9.2 5.2 4.8 3.0 100.0 296 2.3 65+ 42.5 35.1 2.7 8.7 4.7 2.1 4.3 100.0 783 0.9 37.9 25.5 0.0 0.0 0.0 0.0 36.7 100.0 20 0.0 Residence Urban 9.7 28.5 5.0 30.6 15.7 8.8 1.7 100.0 7,081 7.9 Rural 20.1 46.5 6.7 20.1 3.4 2.0 1.2 100.0 9,357 3.6 Region Caprivi 8.3 45.1 6.3 31.9 3.4 4.6 0.4 100.0 803 5.5 Erongo 10.4 25.0 6.9 33.0 16.3 6.1 2.3 100.0 1,303 8.1 Hardap 15.1 37.1 7.3 26.9 9.5 2.8 1.2 100.0 557 5.5 Karas 10.2 30.9 7.5 31.5 15.1 4.1 0.7 100.0 638 7.1 Kavango 18.4 44.4 6.2 24.2 2.5 2.0 2.2 100.0 1,622 3.8 Khomas 8.2 25.2 4.3 29.9 18.9 12.0 1.5 100.0 3,287 8.5 Kunene 41.7 28.5 3.8 15.4 4.7 1.7 4.1 100.0 452 0.9 Ohangwena 21.5 50.9 6.8 15.0 2.1 1.3 2.5 100.0 1,725 2.8 Omaheke 26.4 33.0 4.5 24.6 7.5 3.1 0.9 100.0 804 4.0 Omusati 13.8 51.5 7.0 22.3 2.9 1.9 0.7 100.0 1,610 4.2 Oshana 10.8 46.2 7.5 24.4 6.3 4.0 0.9 100.0 1,181 5.2 Oshikoto 17.4 50.0 6.3 18.0 4.6 3.2 0.6 100.0 1,477 3.7 Otjozondjupa 27.3 34.9 5.0 20.3 7.3 4.7 0.4 100.0 978 3.8 Wealth quintile Lowest 22.8 53.5 5.8 15.1 0.9 0.2 1.7 100.0 2,971 2.7 Second 20.9 49.0 7.2 18.6 2.0 0.9 1.3 100.0 3,032 3.4 Middle 18.5 40.2 7.1 27.1 4.2 1.7 1.2 100.0 3,453 4.6 Fourth 11.9 32.5 6.1 32.5 11.5 4.0 1.5 100.0 3,562 6.8 Highest 5.6 21.8 3.8 27.6 23.0 16.9 1.4 100.0 3,420 9.5 Total 15.6 38.7 6.0 24.6 8.7 4.9 1.4 100.0 16,438 5.2 Note: Total includes 20 unweighted men with information missing on age. 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level | Household Population and Housing Characteristics 12 2.3.2 School Attendance Rates Table 2.4 presents the net attendance ratios (NAR) and gross attendance ratios (GAR) for primary and secondary schools by household residence and regions for the school year that started in 2005. The NAR for primary school is the percentage of the primary-school-age (6-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (13-17 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. The GAR for primary school is the total number of primary school students, of any age, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, of any age, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of over- age and under-age students at a given level of schooling, the GAR can exceed 100 percent. Youth are considered to be attending school if they attended formal academic school at any point during the given school year. The gender parity index (GPI) assesses sex-related differences in school attendance rates and is calculated by dividing the GAR for females by the GAR for males. A GPI of one indicates parity or equality between the rates of participation for males and females. A GPI of less than one indicates a gender disparity in favour of males, i.e., a higher proportion of males than females attends that level of schooling. A GPI greater than one indicates a gender disparity in favour of females. Table 2.4 indicates that the NAR for primary school is 91, which means that 91 percent of children who should be attending primary school are doing so. This is higher by 5 percentage points than the level in 2000. The corresponding figures for secondary school are much lower at 47 percent and 43 percent, respectively. There is no discrimination between male and female children in attending primary school; the NAR is 91 for both boys and girls. Net attendance ratios for primary school are higher in urban than in rural areas, and are 95 percent or higher in Caprivi, Karas, Omusati, Oshana, and Oshikoto. The GAR figures (ratios of 136 for males and 130 for females) indicate that there are children in primary school who are not primary-school age. As expected, the NAR levels are higher for the children in wealthier households. Secondary school attendance is higher for females (NAR of 53) than for males (NAR of 40). Erongo and Khomas regions have the highest NARs at the secondary level (64 percent and 61 percent, respectively), while Kunene has the lowest (25 percent). The GAR shows that there are many secondary school students who are not secondary-school age. The GPI for secondary school is 1.32, indicating that more females attend secondary school than their male counterparts. Oshikoto and Oshana regions have the highest GPI (1.50 and 1.59, respectively), while Kavango region has the lowest (0.92). Household Population and Housing Characteristics | 13 Table 2.4 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Namibia 2006-07 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender parity index3 Male Female Total Gender parity index3 PRIMARY SCHOOL Residence Urban 91.5 91.9 91.7 1.00 123.0 120.6 121.8 0.98 Rural 90.0 91.0 90.5 1.01 143.3 135.3 139.3 0.94 Region Caprivi 95.0 95.9 95.4 1.01 125.8 125.9 125.8 1.00 Erongo 93.3 93.3 93.3 1.00 114.9 118.7 116.8 1.03 Hardap 90.9 95.9 93.4 1.05 123.2 127.4 125.3 1.03 Karas 96.4 97.0 96.7 1.01 119.6 122.4 120.9 1.02 Kavango 86.8 86.8 86.8 1.00 143.7 134.0 138.6 0.93 Khomas 91.7 92.5 92.1 1.01 124.5 119.5 122.2 0.96 Kunene 57.9 54.8 56.2 0.95 79.9 72.3 75.8 0.90 Ohangwena 88.8 93.9 91.3 1.06 145.1 148.9 146.9 1.03 Omaheke 86.5 81.5 83.9 0.94 130.1 108.0 118.7 0.83 Omusati 96.5 95.4 95.9 0.99 156.2 144.1 150.0 0.92 Oshana 95.4 95.1 95.2 1.00 152.5 132.1 141.8 0.87 Oshikoto 93.2 95.9 94.5 1.03 148.6 135.3 142.0 0.91 Otjozondjupa 82.0 82.3 82.1 1.00 109.1 122.7 115.4 1.12 Wealth quintile Lowest 87.8 87.7 87.8 1.00 141.7 133.9 137.8 0.94 Second 90.0 92.2 91.1 1.03 145.6 134.8 140.0 0.93 Middle 89.5 91.5 90.5 1.02 141.4 135.1 138.4 0.96 Fourth 92.1 93.6 92.8 1.02 128.4 124.7 126.6 0.97 Highest 94.7 92.9 93.8 0.98 119.5 118.8 119.1 0.99 Total 90.5 91.3 90.9 1.01 136.3 130.3 133.3 0.96 SECONDARY SCHOOL Residence Urban 52.6 62.7 58.1 1.19 67.3 78.3 73.3 1.16 Rural 33.8 47.0 40.3 1.39 46.1 58.3 52.2 1.26 Region Caprivi 49.6 53.8 51.9 1.08 65.7 65.9 65.8 1.00 Erongo 63.1 64.4 63.8 1.02 77.2 79.3 78.3 1.03 Hardap 43.6 50.1 47.0 1.15 48.3 56.0 52.3 1.16 Karas 51.6 61.2 56.5 1.19 53.8 68.9 61.5 1.28 Kavango 31.5 29.1 30.3 0.92 48.0 39.9 44.0 0.83 Khomas 50.7 69.5 60.6 1.37 64.8 87.3 76.6 1.35 Kunene 21.6 28.5 25.1 1.32 29.7 32.2 31.0 1.09 Ohangwena 30.2 51.2 41.4 1.70 44.0 65.9 55.7 1.50 Omaheke 37.8 49.7 43.1 1.31 46.7 55.0 50.4 1.18 Omusati 41.4 51.1 46.3 1.23 56.9 65.0 61.0 1.14 Oshana 40.0 59.9 50.3 1.50 58.0 75.8 67.2 1.31 Oshikoto 37.1 59.0 47.8 1.59 47.4 70.9 58.9 1.50 Otjozondjupa 36.4 41.8 39.2 1.15 41.4 49.1 45.3 1.18 Wealth quintile Lowest 23.5 35.0 29.3 1.49 34.4 44.1 39.3 1.28 Second 34.1 48.6 41.3 1.43 48.2 60.5 54.3 1.26 Middle 39.4 50.4 44.9 1.28 53.4 63.3 58.3 1.19 Fourth 46.9 60.3 53.8 1.29 60.5 76.0 68.5 1.26 Highest 64.9 73.2 69.5 1.13 78.2 89.2 84.3 1.14 Total 40.0 52.8 46.5 1.32 53.1 65.7 59.6 1.24 1 The NAR for primary school is the percentage of the primary-school-age (7-13 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (14-18 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary- school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. | Household Population and Housing Characteristics 14 Figure 2.2 shows age-specific school attendance rates (i.e., percentage of a given age cohort attending school), for the de jure household population age 5-24. 2.3.3 Grade Repetition and Dropout Rates Repetition and dropout rates presented in Table 2.5 describe the flow of pupils through the educational system in Namibia at the primary level. The repetition rates show the percentage of pupils who attended a particular grade during the school year who attended the same grade during the following school year. Dropout rates show the percentage of pupils in a grade during the school year who no longer attended school the following year. Table 2.5 shows high repetition rates for students in grade 1 regardless of sex or residence. The national repetition average for grade 1 is 12 percent, and may be attributable to the lack of pre- primary schooling. The repetition rate declines with increasing grades. At grade 5 there is a significant increase in repetition rates for both sexes, in urban and rural areas, and in almost all regions. A possible explanation for this is that pupils in grades 1-4 are not required to write examinations; examinations are only given from grade 5 onward. At the regional level, repetition rates in grade 1 are highest in Kunene (33 percent), Omaheke (27 percent) and Caprivi (18 percent) regions. Otjozondjupa (4 percent), Oshana (6 percent), and Oshikoto (8 percent) regions have the lowest rates. Pupils from the higher wealth quintiles have the lowest repetition rates for all grades. Dropout rates by sex and residence are relatively the same. The rates are highest in grades 5 and 7 at about 4 percent. Dropout rates are negatively associated with wealth; pupils in the lowest wealth quintile have the highest dropout rates. Table 2.5 also reveals Kunene region as having the highest dropout rate compared to other regions. This requires further investigation to understand the contributing factors. Figure 2.2 Age-Specific School Attendance Rates 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 10 20 30 40 50 60 70 80 90 100 Percent Female Male NDHS 2006-07Note: Figure shows percentage of the de jure household population age 5-24 years attending school. Household Population and Housing Characteristics | 15 Table 2.5 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade and background characteristics, Namibia 2006-07 School grade Background characteristic 1 2 3 4 5 6 7 REPETITION RATE1 Sex Male 12.4 6.7 8.5 5.5 10.3 5.1 7.6 Female 11.7 5.4 4.0 5.1 10.4 4.7 7.1 Residence Urban 11.1 7.4 7.5 3.9 8.9 2.2 2.3 Rural 12.5 5.6 5.7 6.0 11.1 6.1 9.6 Region Caprivi 18.3 13.6 18.0 17.5 16.8 9.1 14.7 Erongo 16.2 10.6 7.0 1.9 14.1 3.7 7.2 Hardap 10.8 2.8 13.9 3.4 6.1 2.9 5.2 Karas 9.7 1.3 1.2 1.7 12.7 0.0 1.7 Kavango 9.5 6.3 7.2 7.5 17.8 8.3 6.6 Khomas 10.0 11.4 6.4 4.7 8.6 0.0 0.3 Kunene 32.7 6.6 10.8 4.9 3.4 8.8 0.0 Ohangwena 14.6 7.5 7.6 6.9 9.6 5.2 11.9 Omaheke 27.4 17.4 4.2 9.0 26.8 8.2 16.7 Omusati 9.8 2.4 2.6 6.6 7.5 9.4 13.2 Oshana 6.1 0.9 8.8 3.1 5.5 1.4 1.2 Oshikoto 8.4 1.3 2.4 1.0 5.2 4.0 4.5 Otjozondjupa 4.2 2.6 0.0 0.0 6.2 0.0 0.0 Wealth quintile Lowest 13.0 7.8 5.7 6.3 11.4 4.3 13.4 Second 13.9 4.8 8.8 6.5 9.9 7.5 8.6 Middle 13.0 5.2 4.5 5.5 12.7 7.0 7.7 Fourth 11.2 1.0 4.7 2.1 7.4 2.3 4.2 Highest 7.8 11.4 7.5 5.1 9.5 1.2 0.0 Total 12.0 6.1 6.3 5.3 10.4 4.9 7.3 DROPOUT RATE2 Sex Male 1.1 1.5 1.0 1.4 4.1 2.2 4.3 Female 1.8 0.4 0.9 1.1 3.9 2.2 3.3 Residence Urban 0.9 0.4 0.6 1.7 3.9 1.2 3.5 Rural 1.7 1.2 1.1 1.1 4.0 2.6 3.9 Region Caprivi 0.6 0.0 1.5 0.0 4.8 6.5 5.4 Erongo 0.0 0.0 0.0 0.0 7.4 0.0 0.0 Hardap 1.5 0.0 0.9 0.8 3.1 0.0 4.3 Karas 0.0 0.0 0.0 0.0 0.0 2.1 3.3 Kavango 2.8 1.9 0.0 2.5 4.3 5.4 7.2 Khomas 0.0 0.0 0.0 1.7 3.2 0.0 4.2 Kunene 12.5 11.7 0.9 5.8 0.0 18.7 9.7 Ohangwena 2.6 0.7 2.0 2.0 6.6 1.2 3.8 Omaheke 2.6 0.0 4.5 4.3 2.4 0.9 9.5 Omusati 0.0 0.0 1.1 0.2 3.0 2.6 1.8 Oshana 0.0 0.0 0.0 0.6 4.0 2.1 2.8 Oshikoto 0.0 2.9 0.7 0.6 2.9 1.4 0.9 Otjozondjupa 3.1 0.0 1.0 1.4 1.8 0.0 12.9 Wealth quintile Lowest 2.2 2.1 1.4 2.1 5.2 4.6 6.1 Second 1.0 0.6 1.2 0.9 3.9 2.1 1.9 Middle 2.6 1.3 1.4 1.0 4.7 1.3 5.1 Fourth 0.6 0.0 0.2 0.5 5.0 1.8 5.0 Highest 0.0 0.0 0.0 1.6 0.4 0.3 0.7 Total 1.4 1.0 0.9 1.3 4.0 2.2 3.8 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school. | Household Population and Housing Characteristics 16 2.4 HOUSEHOLD ENVIRONMENT The physical characteristics of the dwelling in which a household lives are important determinants of the health status of household members, especially children. They can also be used as indicators of the socio-economic status of households. The 2006-07 NDHS respondents were asked a number of questions about their household environment, including questions on the source of drinking water, type of sanitation facility, type of flooring, walls, and roof, and number of rooms used for sleeping. The results are presented for households and for the de jure population. 2.4.1 Drinking Water Increasing access to improved drinking water is one of the Millennium Development Goals that Namibia, along with other nations worldwide, has adopted (United Nations General Assembly, 2001). Table 2.6 includes a number of indicators that are useful in monitoring household access to improved drinking water (WHO and UNICEF, 2005). The source of drinking water is an indicator of whether it is suitable for drinking. Sources that are likely to provide water suitable for drinking are identified as improved sources in Table 2.7. They include a piped source within the dwelling or plot, public tap, tube well or borehole, protected well or spring and rainwater.1 Lack of ready access to a water source may limit the quantity of suitable drinking water that is available to a household. Even if the water is obtained from an improved source, if it must be fetched from source that is not immediately accessible to the household, it may be contaminated during transport or storage. Another factor in considering the accessibility of water sources is the fact that burden of going for water often falls disproportionately on female members of the household. Finally, home water treatment can be effective in improving the quality of household drinking water. Table 2.6 shows that overall, 88 percent of households in Namibia have access to an improved source of drinking water. Urban households are more likely than rural households to have an improved water source (97 percent compared with 80 percent, respectively). Approximately three- quarters of all households have access to piped water while 11 percent have access to improved sources such as tube well/borehole and protected dug well. Overall, there has been an improvement in access to safe drinking water since 2000, from 79 percent to 88 percent. Twelve percent of the population obtain their drinking water from a non-improved source; this includes 20 percent of the rural population in the rural areas and less than 1 percent of the urban population. Generally, the quality of water available to households in Namibia is safe; about 90 percent of households do not treat the water before drinking. Water treatment differs by urban and rural residence. Rural households are much more likely than urban households to treat the drinking water (16 percent and 6 percent, respectively). Overall, drinking water is available on the premises in 81 percent of households in urban areas and 32 percent in rural areas. In households where water has to be fetched, drinking water is most often collected by adult females (25 percent). The amount of time spent by households to obtain water varies; 39 percent of households in rural areas take less than 30 minutes to obtain water, compared with 17 percent in urban areas. 1 The categorization into improved and non-improved follows that proposed by the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (WHO and UNICEF, 2004). Household Population and Housing Characteristics | 17 Table 2.6 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and the de jure population that treat drinking water, according to residence, Namibia 2006-07 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 97.0 80.4 88.1 96.6 79.3 86.4 Piped water into dwelling/yard/plot 79.5 25.6 50.6 80.7 23.1 46.8 Public tap/standpipe 17.3 31.8 25.1 15.8 32.8 25.8 Tube well or borehole 0.0 16.8 9.0 0.0 16.2 9.6 Protected dug well 0.0 4.1 2.2 0.0 4.8 2.8 Protected spring 0.1 0.4 0.2 0.1 0.4 0.3 Rainwater 0.0 1.7 0.9 0.0 2.0 1.2 Non-improved source 0.4 18.3 10.0 0.5 19.7 11.8 Unprotected dug well 0.1 5.3 2.9 0.1 5.7 3.4 Unprotected spring 0.0 0.6 0.4 0.0 0.8 0.5 Tanker truck/cart with small tank 0.1 1.3 0.7 0.1 1.0 0.7 Surface water 0.1 11.1 6.0 0.2 12.2 7.3 Bottled water, improved source for cooking/washing1 0.9 0.0 0.4 0.7 0.0 0.3 Bottled water, non-improved source for cooking/washing1 0.0 0.0 0.0 0.1 0.0 0.0 Other 1.7 1.3 1.5 2.2 1.0 1.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 97.9 80.4 88.5 97.3 79.3 86.7 Time to obtain drinking water (round trip) Water on premises 81.1 32.3 54.9 82.1 29.7 51.3 Less than 30 minutes 16.5 38.9 28.5 15.1 38.5 28.9 30 minutes or longer 1.9 27.1 15.5 2.0 30.1 18.5 Don't know/missing 0.5 1.7 1.1 0.7 1.7 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 10.2 37.4 24.8 10.0 39.5 27.4 Adult male 15+ 6.0 13.6 10.1 4.4 9.3 7.3 Female child under age 15 0.6 6.7 3.9 1.0 8.8 5.6 Male child under age 15 0.3 2.6 1.5 0.5 3.1 2.0 Other 1.8 7.3 4.7 2.0 9.4 6.4 Water on premises 81.1 32.3 54.9 82.1 29.7 51.3 Missing 0.1 0.1 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 12.6 4.1 8.1 12.5 4.3 7.7 Bleach/chlorine 0.2 0.2 0.2 0.1 0.1 0.1 Strained through cloth 0.0 0.3 0.2 0.0 0.3 0.2 Ceramic, sand or other filter 2.6 0.2 1.3 1.7 0.2 0.8 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 Other 0.7 0.7 0.7 0.8 0.5 0.6 No treatment 83.7 94.3 89.4 84.6 94.4 90.4 Percentage using an appropriate treatment method 3 15.3 4.8 9.6 14.3 4.8 8.7 Number 4,260 4,940 9,200 16,964 24,283 41,247 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering and solar disinfecting. | Household Population and Housing Characteristics 18 Regional access to improved sources of drinking water is presented in Table 2.7, which shows that access ranges from 65 percent in Omusati region to 99 percent in Khomas region. Table 2.7 Household drinking water by region Percent distribution of households and de jure population by source of drinking water, according to region, Namibia 2006-07 Households Population Region Improved source Non- improved source Other Total Number Improved source Non- improved source Other Total Number Caprivi 85.9 12.9 1.2 100.0 514 86.8 12.1 1.1 100.0 2,145 Erongo 94.9 2.4 2.6 100.0 837 95.7 2.0 2.3 100.0 2,754 Hardap 94.7 4.1 1.2 100.0 328 95.9 3.3 0.9 100.0 1,333 Karas 93.9 5.6 0.5 100.0 382 94.3 5.3 0.5 100.0 1,449 Kavango 69.1 27.1 3.8 100.0 750 70.2 26.2 3.6 100.0 4,422 Khomas 98.5 0.3 1.3 100.0 1,950 97.5 0.3 2.2 100.0 7,631 Kunene 77.6 14.8 7.6 100.0 305 72.0 20.3 7.7 100.0 1,327 Ohangwena 86.9 13.1 0.0 100.0 829 86.8 13.2 0.0 100.0 4,733 Omaheke 96.1 1.9 2.0 100.0 426 96.9 1.9 1.3 100.0 1,897 Omusati 65.2 34.6 0.1 100.0 855 62.1 37.8 0.1 100.0 4,368 Oshana 97.0 2.6 0.4 100.0 663 96.7 3.1 0.2 100.0 3,054 Oshikoto 85.2 14.3 0.5 100.0 745 85.4 14.4 0.2 100.0 3,757 Otjozondjupa 96.6 1.4 2.0 100.0 615 97.0 1.4 1.6 100.0 2,377 Total 88.5 10.0 1.5 100.0 9,200 86.7 11.8 1.5 100.0 41,247 2.4.2 Household Sanitation Facilities Ensuring adequate sanitation facilities is another of the Millennium Development Goals. A household is classified as having an improved toilet if the toilet is used only by members of one household (i.e., it is not shared) and if the facility used by the household separates the waste from human contact (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004). Table 2.8 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Namibia 2006-07 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility 57.9 14.1 34.4 61.4 13.3 32.9 Flush/pour flush to piped sewer system 55.0 7.4 29.4 57.8 5.5 27.0 Flush/pour flush to septic tank 0.2 0.3 0.3 0.3 0.2 0.2 Flush/pour flush to pit latrine 0.7 0.4 0.6 0.9 0.4 0.6 Ventilated improved pit (VIP) latrine 1.6 4.3 3.0 1.8 5.1 3.7 Pit latrine with slab 0.2 1.5 0.9 0.2 1.8 1.1 Composting toilet 0.2 0.2 0.2 0.4 0.3 0.3 Non-improved facility 42.1 86.0 65.6 38.7 86.8 67.2 Any facility shared with other households 23.0 3.6 12.6 18.1 2.3 8.8 Flush/pour flush not to sewer/septic tank/ pit latrine 1.9 0.3 1.0 2.0 0.3 1.0 Pit latrine without slab/open pit 1.4 2.7 2.1 1.5 2.9 2.4 Bucket 0.7 1.1 0.9 0.8 1.1 1.0 Hanging toilet/hanging latrine 0.1 0.3 0.2 0.2 0.3 0.3 No facility/bush/field 14.7 77.8 48.6 15.7 79.7 53.4 Other 0.1 0.1 0.1 0.3 0.1 0.2 Missing 0.2 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,260 4,940 9,200 16,964 24,283 41,247 Household Population and Housing Characteristics | 19 Table 2.8 shows that overall, 34 percent of the households have access to improved sanitation facilities. Improved sanitation is biased towards urban households, where 58 percent have improved sanitation facilities compared with 14 percent of rural households. Conversely, households in rural areas are more likely than those in urban areas to have non-improved facilities (86 percent and 42 percent, respectively). Seventy-eight percent of households in rural areas have no toilet facilities. There was no significant change in the proportion of households without toilet facilities compared with the 2000 NDHS. The regional overview presented in Table 2.9 shows that 62 percent of households in Khomas, 53 percent in Erongo, and 52 percent in Karas regions have improved sanitation facility. In contrast, less than 10 percent of households in Caprivi and Ohangwena have improved facilities. Table 2.9 Household sanitation by region Percent distribution of households and de jure population by type of toilet facility (improved/non-improved), according to region, Namibia 2006-07 Households Population Region Improved, not shared facility Non- improved facility Other/ missing Total Number Improved, not shared facility Non- improved facility Other/ missing Total Number Caprivi 8.2 91.8 0.0 100.0 514 9.2 90.8 0.0 100.0 2,145 Erongo 52.9 46.7 0.4 100.0 837 56.7 43.1 0.2 100.0 2,754 Hardap 46.8 52.9 0.3 100.0 328 51.8 47.9 0.3 100.0 1,333 Karas 52.1 47.6 0.3 100.0 382 58.7 41.1 0.2 100.0 1,449 Kavango 11.6 88.3 0.1 100.0 750 11.5 88.4 0.1 100.0 4,422 Khomas 62.0 37.7 0.3 100.0 1,950 67.2 32.0 0.8 100.0 7,631 Kunene 21.7 78.1 0.2 100.0 305 18.5 81.4 0.1 100.0 1,327 Ohangwena 5.4 94.4 0.2 100.0 829 5.3 94.6 0.0 100.0 4,733 Omaheke 22.7 77.3 0.0 100.0 426 22.3 77.7 0.0 100.0 1,897 Omusati 14.3 85.4 0.3 100.0 855 14.8 84.9 0.4 100.0 4,368 Oshana 29.6 70.4 0.0 100.0 663 30.2 69.8 0.0 100.0 3,054 Oshikoto 31.9 68.0 0.1 100.0 745 30.0 69.9 0.1 100.0 3,757 Otjozondjupa 42.8 57.1 0.1 100.0 615 44.9 54.9 0.2 100.0 2,377 Total 34.4 65.4 0.2 100.0 9,200 33.0 66.7 0.3 100.0 41,247 2.4.3 Housing Characteristics Table 2.10 presents information on the characteristics of the dwellings in which the sampled households live. These characteristics reflect the household’s socio-economic situation and may influence environmental conditions. For example, the use of biomass fuels and exposure to indoor pollution may have a direct bearing on the health and welfare of household members. Table 2.10 shows that 44 percent of households and 39 percent of the population have electricity. Use of electricity is more prevalent in urban than in rural areas (78 percent compared with 15 percent, respectively). The percentage of households that have electricity increased by seven percentage points from 37 percent in the 2000 NDHS. The commonly used flooring materials are earth or sand (41 percent), cement (27 percent), and ceramic tiles (16 percent). There was a decrease in the proportion of households living in homes with earth or sand floors from 49 percent in the 2000 NDHS to 41 percent in the 2006-07 NDHS. Over the same period, the use of cement flooring rose slightly from 25 percent to 27 percent. Table 2.10 shows that more than 70 percent of households have two or more rooms used for sleeping, indicating that overcrowding is not significant. | Household Population and Housing Characteristics 20 Table 2.10 Housing characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Namibia 2006-07 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 77.6 14.6 43.7 78.2 11.6 39.0 No 22.4 85.2 56.1 21.8 88.2 60.9 Missing 0.0 0.2 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 13.4 64.9 41.1 14.1 69.0 46.4 Dung 0.9 5.9 3.6 1.1 6.0 4.0 Wood/planks 0.7 0.1 0.4 0.8 0.0 0.3 Palm/bamboo 0.0 0.0 0.0 0.0 0.0 0.0 Parquet or polished wood 1.0 0.3 0.6 0.9 0.3 0.5 Vinyl or asphalt strips 5.2 1.1 3.0 4.8 0.7 2.3 Ceramic tiles 32.5 2.2 16.3 32.5 1.7 14.3 Cement 32.9 22.7 27.4 34.8 19.5 25.8 Carpet 12.4 1.1 6.3 10.3 0.7 4.7 Other 0.7 1.7 1.2 0.8 2.0 1.5 Missing 0.2 0.0 0.1 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 30.0 28.0 28.9 18.7 17.7 18.1 Two 31.6 23.5 27.3 33.3 19.0 24.9 Three or more 37.7 47.4 42.9 47.4 62.1 56.1 Missing 0.7 1.1 0.9 0.6 1.2 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 81.4 44.9 61.8 77.8 47.8 60.2 In a separate building 5.4 15.6 10.9 6.9 15.6 12.0 Outdoors 12.7 39.0 26.8 14.9 36.1 27.4 Other 0.1 0.0 0.1 0.2 0.1 0.1 Missing 0.4 0.4 0.4 0.2 0.4 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 67.1 5.9 34.2 65.6 3.9 29.3 LPG/natural gas/biogas 11.5 3.5 7.2 10.4 2.3 5.7 Kerosene 0.4 0.1 0.3 0.2 0.0 0.1 Coal/lignite 0.0 0.1 0.0 0.0 0.1 0.0 Charcoal 0.1 0.9 0.6 0.1 0.9 0.6 Wood 15.5 88.8 54.9 19.7 92.0 62.3 Agricultural crop 0.0 0.0 0.0 0.0 0.1 0.0 Animal dung 0.0 0.4 0.2 0.0 0.5 0.3 No food cooked in household 0.3 0.1 0.2 0.1 0.0 0.0 Other 5.0 0.1 2.4 3.8 0.1 1.6 Missing 0.1 0.0 0.1 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking 1 15.6 90.3 55.7 19.8 93.6 63.3 Number of households/ population 4,260 4,940 9,200 16,964 24,283 41,247 Number of households/ population using solid fuel 665 4,461 5,126 3,362 22,733 26,095 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung Household Population and Housing Characteristics | 21 The majority of households cook in the house (62 percent). Urban households are more likely than rural households to cook in the house (81 percent and 45 percent, respectively). The predominant type of cooking fuel in Namibia is wood, used by 55 percent of households. There has been an increase in the use of electricity for cooking, from 26 percent in 2000 to 34 percent in 2006-07. Wood is much more common in rural areas than in urban areas (89 percent and 16 percent, respectively). The proportion of rural households that use wood for cooking has increased slightly from 86 percent in 2000. Overall, 90 percent of rural households and 16 percent of urban households use solid fuel for cooking. Almost all households in Namibia (97 percent) cook on an open fire or use a stove with no chimney or hood (data not shown). 2.5 HOUSEHOLD POSSESSIONS The availability of durable consumer goods is a positive indicator of a household’s socio- economic status. Moreover, particular goods have specific benefits. For instance, having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs the wholesomeness of foods; and a means of transport allows greater access to services away from the local area. Table 2.11 shows the availability of selected consumer goods by residence. Table 2.11 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals, by residence, Namibia 2006-07 Households Population Household possession Urban Rural Total Urban Rural Total Household effects Radio 82.0 69.7 75.4 83.9 71.9 76.8 Television 65.6 12.3 37.0 69.4 11.5 35.3 Mobile telephone 77.9 30.5 52.4 79.3 33.3 52.3 Non-mobile telephone 33.3 12.9 22.3 34.1 14.2 22.4 Refrigerator 68.9 14.8 39.9 71.9 13.5 37.5 Means of transport Bicycle 16.9 13.7 15.2 19.0 15.4 16.9 Animal drawn cart 0.9 11.9 6.8 1.1 13.3 8.3 Motorcycle/scooter 2.9 1.2 2.0 2.7 1.2 1.8 Car/truck 37.2 14.9 25.2 37.7 16.2 25.0 Boat with a motor 0.7 0.2 0.4 0.6 0.1 0.3 Ownership of agricultural land 7.6 41.5 25.8 9.2 46.1 30.9 Ownership of farm animals1 13.7 69.7 43.8 15.3 78.0 52.2 Number 4,260 4,940 9,200 16,964 24,283 41,247 1 Cattle, cows, bulls, horses, donkeys, mules, goats, sheep, or chickens The upward trend in possession of durable goods seen in the 2000 NDHS continues with the 2006-07 NDHS. Table 2.11 shows that 75 percent of households in Namibia have a radio, compared with 71 percent in 2000. Mobile telephones and television sets are available in 52 percent and 37 percent of households, respectively. The most commonly owned means of transportation are car/truck (25 percent) and bicycle (15 percent). Possession of durable goods varies between urban and rural households. Televisions, telephones, and refrigerators are much more common in urban households than in rural households. For example, 66 percent of urban households have a television set compared with 12 percent of rural households. On the other hand, rural households are much more likely than urban households to own agricultural land (42 percent compared with 8 percent, respectively) and own farm animals (70 percent compared with 14 percent, respectively). | Household Population and Housing Characteristics 22 2.6 WEALTH INDEX The 2006-07 NDHS incorporates the concept of the wealth index for the first time to enrich the analysis of different components of the survey. The wealth index is used throughout the report as a proxy for the standard of living of the household. It is based on household ownership of consumer goods; dwelling characteristics; type of drinking water source; toilet facilities; and other character- istics related to the household’s socio-economic status. To construct the index, each of these assets was assigned a weight (factor score) generated through principal component analysis and the resulting asset scores were standardized in relation to a standard normal distribution with a mean of zero and a standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset and the scores were summed for each household. Individuals were ranked according to the total score of the household in which they reside. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed on the basis of data from the entire country sample, and this index is used in all the tabulations presented in this report. Table 2.12 shows the distribution of the de jure household population by wealth quintile, according to residence and region. The distribution indicates the degree to which wealth is evenly (or unevenly) distributed in the country. Table 2.12 shows that Erongo, Karas, and Khomas regions have a very large proportion of their population in the two highest wealth quintiles, with almost no representation in the lowest quintile. In contrast, Caprivi, Kavango, Ohangwena, and Omusati regions have the highest proportion of population in the lowest quintile and only a small proportion in the highest quintile. Figure 2.5 Percentage of Households Owning Various Durable Goods 75 37 52 22 40 15 7 2 25 0 26 44 Radio Television Mobile telephone Non-mobile telephone Refrigerator Bicycle Animal-drawn cart Motorcycle/scooter Car/truck Boat with a motor Ownership of agricultural land Ownership of farm animals 0 20 40 60 80 100 NDHS 2006-07 Household Population and Housing Characteristics | 23 Table 2.12 Wealth quintiles Percent distribution of de jure population by wealth quintile, according to residence and region, Namibia 2006-07 Wealth quintile Residence/region Lowest Second Middle Fourth Highest Total Number of population Residence Urban 1.4 3.6 14.8 34.3 45.9 100.0 16,964 Rural 33.0 31.5 23.6 10.0 1.9 100.0 24,283 Region Caprivi 48.8 21.2 17.3 7.7 5.0 100.0 2,145 Erongo 0.0 2.7 12.8 36.8 47.6 100.0 2,754 Hardap 0.2 10.1 26.3 38.8 24.6 100.0 1,333 Karas 0.4 6.5 21.1 35.6 36.4 100.0 1,449 Kavango 46.3 19.1 21.0 10.5 3.0 100.0 4,422 Khomas 0.0 0.7 10.7 29.2 59.4 100.0 7,631 Kunene 25.5 22.2 29.2 17.5 5.6 100.0 1,327 Ohangwena 37.7 41.7 15.7 3.7 1.1 100.0 4,733 Omaheke 1.7 18.6 51.7 22.8 5.1 100.0 1,897 Omusati 32.9 38.7 20.3 6.5 1.6 100.0 4,368 Oshana 12.4 29.9 28.9 19.6 9.3 100.0 3,054 Oshikoto 29.2 27.0 14.7 20.4 8.7 100.0 3,757 Otjozondjupa 2.7 15.0 28.9 35.9 17.6 100.0 2,377 Total 20.0 20.0 20.0 20.0 20.0 100.0 41,247 2.7 BIRTH REGISTRATION The registration of births is the inscription of the facts of the birth into an official log kept at the registrar’s office. A birth certificate is issued at the time of registration (or later) as proof that the birth has been registered. Birth registration is basic to ensuring a child’s legal status and, thus, basic rights and services (UNICEF, 2006; United Nations General Assembly, 2002). In the 2006-07 NDHS, mothers of children under five were asked if their child’s birth had been registered and whether they had a birth certificate for the child. A child’s birth was considered to have been registered if the mother could produce a birth certificate or reported that the birth was registered. Not all children who are registered have a birth certificate because some certificates may have been lost or were never issued. However, all children with a certificate have been registered. Table 2.13 shows that 67 percent of births in the past five years in Namibia were registered, a slight decline from 71 percent in the 2000 NDHS. Only 7 percent of children whose birth was registered did not have a birth certificate. As in the 2000 NDHS, birth registration is more common in urban areas (83 percent) than in rural areas (59 percent). Coverage of birth registration varies widely across regions, ranging from 46 percent in Kavango to 96 percent in Karas. In Erongo, Hardap, Karas, and Khomas regions, at least four in five births are registered. There is a positive relationship between birth registration and wealth quintile; births in households in the higher wealth quintiles are more likely to be registered. | Household Population and Housing Characteristics 24 Table 2.13 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, according to background charac- teristics, Namibia 2006-07 Percentage of children whose births are registered Background characteristic Had birth certificate Did not have birth certificate Total registered Number of children Age <2 49.0 8.6 57.6 2,236 2-4 68.3 5.4 73.7 3,224 Sex Male 58.9 6.8 65.7 2,734 Female 62.0 6.6 68.5 2,726 Residence Urban 77.2 5.3 82.5 1,828 Rural 52.0 7.4 59.3 3,633 Region Caprivi 55.0 6.4 61.5 314 Erongo 85.3 3.2 88.5 267 Hardap 82.5 3.0 85.5 157 Karas 86.7 9.3 96.1 156 Kavango 26.1 20.1 46.3 664 Khomas 81.2 2.7 84.0 763 Kunene 51.6 4.3 55.9 246 Ohangwena 53.6 2.1 55.7 699 Omaheke 68.1 5.9 74.0 367 Omusati 60.8 7.3 68.1 535 Oshana 63.4 10.8 74.2 360 Oshikoto 55.9 5.4 61.3 535 Otjozondjupa 59.4 2.1 61.5 397 Wealth quintile Lowest 36.9 9.4 46.2 1,265 Second 53.2 7.9 61.1 1,252 Middle 60.3 7.3 67.5 1,211 Fourth 77.7 4.3 82.0 935 Highest 89.0 2.5 91.5 797 Total 60.4 6.7 67.1 5,461 Characteristics of Respondents | 25 CHARACTERISTICS OF RESPONDENTS 3 This chapter provides a profile of men and women age 15-49 who were interviewed in the 2006-07 NDHS. Information is presented on a number of basic characteristics including: age, religion, marital status, residence, education, literacy, and media access. The chapter also explores adult employment status, occupation, and earnings. An analysis of these variables provides the socio- economic context within which demographic and reproductive health issues are examined. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS The background characteristics of the 9,804 women age 15-49 and the 3,915 men age 15-49 interviewed in the 2006-07 NDHS are shown in Table 3.1. This table is important because it provides the background for interpreting findings presented later in the report. Twenty-three percent of women and men fall into the 15-19 age group while 19 percent of women and men fall into the 20-24 age group. Smaller proportions of women and men are found in the older age groups. Nine and 10 percent of women and men fall in the 40-44 age group, and 7 percent of women and 6 percent of men are in the 45-49 age group. The Namibian population is predominantly Christian, with 77 percent of women and 70 percent of men being Protestant and a smaller proportion being Roman Catholic (21 percent of women and 26 percent of men). The most widely spoken language is Oshiwambo (48 percent), followed by Damara/Nama (13 percent), Afrikaans (10 percent), and Herero (9 percent). The majority of respondents have never been married (58 percent of women and 65 percent of men). Thirty-five percent of women and 31 percent of men are married or living together. The distribution of women and men by residence is almost equal, with 49 percent of women and 50 percent of men residing urban areas. By region, Khomas has the highest percentage (weighted) of female and male respondents (23 percent and 25 percent, respectively), whereas Kunene has the lowest (3 percent for women and 2 percent for men). The proportion of women age 15-49 with less than primary education is lower than that of men. Conversely, the proportion of women with secondary education is higher than that of men (69 percent and 63 percent, respectively). Place of residence is another characteristic that determines access to services and exposure to information pertaining to reproductive health and other aspects of life. Half of the respondents reside in rural areas, compared with 23 percent of women and 25 percent of men who live in Khomas region, where the capital city, Windhoek, is located. The majority of Namibians have some formal schooling. Only 7 percent of women and 9 percent of men have never gone to school. The level of education has improved since the 2000 NDHS, in which the proportion of women age 15-49 and men age 15-59 who had never attended school was 10 and 13 percent, respectively. 26 | Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Namibia 2006-07 Women Men Background characteristic Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15-19 22.9 2,246 2,205 23.3 910 909 20-24 18.9 1,855 1,876 19.2 750 743 25-29 16.6 1,623 1,562 17.9 702 678 30-34 14.5 1,417 1,423 15.0 586 563 35-39 10.7 1,045 1,074 10.2 400 419 40-44 9.5 928 951 8.5 331 351 45-49 7.0 689 713 6.0 235 252 Religion Roman Catholic 20.9 2,053 2,171 26.3 1,028 1,152 Protestant 77.0 7,547 7,446 70.3 2,754 2,647 No religion 1.4 142 133 2.4 94 90 Other 0.4 35 34 0.6 24 11 Missing 0.3 26 20 0.4 15 15 Language Afrikaans 9.7 954 904 9.5 373 386 Damara/nama 13.4 1,310 1,480 12.8 502 571 English 1.5 145 99 1.7 65 48 Herero 9.2 903 795 10.1 394 366 Kwangali 5.2 514 583 5.1 199 235 Silozi 1.7 166 191 1.9 75 74 Oshiwambo 47.5 4,662 4,476 47.4 1,855 1,747 San 0.7 67 102 0.8 32 43 Other 11.1 1,083 1,174 10.7 420 445 Marital status Never married 57.9 5,673 5,545 65.0 2,545 2,507 Married 19.9 1,949 2,003 18.1 708 699 Living together 15.3 1,501 1,572 12.7 498 530 Divorced/separated 4.3 426 412 3.9 151 160 Widowed 2.6 252 269 0.3 12 18 Missing 0.0 3 3 0.0 1 1 Residence Urban 48.7 4,772 4,405 50.1 1,962 1,673 Rural 51.3 5,032 5,399 49.9 1,953 2,242 Region Caprivi 4.8 474 656 4.8 189 242 Erongo 7.0 688 611 9.2 362 351 Hardap 3.2 315 550 3.4 132 231 Karas 3.2 318 493 4.0 157 267 Kavango 9.5 934 996 8.4 331 365 Khomas 22.6 2,218 996 25.1 984 485 Kunene 2.6 259 433 2.3 92 162 Ohangwena 10.6 1,043 996 7.8 306 260 Omaheke 3.8 373 490 4.8 188 223 Omusati 9.9 975 954 8.2 320 292 Oshana 8.4 819 1,018 6.9 270 350 Oshikoto 8.5 837 901 8.2 322 361 Otjozondjupa 5.6 550 710 6.7 262 326 Education No education/preschool 6.6 651 775 9.2 360 406 Incomplete primary 17.3 1,699 1,833 21.9 856 931 Complete primary 7.5 736 783 6.4 252 258 Incomplete secondary 48.5 4,751 4,712 41.0 1,604 1,585 Complete secondary 13.1 1,286 1,142 13.7 538 503 More than secondary 7.0 682 559 7.8 305 232 Wealth quintile Lowest 16.5 1,621 1,599 14.3 560 561 Second 17.0 1,668 1,751 15.5 607 635 Middle 19.2 1,885 2,223 22.3 875 1,082 Fourth 23.4 2,292 2,450 24.6 963 989 Highest 23.8 2,338 1,781 23.3 911 648 Total 15-49 100.0 9,804 9,804 100.0 3,915 3,915 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Characteristics of Respondents | 27 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Tables 3.2.1 and 3.2.2 present an overview of the relationship between the respondent’s level of education and other background characteristics. Overall, the level of education in Namibia is high. Tables 3.2.1 and 3.2.2 show the percent distributions of women and men by highest level of education attained according to age, urban-rural residence, region, and wealth quintile. The results indicate that 7 percent of women and 9 percent of men have no formal education. The proportion of women and men with no education increases with age from 2 percent for women and 3 percent for men age 15-19 to 16 percent for women and 19 percent for men age 45-49. Children in urban areas are more likely to be educated than those in rural areas. For instance, 13 percent of women in rural areas have no education compared with 5 percent in urban areas. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median number of years completed, according to background characteristics, Namibia 2006-07 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Median years completed Number of women Age 15-24 2.9 12.1 8.2 61.2 12.1 3.5 100.0 8.5 4,101 15-19 2.0 13.0 10.5 66.7 7.0 0.8 100.0 8.3 2,246 20-24 4.1 11.1 5.4 54.6 18.2 6.6 100.0 8.9 1,855 25-29 5.9 13.1 5.5 48.8 18.7 8.0 100.0 9.0 1,623 30-34 7.8 16.6 6.5 42.3 15.8 11.0 100.0 8.7 1,417 35-39 10.6 24.4 7.9 36.9 12.1 8.0 100.0 7.9 1,045 40-44 11.0 26.1 9.5 33.8 9.0 10.6 100.0 7.4 928 45-49 16.1 36.9 7.1 21.6 7.7 10.5 100.0 5.3 689 Residence Urban 3.7 10.2 5.0 49.9 20.4 10.8 100.0 9.3 4,772 Rural 9.4 24.1 9.9 47.1 6.2 3.3 100.0 7.6 5,032 Region Caprivi 5.5 20.4 8.5 58.9 2.2 4.4 100.0 8.2 474 Erongo 3.1 10.5 7.4 48.6 23.6 6.7 100.0 9.3 688 Hardap 6.1 16.9 9.3 51.2 12.7 3.8 100.0 8.2 315 Karas 1.4 10.7 10.1 51.7 20.2 5.9 100.0 8.9 318 Kavango 15.7 29.8 9.5 37.1 4.7 3.2 100.0 6.5 934 Khomas 2.0 7.9 3.4 47.8 23.3 15.6 100.0 9.8 2,218 Kunene 28.1 19.9 7.9 30.6 9.1 4.5 100.0 6.3 259 Ohangwena 6.6 25.0 12.5 47.2 6.1 2.6 100.0 7.5 1,043 Omaheke 17.7 14.9 8.3 45.5 8.4 5.1 100.0 7.9 373 Omusati 2.9 18.9 7.9 56.5 9.2 4.5 100.0 8.4 975 Oshana 2.5 14.5 6.6 57.8 12.9 5.7 100.0 8.7 819 Oshikoto 6.8 23.9 7.6 48.6 8.5 4.6 100.0 8.1 837 Otjozondjupa 13.6 21.5 7.5 42.1 11.5 3.7 100.0 7.7 550 Wealth quintile Lowest 14.2 34.1 10.9 37.8 2.9 0.1 100.0 6.1 1,621 Second 9.6 25.4 10.1 49.5 4.4 1.0 100.0 7.4 1,668 Middle 9.3 18.9 9.5 52.9 6.8 2.5 100.0 8.1 1,885 Fourth 3.0 12.4 6.3 56.6 15.8 5.9 100.0 8.9 2,292 Highest 0.7 3.5 2.8 43.6 28.9 20.5 100.0 10.9 2,338 Total 6.6 17.3 7.5 48.5 13.1 7.0 100.0 8.5 9,804 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level 28 | Characteristics of Respondents Tables 3.2.1 and 3.2.2 also show that women are slightly more likely to be educated and reach higher levels of education than men. The median number of years of schooling for women is 8.5, compared with 7.2 years for men. The proportion of men and women with no education is higher in Kunene, Omaheke, and Otjozondjupa than in other regions. Overall, the results show that there is improvement in education compared with the 2000 NDHS. Higher wealth status is associated with higher levels of educational attainment. Fourteen percent of women in the lowest wealth quintile have no education compared with less than 1 percent of women in the highest wealth quintile. Among men, 15 percent in the lowest quintile have no education compared with 2 percent in the highest quintile. Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median number of years completed, according to background characteristics, Namibia 2006-07 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Median years completed Number of men Age 15-24 5.1 19.9 8.5 51.7 11.7 3.1 100.0 7.2 1,661 15-19 3.2 23.4 12.3 53.2 7.8 0.1 100.0 6.8 910 20-24 7.4 15.7 3.9 49.8 16.4 6.7 100.0 7.8 750 25-29 10.1 16.8 5.1 39.3 17.9 10.8 100.0 7.8 702 30-34 11.1 19.3 4.2 33.2 18.7 13.5 100.0 7.6 586 35-39 11.4 25.4 4.1 34.1 15.1 9.8 100.0 7.2 400 40-44 14.7 33.4 6.5 27.3 9.6 8.5 100.0 6.1 331 45-49 18.9 34.5 5.4 20.8 6.9 13.5 100.0 5.0 235 Residence Urban 5.3 13.6 4.5 45.4 19.8 11.4 100.0 8.2 1,962 Rural 13.1 30.2 8.4 36.6 7.6 4.1 100.0 6.3 1,953 Region Caprivi 6.3 27.4 4.3 50.0 4.4 7.6 100.0 7.0 189 Erongo 5.7 19.9 4.6 44.8 19.7 5.3 100.0 7.7 362 Hardap 9.7 21.6 6.8 41.9 17.2 2.9 100.0 7.0 132 Karas 2.0 9.8 7.7 53.2 22.9 4.3 100.0 8.0 157 Kavango 7.7 24.8 9.1 48.9 6.1 3.4 100.0 6.8 331 Khomas 5.6 10.4 5.1 44.2 18.8 16.0 100.0 8.4 984 Kunene 31.9 22.5 6.2 25.5 10.8 3.0 100.0 4.2 92 Ohangwena 11.3 34.5 11.4 32.5 6.9 3.3 100.0 6.2 306 Omaheke 26.3 18.2 5.0 25.6 18.2 6.8 100.0 6.3 188 Omusati 5.1 33.8 7.7 41.7 8.8 2.9 100.0 6.6 320 Oshana 5.1 20.8 5.6 46.5 15.6 6.5 100.0 7.5 270 Oshikoto 11.9 35.1 9.5 29.7 6.9 6.9 100.0 6.2 322 Otjozondjupa 18.7 25.5 2.3 32.9 14.0 6.7 100.0 6.6 262 Wealth quintile Lowest 15.4 40.8 9.1 30.7 3.4 0.6 100.0 5.3 560 Second 12.0 32.1 9.3 39.0 5.5 2.1 100.0 6.3 607 Middle 13.9 24.7 6.7 43.0 8.4 3.3 100.0 6.7 875 Fourth 6.6 17.2 6.4 46.7 16.8 6.3 100.0 7.6 963 Highest 1.8 5.6 2.7 40.6 27.4 21.9 100.0 9.8 911 Total 15-49 9.2 21.9 6.4 41.0 13.7 7.8 100.0 7.2 3,915 1 Completed 7th grade at the primary level 2 Completed 5th grade at the secondary level Characteristics of Respondents | 29 3.3 LITERACY The ability to read and write is an important personal asset, allowing individuals to increase their opportunities in life. Knowing the distribution of the literate population can help programme managers reach women and men with messages. The 2006-07 NDHS assessed the ability to read among women and men who had never been to school or who had attended only the primary level by asking respondents to read a simple, short sentence.1 Tables 3.3.1 and 3.3.2 show the percent distribution of women and men by level of schooling attended and level of literacy, and the percentage literate according to background characteristics. Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Namibia 2006-07 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Percent- age literate1 Number Age 15-19 74.6 16.0 4.3 4.1 0.5 0.0 0.5 100.0 94.9 2,246 20-24 79.4 8.4 4.7 6.5 0.6 0.1 0.3 100.0 92.5 1,855 25-29 75.6 10.8 5.1 7.3 0.6 0.0 0.5 100.0 91.5 1,623 30-34 69.1 16.1 5.9 7.9 0.5 0.1 0.3 100.0 91.1 1,417 35-39 57.0 22.9 9.1 9.6 1.2 0.1 0.2 100.0 89.0 1,045 40-44 53.4 22.6 11.2 11.0 1.1 0.4 0.4 100.0 87.2 928 45-49 39.9 27.6 12.8 16.3 1.1 0.5 1.9 100.0 80.2 689 Residence Urban 81.1 10.3 3.8 3.9 0.3 0.1 0.6 100.0 95.1 4,772 Rural 56.6 21.3 9.1 11.4 1.1 0.1 0.4 100.0 86.9 5,032 Region Caprivi 65.5 11.5 11.2 11.0 0.0 0.3 0.5 100.0 88.3 474 Erongo 78.9 14.6 2.2 3.5 0.3 0.2 0.3 100.0 95.8 688 Hardap 67.7 18.3 5.1 8.9 0.0 0.0 0.1 100.0 91.0 315 Karas 77.8 13.0 5.7 3.5 0.0 0.0 0.0 100.0 96.5 318 Kavango 45.1 15.6 15.8 19.9 2.9 0.4 0.3 100.0 76.5 934 Khomas 86.7 7.9 2.1 2.1 0.3 0.1 0.8 100.0 96.7 2,218 Kunene 44.1 13.4 10.6 29.2 2.2 0.3 0.2 100.0 68.1 259 Ohangwena 55.9 30.0 7.1 6.2 0.1 0.0 0.8 100.0 92.9 1,043 Omaheke 59.1 13.0 5.7 20.6 0.9 0.1 0.6 100.0 77.8 373 Omusati 70.3 20.3 5.3 3.3 0.1 0.1 0.6 100.0 95.8 975 Oshana 76.4 15.6 4.1 3.3 0.0 0.0 0.6 100.0 96.1 819 Oshikoto 61.7 20.7 9.2 6.2 2.0 0.0 0.3 100.0 91.6 837 Otjozondjupa 57.4 16.4 10.1 15.0 1.0 0.0 0.1 100.0 83.9 550 Wealth quintile Lowest 40.7 25.0 13.1 18.4 2.1 0.1 0.7 100.0 78.8 1,621 Second 54.9 24.5 9.0 10.2 0.7 0.2 0.4 100.0 88.4 1,668 Middle 62.2 18.2 8.0 10.3 0.8 0.1 0.3 100.0 88.4 1,885 Fourth 78.3 12.6 4.5 3.4 0.3 0.2 0.7 100.0 95.4 2,292 Highest 93.0 4.9 1.0 0.8 0.1 0.0 0.3 100.0 98.8 2,338 Total 68.5 15.9 6.5 7.7 0.7 0.1 0.5 100.0 90.9 9,804 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 1 These sentences include the following: The child is reading a book, The rains came late this year, Parents must care for their children, and Farming is hard work 30 | Characteristics of Respondents Twenty-seven percent of women age 45-49 had no education but could read a whole sentence. Ohangwena region has the highest proportion of women who could read a whole sentence but had no schooling (30 percent). On the other hand, 23 percent respondents of men age 45-49 had no schooling but could read a whole sentence. One-fifth of women and men in rural areas were able to read a sentence, with women exceeding men by 1 percent. Literacy rates in Namibia are high. Overall, 91 percent of women and 89 percent of men are literate. In general, literacy decreases as age increases for both women and men. The percentage literate is higher for women than for men in all age groups. Women and men in urban areas have higher literacy rates (95 percent each) than their rural counterparts (87 percent for women and 82 percent for men). Literacy rates for women are 95 percent or higher in Erongo, Karas, Omusati, and Oshana regions. For men, the highest literacy rate is in Khomas (97 percent). As with educational attainment, literacy shows a direct association with wealth status. Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Namibia 2006-07 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Percent- age literate1 Number Age 15-19 61.1 20.5 10.0 7.4 0.7 0.0 0.4 100.0 91.5 910 20-24 72.9 10.0 7.7 7.4 1.4 0.1 0.5 100.0 90.6 750 25-29 68.0 10.5 9.5 10.6 1.2 0.1 0.1 100.0 88.0 702 30-34 65.4 12.8 11.9 8.7 0.7 0.1 0.5 100.0 90.1 586 35-39 59.0 14.9 12.9 12.6 0.6 0.0 0.0 100.0 86.8 400 40-44 45.4 23.4 14.4 15.4 1.1 0.0 0.3 100.0 83.2 331 45-49 41.2 23.0 15.9 17.9 0.9 0.3 0.8 100.0 80.1 235 Residence Urban 76.6 10.4 8.1 4.0 0.4 0.0 0.3 100.0 95.2 1,962 Rural 48.3 20.3 13.4 16.0 1.5 0.1 0.3 100.0 82.0 1,953 Region Caprivi 62.0 10.9 8.8 18.1 0.0 0.0 0.3 100.0 81.7 189 Erongo 69.8 19.5 5.0 4.3 1.1 0.0 0.3 100.0 94.3 362 Hardap 62.0 10.8 10.1 12.9 1.3 0.0 2.9 100.0 82.9 132 Karas 80.4 10.3 5.5 3.8 0.0 0.0 0.0 100.0 96.2 157 Kavango 58.3 12.1 14.4 11.6 2.8 0.2 0.5 100.0 84.9 331 Khomas 79.0 7.7 10.1 2.9 0.1 0.0 0.1 100.0 96.9 984 Kunene 39.3 8.4 19.3 25.3 6.4 1.4 0.0 100.0 67.0 92 Ohangwena 42.8 25.0 19.2 13.0 0.0 0.0 0.0 100.0 87.0 306 Omaheke 50.6 9.0 7.1 33.0 0.4 0.0 0.0 100.0 66.6 188 Omusati 53.4 24.8 14.3 7.2 0.0 0.3 0.0 100.0 92.5 320 Oshana 68.5 14.8 10.8 4.5 0.0 0.0 1.4 100.0 94.1 270 Oshikoto 43.5 29.8 9.4 12.6 4.7 0.0 0.0 100.0 82.7 322 Otjozondjupa 53.6 17.7 8.6 19.5 0.0 0.0 0.6 100.0 79.9 262 Wealth quintile Lowest 34.7 21.6 20.4 20.8 2.2 0.1 0.0 100.0 76.8 560 Second 46.6 22.6 14.1 14.0 2.0 0.3 0.4 100.0 83.3 607 Middle 54.7 18.0 12.2 13.5 0.9 0.1 0.5 100.0 85.0 875 Fourth 69.8 14.2 9.7 5.3 0.5 0.0 0.6 100.0 93.7 963 Highest 89.9 5.3 2.4 2.4 0.0 0.0 0.1 100.0 97.6 911 Total 15-49 62.5 15.3 10.8 10.0 1.0 0.1 0.3 100.0 88.6 3,915 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Respondents | 31 3.4 ACCESS TO MASS MEDIA Information access is essential in increasing people’s knowledge and awareness of what is taking place around them, which may eventually affect their perceptions and behaviour. It is important to know which subgroups are likely to be reached by the media for purposes of planning programmes intended to inform people about health and family planning. In the 2006-07 NDHS, exposure to the media was assessed by asking how often a respondent reads a newspaper, watches television, or listens to a radio. Tables 3.4.1 and 3.4.2 show the percentage of women and men exposed to different types of media by age, urban-rural residence, region, level of education, and wealth quintile. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Namibia 2006-07 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number Age 15-19 49.8 43.9 80.3 27.8 12.2 2,246 20-24 53.6 48.1 82.6 33.3 10.1 1,855 25-29 50.5 47.6 80.4 30.6 10.3 1,623 30-34 49.2 44.8 81.3 32.2 12.4 1,417 35-39 45.9 41.4 80.9 27.5 13.0 1,045 40-44 45.9 40.9 78.7 27.9 13.3 928 45-49 38.9 40.9 78.3 25.6 14.1 689 Residence Urban 67.7 74.0 85.2 52.0 4.8 4,772 Rural 31.3 16.9 76.3 8.6 18.5 5,032 Region Caprivi 32.8 34.9 74.9 17.4 19.7 474 Erongo 71.3 72.0 86.0 50.1 2.6 688 Hardap 54.9 56.1 81.4 34.7 7.3 315 Karas 49.2 57.1 81.0 33.0 8.7 318 Kavango 26.5 27.4 69.2 12.3 24.9 934 Khomas 74.3 80.3 85.1 59.5 3.5 2,218 Kunene 33.0 35.8 79.1 20.3 15.7 259 Ohangwena 34.6 13.9 73.1 7.7 21.3 1,043 Omaheke 30.3 27.4 84.7 13.9 11.9 373 Omusati 37.7 20.0 78.8 12.4 15.0 975 Oshana 53.7 32.8 87.9 25.6 8.1 819 Oshikoto 40.5 28.3 81.4 19.7 13.3 837 Otjozondjupa 41.3 51.3 83.7 29.2 10.2 550 Education No education/preschool 3.6 13.1 63.7 1.4 33.7 651 Incomplete primary 21.6 20.3 72.0 7.8 22.8 1,699 Complete primary 34.3 27.5 80.6 15.1 14.7 736 Incomplete secondary 53.8 46.8 83.7 30.3 8.2 4,751 Complete secondary 79.3 74.4 85.5 58.2 2.9 1,286 More than secondary 85.8 83.1 88.3 70.1 3.0 682 Wealth quintile Lowest 20.9 5.7 62.6 2.5 32.9 1,621 Second 29.4 9.6 77.3 4.5 17.6 1,668 Middle 33.9 20.3 82.6 8.7 12.1 1,885 Fourth 61.2 66.7 86.5 41.0 3.6 2,292 Highest 82.6 94.8 88.4 72.6 1.0 2,338 Total 49.0 44.7 80.7 29.8 11.8 9,804 32 | Characteristics of Respondents Radio is the most widely accessed mass media, with 81 percent of women and 83 percent of men listening to the radio at least once a week. Newspaper reading and television watching at least once a week by men is almost equal (52 percent and 51 percent, respectively), while for women the corresponding percentages are 49 percent for newspapers and 45 percent for television. Only 11 percent of women and 11 percent of men are not exposed to any of these media on a weekly basis. Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Namibia 2006-07 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number Age 15-19 47.2 50.1 79.1 31.8 13.7 910 20-24 52.1 52.5 82.8 35.1 9.4 750 25-29 53.8 53.0 85.4 38.1 8.9 702 30-34 57.8 51.9 84.1 39.3 8.1 586 35-39 51.4 54.8 86.3 36.9 9.4 400 40-44 48.9 47.8 84.6 35.6 12.0 331 45-49 49.9 46.9 85.6 36.8 11.6 235 Residence Urban 72.2 77.1 88.8 56.2 2.7 1,962 Rural 31.0 25.7 77.7 15.4 18.3 1,953 Region Caprivi 21.2 24.7 68.1 10.6 26.4 189 Erongo 64.8 68.2 92.5 48.7 2.2 362 Hardap 59.6 62.5 88.0 42.6 5.9 132 Karas 67.1 68.4 89.7 53.8 4.7 157 Kavango 32.3 38.8 73.8 20.6 19.5 331 Khomas 72.7 77.7 87.1 54.9 2.1 984 Kunene 30.8 38.8 69.7 22.5 24.2 92 Ohangwena 22.3 20.6 52.5 9.6 38.7 306 Omaheke 28.9 27.7 87.8 15.9 11.0 188 Omusati 45.1 26.0 90.5 17.9 5.1 320 Oshana 76.9 67.0 95.3 59.5 2.7 270 Oshikoto 35.9 26.9 83.3 20.3 13.3 322 Otjozondjupa 46.8 51.8 89.2 35.7 9.1 262 Education No education/preschool 5.2 20.5 69.9 1.7 28.1 360 Incomplete primary 24.7 29.9 75.7 12.3 19.3 856 Complete primary 37.0 43.8 84.9 23.4 10.6 252 Incomplete secondary 61.7 56.9 86.2 41.8 6.5 1,604 Complete secondary 83.1 75.9 91.6 63.7 0.6 538 More than secondary 86.1 83.0 89.2 71.8 2.9 305 Wealth quintile Lowest 15.9 11.4 60.7 4.1 35.3 560 Second 30.9 21.3 78.8 13.3 15.8 607 Middle 42.7 32.7 85.1 20.5 9.8 875 Fourth 66.3 71.0 92.3 49.2 2.7 963 Highest 80.5 93.4 88.8 70.8 0.5 911 Total 15-49 51.7 51.4 83.3 35.8 10.5 3,915 There are only small differences in access to mass media by age. Urban residents are much more likely than rural residents to read newspapers, watch television, and listen to the radio. Fifty percent or more of women in Erongo and Khomas regions and men in Khomas and Oshana regions have access to all three media on a weekly basis. On the other hand, exposure to mass media is less than 10 percent for women and men in Ohangwena. There is a direct relationship between level of education and media exposure. Characteristics of Respondents | 33 Media exposure among women and men is also affected by wealth status. Eight in ten women (83 percent) in the highest wealth quintile read a newspaper at least once a week, compared with 21 percent of women in the lowest wealth quintile. Similarly, 81 percent of men in the highest wealth quintile read a newspaper at least once a week, compared with 16 percent of men in the lowest wealth quintile. The majority of women and men in the highest wealth quintile (73 percent of women and 71 percent of men) have access to all three mass media compared with 3 percent of women and 4 percent of men in the lowest wealth quintile. 3.5 EMPLOYMENT Male and female respondents age 15-49 were asked whether they were employed at the time of the survey and if not, whether they were employed in the 12 months preceding the survey. Measuring employment is difficult because some work, especially work on family farms, in family businesses, or in the informal sector, may not be perceived as employment and hence, not reported as such. To avoid underestimating a respondent’s employment, the 2006-07 NDHS asked women and men several questions to probe for their employment status and to ensure complete coverage of employment in both the formal and informal sectors. Respondents were asked a number of questions to elicit their current employment status and continuity of employment in the 12 months prior to the survey. Employed individuals are those who say that they are currently working (i.e., worked in the past 7 days) and those who worked at any time during the 12 months preceding the survey. Tables 3.5.1 and 3.5.2 show the percent distribution of 2006-07 NDHS respondents according to current and recent employment. The data show that 44 percent of women and 62 percent of men were employed at the time of the survey, while an additional 9 percent of women and 6 percent of men were employed at some time during the 12 months before the survey (Figure 3.1). The proportion currently employed is considerably lower among younger respondents, especially those age 15-19, probably because many are still in school. Single women and men are also less likely to be working than those who are married or formerly married. For example, 38 percent of women who have never married were employed, compared with 54 percent of women who are married or living together. Women and men with no children are less likely to be working than those who have children. The proportion working is higher among women and men in urban areas than those in rural areas. By region, employment among women ranges from 28 percent in Ohangwena to 63 percent in Erongo. For men, the corresponding percentages are 16 percent in Ohangwena and 83 percent in Erongo. The survey data show a direct relationship between level of education and current employ- ment among women. While three in ten women with no education are currently employed, 80 percent of women with more than secondary education are employed. Conversely, unemployment decreases as women’s level of education increases. Eighteen percent of currently employed men have more than secondary education while 43 percent of unemployed men have not completed primary education. 34 | Characteristics of Respondents Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Namibia 2006-07 Employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Not employed in the 12 months preceding the survey Missing/ don't know Total Number of women Age 15-19 15.7 9.9 74.2 0.2 100.0 2,246 20-24 38.9 9.2 51.9 0.0 100.0 1,855 25-29 54.2 8.5 37.3 0.0 100.0 1,623 30-34 60.8 8.0 31.1 0.1 100.0 1,417 35-39 59.0 8.0 33.0 0.0 100.0 1,045 40-44 59.8 8.4 31.8 0.0 100.0 928 45-49 53.7 9.7 36.5 0.1 100.0 689 Marital status Never married 37.8 9.5 52.6 0.1 100.0 5,673 Married or living together 53.5 7.6 38.9 0.0 100.0 3,451 Divorced/separated/widowed 53.8 10.6 35.5 0.1 100.0 678 Number of living children 0 30.3 9.3 60.4 0.1 100.0 3,419 1-2 52.8 7.8 39.3 0.0 100.0 3,620 3-4 55.6 8.8 35.6 0.0 100.0 1,789 5+ 42.6 12.0 45.4 0.1 100.0 976 Residence Urban 55.2 5.6 39.2 0.0 100.0 4,772 Rural 34.2 12.1 53.6 0.1 100.0 5,032 Region Caprivi 40.3 17.7 41.8 0.2 100.0 474 Erongo 63.4 7.0 29.7 0.0 100.0 688 Hardap 39.4 9.0 51.6 0.0 100.0 315 Karas 51.5 7.4 41.1 0.0 100.0 318 Kavango 34.5 1.3 64.1 0.1 100.0 934 Khomas 56.5 3.2 40.2 0.0 100.0 2,218 Kunene 34.4 23.7 41.9 0.0 100.0 259 Ohangwena 27.6 4.9 67.1 0.4 100.0 1,043 Omaheke 36.4 3.8 59.9 0.0 100.0 373 Omusati 39.9 19.0 41.0 0.0 100.0 975 Oshana 48.4 20.0 31.5 0.0 100.0 819 Oshikoto 42.8 13.3 43.9 0.0 100.0 837 Otjozondjupa 37.8 3.3 58.9 0.0 100.0 550 Education No education/preschool 30.1 13.2 56.6 0.1 100.0 651 Incomplete primary 37.8 11.3 50.8 0.1 100.0 1,699 Complete primary 37.7 8.7 53.5 0.0 100.0 736 Incomplete secondary 39.6 9.0 51.3 0.1 100.0 4,751 Complete secondary 63.6 7.0 29.3 0.0 100.0 1,286 More than secondary 79.7 1.9 18.4 0.0 100.0 682 Wealth quintile Lowest 29.9 15.2 54.8 0.0 100.0 1,621 Second 29.4 13.4 57.1 0.2 100.0 1,668 Middle 38.4 8.9 52.6 0.1 100.0 1,885 Fourth 56.7 5.7 37.7 0.0 100.0 2,292 Highest 58.1 4.6 37.3 0.0 100.0 2,338 Total 44.4 8.9 46.6 0.1 100.0 9,804 Note: Total includes three unweighted women with information missing on marital status. 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Respondents | 35 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Namibia 2006-07 Employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Not employed in the 12 months preceding the survey Missing/ don't know Total Number of men Age 15-19 28.7 5.7 65.6 0.0 100.0 910 20-24 57.4 8.9 33.5 0.1 100.0 750 25-29 72.6 6.7 20.7 0.0 100.0 702 30-34 78.7 5.7 15.6 0.0 100.0 586 35-39 82.1 5.2 12.7 0.0 100.0 400 40-44 80.1 4.7 15.3 0.0 100.0 331 45-49 79.2 6.3 14.5 0.0 100.0 235 Marital status Never married 50.2 6.8 42.9 0.0 100.0 2,545 Married or living together 85.8 4.3 9.9 0.0 100.0 1,205 Divorced/separated/widowed 79.2 15.2 5.6 0.0 100.0 163 Number of living children 0 47.6 6.2 46.2 0.1 100.0 2,096 1-2 78.5 5.7 15.8 0.0 100.0 967 3-4 77.5 9.5 13.0 0.0 100.0 481 5+ 84.6 5.3 10.1 0.0 100.0 370 Residence Urban 69.4 7.6 23.1 0.0 100.0 1,962 Rural 55.4 5.2 39.3 0.1 100.0 1,953 Region Caprivi 64.6 3.0 32.4 0.0 100.0 189 Erongo 83.2 7.0 9.9 0.0 100.0 362 Hardap 64.6 13.3 22.2 0.0 100.0 132 Karas 65.0 9.9 25.1 0.0 100.0 157 Kavango 51.5 6.0 42.5 0.0 100.0 331 Khomas 69.6 9.1 21.3 0.0 100.0 984 Kunene 81.8 2.0 16.3 0.0 100.0 92 Ohangwena 15.8 5.1 78.7 0.4 100.0 306 Omaheke 75.9 3.9 20.2 0.0 100.0 188 Omusati 54.1 6.1 39.8 0.0 100.0 320 Oshana 53.9 3.9 42.2 0.0 100.0 270 Oshikoto 65.1 3.3 31.6 0.0 100.0 322 Otjozondjupa 69.7 4.4 25.9 0.0 100.0 262 Education No education/preschool 76.8 1.9 21.0 0.3 100.0 360 Incomplete primary 62.6 6.3 31.1 0.0 100.0 856 Complete primary 51.0 6.0 43.0 0.0 100.0 252 Incomplete secondary 55.2 7.2 37.7 0.0 100.0 1,604 Complete secondary 70.2 7.2 22.6 0.0 100.0 538 More than secondary 78.4 7.0 14.6 0.0 100.0 305 Wealth quintile Lowest 48.7 4.1 47.3 0.0 100.0 560 Second 52.5 4.8 42.5 0.2 100.0 607 Middle 64.7 5.6 29.7 0.0 100.0 875 Fourth 67.4 9.0 23.6 0.0 100.0 963 Highest 70.0 6.8 23.2 0.0 100.0 911 Total 15-49 62.4 6.4 31.2 0.0 100.0 3,915 Note: Total includes one unweighted men with information missing on marital status. 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 36 | Characteristics of Respondents 3.6 OCCUPATION Respondents who were currently employed were asked to state their occupation; and the results are presented in Tables 3.6.1 and 3.6.2. Nationally, sales and services employ the largest pro- portion of women (44 percent). For men, the largest proportion work as skilled labour (27 percent). Agricultural jobs absorb 17 percent of women and 27 percent of men. For women and men, residence determines the type of work they do. People who live in urban areas are more likely to be employed in professional, clerical, sales, and services, while agriculture is the predominant occupation of people living in rural areas. Urban women are most often employed in sales and services (48 percent). The most common occupations of urban men are skilled manual labour (36 percent) and sales and services (22 percent). In rural areas, more than 33 percent of women and 56 percent of men are employed in agriculture. Variations by region show that almost half of women in Caprivi are employed in agricultural occupations while 50 percent or more women in Erongo, Hardap, Omaheke, and Oshana are in sales and services jobs. Tables 3.6.1 and 3.6.2 show that men and women with more than secondary education are more likely to be employed in professional, technical, or managerial occupations. NDHS 2006-07 Figure 3.1 Women’s Employment Status in the Past 12 Months Currently employed 44% Not employed in past 12 months 47% Not currently employed, but was in past 12 months 9% Characteristics of Respondents | 37 Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Namibia 2006-07 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of women Age 15-19 1.5 6.7 35.8 0.8 1.0 24.4 29.9 100.0 575 20-24 8.5 10.1 49.6 4.5 2.6 16.2 8.6 100.0 892 25-29 14.0 10.5 46.6 6.9 1.9 12.9 7.2 100.0 1,018 30-34 14.8 10.7 44.6 7.0 2.5 14.6 5.8 100.0 975 35-39 16.1 10.7 45.4 4.3 1.0 16.8 5.9 100.0 700 40-44 22.7 6.4 41.1 4.9 2.3 16.9 5.7 100.0 633 45-49 23.2 6.2 41.4 3.5 1.5 20.1 4.0 100.0 437 Marital status Never married 9.8 9.6 45.5 5.3 2.0 15.5 12.2 100.0 2,684 Married or living together 19.1 9.1 41.8 4.4 1.6 17.7 6.2 100.0 2,108 Divorced/separated/widowed 13.9 7.4 49.0 5.1 2.7 17.9 4.0 100.0 436 Number of living children 0 13.2 9.8 38.4 4.3 1.4 13.9 18.9 100.0 1,352 1-2 14.9 11.2 46.4 6.0 2.2 13.4 5.9 100.0 2,195 3-4 15.9 8.4 46.8 4.0 2.2 17.3 5.4 100.0 1,152 5+ 7.4 1.2 45.2 4.2 1.7 35.3 4.9 100.0 533 Residence Urban 17.5 14.0 48.4 5.9 2.4 2.8 9.1 100.0 2,901 Rural 9.5 3.3 39.2 3.8 1.3 33.8 9.0 100.0 2,330 Region Caprivi 5.6 2.8 34.8 0.8 1.0 48.4 6.6 100.0 275 Erongo 14.1 10.5 50.0 6.7 5.4 6.1 7.2 100.0 484 Hardap 12.2 8.9 62.3 5.2 1.7 4.9 4.7 100.0 153 Karas 15.9 17.4 43.9 4.2 4.4 8.2 6.1 100.0 187 Kavango 11.2 3.9 41.2 3.7 0.9 35.9 3.3 100.0 335 Khomas 20.7 17.0 44.0 6.9 2.0 0.8 8.4 100.0 1,326 Kunene 10.9 6.5 44.4 1.7 2.5 27.6 6.4 100.0 151 Ohangwena 11.1 2.7 46.1 9.2 2.2 17.4 11.3 100.0 339 Omaheke 20.3 13.0 49.5 5.6 1.8 3.8 6.1 100.0 150 Omusati 10.4 3.5 37.0 2.2 0.1 39.7 7.0 100.0 575 Oshana 10.6 5.3 49.9 2.8 1.4 9.1 21.0 100.0 561 Oshikoto 10.4 6.4 33.1 4.5 0.9 32.4 12.3 100.0 469 Otjozondjupa 14.3 9.1 59.2 5.5 2.1 6.9 2.9 100.0 226 Education No education/preschool 0.7 0.5 47.7 3.2 2.1 40.8 5.1 100.0 282 Incomplete primary 0.8 0.8 51.6 4.4 1.9 35.2 5.3 100.0 834 Complete primary 1.3 1.5 58.6 5.7 1.7 21.2 10.0 100.0 342 Incomplete secondary 6.5 7.4 52.2 5.5 2.6 14.9 10.9 100.0 2,308 Complete secondary 19.9 26.1 34.1 6.2 1.0 4.7 8.0 100.0 909 More than secondary 69.5 11.2 6.5 1.5 0.6 0.4 10.3 100.0 556 Wealth quintile Lowest 1.4 0.5 26.3 2.8 0.5 58.8 9.7 100.0 732 Second 5.0 1.2 45.7 4.3 1.4 33.0 9.4 100.0 713 Middle 8.1 3.9 56.6 6.8 2.3 13.5 8.8 100.0 892 Fourth 12.1 9.7 57.3 5.6 3.2 3.9 8.1 100.0 1,428 Highest 29.9 20.3 32.3 4.5 1.4 1.9 9.7 100.0 1,466 Total 13.9 9.2 44.3 4.9 1.9 16.6 9.1 100.0 5,231 Note: Total includes two unweighted women with information missing on marital status. 38 | Characteristics of Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Namibia 2006-07 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of men Age 15-19 3.9 2.7 9.3 14.5 4.2 46.7 18.8 100.0 314 20-24 6.9 2.5 17.1 25.4 6.0 30.4 11.8 100.0 498 25-29 11.3 2.2 17.0 29.5 7.6 22.4 10.1 100.0 556 30-34 13.2 2.1 16.9 32.4 3.5 21.9 10.0 100.0 494 35-39 10.9 2.6 23.0 27.2 5.0 22.2 9.1 100.0 349 40-44 14.4 1.3 16.6 28.0 4.7 23.5 11.6 100.0 281 45-49 12.7 0.7 13.4 26.6 3.9 28.4 14.3 100.0 201 Marital status Never married 7.7 2.2 15.0 26.1 5.5 31.1 12.4 100.0 1,452 Married or living together 14.4 2.3 18.5 26.8 5.1 21.7 11.2 100.0 1,086 Divorced/separated/widowed 6.9 0.0 17.5 33.7 3.3 29.1 9.6 100.0 154 Number of living children 0 7.6 2.3 15.1 21.9 6.3 33.3 13.5 100.0 1,128 1-2 11.9 1.5 16.8 32.6 4.8 22.5 9.9 100.0 815 3-4 12.8 3.7 16.0 26.0 5.1 24.7 11.8 100.0 418 5+ 12.9 1.0 21.7 30.5 2.9 20.8 10.2 100.0 333 Residence Urban 14.1 3.0 22.2 35.8 5.9 4.4 14.5 100.0 1,510 Rural 5.5 1.0 9.4 15.4 4.4 56.2 8.1 100.0 1,184 Region Caprivi 8.0 0.4 11.7 15.4 4.5 52.4 7.6 100.0 128 Erongo 9.2 2.5 15.7 41.2 9.7 7.7 14.0 100.0 326 Hardap 6.0 0.6 14.0 38.4 7.5 25.0 8.6 100.0 103 Karas 11.9 2.6 18.5 28.2 10.0 21.9 6.9 100.0 118 Kavango 8.8 1.9 27.5 11.7 1.3 37.0 11.8 100.0 190 Khomas 16.3 3.2 18.6 36.4 5.7 3.8 15.8 100.0 775 Kunene 6.1 0.0 9.2 10.3 11.0 57.4 6.0 100.0 77 Ohangwena 19.6 2.4 23.1 23.4 0.5 15.0 15.8 100.0 64 Omaheke 4.7 0.5 10.9 13.2 0.6 63.3 6.9 100.0 150 Omusati 4.9 0.6 6.6 16.6 2.0 63.7 5.6 100.0 192 Oshana 12.2 3.5 26.5 22.4 1.6 25.9 7.8 100.0 156 Oshikoto 7.1 1.3 11.5 21.4 0.0 42.2 16.4 100.0 221 Otjozondjupa 3.6 2.4 15.1 17.9 10.9 42.6 7.5 100.0 194 Education No education/preschool 1.5 1.1 8.5 27.5 5.5 52.6 3.4 100.0 283 Incomplete primary 0.9 0.5 15.5 27.3 5.4 43.2 7.1 100.0 590 Complete primary 2.6 0.0 10.9 33.6 5.5 35.7 11.8 100.0 144 Incomplete secondary 5.7 2.3 20.2 31.1 6.3 21.8 12.6 100.0 1,000 Complete secondary 18.0 4.9 22.3 21.5 4.5 10.5 18.3 100.0 416 More than secondary 51.4 3.0 7.8 13.5 1.6 5.5 17.3 100.0 261 Wealth quintile Lowest 2.5 0.0 8.4 11.7 1.4 68.0 8.0 100.0 295 Second 3.6 0.3 10.6 15.5 4.7 56.6 8.8 100.0 348 Middle 5.2 0.8 18.8 29.2 4.3 35.2 6.5 100.0 615 Fourth 8.5 2.6 21.1 36.2 7.5 12.5 11.6 100.0 736 Highest 23.5 4.6 16.3 27.0 5.5 3.6 19.5 100.0 700 Total 15-49 10.4 2.1 16.6 26.8 5.2 27.2 11.7 100.0 2,693 Note: Total includes one unweighted man with information missing on marital status. Characteristics of Respondents | 39 3.7 EARNINGS AND TYPE OF EMPLOYMENT Table 3.7 shows the percent distribution of women employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural). Four in five women employed in agricultural work are not paid for their work, while 83 percent of women employed in non-agricultural work are given their earnings as cash only. More than half of women employed in agricultural work are employed by a family member. Thirty-one percent of women in agricultural work and 22 percent of women in non- agricultural work are self-employed. Differentials by continuity of employment show that 70 percent of women in agricultural work are seasonally employed, whereas 77 percent of women in non- agricultural work are employed all year. Table 3.7 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Namibia 2006-07 Employment characteristic Agricultural work Non-agricultural work Missing Total Type of earnings Cash only 16.4 83.3 44.2 68.6 Cash and in-kind 1.5 3.3 1.5 2.8 In-kind only 1.3 1.7 3.2 1.8 Not paid 80.7 11.4 47.7 26.3 Missing 0.1 0.2 3.4 0.5 Total 100.0 100.0 100.0 100.0 Type of employer Employed by family member 52.7 11.3 14.7 18.5 Employed by non-family member 16.2 66.1 40.2 55.5 Self-employed 31.1 22.4 41.7 25.6 Missing 0.0 0.2 3.4 0.4 Total 100.0 100.0 100.0 100.0 Continuity of employment All year 26.8 76.8 72.0 68.1 Seasonal 70.1 14.0 17.0 23.6 Occasional 3.1 9.0 7.3 7.9 Missing 0.0 0.2 3.7 0.5 Total 100.0 100.0 100.0 100.0 Number of women employed during the past 12 months 870 3,887 474 5,231 Women age 15-49 are employed in two major areas: namely agricultural work and non- agricultural work. Overall, 69 percent of women receive cash only, while 26 percent are not paid. Most women (81 percent) in agricultural work are not paid. Fifty-six percent of women are employed by non-family members, 19 percent by family members, and 26 percent are self-employed. Sixty-six percent of women employed in non-agricultural work are employed by non-family members, 22 percent are self-employed, and 11 percent are employed by family members. With regard to continuity of employment, 68 percent of employed women work all year, 24 percent are seasonal workers, and 8 percent are considered occasional workers. Seventy-seven percent of women employed in non-agricultural work are employed all year, 14 percent are seasonal workers, and 9 percent are considered occasional workers. The majority of women employed in agriculture are seasonal workers, while 27 percent work all year. Fertility | 41 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4 This chapter looks at a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women begin childbearing. Information on current and cumulative fertility is essential in monitoring population growth. The data on birth intervals are important because short intervals are strongly associated with childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the mother and the child. Data on fertility were collected in several ways. Each woman was asked about all of the births she had had in her lifetime. To ensure completeness of the responses, the duration, the month and year of termination, and the result of the pregnancy were recorded for each pregnancy. In addition, questions were asked separately about sons and daughters who live with the mother, those who live elsewhere, and those who have died. Subsequently, a list of all births was recorded along with name, age if still alive, and age at death if dead. Finally, information was collected on whether the women were pregnant at the time of the survey. 4.1 CURRENT FERTILITY Measures of current fertility presented in this chapter include age-specific fertility rates (ASFRs), the total fertility rate (TFR), the general fertility rate (GFR), and the crude birth rate (CBR). These rates are generally presented for the three-year period preceding the survey, a period covering portions of calendar years 2005 through 2007. The three-year period was chosen for calculating these rates (rather than a longer or a shorter period) to provide the most current information, to reduce sampling error, and to avoid problems of the displacement of births. Age-specific fertility rates are useful in understanding the age pattern of fertility. Numerators of ASFRs are calculated by identifying live births that occurred in the period 1-36 months prior to the survey (determined from the date of interview and date of birth of the child), and classifying them by the age (in five-year groups) of the mother at the time of the child’s birth. The denominators of these rates are the number of woman- years lived in each of the specified five-year age groups in the period 1-36 months prior to the survey. The total fertility rate is a common measure of current fertility and is defined as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed age-specific rates. The general fertility rate is the number of live births occurring during a specified period per 1,000 women age 15-44. The crude birth rate is the number of births per 1,000 population during a specified period. Current estimates of fertility levels are presented in Table 4.1 and Figure 4.1 by urban-rural residence. The TFR in Namibia for the period 2005 to 2007 is 3.6 births per woman, 0.6 births lower than that recorded in the 2000 NDHS (4.2 births per woman). On average, rural women have 1.5 more children than urban women (4.3 compared with 2.8 children per woman). The difference in fertility rates between urban and rural women can be attributed to better education and greater access to family planning information and services in urban areas (see Chapters 3 and 5). The age pattern of fertility indicates that childbearing in Namibia begins early. According to the cumulative age-specific fertility rates shown in Table 4.1, fertility peaks in the age group 20-24 (204 births per thousand women in rural and 136 births per thousand women in urban areas). Age- specific fertility rates are higher in rural areas than in urban areas for all age groups. 42 | Fertility Table 4.1 Current fertility Age-specific and total fertility rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Namibia 2006-07 Residence Age group Urban Rural Total 15-19 58 92 78 20-24 136 204 169 25-29 133 192 159 30-34 116 180 145 35-39 87 133 110 40-44 27 58 44 45-49 9 8 8 TFR 2.8 4.3 3.6 GFR 100 143 122 CBR 28.8 29.6 29.2 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate expressed per 1,000 population + + + + + + + & & & & & & &) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 50 100 150 200 250 Births per 1,000 women Urban Rural Total) & + NDHS 2006-07 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence Fertility | 43 Compared with other countries in south-eastern Africa that have participated in the DHS programme, fertility in Namibia is slightly higher than that in Lesotho and slightly lower than that in Zimbabwe and Swaziland (Figure 4.2). 4.2 FERTILITY DIFFERENTIALS BY BACKGROUND CHARACTERISTICS Fertility is known to vary by residence, educational background, and other background characteristics of a woman. Table 4.2 shows that the TFR varies between regions, ranging from 2.6 children per woman in Khomas to 5.1 children per woman in Omaheke. Teenage fertility is high in Kavango (140 births per 1,000 women), Omaheke (137 per 1,000), Caprivi (121 per 1,000), and Otjozondjupa (120 per 1,000), while Khomas, Omusati, and Oshana have the lowest rates (42, 49, and 49 births per 1,000 women, respectively). Table 4.2 Current fertility by region Age-specific and total fertility rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Namibia 2006-07 Region Age group Caprivi Erongo Hardap Karas Kavango Khomas Kunene Ohang- wena Omaheke Omusati Oshana Oshikoto Otjozond- jupa Total 15-19 121 76 103 112 140 42 112 70 137 49 49 63 120 78 20-24 157 136 163 119 213 132 194 203 214 196 147 175 212 169 25-29 159 145 134 198 184 122 222 185 235 167 131 201 172 159 30-34 143 141 153 122 151 101 195 230 227 138 142 148 144 145 35-39 61 57 75 68 180 98 107 117 145 119 90 111 179 110 40-44 67 9 14 15 82 27 100 39 44 55 38 70 55 44 45-49 11 0 9 0 33 0 0 8 10 8 0 23 8 8 TFR 3.6 2.8 3.3 3.2 4.9 2.6 4.7 4.3 5.1 3.7 3.0 4.0 4.5 3.6 GFR 129 101 116 110 166 94 163 138 167 118 99 126 152 122 CBR 30.8 24.8 26.6 23.6 36.7 28.2 33.6 29.7 31.5 26.4 26.5 27.9 33.6 29.2 6.7 6 5.9 5.7 5.5 4.9 3.8 3.8 3.6 3.5 Uganda 2006 Malawi 2004 Zambia 2001-02 Tanzania 2004 Mozambique 2003 Kenya 2003 Zimbabwe 2005-06 Swaziland 2006-07 Namibia 2006-07 Lesotho 2004 0 1 2 3 4 5 6 7 8 Births per woman Figure 4.2 Total Fertility Rates for Selected Countries NDHS 2006-07 6.0 44 | Fertility Table 4.3 shows several fertility measurements, namely the total fertility rate, mean number of births to women age 40-49, and the percentage of women who are currently pregnant. The mean number of births to women age 40-49 is an indicator of cumulative fertility; it reflects the fertility performance of older women who are nearing the end of their reproductive period. If fertility remained stable over time and the reported data on both children ever born and births during the three years preceding the survey are reasonably accurate, the total fertility rate (TFR) and the mean number of children ever born (CEB) tend to be similar. When fertility levels are falling, the TFR will be substantially lower than the mean number of children ever born among women age 40-49. The percentage pregnant provides a useful additional measure of current fertility, although it is recognized that it may not capture some pregnancies that are in an early stage. Table 4.3 shows the decline in fertility by background characteristics. The current TFR is 0.8 children lower than the mean number of children among women age 40-49 (3.6 births per woman and 4.4 children, respectively). Educational attainment is closely linked to a woman’s fertility; the TFR for women with no formal education (6.3) and women with a primary education (4.0-4.7) is four or more children per woman, while that for women with at least some secondary education is three or fewer children per woman (2.1-3.2). A comparison of current (total) fertility with past (completed) fertility shows that there have been substantial and roughly equivalent declines in both urban and rural areas and within all regional and education categories. Table 4.3 indicates that 5 percent of women were pregnant at the time of the survey. This is likely to be an underestimate because women in the early stages of pregnancy may be unaware or unsure that they are pregnant while some may not report that they are pregnant. Kunene has the highest pregnancy rate (10 percent). Differentials in pregnancy status parallel differentials in current fertility; the proportion of women who are currently pregnant declines as the level of education increases and wealth status rises. 4.3 FERTILITY TRENDS Table 4.4 uses information from the retrospective birth histories obtained from the 2006-07 NDHS respondents to examine trends in age-specific fertility rates for successive five-year periods Table 4.3 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Namibia 2006-07 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 2.8 4.6 3.7 Rural 4.3 6.1 4.9 Region Caprivi 3.6 7.2 4.7 Erongo 2.8 5.3 3.8 Hardap 3.3 7.0 4.2 Karas 3.2 4.0 3.8 Kavango 4.9 6.2 5.0 Khomas 2.6 4.0 3.5 Kunene 4.7 10.2 5.6 Ohangwena 4.3 5.1 5.4 Omaheke 5.1 7.4 4.7 Omusati 3.7 4.8 4.2 Oshana 3.0 4.1 4.5 Oshikoto 4.0 5.6 5.1 Otjozondjupa 4.5 7.3 4.6 Education No education/preschool 6.3 7.2 5.5 Incomplete primary 4.7 6.5 5.4 Complete primary 4.0 5.9 4.9 Incomplete secondary 3.2 5.0 3.7 Complete secondary 2.8 4.6 2.8 More than secondary 2.1 4.6 2.7 Wealth quintile Lowest 5.1 6.9 5.5 Second 4.3 5.6 4.9 Middle 4.1 6.4 4.7 Fourth 2.8 5.1 4.2 Highest 2.4 3.6 3.1 Total 3.6 5.4 4.4 Note: Total fertility rates are for the period 1-36 months prior to interview. Fertility | 45 before the survey. To calculate these rates, births were classified according to the period of time in which the birth occurred and the mother’s age at the time of birth. Because birth histories were not collected for women over age 50, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years or more prior to the survey because women in that age group would have been age 50 or over at the time of the survey. Table 4.4 shows that fertility rates for all age groups have decreased over time. For example, the fertility rate for women age 15-19 was 88 births per 1,000 women in 1988-1992 compared with 74 births per 1,000 women in 2003-2007. Another way to examine fertility trends is to compare current estimates with earlier surveys. Table 4.5 and Figure 4.3 show the age-specific fertility rates and TFRs from the 1992, 2000, and 2006-07 NDHS surveys. The data show that fertility declined from 5.4 children per woman in the early 1990s to 3.6 children per woman in 2005-07. Across age groups, the sharpest decline is seen among women age 25-29, from 241 in 1990-92 to 159 children per woman in 2005-07. Table 4.4 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Namibia 2006-07 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 74 82 87 88 20-24 165 161 179 193 25-29 159 174 200 218 30-34 143 167 191 [194] 35-39 108 125 [137] 40-44 45 [85] 45-49 [9] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. Table 4.5 Trends in age-specific and total fertility rates Age-specific and total fertility rates (TFR) for the three-year period preceding several surveys, Namibia 1992-2007 Mother’s age at birth NDHS 1992 (1990-92) NDHS 2000 (1998-2000) NDHS 2006-07 (2006-07) 15-19 109 88 78 20-24 207 166 169 25-29 241 176 159 30-34 208 160 145 35-39 166 137 110 40-44 105 71 44 45-49 37 38 8 TFR 5.4 4.2 3.6 Note: Age-specific fertility rates are per 1,000 women. 109 207 241 208 166 105 37 88 166 176 160 137 71 38 78 169 159 145 110 44 8 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 50 100 150 200 250 300 Births per 1,000 women NDHS 1992 NDHS 2000 NDHS 2006-07 Figure 4.3 Trends in Age-specific Fertility Rates, Namibia 1992-2007 46 | Fertility 4.4 CHILDREN EVER BORN AND LIVING Table 4.6 presents the distribution of all women and currently married women by number of children ever born, according to five-year age groups. The table also shows the mean number of children ever born. Data on the number of children ever born reflect the accumulation of births to women over their entire reproductive years and therefore have limited reference to current fertility levels, particularly when a country has experienced a decline in fertility. However, the information on children ever born is useful for observing how average family size varies across age groups and for observing the level of primary infertility. Table 4.6 shows that 87 percent of women age 15-19 have never given birth. However, this proportion declines rapidly to 5 percent or less for women age 35 and over. Namibian women have an average of 4.75 children by the end of their reproductive years, which is 1.15 children more than the TFR. This discrepancy is largely attributable to the fertility decline between the 1992 and 2000 NDHS surveys. As expected, both the mean number of children ever born and the mean number of children surviving rise with increasing age of women. The last two columns in Table 4.6 compare these two variables, and reveal the level of child loss among Namibian women. By the end of their reproductive years (age 45-49), women in Namibia have given birth to an average of 1.91 children, with 1.76 surviving. This means that 92 percent of children ever born have survived. The same pattern is replicated for currently married women, except that the mean number of children ever born is higher for currently married women (3.15 children) than for all women (1.91 children). The difference is due to the lower levels of fertility among women in the “all women” category. Table 4.6 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born and mean number of living children, according to age group, Namibia 2006-07 Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number of women Mean number of children ever born Mean number of living children ALL WOMEN 15-19 87.4 11.0 1.4 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,246 0.15 0.14 20-24 42.0 37.1 16.4 3.7 0.7 0.1 0.0 0.0 0.0 0.0 0.0 100.0 1,855 0.84 0.80 25-29 20.6 27.8 29.3 14.9 5.2 1.9 0.2 0.0 0.0 0.0 0.0 100.0 1,623 1.63 1.54 30-34 9.5 20.3 24.8 21.7 11.7 6.9 3.3 1.4 0.3 0.0 0.0 100.0 1,417 2.49 2.32 35-39 4.9 12.1 18.6 20.8 17.6 10.5 7.7 4.9 2.0 0.7 0.3 100.0 1,045 3.41 3.20 40-44 4.4 6.1 15.1 16.8 19.1 12.6 10.5 6.8 4.3 2.3 2.0 100.0 928 4.12 3.75 45-49 3.6 6.2 12.0 13.6 15.0 12.5 12.3 9.3 5.0 6.0 4.7 100.0 689 4.75 4.19 Total 33.9 19.4 16.1 11.1 7.4 4.5 3.2 2.0 1.0 0.7 0.6 100.0 9,804 1.91 1.76 CURRENTLY MARRIED WOMEN 15-19 38.7 48.2 11.2 2.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 118 0.76 0.72 20-24 14.2 40.2 34.4 8.2 2.5 0.5 0.0 0.0 0.0 0.0 0.0 100.0 398 1.46 1.37 25-29 8.8 23.8 34.4 20.7 9.2 2.5 0.6 0.0 0.0 0.0 0.0 100.0 625 2.08 1.96 30-34 4.2 15.2 26.5 24.1 14.1 8.3 5.2 1.9 0.6 0.0 0.0 100.0 751 2.87 2.69 35-39 2.5 9.1 15.7 21.6 19.5 11.6 9.0 6.5 3.2 0.7 0.5 100.0 612 3.79 3.56 40-44 3.0 4.2 14.4 17.5 17.4 13.0 11.1 8.7 5.3 2.5 2.8 100.0 522 4.42 4.06 45-49 2.0 4.9 12.9 14.1 13.8 12.1 11.7 8.3 6.1 7.9 6.1 100.0 424 5.01 4.40 Total 6.6 16.8 22.9 18.2 12.8 7.8 6.0 3.9 2.3 1.5 1.3 100.0 3,451 3.15 2.91 Fertility | 47 Voluntary childlessness is uncommon in Namibia and currently married women with no children are likely to be those who are sterile or unable to bear children. The level of childlessness among married women at the end of their reproductive years can be used as an indicator of the level of primary sterility. In Namibia, primary sterility among all women age 45-49 is around 4 percent. 4.5 BIRTH INTERVALS A birth interval is defined as the length of time between two live births. The study of birth intervals is important in understanding the health status of young children. Research has shown that short birth intervals are closely associated with poor health of children, especially during infancy. Children born too close to a previous birth, especially if the interval between the births is less than two years, are at increased risk of health problems and dying at an early age. Longer birth intervals, on the other hand, contribute to the improved health status of both mother and child. The study of birth intervals is done using two measures, namely median birth interval and proportion of non-first births that occur with an interval of 24 months or more after the previous birth. Table 4.7 presents the distribution of second and higher-order births in the five years preceding the survey by the number of months since the previous birth, according to background characteristics. The table also includes the median number of months since the preceding birth. Table 4.7 shows that the overall median birth interval for Namibia is 42.3 months. In the five years preceding the survey 13 percent of children were born within 24 months after a preceding birth, 26 percent were born 2 to 3 years after their older sibling, and 42 percent were born 4 years or more after a preceding birth. The shortest birth intervals are observed among children born to women age 15-19 (24.7 months) and children whose preceding sibling died (30.4 months). Birth intervals are longest for children born to women with higher than secondary education (47.6 months). The median birth interval is 10 months longer in urban areas than in rural areas. In all regions, the median birth interval is longer than 36 months. The medians range from 36.5 months in Omaheke to 52.1 months in Erongo. A large proportion (44 percent) of children of younger women (15-19) are born less than 24 months after the preceding birth, indicating that birth intervals among younger women are very short, increasing the health risks to both children and mothers. 48 | Fertility Table 4.7 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Namibia 2006-07 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48-59 60+ Total Number of non-first births Median number of months since preceding birth Age 15-19 22.8 21.3 24.1 25.1 4.3 2.3 100.0 42 24.7 20-29 6.2 11.0 29.7 21.1 12.2 19.9 100.0 1,355 37.2 30-39 4.3 6.4 23.7 17.6 13.7 34.2 100.0 1,562 46.8 40-49 2.8 5.8 20.9 19.9 11.3 39.2 100.0 412 48.5 Birth order 2-3 5.1 8.2 23.6 18.5 12.3 32.3 100.0 2,040 44.4 4-6 4.6 8.2 28.6 19.8 14.3 24.7 100.0 1,043 40.7 7+ 7.3 9.8 30.8 24.9 9.8 17.3 100.0 288 36.8 Sex of preceding birth Male 5.7 9.0 23.9 20.8 12.5 28.1 100.0 1,705 42.6 Female 4.6 7.7 27.7 18.0 12.8 29.2 100.0 1,667 42.0 Survival of preceding birth Living 4.4 7.7 25.8 20.0 12.9 29.4 100.0 3,152 43.1 Dead 15.7 17.9 25.9 11.6 10.3 18.7 100.0 219 30.4 Residence Urban 5.7 6.3 19.9 17.3 14.4 36.5 100.0 1,338 48.6 Rural 4.7 9.7 29.6 20.8 11.6 23.5 100.0 2,034 38.8 Region Caprivi 3.5 6.1 21.0 21.8 14.0 33.7 100.0 180 46.6 Erongo 4.2 6.3 14.7 17.6 17.6 39.6 100.0 197 52.1 Hardap 7.2 12.6 21.6 14.6 11.3 32.8 100.0 98 40.0 Karas 7.4 4.3 20.6 18.4 16.1 33.4 100.0 98 47.7 Kavango 1.0 5.2 25.9 20.4 17.8 29.7 100.0 398 46.5 Khomas 8.6 6.3 18.8 17.5 13.8 35.0 100.0 586 47.5 Kunene 4.8 15.4 28.2 23.3 9.3 19.2 100.0 140 36.8 Ohangwena 5.3 9.7 31.4 25.3 9.6 18.7 100.0 400 36.9 Omaheke 8.2 13.6 27.4 13.7 10.7 26.4 100.0 163 36.5 Omusati 2.7 7.8 29.7 19.9 11.5 28.4 100.0 295 41.7 Oshana 2.6 10.0 34.2 20.8 10.0 22.4 100.0 231 37.1 Oshikoto 4.1 8.5 31.7 20.9 9.3 25.5 100.0 336 39.3 Otjozondjupa 8.1 10.9 25.8 12.7 13.0 29.6 100.0 250 40.3 Education No education/preschool 6.2 10.2 29.2 20.8 14.3 19.3 100.0 478 38.3 Incomplete primary 3.7 7.2 28.8 23.9 12.8 23.5 100.0 836 40.6 Complete primary 3.9 9.0 28.9 13.6 13.0 31.6 100.0 265 42.9 Incomplete secondary 5.0 8.1 24.1 17.6 11.4 33.7 100.0 1,313 45.0 Complete secondary 7.5 8.8 23.9 16.1 13.8 29.9 100.0 309 43.3 More than secondary 7.2 8.4 12.6 22.4 14.7 34.7 100.0 171 47.6 Wealth quintile Lowest 3.1 9.6 32.0 23.1 11.4 20.7 100.0 790 38.6 Second 5.6 8.8 29.0 20.8 12.0 23.8 100.0 683 39.2 Middle 6.1 9.0 25.6 18.8 13.7 26.9 100.0 764 41.3 Fourth 4.5 8.6 22.8 16.4 12.7 35.0 100.0 661 46.4 Highest 7.2 4.2 15.1 16.5 14.0 43.1 100.0 474 53.0 Total 5.1 8.3 25.8 19.4 12.7 28.7 100.0 3,372 42.3 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Fertility | 49 4.6 AGE AT FIRST BIRTH The age at which childbearing commences is an important determinant of the overall level of fertility as well as the health and welfare of the mother and the child. In some societies, postponement of first births because of increasing age at first marriage has contributed to overall fertility decline. Table 4.8 shows the percentage of women who gave birth by specific ages, according to age at the time of the survey. Table 4.8 shows trends in the median age at first birth across age cohorts. The measures are presented for women age 25-49 to ensure that half of the women have already had a birth. Almost one-fifth of women age 25-49 have given birth before reaching age 18, while 57 percent have had a birth by age 20. The median age at first birth is about 21 years across all age cohorts, indicating virtually no change in the age at first birth. The median age at first birth for age group (25-49) is 21.4 years, which is similar to that recorded in the 2000 NDHS (21.1 years). Table 4.8 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Namibia 2006-07 Percentage who gave birth by exact age Current age 15 18 20 22 25 Percentage who have never given birth Number of women Median age at first birth 15-19 1.4 na na na na 87.4 2,246 a 20-24 2.3 17.0 35.1 na na 42.0 1,855 a 25-29 1.5 17.7 36.1 54.5 70.9 20.6 1,623 21.4 30-34 1.9 16.2 36.6 52.5 71.8 9.5 1,417 21.6 35-39 1.7 17.1 38.9 57.0 76.3 4.9 1,045 21.2 40-44 2.5 18.8 36.8 52.8 71.9 4.4 928 21.6 45-49 4.9 17.5 41.9 59.4 79.1 3.6 689 21.0 20-49 2.2 17.3 37.0 na na 18.1 7,558 21.5 25-49 2.2 17.4 37.6 54.8 73.3 10.3 5,703 21.4 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.9 shows that the median age at first birth is almost the same in urban and rural areas (21.8 and 21.0 years, respectively). Among regions, the highest median age at first birth for women 25-49 is 22.5 years or higher in Khomas, Omusati, and Oshana. Women in Kunene began child- bearing three years earlier than women in Omusati (19.5 years). Median age at first birth increases with the woman’s education and household wealth status. Women who completed secondary school began childbearing at 24.2 years compared with 19.9 years for women with no education. Women in the poorest households had their first child at 20.4 years compared with 23.1 years for women in the wealthiest households. 50 | Fertility Table 4.9 Median age at first birth Median age at first birth among women age 25-49, according to background characteristics, Namibia 2006-07 Age Background characteristic 25-29 30-34 35-39 40-44 45-49 Women 25-49 Residence Urban 22.3 22.1 21.5 21.3 20.9 21.8 Rural 20.8 20.9 21.0 21.8 21.0 21.0 Region Caprivi 19.8 19.5 22.0 19.6 19.5 19.9 Erongo 22.4 21.0 21.6 21.6 20.1 21.3 Hardap 20.3 21.4 20.7 20.0 20.5 20.6 Karas 21.3 22.6 21.4 21.3 19.3 21.4 Kavango 19.8 19.3 19.5 20.2 20.9 19.7 Khomas 23.5 22.8 20.9 21.1 21.9 22.5 Kunene 20.3 19.2 19.2 18.9 19.2 19.5 Ohangwena 20.9 22.4 21.8 21.9 21.5 21.7 Omaheke 20.1 20.8 20.0 20.7 19.9 20.3 Omusati 22.0 22.4 22.0 24.6 24.3 22.9 Oshana 22.4 21.6 22.6 23.5 21.6 22.5 Oshikoto 20.8 20.5 22.1 23.1 21.0 21.3 Otjozondjupa 20.9 20.2 19.7 19.2 20.1 20.2 Education No education/preschool 19.9 19.7 19.7 20.3 19.9 19.9 Incomplete primary 19.0 19.1 19.5 20.0 20.0 19.5 Complete primary 19.4 20.3 19.6 20.8 20.8 20.1 Incomplete secondary 21.4 21.9 22.1 21.7 21.0 21.6 Complete secondary 24.1 25.0 24.1 24.0 22.4 24.2 More than secondary a 27.0 26.2 26.8 25.6 a Wealth quintile Lowest 20.2 19.9 20.3 21.0 21.2 20.4 Second 20.7 21.6 20.9 22.1 21.2 21.1 Middle 20.8 20.8 21.0 21.6 20.3 20.9 Fourth 21.7 21.2 20.7 20.9 19.8 21.0 Highest 24.7 24.1 22.9 22.4 21.8 23.1 Total 21.4 21.6 21.2 21.6 21.0 21.4 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 4.7 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy is a major health concern because of its association with higher morbidity and mortality for both the mother and child. Childbearing during the teenage years frequently has adverse social consequences, particularly for female educational attainment because women who become mothers in their teens are more likely to curtail their education. Using information from the 2006-07 NDHS, Table 4.10 shows the percentage of women age 15-19 who are mothers or who are pregnant with their first child. Overall, 15 percent of teenagers in Namibia have started childbearing; 13 percent have had a live birth and 3 percent are pregnant with their first child. Childbearing among teenagers increases rapidly between the ages of 17 and 19—from 14 percent among women age 17, to 35 percent among women age 19. Rural teenagers are more likely than urban teenagers to have started childbearing (18 percent and 12 percent, respectively). Fertility | 51 Across regions, there appears to be two patterns of childbearing among teenagers. There are regions with high teenage pregnancy rates (27 percent or higher), such as Omaheke (27 percent), Otjozondjupa (27 percent), Caprivi (30 percent), Kunene (31 percent), and Kavango (34 percent). On the other hand, teenage pregnancy is 10 percent or less in Khomas, Ohangwena, Omusati, and Oshana regions. The childbearing rates among teenagers in the remaining regions are between 13 percent (Karas) and 19 percent (Hardap). Teenage pregnancy rates have a negative association with education and wealth status. Fifty- eight percent of teenagers with no education have started childbearing, more than twice the rate for teenagers who have incomplete primary school (25 percent), and almost ten times higher than the rate for those who completed secondary school (6 percent). Teenagers from the poorest households are nearly five times as likely to have been pregnant as those from the richest households (22 percent compared with 5 percent). Table 4.10 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child and percentage who have begun childbearing, by background characteristics, Namibia 2006-07 Percentage who: Background characteristic Have had a live birth Are pregnant with first child Percentage who have begun childbearing Number of women Age 15 2.0 0.8 2.7 401 16 3.5 2.1 5.5 508 17 11.5 2.3 13.9 456 18 17.0 4.5 21.6 466 19 30.4 4.2 34.6 415 Residence Urban 9.5 2.3 11.8 908 Rural 14.7 3.2 17.9 1,338 Region Caprivi 22.0 7.7 29.7 103 Erongo 11.5 3.1 14.6 118 Hardap 15.5 3.7 19.2 68 Karas 12.1 1.1 13.2 52 Kavango 27.9 6.0 34.0 239 Khomas 5.5 0.8 6.3 401 Kunene 25.4 5.1 30.5 52 Ohangwena 9.1 0.9 10.0 346 Omaheke 25.5 1.7 27.1 85 Omusati 6.8 2.5 9.3 261 Oshana 6.6 2.7 9.3 198 Oshikoto 11.3 2.3 13.6 228 Otjozondjupa 20.1 6.4 26.5 94 Education No education/preschool 45.3 12.7 58.0 45 Incomplete primary 22.8 2.3 25.1 291 Complete primary 20.0 2.2 22.3 235 Incomplete secondary 9.5 2.9 12.4 1,498 Complete secondary 4.6 1.6 6.1 157 More than secondary 0.0 0.0 0.0 19 Wealth quintile Lowest 18.3 4.2 22.4 445 Second 12.3 2.5 14.8 474 Middle 17.8 3.1 20.9 423 Fourth 12.6 2.9 15.5 419 Highest 3.4 1.4 4.8 485 Total 12.6 2.8 15.4 2,246 Family Planning | 53 FAMILY PLANNING 5 This chapter presents results from the 2006-07 NDHS regarding aspects of contraceptive knowledge, attitudes, and behaviour. Although the focus is on women, some results from male respondents are discussed because men play an important role in achieving family planning goals. To get an indication of interspousal communication and agreement on knowledge and attitudes of couples regarding family planning, the study compares the responses of men, where possible, with responses of their wives in the same household. Where feasible, comparisons are also made with findings from previous survey rounds to highlight trends in important indicators. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS One major objective of the 2006-07 NDHS was to assess the level of knowledge of contraceptive methods among women and men. Individuals who have adequate information about the available methods of contraception are better able to develop a rational approach to planning their families. Information on respondents’ knowledge of contraception was collected in the survey by asking female and male respondents to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent had heard of it. In Table 5.1, contraceptive methods are grouped into two types, modern and traditional. Modern methods include female and male sterilization, the pill, the intrauterine device (IUD), injectables, implants, male condom, female condom, lactational amenorrhoea (LAM), and emergency contraception. Traditional methods include the rhythm method (periodic abstinence) and withdrawal. Provision was also made in the questionnaire to record any other methods, including folk methods, named spontaneously by the respondent. Specific contraceptive methods asked about were the same as those in the 2000 NDHS (MoHSS, 2003), except that in the 2006-07 NDHS, the diaphragm, foam, and jelly were not explicitly asked about, while implants were. Table 5.1 shows the level of knowledge of specific contraceptive methods among all women and men, among married women and men, and among unmarried but sexually active women and men. The 2006-07 NDHS finds that knowledge of contraception is practically universal; 98 percent of all women and men know at least one contraceptive method. Knowledge of modern contraception among the sexually active respondents is also high, regardless of sex or marital status. Knowledge of traditional methods is considerably lower for both women and men regardless of marital status with men showing somewhat higher levels of knowledge of these traditional methods. The most widely known modern methods of contraception among all women are male condom (95 percent), injectables (93 percent), the pill (90 percent), and female condom (83 percent). The least commonly cited modern methods by all women are implants (19 percent), emergency contraception (21 percent), and male sterilization (32 percent). In general, married women and sexually active unmarried women show similar levels of knowledge of both modern and traditional contraceptive methods, except that married women seem somewhat more aware of longer-term methods, such as sterilization, the IUD, and implants. Compared with married women, sexually active unmarried women were slightly more likely to have heard of male and female condoms, emergency contraception, and the withdrawal method. Among sexually active unmarried women, the male condom is also the most widely known contraceptive method (98 percent). In general, for both men and women there have been only slight increases in knowledge of contraceptive methods since the 2000 NDHS. Among all women, the major exceptions are that knowledge of the female condom increased from 66 percent in 2000 to 83 percent in 2006-07 and knowledge of the IUD decreased from 52 percent in 2000 to 46 percent in 2006-07. 54 | Family Planning Among sexually active unmarried women, while there is an increase in the level of knowledge of male and female condoms from the level in 2000, knowledge of some modern contraceptive methods in the 2006-07 NDHS is lower than that in the 2000 NDHS. For example, knowledge of the IUD declined from 60 percent to 49 percent, knowledge of female sterilization declined from 69 percent to 62 percent, and knowledge of male sterilization declined from 38 percent to 33 percent. Table 5.1 also shows that virtually all sexually active men know at least one modern method of fertility regulation. Among all men, most widely known modern methods of contraception are the male condom (98 percent), female condom (82 percent), injectables (80 percent), and the pill (78 percent). Among men, the least commonly mentioned modern contraceptive methods are emergency contraception (25 percent), implants (26 percent), and male sterilization (42 percent). Compared with the 2000 NDHS, all men are currently less likely to have heard of female sterilization (58 percent in the 2000 NDHS and to 54 percent currently), the pill (83 percent and 78 percent), and injectables (86 percent and 80 percent). Over the same period, all men were somewhat more likely to have heard of male sterilization (38 percent in the 2000 NDHS and 42 percent currently), the IUD (35 percent and 40 percent), and female condom (74 percent and 82 percent). Table 5.2 presents knowledge of family planning methods across subgroups of women and men. The table shows that knowledge of at least one modern method of family planning is universal (98 percent or more) among all subgroups of currently married women in Namibia, except among the youngest age group (96 percent). Married men are as knowledgeable about modern family planning methods as married women. There is little variation between respondents in different regions with all showing near universal knowledge of at least one contraceptive method. The only exception is married men in Ohangwena, who are least likely to know a modern method of fertility regulation (79 percent). For both married women and men, limited education is associated with having somewhat lower levels of knowledge of contraception. Similarly, being in the lowest wealth quintile is associated with somewhat lower levels of contraceptive knowledge. Table 5.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who know any contraceptive method, by specific method, Namibia 2006-07 Women Men Method All women Currently married women Sexually active unmarried woman1 All men Currently married men Sexually active unmarried men1 Any method 98.3 99.1 99.5 98.0 99.0 100.0 Any modern method 98.3 99.0 99.4 98.0 99.0 100.0 Female sterilization 58.7 67.5 61.5 54.4 61.6 59.9 Male sterilization 31.5 35.1 32.7 41.6 45.3 45.1 Pill 89.7 91.9 92.4 77.7 85.4 82.4 IUD 45.5 50.9 48.6 40.0 43.8 42.3 Injectables 92.5 95.7 95.4 79.9 87.6 85.9 Implants 18.8 21.9 17.6 26.1 30.6 26.9 Male condom 94.6 93.9 97.9 97.6 98.3 99.8 Female condom 83.0 81.1 89.2 82.3 85.6 85.7 Emergency contraception 20.7 23.2 25.6 25.4 24.6 29.2 Any traditional method 47.3 50.2 53.3 56.4 61.4 60.0 Rhythm 33.8 35.8 36.4 36.4 41.7 38.2 Withdrawal 32.9 36.1 40.0 47.0 48.4 50.9 Folk method 5.4 7.0 4.1 5.8 6.9 6.3 Mean number of methods known by respondents 15-49 6.1 6.4 6.4 6.1 6.6 6.5 Number of respondents 9,804 3,451 1,343 3,915 1,205 733 1 Had last sexual intercourse within 30 days preceding the survey Family Planning | 55 Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method by background characteristics, Namibia 2006-07 Women Men Background characteristic Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number Age 15-19 95.5 95.5 118 * * 3 20-24 99.5 99.5 398 98.2 98.2 76 25-29 99.1 99.1 625 99.5 99.5 199 30-34 99.3 99.2 751 99.4 99.4 260 35-39 99.1 99.0 612 99.2 99.2 248 40-44 99.8 99.7 522 98.5 98.5 242 45-49 98.1 98.0 424 98.6 98.6 178 Residence Urban 99.5 99.4 1,731 100.0 100.0 714 Rural 98.6 98.5 1,719 97.6 97.6 491 Region Caprivi 98.8 98.8 200 100.0 100.0 82 Erongo 99.9 99.9 327 100.0 100.0 163 Hardap 100.0 100.0 131 98.7 98.7 45 Karas 99.7 99.7 139 99.2 99.2 48 Kavango 98.4 97.9 477 100.0 100.0 125 Khomas 99.6 99.6 749 100.0 100.0 332 Kunene 97.6 97.6 141 99.6 99.6 43 Ohangwena 97.7 97.7 218 78.8 78.8 38 Omaheke 99.2 99.2 150 100.0 100.0 53 Omusati 97.8 97.8 195 (97.5) (97.5) 47 Oshana 99.6 99.6 197 100.0 100.0 53 Oshikoto 99.4 99.4 246 100.0 100.0 73 Otjozondjupa 99.0 98.9 278 98.6 98.6 104 Education No education/preschool 95.2 94.9 408 95.2 95.2 159 Incomplete primary 99.1 99.0 805 98.9 98.9 284 Complete primary 99.7 99.7 242 99.0 99.0 56 Incomplete secondary 99.7 99.6 1,226 99.9 99.9 381 Complete secondary 99.9 99.9 435 100.0 100.0 168 More than secondary 99.8 99.8 334 100.0 100.0 156 Wealth quintile Lowest 97.4 97.2 590 94.1 94.1 154 Second 98.9 98.8 502 99.0 99.0 134 Middle 98.6 98.6 698 99.7 99.7 246 Fourth 99.8 99.7 798 99.8 99.8 311 Highest 99.9 99.9 863 100.0 100.0 360 Total 15-49 99.1 99.0 3,451 99.0 99.0 1,205 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 1 Female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, diaphragm, foam or jelly, lactational amenorrhoea method (LAM), and emergency contraception 5.2 EVER USE OF CONTRACEPTION All women interviewed in the 2006-07 NDHS who said they had heard of a method of family planning were asked whether they had ever used that method. Men were only asked about ever use of male methods, i.e., male sterilization, male condom, rhythm method, and withdrawal. Table 5.3.1 shows the percentage of all women, currently married women, and sexually active unmarried women who have ever used specific methods of family planning, by age, while Table 5.3.2 shows comparable information for men. 56 | Family Planning Overall, 72 percent of all women reported using a method at some time and 71 percent have ever used a modern method (Table 5.3.1). This is an increase from 2000, when 63 percent of all women reported having using a contraceptive method. Among currently married women, 86 percent have used a method in the past and 84 percent have used a modern method at some time. The most common ever used modern methods among currently married women are injectables (57 percent), male condoms (43 percent), and the pill (37 percent). Among women who are unmarried but sexually active, 93 percent have used a family planning method at some time, and the most commonly used methods are condoms (81 percent), injectables (50 percent), and the pill (25 percent). Table 5.3.1 Ever use of contraception: Women Percentage of all women, currently married women, and sexually active unmarried women age 15-49 who have ever used any contraceptive method by method, according to age, Namibia 2006-07 Modern method Traditional method Age Any method Any modern method Female sterili- zation Male sterili- zation Pill IUD Inject- ables Im- plants Male con- dom Female con- dom Emer- gency contra- ception Any tradi- tional method Rhythm With- drawal Folk method Number of women ALL WOMEN 15-19 36.3 35.2 0.1 0.0 3.6 0.0 14.4 0.0 29.4 2.8 0.6 5.4 3.2 1.9 0.9 2,246 20-24 80.0 79.1 0.2 0.0 18.9 0.2 44.4 0.2 62.8 6.0 2.3 13.5 6.6 7.3 2.3 1,855 25-29 87.6 86.6 1.1 0.0 27.7 1.1 55.5 0.5 64.1 8.4 2.3 18.1 9.6 9.9 2.1 1,623 30-34 87.6 86.4 3.4 0.5 35.4 2.8 58.6 0.5 56.9 8.6 1.7 18.0 10.1 8.9 3.0 1,417 35-39 83.8 82.4 9.9 1.5 36.1 4.9 54.3 0.6 46.4 9.3 1.9 17.8 8.8 8.9 4.2 1,045 40-44 77.5 75.7 16.3 1.4 37.3 9.4 47.5 0.7 39.2 7.9 1.9 16.0 9.6 7.4 2.9 928 45-49 68.0 66.7 23.6 1.5 28.7 7.3 34.9 0.5 25.3 4.4 0.6 12.1 6.3 5.7 3.9 689 Total 71.7 70.5 5.0 0.5 23.5 2.5 42.1 0.4 47.9 6.4 1.6 13.6 7.3 6.8 2.4 9,804 CURRENTLY MARRIED WOMEN 15-19 73.5 72.7 0.0 0.0 22.0 0.0 45.0 0.9 50.3 6.8 3.1 13.1 8.8 7.5 1.3 118 20-24 87.9 86.4 0.4 0.0 29.8 0.1 68.6 0.8 48.6 3.6 1.6 12.5 3.8 5.7 4.9 398 25-29 91.8 90.6 1.3 0.1 35.9 2.5 65.7 0.8 53.8 6.1 2.0 17.0 8.9 11.2 2.8 625 30-34 90.0 88.4 5.0 0.7 42.3 4.2 63.6 0.4 48.9 9.2 1.1 20.0 9.4 11.2 3.5 751 35-39 87.9 86.7 14.0 2.5 41.1 7.2 56.2 0.5 42.2 9.4 1.8 19.3 8.4 11.1 5.2 612 40-44 79.8 77.7 19.4 2.4 37.7 11.2 48.8 1.2 32.5 8.1 2.2 14.9 8.3 6.1 3.0 522 45-49 72.6 71.2 28.5 2.1 31.0 9.0 36.3 0.1 25.9 5.6 0.6 13.0 7.6 6.3 4.8 424 Total 85.5 84.0 10.3 1.2 36.7 5.4 57.0 0.6 43.3 7.3 1.6 16.6 8.1 9.0 3.8 3,451 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-19 89.4 88.8 0.5 0.4 7.4 0.3 35.7 0.0 79.3 7.7 3.2 11.5 5.1 5.4 1.0 250 20-24 94.5 94.2 0.0 0.2 23.1 0.2 51.2 0.0 84.4 8.3 5.7 20.5 10.1 14.9 0.8 415 25-29 97.0 96.8 1.3 0.0 26.2 0.6 57.3 0.0 86.7 9.5 3.0 21.0 9.2 13.7 0.5 278 30-34 92.7 92.3 2.5 1.1 32.9 1.2 52.8 1.8 75.9 7.5 3.2 15.2 11.3 6.3 0.8 169 35-39 87.9 86.5 0.9 0.0 39.3 4.4 60.0 0.0 73.8 18.0 3.9 20.4 10.5 9.9 4.2 101 40-44 94.2 92.4 17.0 0.0 41.2 8.9 62.8 0.0 76.8 11.6 5.2 22.4 14.4 15.6 1.8 93 45-49 (72.3) (69.6) (29.3) (0.0) (38.4) (5.9) (20.6) (0.0) (53.1) (5.5) (0.0) (25.2) (9.0) (16.2) (0.0) 38 Total 92.7 92.1 2.7 0.3 25.0 1.5 50.4 0.2 80.7 9.2 4.0 18.5 9.4 11.5 1.1 1,343 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Women who had sexual intercourse within 30 days preceding the survey Table 5.3.2 shows that 75 percent of all men have used a male contraceptive method at some time and almost all of these men used a modern method. Sexually active unmarried men (93 percent) are more likely than currently married men (80 percent) to have used a male contraceptive method at some time. The most common ever used method among all men is the male condom (73 percent), although currently married men (76 percent) are less likely to have ever used a male condom than sexually active unmarried men (92 percent). The second most common ever-used male contraceptive method is withdrawal (16 percent), while use of male sterilization is 1 percent. Family Planning | 57 Table 5.3.2 Ever use of contraception: Men Percentage of all men, currently married men, and sexually active unmarried men age 15-49 who have ever used any contraceptive method by method, according to age, Namibia 2006-07 Modern method Traditional method Age Any method Any modern method Male sterili- zation Male condom Any tradi- tional method Rhythm With- drawal Number of men ALL MEN 15-19 45.7 44.4 0.4 44.2 6.4 3.7 3.3 909 20-24 84.7 83.3 1.1 83.3 23.5 12.5 16.2 751 25-29 88.8 87.6 0.7 87.6 29.0 15.4 21.7 702 30-34 90.0 88.5 1.5 88.0 32.0 13.3 24.6 586 35-39 82.7 79.9 1.7 79.0 26.2 14.1 18.8 400 40-44 74.7 71.6 2.5 70.9 23.4 12.8 16.2 331 45-49 64.7 57.5 1.1 57.1 25.1 15.0 16.5 236 Total 15-49 74.9 72.9 1.1 72.6 22.2 11.5 15.7 3,915 CURRENTLY MARRIED MEN 15-19 * * * * * * * 3 20-24 85.2 82.7 5.3 82.7 44.7 33.0 18.8 76 25-29 86.2 83.4 0.3 83.4 35.8 22.4 25.4 199 30-34 87.9 85.9 3.0 84.9 33.4 12.0 28.1 260 35-39 80.4 76.4 2.7 74.9 29.5 17.3 19.6 248 40-44 75.3 71.0 3.1 70.1 24.4 13.7 16.6 241 45-49 67.2 59.5 1.1 59.0 26.6 16.4 16.7 178 Total 15-49 80.3 76.5 2.4 75.7 30.8 17.1 21.3 1,206 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 90.8 88.0 1.5 87.4 11.3 5.9 6.6 107 20-24 95.1 94.7 1.7 94.7 24.7 15.1 16.1 203 25-29 96.0 96.0 0.8 96.0 30.5 13.3 23.9 173 30-34 96.8 96.8 0.9 96.8 32.3 11.1 25.4 137 35-39 87.5 87.5 0.0 87.5 21.2 7.5 19.3 68 40-44 (80.1) (80.1) (2.3) (80.1) (22.0) (1.2) (20.7) 33 45-49 * * * * * * * 13 Total 15-49 93.1 92.3 1.2 92.3 25.0 11.1 18.9 733 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 1 Men who had sexual intercourse within 30 days preceding the survey 5.3 CURRENT USE OF CONTRACEPTIVE METHODS This section presents information on the current level of contraceptive use among all women, currently married women, and sexually active unmarried women age 15-49. The contraceptive prevalence rate is the most widely used and valuable measure of the success of family planning programmes. Furthermore, it can be used to estimate the reduction in fertility attributable to contraception. 58 | Family Planning Current use of modern contraceptive methods among currently married women increases with age from 41 percent among women age 15-19 to 57-58 percent among those age 25-39, and then declines to 49 percent among women age 45-49. Among married women, injectables are the most commonly used contraceptive method (22 percent), followed by male condoms (11 percent) and female sterilization (10 percent). In contrast, sexually active unmarried women prefer to use injectables (24 percent) followed by male condoms (23 percent). Regardless of marital status, use of female sterilization increases with age, whereas injectables are mostly used by women while they are in their main childbearing years (age 15-34). Although not uncommonly used by women of all ages, the pill is most commonly used by women in their thirties. Younger women seem somewhat more likely to use male condoms, although male condoms are used by women of all ages. Use of female condom is very limited (less than 1 percent). Table 5.4 Current use of contraception by age Percent distribution of all women, currently married women, and sexually active unmarried women age 15-49 by contraceptive method currently used, according to age, Namibia 2006-07 Modern method Traditional method Age Any method Any modern method Female sterili- zation Male sterili- zation Pill IUD Inject- ables Im- plants Male con- dom Female con- dom Dia- phragm Any tradi- tional method Rhythm With- drawal Folk method Not currently using Total Number of women ALL WOMEN 15-19 25.2 24.5 0.1 0.0 0.9 0.0 9.4 0.0 14.0 0.1 0.0 0.7 0.4 0.0 0.3 74.8 100.0 2,246 20-24 52.6 51.4 0.2 0.0 5.3 0.1 20.7 0.0 24.4 0.6 0.0 1.2 0.2 0.2 0.8 47.4 100.0 1,855 25-29 57.8 57.5 1.1 0.0 8.0 0.4 25.6 0.0 22.0 0.2 0.2 0.2 0.0 0.0 0.2 42.2 100.0 1,623 30-34 54.7 53.5 3.4 0.1 9.9 0.9 22.5 0.3 15.9 0.4 0.2 1.2 0.6 0.1 0.5 45.3 100.0 1,417 35-39 52.6 51.5 9.9 0.3 7.2 2.1 18.7 0.4 12.3 0.5 0.0 1.1 0.4 0.2 0.4 47.4 100.0 1,045 40-44 51.2 49.8 16.3 0.9 4.1 1.0 13.3 0.1 13.6 0.2 0.2 1.4 0.3 0.1 1.0 48.8 100.0 928 45-49 41.9 40.6 23.6 0.3 3.5 0.3 4.3 0.0 8.4 0.2 0.0 1.3 0.3 0.2 0.9 58.1 100.0 689 Total 46.6 45.7 5.0 0.2 5.4 0.6 17.1 0.1 17.0 0.3 0.1 0.9 0.3 0.1 0.5 53.4 100.0 9,804 CURRENTLY MARRIED WOMEN 15-19 40.9 39.1 0.0 0.0 3.1 0.0 27.0 0.9 8.0 0.0 0.0 1.8 0.5 0.0 1.3 59.1 100.0 118 20-24 54.4 51.5 0.4 0.0 9.8 0.0 29.6 0.2 11.4 0.0 0.0 3.0 0.2 0.8 1.9 45.6 100.0 398 25-29 56.6 56.2 1.3 0.0 9.8 1.0 29.9 0.0 13.8 0.0 0.4 0.4 0.0 0.0 0.4 43.4 100.0 625 30-34 57.6 55.8 5.0 0.2 13.3 1.5 26.2 0.2 8.9 0.4 0.1 1.8 1.1 0.3 0.5 42.4 100.0 751 35-39 56.6 55.4 14.0 0.6 8.0 3.3 18.9 0.1 10.4 0.1 0.0 1.2 0.2 0.4 0.6 43.4 100.0 612 40-44 56.0 54.0 19.4 1.6 4.4 1.6 15.9 0.2 10.4 0.2 0.3 2.0 0.5 0.1 1.4 44.0 100.0 522 45-49 49.4 47.6 28.5 0.5 4.8 0.5 4.4 0.0 9.0 0.0 0.0 1.8 0.1 0.3 1.4 50.6 100.0 424 Total 55.1 53.4 10.3 0.4 8.6 1.4 21.8 0.2 10.6 0.1 0.1 1.6 0.4 0.3 0.9 44.9 100.0 3,451 SEXUALLY ACTIVE WOMEN1 15-19 68.1 67.3 0.4 0.0 3.5 0.0 24.1 0.3 39.0 0.0 0.0 0.8 0.5 0.0 0.3 31.9 100.0 334 20-24 70.8 69.6 0.0 0.0 8.8 0.1 28.6 0.1 31.5 0.4 0.0 1.2 0.1 0.5 0.7 29.2 100.0 684 25-29 71.7 71.4 1.5 0.0 10.9 0.8 31.3 0.0 26.5 0.0 0.3 0.3 0.0 0.0 0.3 28.3 100.0 742 30-34 66.5 64.9 4.7 0.2 14.3 1.6 26.6 0.3 16.7 0.4 0.0 1.6 0.8 0.3 0.5 33.5 100.0 718 35-39 64.5 63.1 12.1 0.7 10.2 3.5 20.6 0.2 15.7 0.3 0.0 1.3 0.4 0.5 0.4 35.5 100.0 528 40-44 64.6 62.5 18.6 1.5 4.7 1.9 18.6 0.2 16.9 0.0 0.0 2.1 0.5 0.1 1.5 35.4 100.0 450 45-49 54.7 52.3 30.6 0.7 6.3 0.7 3.7 0.0 10.4 0.0 0.0 2.4 0.1 0.4 1.9 45.3 100.0 316 Total 66.9 65.6 7.7 0.4 9.3 1.3 24.0 0.2 22.6 0.2 0.1 1.3 0.4 0.3 0.7 33.1 100.0 3,772 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Women who have had sexual intercourse within 30 days preceding the survey Family Planning | 59 Table 5.5 and Figure 5.1 present trends in the levels of current use of family planning meth- ods among all women between 1992 (MoHSS and ORC Macro, 1993) and 2006-07. Table 5.5 shows that the substantial increase in the proportion of all women using any method of family planning from 23 percent in 1992 to 47 percent in 2006-07 can be attributed to a sharp increase in the use of injectables and male condoms and, to a lesser extent, the use of female sterilization. Use of the pill among all women seems to have decreased somewhat, from 7 percent in 1992 to 5 percent in 2006-07. Figure 5.1 summarises the data in Table 5.5. In the 15 years between 1992 and 2006-07, the proportion of all women using family planning doubled. Use of modern contraceptive methods increased from 21 percent in 1992 to 46 percent in the 2006-07. 5.4 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS Table 5.6 presents information on the prevalence of current contraceptive use among sexually active women by background characteristics. These results enable us to examine differences in the method mix among current users in the different subgroups. Sexually active women in urban areas are more likely to use modern contraceptives (74 percent) than rural women (55 percent). Overall use of modern family planning methods is highest in Erongo and Khomas regions (79 and 78 percent, respectively), while sexually active women in Kavango are the least likely to use a modern contraceptive method (47 percent). In Oshana and Omusati, sexually active women are much more Table 5.5 Trends in contraceptive use Percentage of all women who are currently using contracep- tion, by specific method, Namibia 1992, 2000, and 2006-07 Method 1992 NDHS 2000 NDHS 2006-07 NDHS Any method 23.3 37.8 46.6 Any modern method 21.4 37.1 45.7 Female sterilization 3.8 4.3 5.0 Male sterilization 0.1 0.3 0.2 Pill 7.1 5.7 5.4 IUD 1.3 0.7 0.6 Injectables 8.6 17.0 17.1 Implants u u 0.1 Male condom 0.5 8.9 17.0 Female condom u u 0.3 Any traditional method 1.8 0.7 0.9 Rhythm/periodic abstinence 0.6 0.1 0.3 Withdrawal 0.2 0.1 0.1 Other traditional methods 1.0 0.5 0.5 Number of women 5,421 6,755 9,804 u = Unknown 23 21 38 37 47 46 Any method Any modern method 0 20 40 60 Percent 1992 NDHS 2000 NDHS 2006-07 NDHS Figure 5.1 Trends in Contraceptive Use among All Women Age 15-49, Namibia 1992-2006-07 60 | Family Planning likely to use male condoms than women in other regions (35 and 38 percent, respectively). In other regions, use of condoms ranges from 7 percent in Caprivi to 29 percent in Khomas region. As expected, contraceptive use increases with women’s level of education. Use of modern methods ranges from 37 percent among sexually active women with no education to 79 percent among women who completed secondary education. A large proportion of women (68 percent) start using contraception before having any children. The proportion of sexually active women using modern methods decreases with the number of children they have, ranging from 68 percent for women with 1-2 children to 52 percent for women with five or more children. Use of modern methods rises from 43 percent among sexually active women in the lowest wealth quintile to 78 percent among those in the highest wealth quintile. Table 5.6 Current use of contraception among sexually active women by background characteristics Percent distribution of sexually active women age 15-49 by contraceptive method currently used, according to background characteristics, Namibia 2006-07 Modern method Traditional method Background characteristic Any meth- od Any mod- ern meth- od Female sterili- zation Male sterili- zation Pill IUD Inject- ables Im- plants Male con- dom Female con- dom Dia- phragm Any tradi- tional method Rhythm With- drawal Folk method Not currently using Total Number of women Residence Urban 75.6 74.4 9.7 0.6 10.4 2.0 25.4 0.2 25.9 0.0 0.1 1.2 0.3 0.2 0.7 24.4 100.0 2,082 Rural 56.3 54.8 5.3 0.1 8.0 0.3 22.2 0.1 18.6 0.4 0.0 1.4 0.4 0.3 0.7 43.7 100.0 1,689 Region Caprivi 51.1 50.7 0.7 0.0 11.4 0.0 32.1 0.0 6.6 0.0 0.0 0.4 0.2 0.2 0.0 48.9 100.0 228 Erongo 79.5 78.5 10.2 2.1 12.1 1.4 26.1 0.3 26.3 0.0 0.0 1.0 0.0 0.0 1.0 20.5 100.0 352 Hardap 63.3 63.3 12.7 0.3 9.4 0.6 30.4 0.0 10.0 0.0 0.0 0.0 0.0 0.0 0.0 36.7 100.0 127 Karas 68.5 68.2 16.6 2.0 11.6 2.6 21.1 0.0 14.4 0.0 0.0 0.3 0.0 0.0 0.3 31.5 100.0 146 Kavango 49.6 47.1 1.4 0.0 5.4 0.0 30.8 0.0 9.5 0.0 0.0 2.4 0.0 0.0 2.4 50.4 100.0 379 Khomas 79.6 77.7 11.4 0.3 11.1 3.0 22.6 0.2 28.8 0.0 0.3 1.8 0.5 0.3 1.1 20.4 100.0 970 Kunene 57.2 56.3 3.8 0.0 6.2 0.6 21.9 0.0 23.9 0.0 0.0 0.9 0.9 0.0 0.0 42.8 100.0 137 Ohangwena 53.8 53.2 4.0 0.0 11.0 0.0 13.6 0.4 22.1 2.0 0.0 0.6 0.6 0.0 0.0 46.2 100.0 254 Omaheke 60.7 57.7 11.7 0.0 6.0 0.5 24.0 0.0 15.5 0.0 0.0 2.9 0.0 1.9 1.0 39.3 100.0 181 Omusati 66.3 66.3 3.2 0.0 6.5 0.0 17.7 0.0 38.4 0.5 0.0 0.0 0.0 0.0 0.0 33.7 100.0 247 Oshana 68.8 68.4 5.3 0.0 8.0 1.0 18.8 0.4 34.7 0.3 0.0 0.4 0.4 0.0 0.0 31.2 100.0 210 Oshikoto 62.4 60.6 6.9 0.0 6.7 0.9 21.9 0.4 23.8 0.0 0.0 1.7 1.7 0.0 0.0 37.6 100.0 248 Otjozondjupa 68.5 66.8 8.3 0.0 9.4 1.2 30.0 0.0 18.0 0.0 0.0 1.6 0.2 1.1 0.3 31.5 100.0 293 Education No education/ preschool 39.1 36.7 5.4 0.0 6.1 0.0 14.3 0.0 10.9 0.0 0.0 2.5 0.4 1.2 0.8 60.9 100.0 312 Incomplete primary 54.1 52.7 8.2 0.0 5.5 0.1 23.8 0.3 14.7 0.1 0.0 1.4 0.4 0.0 1.1 45.9 100.0 748 Complete primary 54.4 53.7 5.8 0.0 7.7 0.4 21.6 0.0 18.0 0.2 0.0 0.7 0.4 0.0 0.3 45.6 100.0 252 Incomplete secondary 73.1 72.5 6.6 0.0 8.8 1.0 29.2 0.0 26.5 0.4 0.0 0.6 0.1 0.2 0.3 26.9 100.0 1,530 Complete secondary 81.0 78.9 9.2 1.4 14.4 1.8 21.6 0.2 29.8 0.0 0.4 2.1 0.3 0.4 1.3 19.0 100.0 584 More than secondary 78.1 75.9 12.5 1.4 15.0 6.0 15.5 0.9 24.6 0.0 0.0 2.2 1.5 0.0 0.7 21.9 100.0 345 Number of living children 0 68.6 68.1 0.1 0.0 5.6 0.1 12.0 0.3 49.5 0.6 0.0 0.5 0.5 0.0 0.0 31.4 100.0 676 1-2 69.0 67.6 3.2 0.7 12.1 1.5 29.3 0.0 20.8 0.0 0.0 1.4 0.2 0.3 1.0 31.0 100.0 1,659 3-4 69.2 67.9 14.7 0.2 8.6 2.3 27.7 0.3 13.6 0.3 0.3 1.3 0.4 0.2 0.6 30.8 100.0 926 5+ 54.0 51.9 19.7 0.0 6.5 0.3 15.7 0.4 9.4 0.0 0.0 2.1 0.5 0.6 1.0 46.0 100.0 511 Wealth quintile Lowest 44.6 42.6 1.6 0.0 7.7 0.0 20.3 0.0 12.9 0.0 0.0 2.0 0.6 0.1 1.3 55.4 100.0 531 Second 57.9 57.1 3.7 0.0 6.5 0.0 23.6 0.0 22.2 1.1 0.0 0.8 0.2 0.3 0.3 42.1 100.0 540 Middle 59.3 58.5 4.7 0.0 8.3 0.3 25.7 0.1 19.3 0.0 0.0 0.8 0.3 0.2 0.3 40.7 100.0 720 Fourth 75.7 75.1 8.5 0.0 7.8 1.3 28.9 0.0 28.5 0.1 0.0 0.6 0.1 0.3 0.2 24.3 100.0 985 Highest 80.6 78.4 14.5 1.3 13.8 3.3 20.0 0.5 24.6 0.0 0.2 2.2 0.6 0.2 1.4 19.4 100.0 996 Total 66.9 65.6 7.7 0.4 9.3 1.3 24.0 0.2 22.6 0.2 0.1 1.3 0.4 0.3 0.7 33.1 100.0 3,772 Note: If more than one method is used, only the most effective method is considered in this tabulation. Family Planning | 61 Table 5.7 presents information on the prevalence of contraceptive use among all women by background characteristics. The results show that the pattern of differentials across subgroups is similar to the pattern for sexually active women. Table 5.7 Current use of contraception among all women by background characteristics Percent distribution of all women age 15-49 by contraceptive method currently used, according to background characteristics, Namibia 2006-07 Modern method Traditional method Background characteristic Any meth- od Any mod- ern meth- od Female sterili- zation Male sterili- aation Pill IUD Inject- ables Im- plants Male con- dom Female con- dom Dia- phragm Any tradi- tional method Rhythm With- drawal Folk method Not currently using Total Number of women Residence Urban 55.8 55.0 7.0 0.3 6.6 0.9 19.0 0.2 20.6 0.3 0.1 0.9 0.3 0.1 0.5 44.2 100.0 4,772 Rural 37.8 36.8 3.1 0.0 4.2 0.2 15.3 0.0 13.5 0.4 0.0 1.0 0.3 0.1 0.6 62.2 100.0 5,032 Region Caprivi 41.4 40.8 0.3 0.0 8.2 0.0 28.1 0.0 4.1 0.0 0.0 0.7 0.6 0.1 0.0 58.6 100.0 474 Erongo 60.1 59.4 8.1 1.3 8.9 0.7 21.7 0.2 18.5 0.1 0.0 0.7 0.2 0.0 0.5 39.9 100.0 688 Hardap 50.0 50.0 9.2 0.1 6.1 0.2 25.9 0.0 8.3 0.0 0.2 0.0 0.0 0.0 0.0 50.0 100.0 315 Karas 53.6 53.3 11.3 1.0 8.0 1.2 20.2 0.0 11.7 0.0 0.0 0.3 0.0 0.0 0.3 46.4 100.0 318 Kavango 37.9 35.6 1.0 0.0 3.5 0.0 23.6 0.0 7.2 0.3 0.0 2.3 0.1 0.0 2.2 62.1 100.0 934 Khomas 57.4 56.5 8.1 0.1 6.9 1.3 16.1 0.3 23.3 0.2 0.3 0.9 0.2 0.1 0.6 42.6 100.0 2,218 Kunene 49.1 48.0 3.5 0.0 4.3 0.3 18.2 0.0 21.5 0.2 0.0 1.1 0.5 0.0 0.6 50.9 100.0 259 Ohangwena 28.2 27.7 1.5 0.0 3.5 0.1 9.3 0.1 12.4 0.8 0.0 0.4 0.4 0.0 0.0 71.8 100.0 1,043 Omaheke 50.2 48.5 8.4 0.0 4.8 0.6 22.2 0.4 12.1 0.0 0.0 1.8 0.0 0.9 0.8 49.8 100.0 373 Omusati 37.4 37.1 2.4 0.0 2.9 0.1 8.8 0.0 22.2 0.6 0.0 0.4 0.0 0.0 0.4 62.6 100.0 975 Oshana 43.9 42.7 3.1 0.0 4.7 0.3 11.4 0.1 22.6 0.6 0.0 1.2 0.9 0.0 0.4 56.1 100.0 819 Oshikoto 42.5 41.7 4.4 0.0 4.2 0.6 13.7 0.1 18.4 0.2 0.0 0.9 0.9 0.0 0.0 57.5 100.0 837 Otjozondjupa 57.0 55.6 6.4 0.0 5.4 0.7 27.6 0.0 15.2 0.3 0.0 1.4 0.1 0.6 0.7 43.0 100.0 550 Education No education/ preschool 31.0 29.1 4.4 0.0 3.6 0.0 12.7 0.0 8.2 0.2 0.0 1.9 0.5 0.6 0.9 69.0 100.0 651 Incomplete primary 40.3 39.0 5.9 0.0 3.9 0.1 18.1 0.1 10.8 0.1 0.0 1.3 0.4 0.0 0.9 59.7 100.0 1,699 Complete primary 38.0 37.5 5.8 0.0 4.3 0.1 15.7 0.0 11.0 0.5 0.0 0.6 0.3 0.0 0.2 62.0 100.0 736 Incomplete secondary 47.2 46.7 3.8 0.0 4.5 0.4 19.1 0.0 18.5 0.4 0.1 0.5 0.2 0.1 0.3 52.8 100.0 4,751 Complete secondary 59.2 58.1 6.2 0.6 9.5 1.0 15.1 0.2 25.3 0.1 0.2 1.1 0.1 0.2 0.8 40.8 100.0 1,286 More than secondary 58.3 56.3 8.4 0.8 10.2 3.1 10.9 1.0 21.1 0.6 0.3 2.1 1.1 0.0 1.0 41.7 100.0 682 Number of living children 0 30.9 30.2 0.2 0.0 1.9 0.0 5.7 0.1 21.8 0.4 0.0 0.7 0.4 0.0 0.3 69.1 100.0 3,419 1-2 57.3 56.4 2.7 0.4 8.3 0.8 26.1 0.0 17.9 0.3 0.1 0.9 0.2 0.1 0.6 42.7 100.0 3,620 3-4 55.2 54.0 12.0 0.1 6.5 1.4 22.2 0.3 10.9 0.3 0.3 1.1 0.4 0.1 0.6 44.8 100.0 1,789 5+ 46.1 44.7 17.3 0.0 5.0 0.2 14.5 0.2 7.4 0.1 0.0 1.4 0.3 0.3 0.8 53.9 100.0 976 Wealth quintile Lowest 30.2 29.0 1.5 0.0 3.9 0.1 14.4 0.0 8.9 0.3 0.0 1.2 0.2 0.0 0.9 69.8 100.0 1,621 Second 37.6 36.7 2.2 0.0 3.7 0.1 15.9 0.0 14.3 0.4 0.0 0.8 0.3 0.1 0.5 62.4 100.0 1,668 Middle 43.6 43.0 3.2 0.0 4.5 0.2 18.2 0.1 16.4 0.3 0.1 0.7 0.3 0.1 0.3 56.4 100.0 1,885 Fourth 58.1 57.3 6.6 0.1 5.5 0.6 21.9 0.0 22.3 0.4 0.0 0.8 0.3 0.1 0.3 41.9 100.0 2,292 Highest 55.6 54.4 9.2 0.6 8.2 1.5 14.3 0.4 19.7 0.2 0.2 1.2 0.3 0.1 0.8 44.4 100.0 2,338 Total 46.6 45.7 5.0 0.2 5.4 0.6 17.1 0.1 17.0 0.3 0.1 0.9 0.3 0.1 0.5 53.4 100.0 9,804 5.5 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION Couples using family planning as a means to control family size (i.e., to stop having children) adopt contraception when they have already had the number of children they want. When contraception is used to space births, couples may start to use family planning earlier, with the intention to delay a possible pregnancy. This may be done before a couple has had their desired number of children. In a culture where smaller family size is becoming the norm, young women adopt family planning at an earlier age than their older counterparts. 62 | Family Planning Women interviewed in the 2006-07 NDHS were asked how many children they had the first time they used a method of family planning. Table 5.8 shows the percent distribution of women by number of living children at the time of first use of contraception, according to current age. The results indicate that overall, Namibian women are adopting family planning earlier than in the past. The proportion of women who started using a family planning method before they had any children increased from 25 percent in 2000 (MOHSS, 2003) to 32 percent in 2006-07. Table 5.8 also shows that women are using contraception at lower parities (i.e., when they have fewer children). Among women age 20-24, 52 percent first used contraception before having any children and 74 percent used contraception before having their second child. Among older women (age 45-49), only 12 percent used contraception before having any children and 29 percent used contraception before having their second child. Table 5.8 Number of children at first use of contraception Percent distribution of women age 15-49 by number of living children at the time of first use of contraception, according to current age, Namibia 2006-07 Number of living children at time of first use of contraception Current age Never used 0 1 2 3 4+ Missing Total Number of women 15-19 63.7 31.4 4.4 0.3 0.1 0.0 0.1 100.0 2,246 20-24 20.0 51.6 21.9 5.0 0.9 0.0 0.6 100.0 1,855 25-29 12.4 40.5 31.0 11.1 4.1 0.8 0.1 100.0 1,623 30-34 12.4 27.9 30.9 14.4 7.3 6.7 0.5 100.0 1,417 35-39 16.2 18.5 27.6 14.0 9.6 13.4 0.7 100.0 1,045 40-44 22.5 15.7 21.2 13.5 9.7 17.0 0.4 100.0 928 45-49 32.0 12.3 17.0 10.4 9.3 18.8 0.2 100.0 689 Total 28.3 32.0 20.9 8.4 4.5 5.5 0.4 100.0 9,804 5.6 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for successful practice of coitus-associated methods such as withdrawal and condoms. Such knowledge is particularly important for the use of the rhythm method. The 2006-07 NDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during the menstrual cycle. Respondents were asked, “From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?” If the answer was “yes,” they were further asked whether that time was just before her period begins, during her period, right after her period has ended, or halfway between two periods. Table 5.9 shows that knowledge of the fertile period is generally low among the respon- dents. Eighteen percent of all women and 23 percent of men report that they do not know when the fertile period occurs. Only 16 percent of women and 10 percent of men know that the monthly fertile period falls halfway between two periods. More than one-third of women (36 percent) and one in four men (25 percent) think that the fertile period is right after the end of the period. Compared with the results from the NDHS 2000, there has been little change in knowledge of the fertile period. Table 5.9 Knowledge of fertile period Percent distribution of all women and all men age 15-19 by knowledge of the fertile period during the ovulatory cycle, Namibia 2006-07 Perceived fertile period All women All men Just before her menstrual period begins 11.8 16.0 During her menstrual period 5.9 6.0 Right after her menstrual period has 35.9 24.7 Halfway between two menstrual periods 15.5 10.0 Other 0.1 0.9 No specific time 12.8 18.7 Don't know 17.8 23.4 Missing 0.2 0.4 Total 100.0 100.0 Number of women 9,804 3,915 Family Planning | 63 5.7 TIMING OF STERILIZATION Sterilization is a very effective, permanent method of family planning, which can be used by couples who do not want to have any more children. Consequently, it is of interest to know whether the age at which women adopt sterilization is increasing or declining. In the 2006-07 NDHS, women who reported that they use female sterilization as a contraceptive method were asked additional questions about how old they were when the procedure was performed. More than half (56 percent) of sterilized women were sterilized before age 35, and 86 percent were sterilized before age 40 (Table 5.10). Data from the 2006-07 NDHS indicate that the median age at sterilization may have decreased recently: it was 35.8 years among women who had the operation 4-5 years prior to the survey and 33.5 years among women who were sterilized less than two years before the survey. Compared with the 2000 NDHS, the age at which women are sterilized has remained relatively steady. Table 5.10 Timing of sterilization Percent distribution of sterilized women age 15-49 by age at the time of sterilization and median age at sterilization, according to the number of years since the operation, Namibia 2006-07 Age at time of sterilization Years since operation <25 25-29 30-34 35-39 40-44 45-49 Total Number of women Median age1 <2 4.4 14.5 19.1 26.6 28.4 7.0 100.0 92 33.5 2-3 6.4 13.9 32.0 28.6 16.8 2.3 100.0 77 34.3 4-5 5.0 6.7 27.7 46.2 14.4 0.0 100.0 59 35.8 6-7 0.5 14.9 27.1 40.6 16.9 0.0 100.0 66 34.7 8+ 6.1 28.3 41.5 23.4 0.7 0.0 100.0 193 a Total 4.9 19.0 32.1 29.9 12.4 1.7 100.0 488 33.2 1 Median age at sterilization is calculated only for women sterilized before age 40 to avoid problems of censoring a = Not calculated due to censoring 5.8 SOURCE OF CONTRACEPTION Information on where women obtain their contraceptives is useful for family planning programme managers and implementers of logistic planning. In the 2006-07 NDHS, women who reported using a modern contraceptive method at the time of the survey were asked where they obtained the method the last time. Because some women may not know in which source category their method falls (e.g., government or private, health centre or clinic), interviewers were instructed to note the full name of the source or facility. Supervisors and field editors were told to verify that the name and source type were consistent, asking informants in the clusters for the names of local family planning outlets, if necessary. This practice was designed to improve the accuracy of source reporting. Table 5.11 shows that public (government) facilities provide contraceptives to 75 percent of users, while 10 percent are supplied through private medical sources and 13 percent through other private sources (e.g., shops, friends). The most common single source of contraceptive methods in Namibia is government health centres, which supply 46 percent of all users of modern methods. Government hospitals supply about one-fourth of users. As expected, government sources supply a larger proportion of users of long-term methods, such as injectables (95 percent), the pill (82 percent), and female sterilization (74 percent). On the other hand, two in three women who use the IUD had their IUD inserted at a private medical institution, 26 percent in a private hospital or clinic, and 38 percent by a private doctor. More than half of all condom users get their supplies from public sources and 36 percent from private, nonmedical sources, such as shops and friends. The most common sources of male condoms are private shops (29 percent), government health centres (27 percent), and government hospitals (21 percent). 64 | Family Planning Over time, pill users are more likely to obtain their pills from private medical facilities—17 percent in 2006-07 compared with 12 percent in 2000 (MOHSS, 2003). Over the same period, shops have gained considerable popularity in supplying male condoms—from 4 percent in 2000 to 29 percent in 2006-07. In fact, the increase in the use of other private sources for condoms—from 14 percent in 2000 to 36 percent in 2006-07 can be attributed to the increase in shops that sell male condoms. Table 5.11 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Namibia 2006-07 Source Female sterili- zation Pill IUD Inject- ables Male condom Total Public 74.0 82.0 32.7 95.2 53.7 74.5 Government hospital 71.9 15.2 32.7 20.3 21.0 25.9 Government health centre 2.1 65.2 0.0 74.0 27.3 46.0 PHC clinic (mobile) 0.0 1.3 0.0 0.7 1.9 1.1 Community health worker 0.0 0.2 0.0 0.1 1.7 0.7 Other public 0.0 0.0 0.0 0.1 1.9 0.8 Private medical 24.4 16.9 65.5 3.9 6.9 10.1 Hospital/clinic 23.6 3.8 25.9 1.9 0.2 4.5 Pharmacy 0.0 7.1 1.4 0.1 6.3 3.3 Private doctor 0.8 6.0 38.2 1.8 0.3 2.2 Other private 0.0 0.0 0.0 0.2 0.0 0.1 Other private 0.0 0.8 1.8 0.2 35.5 13.4 Shop 0.0 0.3 1.8 0.2 29.4 11.1 Church 0.0 0.0 0.0 0.0 0.1 0.0 Friend/relative 0.0 0.5 0.0 0.0 6.1 2.3 Other 0.1 0.0 0.0 0.2 2.9 1.2 Don’t know 0.6 0.0 0.0 0.0 0.0 0.1 Missing 0.9 0.3 0.0 0.5 1.0 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 488 528 54 1,678 1,663 4,477 Note: The total includes users of male sterilization (15), implants (11), female condom (32), and diaphragm (7) which are not shown separately, but excludes lactational amenorrhoea method (LAM). 5.9 COST OF CONTRACEPTION Information on the cost of obtaining contraceptive methods is useful to family planning programmes. In Namibia, to improve accessibility, family planning services provide contraceptive methods free of charge in government health facilities. In the 2006-07 NDHS, for the first time, women who were using modern methods of contra- ception were asked how much they paid in total the last time they obtained their method, including the cost of the method and any consultation costs they may have paid. Table 5.12 shows the percentage of women who obtain their method free and, for those who paid, the median cost by method and source. These results should be used with caution, however, because of the large proportion of respondents that were unable to report the cost of the contraceptive method they were using. The median cost is calculated based on users who paid for their method. Forty-two percent of sterilization users who had their operation in a public facility did not pay for the service and 16 percent did not know how much the operation cost. Therefore, the median cost was based on the remaining 42 percent of women (152 women) who paid for the sterilization operation. By the same token, 4 percent of users who had the operation in a private facility did not pay for the service and 73 percent did not know how much they paid for the operation. Therefore, the median cost was based on the remaining 23 percent of women (29 women) who paid for the sterilization operation. the reason Family Planning | 65 for the large proportion of respondents who were unable to report the cost of the service is partly due to payment procedures, especially in the private sector where the claims are handled by the service providers. Overall, male condoms are the least expensive contraceptive method (N$4), and the IUD is the most expensive (N$349). The cost for contraception varies markedly between public and private sectors. For example, the cost of female sterilization in the public sector is only N$30 compared with N$567 in the private sector. While a cycle of pills costs only N$9 in the public sector, it is N$70 in the private sector. On the other hand, the price of male condoms does not vary much between the public and private sectors (N$3 and N$4 per packet, respectively). Table 5.12 Cost of modern contraceptive methods Percentage of current users of modern contraceptive methods age 15-49 who did not pay for the method and who do not know the cost of the method and the median cost of the method by current method and source of current method, Namibia 200-07 Source of method/cost Female sterili- zation Pill IUD Inject- ables Male condom Total Public sector Percentage free 42.2 0.0 0.0 0.0 0.0 4.6 Do not know cost 16.1 0.0 0.0 0.1 0.6 2.0 Median cost1 29.6 8.5 * 4.7 2.9 19.7 Number of women 362 433 18 1,598 893 3,334 Private medical sector/other Percentage free 3.8 0.0 0.0 0.0 0.0 0.4 Do not know cost 72.7 0.7 0.0 1.5 2.7 10.9 Median cost1 566.5 69.9 (399.4) 29.6 4.2 4.7 Number of women 127 95 37 80 771 1,143 Total Percentage free 32.2 0.0 0.0 0.0 0.0 3.5 Do not know cost 30.8 0.1 0.0 0.1 1.6 4.3 Median cost1 34.8 59.8 349.2 25.6 4.1 4.9 Number of women 488 528 55 1,678 1,664 4,477 Note: The total includes users of male sterilization (15), implants (11), female condom (32), and diaphragm (7) which are not shown separately. Table excludes lactational amenorrhoea method (LAM). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 cases and has been suppressed. 1 In Namibian dollars. Costs are based on the last time current users obtained method. Costs include consultation costs, if any. For condoms, costs are per package; for pills, per cycle. For sterilization, data are based on women who received the operation in the five years before the survey. 5.10 INFORMED CHOICE Current users of modern contraceptive methods who are well informed about the side effects and problems associated with methods and know a range of method options are better prepared to make an informed choice about the method they would like to use. Current users of modern contraceptive methods were asked whether, at the time they adopted the particular method, they were informed about side effects or problems that they might have with the method. Table 5.13 shows the percentage of current users of modern methods who were informed about the side effects or problems with the method used, informed about what to do if side effects were experienced, and informed about other methods they could use by type of method and source of method. 66 | Family Planning Table 5.13 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods that could use, by method and initial source of method, Namibia 2006-07 Among women who started last episode of modern contraceptive method within five years preceding the survey: Method/source Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if side effects experienced Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilization 55.1 47.7 56.5 200 Pill 59.7 54.2 62.1 426 IUD 69.5 71.9 69.9 41 Injectables 50.7 46.2 56.7 1,473 Other (17.8) (20.5) (66.5) 40 Initial source of method1 Public 53.5 48.9 58.4 1,912 Government hospital 62.2 58.2 61.1 594 Government health centre 49.5 44.5 56.9 1,291 Other public (54.5) (48.7) (69.2) 27 Private medical 69.6 63.2 74.9 187 Private hospital/clinic 59.8 57.0 73.5 106 Private pharmacy 77.9 46.4 65.6 19 Private doctor 84.6 79.6 80.0 62 Other private 32.8 32.8 59.2 7 Other 100.0 100.0 100.0 7 Total 53.3 48.6 58.2 2,180 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Source at start of current episode of use Overall, 53 percent of current users of modern methods were informed about the side effects or problems associated with the method used, 49 percent were informed of what to do if they experienced side effects, and 58 percent were informed by a health or family planning worker of other methods that could be used. Users of the IUD were most likely to be informed of side effects, what to do if the user experiences them, and what other contraceptive methods are available. In general, users were more likely to be informed of contraceptive options and the potential side effects and problems when seeking contraceptive methods from private medical facilities rather than from public facilities. Substantial improvements in informed choice were observed since the 2000 NDHS (MOHSS, 2003). Overall, those informed about side effects increased from 38 percent in 2000 to 53 percent in 2006-07. The proportion of women who were informed about what to do if they experienced side effects increased from 33 percent to 49 percent in the same period. Information about alternative contraceptive methods was given to 58 percent of women in 2006-07, an increase from 40 percent in 2000. Larger gains were observed among private medical facilities, where estimates for each indicator doubled. Family Planning | 67 5.11 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which nonusers of contraception plan to use a method. Women who were not currently using a method of contraception were asked about their intention to use family planning in the future. The results are presented in Table 5.14. Sixty-two percent of nonusers say that they intend to use contraception in the future, 28 percent do not intend to use contraception, and 8 percent are unsure. The proportion of women who intend to use a contraceptive method varies with the number of living children, decreasing from 66 percent for those with no child to 48 percent for women with four or more children. There has been a slight decline in the proportion of nonusers who say they intend to use contraception in the future, from 64 percent in 2000 to 62 percent in 2006-07. Likewise, the proportion of nonusers who do not intend to use contraception decreased from 30 percent in 2000 to 28 percent in 2006-07. Table 5.14 Future use of contraception Percent distribution of women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Namibia 2006-07 Number of living children1 Intention 0 1 2 3 4+ Total Intends to use 66.4 67.4 64.2 59.6 48.3 62.4 Unsure 9.5 4.6 5.3 7.8 7.1 7.5 Does not intend to use 22.4 25.4 28.7 30.1 42.9 28.2 Missing 1.7 2.7 1.8 2.4 1.7 1.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,210 858 736 506 925 5,235 1 Includes current pregnancy 5.12 REASONS FOR NOT INTENDING TO USE Table 5.15 presents the main reasons for not intending to use contraception as reported by currently married female nonusers and all female nonusers who do not intend to use a contraceptive method in the future. The most commonly cited reasons for intending not to use contraception were related to: fertility desires or problems (43 percent for currently married women and 47 percent for all women), concerns with contraceptive methods (21 percent for currently married women and 23 percent for all women), and general opposition to use (14 percent for currently married women and 9 percent for all women). The most common specific reasons for not intending to use contraception were a desire for more children (17 percent for currently married women and 9 percent for all women), being menopausal or having had a hysterectomy (13 percent for currently married women and 8 percent for all women), and health concerns related to contraceptive methods (11 percent for currently married women and 10 percent for all women). Comparing the 2000 NDHS and the 2006-07 NDHS, there has been a slight decrease in the proportion of all women who cited the various reasons for not intending to use contraception except infrequent sex, which has increased from 15 percent in 2000 to 19 percent in 2006-07. The proportion of women who cited health concerns and fear of the side effects of using contraception has not changed since 2000 (15 percent). 68 | Family Planning Table 5.15 Reason for not intending to use contraception in the future Percent distribution of currently married women and all women age 15-49 who are not using contraception and who do not intending to use in the future by main reason for not intending to use, Namibia 2006 Percent Reason Currently married women All women Fertility-related reasons 42.7 47.3 Infrequent sex/no sex 5.0 18.8 Menopausal/had hysterectomy 12.7 7.9 Subfecund/infecund 7.8 8.3 Wants as many children as possible 17.2 12.3 Opposition to use 13.9 9.1 Respondent opposed 7.0 4.9 Husband/partner opposed 5.2 2.3 Others opposed 0.3 0.4 Religious prohibition 1.4 1.5 Lack of knowledge 4.0 4.0 Knows no method 3.9 3.8 Knows no source 0.1 0.2 Method-related reasons 20.9 23.4 Health concerns 10.9 10.4 Fear of side effects 4.3 8.5 Lack of access/too far 0.1 0.0 Cost too much 1.1 0.9 Inconvenient to use 0.8 1.0 Interfere with body's normal process 3.7 2.6 Other 12.3 9.2 Don't know 5.3 6.6 Missing 0.9 0.5 Total 100.0 100.0 Number of women 544 1,346 5.13 PREFERRED METHOD FOR FUTURE USE Demand for specific contraceptive methods can be assessed by asking nonusers which method they intend to use in the future. Table 5.16 presents information on preferred contraceptive method among married women and all women who are not using contraception but say they intend to use in the future. The majority of currently married women (55 percent) and nearly half of all women (44 percent) reported injectables as their preferred method. Fifteen percent of currently married women and 19 percent of all women prefer the pills and 13 percent of currently married women and 24 percent of all women prefer male condoms. Female sterilization is favoured by 11 percent of currently married women and 5 percent of all women. Family Planning | 69 The popularity of injectables declined slightly between the 2000 NDHS and the 2006-07 NDHS, from 46 percent to 44 percent, as did female sterilization, from 8 percent to 5 percent. On the other hand, preference for male condoms increased from 20 percent to 24 percent. Less than 1 percent of women said that they plan to use a traditional method of contraception (e.g., rhythm, periodic abstinence, and withdrawal), which is the same rate as in the 2000 NDHS. 5.14 EXPOSURE TO FAMILY PLANNING MESSAGES The media can be a major source of family planning messages. Information on the level of public exposure to particular types of media allows policymakers to use the most effective media to target different population groups. To assess the effectiveness of such media on the dissemi- nation of family planning information, all respondents in the 2006-07 NDHS were asked whether they had heard or seen family planning messages in the past six months on the radio, on television, or in a newspaper or magazine. Table 5.17 shows that there are only small differ- ences in exposure to family planning messages through the media according to gender. More than half of women and men heard a family planning message on the radio, 27 to 28 percent saw a message on the television, and 30 to 32 percent read about family planning in a newspaper or magazine. Thirty- nine percent of women and 36 percent of men were not exposed to any family planning messages through these media sources. Urban respondents are more likely than rural respondents to be exposed to family planning messages through mass media, especially through television and print media. Respondents age 25-39 are generally more likely to have been exposed to a family planning message than respondents in other age groups. Across regions, women in Caprivi, Omusati, and Kunene are the least likely to be exposed to any of the media messages. Among men, the least likely to be exposed to family planning messages through mass media are those who live in Oshana, Kunene, and Oshikoto. Media exposure to family planning messages is positively related to the respondent’s education and wealth quintile. Table 5.16 Preferred method of contraception for future use Percent distribution of currently married women and all women age 15-49 who are not using a contraceptive method but who intend to use in the future by preferred method, Namibia 2006 Percent Method Currently married women All women Female sterilization 11.2 5.3 Male sterilization 0.1 0.3 Pill 14.7 19.0 IUD 2.2 1.0 Injectables 54.7 44.2 Implants 0.7 0.3 Condom 12.7 24.4 Female condom 0.4 2.4 Diaphragm 0.0 0.1 Periodic abstinence 0.2 0.2 Withdrawal 0.1 0.0 Other 0.6 0.5 Unsure 2.3 2.3 Total 100.0 100.0 Number of women 880 3,266 70 | Family Planning Table 5.17 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on the radio or television or in a newspaper in the past six months, according to background characteristics, Namibia 2006-07 Women Men Background characteristic Radio Television News- paper/ magazine None of these three media sources Number of women Radio Television News- paper/ magazine None of these three media sources Number of men Age 15-19 44.8 25.8 28.3 44.3 2,246 44.0 24.9 27.3 41.1 910 20-24 53.2 29.4 31.7 38.3 1,855 53.9 26.1 31.8 34.3 750 25-29 55.5 30.9 32.4 36.8 1,623 54.2 28.1 33.3 36.1 702 30-34 56.2 28.7 32.1 36.5 1,417 60.5 28.9 35.7 33.5 586 35-39 55.6 26.6 30.6 38.7 1,045 59.1 31.9 35.7 29.5 400 40-44 55.4 28.3 30.0 36.7 928 60.7 27.3 33.7 33.7 331 45-49 51.0 23.9 25.2 42.5 689 56.3 28.4 31.5 35.5 235 Residence Urban 57.1 45.8 44.4 29.4 4,772 56.3 40.5 44.8 27.9 1,962 Rural 47.9 11.0 17.0 48.8 5,032 51.5 14.2 19.5 43.4 1,953 Region Caprivi 41.2 10.8 7.3 57.3 474 52.8 18.9 25.9 44.9 189 Erongo 61.3 47.3 50.6 20.7 688 48.2 28.1 41.6 32.9 362 Hardap 59.6 38.6 37.0 30.6 315 56.2 27.2 25.6 37.9 132 Karas 56.0 36.6 36.7 35.9 318 61.4 46.9 41.7 25.7 157 Kavango 53.5 18.2 13.1 44.3 934 64.8 18.9 14.5 30.6 331 Khomas 55.0 48.8 48.6 28.8 2,218 55.4 42.8 45.3 27.0 984 Kunene 45.3 23.5 21.4 50.1 259 47.9 24.6 20.4 48.2 92 Ohangwena 50.7 10.0 22.5 45.1 1,043 63.0 24.9 30.1 33.6 306 Omaheke 49.0 17.3 14.1 46.9 373 51.2 17.4 18.9 40.0 188 Omusati 39.9 10.0 20.3 55.9 975 61.2 10.5 25.2 33.4 320 Oshana 56.7 23.1 29.4 36.9 819 30.4 13.3 29.4 54.1 270 Oshikoto 54.8 18.7 24.5 40.0 837 48.6 17.9 25.7 47.2 322 Otjozondjupa 53.0 36.4 31.1 40.4 550 53.1 32.3 29.5 40.2 262 Education No education/ preschool 34.8 5.5 3.9 63.6 651 45.1 11.4 6.0 53.9 360 Incomplete primary 46.4 11.8 10.2 51.5 1,699 48.2 12.7 14.2 47.9 856 Complete primary 51.2 16.8 19.5 46.1 736 51.6 22.6 20.9 39.2 252 Incomplete secondary 54.8 29.2 32.3 37.1 4,751 55.7 29.8 35.7 32.1 1,604 Complete secondary 58.5 50.8 55.4 23.3 1,286 61.9 45.3 53.9 20.1 538 More than secondary 57.3 50.1 56.2 24.9 682 58.9 47.8 66.0 22.0 305 Wealth quintile Lowest 37.4 3.3 9.1 60.8 1,621 44.6 5.1 10.2 54.2 560 Second 49.2 6.5 13.9 48.3 1,668 56.2 12.7 19.9 38.8 607 Middle 52.1 13.3 18.5 44.4 1,885 53.1 15.7 22.7 41.3 875 Fourth 62.1 43.3 42.2 27.8 2,292 61.7 43.7 43.7 26.2 963 Highest 55.8 57.1 54.7 25.3 2,338 50.7 45.1 50.7 26.5 911 Total 15-49 52.4 27.9 30.3 39.4 9,804 53.9 27.4 32.2 35.6 3,915 5.15 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS In the 2006-07 NDHS, women who were not using any family planning method were asked whether they had been visited by a health worker who talked with them about family planning in the 12 months preceding the survey. This information is especially useful for determining whether nonusers of family planning are being reached by family planning outreach programmes. Nonusers were also asked if they had visited a health facility in the preceding 12 months for any reason other than family planning and, if so, whether any health worker at the facility spoke to them about family planning. These questions can assess the level of so-called “missed opportunities” to inform women about contraception. The findings are presented in Table 5.18. Family Planning | 71 Only 7 percent of women who were not using family planning were visited by a community health worker and discussed family planning with the fieldworker, and 7 percent of women went to a health facility for some reason other than family planning but did discuss family planning with the staff. The majority of women (88 percent) neither discussed family planning at home with a fieldworker nor at a health facility. The extent of missed opportunities does not vary much by background characteristics, except by region, ranging from 82 percent in Ohangwena to 96 percent in Hardap. Table 5.18 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the last 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who neither discussed family planning with a fieldworker nor at a health facility, by background characteristics, Namibia 2006-07 Percentage of women who visited a health facility in the past 12 months and who: Background characteristic Percentage of women who were visited by a fieldworker who discussed family planning Discussed family planning Did not discuss family planning Percentage of women who neither discussed family planning with a field- worker nor at a health facility Number of women Age 15-19 7.2 2.9 14.9 91.5 1,679 20-24 6.6 8.3 19.1 87.1 880 25-29 9.1 10.1 22.7 83.9 685 30-34 6.6 11.6 24.8 84.3 642 35-39 8.8 6.6 29.0 88.6 496 40-44 6.7 5.5 25.2 90.0 453 45-49 7.4 4.8 21.4 89.9 400 Residence Urban 5.7 5.7 20.6 90.2 2,107 Rural 8.6 7.1 20.6 87.1 3,128 Region Caprivi 3.2 8.0 29.3 90.2 278 Erongo 4.9 7.6 19.8 87.9 275 Hardap 1.4 3.5 18.1 95.7 157 Karas 7.6 7.6 17.0 86.0 147 Kavango 5.0 6.1 13.1 91.5 580 Khomas 4.3 5.1 20.8 91.8 944 Kunene 9.1 5.6 30.4 89.2 132 Ohangwena 14.3 8.3 22.4 82.3 749 Omaheke 8.0 6.7 17.3 87.7 186 Omusati 9.0 6.9 23.0 86.6 610 Oshana 8.0 5.4 17.3 88.5 460 Oshikoto 10.7 7.1 18.4 84.8 481 Otjozondjupa 2.1 6.7 28.6 92.3 236 Education No education/preschool 5.9 3.6 21.5 92.0 449 Incomplete primary 8.6 6.3 21.6 88.0 1,015 Complete primary 7.2 4.6 21.4 89.7 456 Incomplete secondary 7.7 7.2 18.1 87.5 2,507 Complete secondary 6.6 6.8 22.9 88.1 525 More than secondary 4.5 8.7 32.0 89.6 284 Wealth quintile Lowest 8.9 6.2 21.3 87.9 1,132 Second 8.7 6.8 19.4 86.6 1,042 Middle 7.0 7.8 19.6 88.2 1,063 Fourth 6.5 7.2 18.4 88.5 961 Highest 5.7 4.7 24.0 90.6 1,039 Total 7.4 6.5 20.6 88.3 5,235 72 | Family Planning 5.16 HUSBAND/PARTNER’S KNOWLEDGE OF WOMEN’S CONTRACEPTIVE USE Use of family planning methods is facilitated when couples discuss and agree on the issue. To assess the extent to which women use contraception without telling their husband/partners, the 2006- 07 NDHS asked married women whether their husband/partners knew that they were using a method of family planning. The majority of women (92 percent) reported that their husband was aware that they were using contraception (Table 5.19). Husband’s knowledge of their wife’s use of contraception increases with age, education, and wealth status. Across regions, it ranges from 85 percent in Kunene to 96 percent in Omusati. Table 5.19 Husband/partner's knowledge of women's use of contraception Among currently married women age 15-49 who are using a contraceptive method, percent distribution by whether they report that their husband/partners know about their use of contraception, according to background characteristics, Namibia 2006-07 Background characteristic Knows1 Does not know Unsure whether knows/ missing Total Number of women Age 15-19 86.4 4.9 8.7 100.0 48 20-24 89.9 4.0 6.1 100.0 217 25-29 92.2 4.8 2.9 100.0 354 30-34 91.8 3.2 5.0 100.0 433 35-39 89.8 4.8 5.4 100.0 346 40-44 94.1 4.3 1.6 100.0 292 45-49 92.2 2.2 5.6 100.0 209 Residence Urban 91.7 3.2 5.2 100.0 1,132 Rural 91.4 5.2 3.4 100.0 767 Region Caprivi 88.1 6.3 5.6 100.0 88 Erongo 91.6 3.2 5.2 100.0 228 Hardap 90.5 5.5 4.0 100.0 82 Karas 94.1 1.5 4.4 100.0 89 Kavango 87.8 8.1 4.1 100.0 187 Khomas 93.6 1.4 5.0 100.0 514 Kunene 85.0 3.0 12.0 100.0 64 Ohangwena 89.0 8.7 2.3 100.0 83 Omaheke 87.4 5.0 7.6 100.0 78 Omusati 96.4 1.8 1.9 100.0 97 Oshana 91.1 5.6 3.2 100.0 107 Oshikoto 91.2 5.6 3.1 100.0 124 Otjozondjupa 93.8 4.4 1.7 100.0 160 Education No education/preschool 88.3 7.7 3.9 100.0 138 Incomplete primary 87.5 6.7 5.8 100.0 371 Complete primary 87.9 9.4 2.6 100.0 112 Incomplete secondary 93.3 2.9 3.8 100.0 758 Complete secondary 92.4 1.0 6.7 100.0 298 More than secondary 94.9 2.3 2.8 100.0 224 Wealth quintile Lowest 89.3 7.5 3.2 100.0 188 Second 88.1 7.2 4.7 100.0 235 Middle 92.0 5.0 2.9 100.0 333 Fourth 91.7 2.8 5.4 100.0 530 Highest 93.2 2.1 4.7 100.0 614 Total 91.6 4.0 4.5 100.0 1,900 1 Includes women who reported use of male sterilization, male condoms or withdrawal Family Planning | 73 5.17 Men's Attitude Towards Contraception When couples have a positive attitude toward family planning, they are more likely to adopt a family planning method. It is especially important that the man's attitude is positive because the man is usually the main decision maker in the household. Male respondents in the 2006-07 NDHS were asked to indicate whether they agree or disagree with two statements: 1) Contraception is women’s business and a man should not have to worry about it, and 2) Women who use contraception may become promiscuous. The results are presented in Table 5.20. Overall, 22 percent of men say that contraception is women’s business. This view varies little according to men’s age, urban-rural residence, and wealth except that men in the highest wealth quintile are the least likely to hold the view (17 percent). In general, men who are less educated are more likely to agree with the statement. The view is also more common among men who are divorced, separated, or widowed (34 percent) and among men who live in Ohangwena (32 percent), Oshana (31 percent), and Omaheke (28 percent). Forty-three percent of all men say that women who use contraception may become promiscuous. In general, this view is more common among never-married men (45 percent), rural men (49 percent), and men who live in Omusati (78 percent) and Kunene (64 percent). Less educated men and less wealthy men are also more likely to agree with these statements. For instance, while 50 percent of men who did not complete primary education say that using contraception may make a woman promiscuous, only 34 percent of men who completed secondary education share this view. Similarly, while 49 percent of men in the lowest wealth quintile say that using contracep- tion may make a woman promiscuous, only 30 percent of men in the highest wealth quintile do. Men who live in Erongo and Karas (both 24 percent) were the least likely to hold this view. Table 5.20 Male attitudes about the use of contraception Among men age 15-49, percentage who believe that contraception is a woman's business and percentage who believe that a woman using contraception may become promiscuous, according to background characteristics, Namibia 2006 Background characteristic Believes contraception is a woman's business Believes a woman using contraception may become promiscuous Number of men Age 15-19 22.8 42.6 910 20-24 22.6 46.3 750 25-29 21.9 43.9 702 30-34 22.2 42.0 586 35-39 19.2 42.1 400 40-44 23.0 36.0 331 45-49 22.6 43.8 235 Marital status Never married 22.6 44.5 2,545 Married or living together 19.7 39.8 1,205 Divorced/separated/ widowed 34.1 40.9 163 Residence Urban 22.8 37.3 1,962 Rural 21.5 48.6 1,953 Region Caprivi 21.8 46.8 189 Erongo 19.9 23.5 362 Hardap 18.7 34.9 132 Karas 18.1 23.7 157 Kavango 22.2 37.4 331 Khomas 25.8 41.6 984 Kunene 24.5 63.5 92 Ohangwena 32.1 42.8 306 Omaheke 28.3 45.3 188 Omusati 12.1 78.2 320 Oshana 31.4 48.4 270 Oshikoto 8.6 46.5 322 Otjozondjupa 18.4 32.3 262 Education No education/preschool 20.8 46.0 360 Incomplete primary 27.2 49.7 856 Complete primary 27.3 48.6 252 Incomplete secondary 23.4 44.6 1,604 Complete secondary 17.1 34.2 538 More than secondary 7.6 21.8 305 Wealth quintile Lowest 23.1 49.2 560 Second 20.2 54.3 607 Middle 25.2 48.3 875 Fourth 24.7 39.2 963 Highest 17.3 30.3 911 Total 22.2 42.9 3,915 Note: Total includes one man with information missing on marital status 74 | Family Planning 5.18 Men's Attitude Towards Childbearing Male respondents in the 2006- 07 NDHS were also asked to indicate whether they agree or disagree with two statements: 1) Childbearing is a woman’s concern and there is no need for the father to get involved, and 2) It is crucial for the health of the mother and child that a woman has assistance from a doctor or nurse at delivery. The findings are presented in Table 5.21. Overall, 16 percent of men say that having children is women’s busi- ness. This view varies according to background characteristics. Younger men tend to agree with this statement (18 percent for men age 15-19 com- pared with 12 percent of men age 45-49). Never-married men and men who were formerly married are more likely than married men to say that having children is women’s business. This view is more accepted by rural men than by urban men. Men in Ohangwena are by far the most likely to agree with this statement (40 per- cent), while in other regions the pro- portion ranges from 5 percent in Karas to 22 percent in Oshana. Acceptance of this view declines with the man’s education and household wealth quin- tile. For example, 24 percent of men with no education agree with this statement compared with 4 percent of men with more than secondary edu- cation. Men in the highest wealth quintile are the least likely to hold the view (8 percent) compared with 21 percent of men in the lowest wealth quintile. Nine in ten men acknowledge the importance of consultation with medical personnel during delivery. There are small variations across sub- groups of men. Table 5.21 Male attitudes about childbearing Among men age 15-49, percentage who believe that childbearing is a woman's concern and there is no need for the father to get involved and percentage who agree that assistance from a doctor or nurse at delivery is crucial for the health of the mother and child, according to background characteristics, Namibia 2006 Background characteristic Believe childbearing is a woman's business and there is no need for the father to get involved Agree that assistance from a doctor or nurse at delivery is crucial for the mother and child's health Number of men Age 15-19 18.4 88.4 910 20-24 16.8 91.7 750 25-29 13.9 91.6 702 30-34 15.9 90.2 586 35-39 11.7 94.1 400 40-44 15.6 89.9 331 45-49 11.7 89.7 235 Marital status Never married 16.9 89.5 2,545 Married or living together 12.4 92.6 1,205 Divorced/separated/ widowed 19.4 94.9 163 Residence Urban 12.2 94.0 1,962 Rural 19.0 87.3 1,953 Region Caprivi 13.1 96.9 189 Erongo 10.9 96.4 362 Hardap 10.6 97.6 132 Karas 5.4 80.4 157 Kavango 19.4 93.6 331 Khomas 12.4 95.2 984 Kunene 19.0 95.4 92 Ohangwena 39.9 60.6 306 Omaheke 18.8 78.4 188 Omusati 9.3 97.5 320 Oshana 21.8 96.5 270 Oshikoto 7.1 94.9 322 Otjozondjupa 19.5 82.9 262 Education No education/preschool 24.3 83.8 360 Incomplete primary 22.4 87.2 856 Complete primary 18.4 91.7 252 Incomplete secondary 14.3 92.4 1,604 Complete secondary 7.8 94.2 538 More than secondary 4.2 92.2 305 Wealth quintile Lowest 20.9 85.9 560 Second 20.6 89.1 607 Middle 19.8 89.7 875 Fourth 12.5 90.5 963 Highest 8.2 95.7 911 Total 15.6 90.7 3,915 Note: Total includes one man with information missing on marital status Other Proximate Determinants of Fertility | 75 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter addresses the principal factors, other than contraception, which affect a woman’s risk of becoming pregnant. These factors include marriage, polygyny, sexual activity, postpartum amenorrhoea, abstinence from sexual activity, and onset of menopause. In societies where sexual activity usually takes place within marriage, marriage signals the onset of a woman’s exposure to the risk of pregnancy. Populations in which age at first marriage is low tend to have early childbearing and high fertility. Postpartum amenorrhoea and sexual abstinence affect the duration of a woman’s insusceptibility to pregnancy, which in turn affects birth spacing. These variables taken together determine the length and pace of a woman’s reproductive life and are therefore important for understanding fertility. 6.1 CURRENT MARITAL STATUS While marriage and cohabitation are generally considered to be primary indicators of exposure to the risk of pregnancy, many women in Namibia bear children without entering a stable union. Visiting relationships are common and many women have children in the context of such unions. Table 6.1 shows data on the current marital status of women and men interviewed in the survey. In this table, the term “married” is intended to mean legal, traditional, or formal marriage, while “living together” designates an informal union. However, in future tables, the term “currently married” refers to both formal and informal unions. Table 6.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Namibia 2006-07 Marital status Age Never married Married Living together Divorced Separated Widowed Missing Total Percentage of respondents currently in union Number of respondents WOMEN 15-19 94.5 1.0 4.2 0.0 0.2 0.0 0.0 100.0 5.3 2,246 20-24 75.9 5.2 16.2 0.0 2.3 0.2 0.1 100.0 21.5 1,855 25-29 55.4 17.0 21.5 0.4 4.7 1.0 0.0 100.0 38.5 1,623 30-34 39.7 31.6 21.4 1.5 3.5 2.3 0.0 100.0 53.0 1,417 35-39 30.7 37.9 20.7 1.3 5.0 4.3 0.1 100.0 58.5 1,045 40-44 26.1 41.8 14.5 4.2 5.5 8.0 0.0 100.0 56.2 928 45-49 17.1 46.7 14.8 3.7 6.0 11.7 0.0 100.0 61.5 689 Total 15-49 57.9 19.9 15.3 1.1 3.3 2.6 0.0 100.0 35.2 9,804 MEN 15-19 99.6 0.0 0.3 0.0 0.1 0.0 0.0 100.0 0.3 910 20-24 87.1 1.9 8.2 0.2 2.6 0.0 0.0 100.0 10.1 750 25-29 65.4 12.3 16.1 0.1 5.8 0.2 0.2 100.0 28.4 702 30-34 47.9 22.0 22.4 0.7 6.5 0.5 0.0 100.0 44.4 586 35-39 33.5 38.8 23.2 0.6 3.8 0.0 0.0 100.0 62.0 400 40-44 21.3 54.9 18.0 1.1 3.4 1.2 0.0 100.0 72.9 331 45-49 17.3 60.2 15.5 2.7 2.6 1.8 0.0 100.0 75.7 235 Total 15-49 65.0 18.1 12.7 0.5 3.4 0.3 0.0 100.0 30.8 3,915 76 | Other Proximate Determinants of Fertility Fifty-eight percent of women of childbearing age have never been married, while 35 percent are either currently married (20 percent) or living together (15 percent). Seven percent of women are formerly married (divorced, separated, or widowed). Marriage occurs relatively late in Namibia and a large proportion of women never marry; 17 percent of those age 45-49 have not married. The trend toward later marriage can be seen in the higher proportion of women and men who have never married in the 2006-07 survey compared with the 2000 survey. For example, 54 percent of women age 15-49 had never been married in the 2000 survey (MoHSS, 2003), compared with 58 percent in the 2006-07 survey. Conversely, the proportion of women who were married decreased from 23 percent in 2000 to 20 percent in 2006-07. As expected, the proportion of women who are divorced, separated, or widowed generally increases with age. Men display a similar pattern. Sixty-five percent of men age 15-49 have never been married, while 18 percent are married and 13 percent are living together. Four percent of men are either widowed, divorced, or separated. Men are less likely to be married and tend to marry at an older age than women. 6.2 POLYGYNY Polygyny (the practice of having more than one wife) is common in Namibia and has implications for the frequency of exposure to sexual activity and, therefore, fertility. The prevalence of polygyny in the 2006-07 NDHS was ascertained by asking currently married women whether their husband or partner had other wives and, if so, how many. Similarly, currently married men were asked for the number of wives or partners they lived with. Table 6.2 shows the proportion of currently married women and men age 15-49 who are in a polygynous union by background characteristics. Data from the 2006-07 NDHS indicate that 6 percent of currently married women are in a polygynous union and have co-wives. This is a large decrease from the 2000 NDHS in which the proportion was double (12 percent). It is interesting to note that 13 percent of married women have no knowledge about the number of co-wives they have. This phenomenon was also observed in the 2000 NDHS (18 percent). The data further indicate that the prevalence of polygyny does not vary much by women’s age. Rural women are more likely than urban women to live in a polygynous union. Polygyny is most prevalent in Kunene (17 percent), while Karas has the least (2 percent). The number of co-wives decreases with increasing level of education and wealth quintile. Married men are less likely to report having multiple wives. Three percent of married men reported having two or more wives, compared with 6 percent of women who reported having co- wives. Differentials by residence are substantial. While 8 percent of men in Ohangwena have more than one wife, none in Hardap, Karas, or Kavango have multiple wives. The relationship between polygyny and education and wealth among men is unclear. Other Proximate Determinants of Fertility | 77 Table 6.2 Number of women's co-wives and men’s wives Percent distribution of currently married women age 15-49 by number of co-wives and percentage of men with two or more wives, according to background characteristics, Namibia 2006 Women: number of co-wives Men with two or more wives Background characteristic 0 1 2+ Don’t know/ missing Total Number of women Percentage Number of men Age 15-19 82.3 3.4 1.1 13.1 100.0 118 * 3 20-24 82.2 4.8 0.2 12.8 100.0 398 1.9 76 25-29 82.3 5.0 0.1 12.5 100.0 625 1.0 199 30-34 82.5 4.2 0.7 12.6 100.0 751 1.4 260 35-39 78.9 5.0 1.0 15.0 100.0 612 4.1 248 40-44 81.5 3.5 2.4 12.5 100.0 522 4.2 242 45-49 78.2 5.5 1.1 15.3 100.0 424 2.8 178 Residence Urban 83.8 2.8 0.3 13.0 100.0 1,731 2.3 714 Rural 78.4 6.4 1.5 13.7 100.0 1,719 3.2 491 Region Caprivi 86.3 10.3 1.0 2.4 100.0 200 7.2 82 Erongo 86.0 2.7 0.0 11.3 100.0 327 2.1 163 Hardap 93.4 1.7 0.0 4.9 100.0 131 0.0 45 Karas 85.2 1.3 1.1 12.4 100.0 139 0.0 48 Kavango 82.2 9.3 0.4 8.1 100.0 477 0.0 125 Khomas 85.3 1.6 0.0 13.0 100.0 749 3.0 332 Kunene 67.0 12.0 4.9 16.1 100.0 141 2.8 43 Ohangwena 66.6 3.9 5.5 24.0 100.0 218 8.3 38 Omaheke 90.8 2.2 0.2 6.8 100.0 150 1.9 53 Omusati 71.8 6.7 0.0 21.4 100.0 195 3.3 47 Oshana 80.9 2.5 1.1 15.4 100.0 197 2.7 53 Oshikoto 81.3 6.1 0.9 11.8 100.0 246 2.7 73 Otjozondjupa 70.2 2.4 1.1 26.3 100.0 278 2.6 104 Education No education/preschool 74.7 8.5 2.5 14.3 100.0 408 3.9 159 Incomplete primary 78.9 7.4 1.5 12.2 100.0 805 4.9 284 Complete primary 78.0 5.7 0.6 15.7 100.0 242 0.0 56 Incomplete secondary 82.1 3.6 0.4 13.9 100.0 1,226 2.2 381 Complete secondary 85.3 0.7 0.2 13.8 100.0 435 0.9 168 More than secondary 87.6 1.0 0.6 10.9 100.0 334 1.3 156 Wealth quintile Lowest 77.3 9.2 1.8 11.6 100.0 590 3.1 154 Second 76.3 7.1 2.2 14.4 100.0 502 4.1 134 Middle 80.0 5.2 0.6 14.2 100.0 698 3.6 246 Fourth 81.0 2.9 0.4 15.7 100.0 798 3.5 311 Highest 87.4 1.1 0.3 11.2 100.0 863 0.6 360 Total 81.1 4.6 0.9 13.4 100.0 3,451 2.7 1,205 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 6.3 AGE AT FIRST MARRIAGE Age at first marriage has a major effect on childbearing because women who marry early have, on average, a longer period of exposure to the risk of pregnancy and a greater number of lifetime births. Information on age at first marriage was obtained by asking respondents the month and year, or age, at which they started living with their first husband or wife. Table 6.3 shows the percentage of women and men who had married by specific ages, according to current age. Age at marriage for both women and men in Namibia is high. The median age at marriage for women age 25-49 years is 29.1 years. Over time, age at marriage has increased. The median age for women age 45-49 is 24.9 years, compared with 29.2 years for women age 30-34 years. 78 | Other Proximate Determinants of Fertility Table 6.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Namibia 2006-07 Percentage first married by exact age: Current age 15 18 20 22 25 Percentage never married Number Median age at first marriage WOMEN 15-19 1.1 na na na na 94.5 2,246 a 20-24 2.4 8.6 15.6 na na 75.9 1,855 a 25-29 2.2 9.2 16.0 23.9 35.5 55.4 1,623 a 30-34 2.0 8.5 13.8 21.3 34.7 39.7 1,417 29.2 35-39 1.8 10.1 16.9 24.3 34.9 30.7 1,045 29.4 40-44 2.1 11.5 18.4 26.0 38.9 26.1 928 27.8 45-49 4.4 12.6 24.3 38.4 50.2 17.1 689 24.9 20-49 2.3 9.6 16.7 na na 47.0 7,558 34.4 25-49 2.3 10.0 17.0 25.4 37.5 37.6 5,703 29.1 MEN 15-19 0.0 na na na na 99.6 910 a 20-24 0.0 0.3 2.3 na na 87.1 750 a 25-29 0.1 2.1 4.6 9.0 14.4 65.4 702 a 30-34 0.2 3.3 6.3 9.3 16.5 47.9 586 a 35-39 0.7 3.1 5.2 10.6 18.6 33.5 400 a 40-44 0.6 2.2 3.6 9.7 18.7 21.3 331 34.9 45-49 0.0 3.2 4.8 11.2 22.7 17.3 235 34.6 20-49 0.2 2.1 4.3 na na 54.5 3,005 a 25-49 0.3 2.7 5.0 9.7 17.2 43.7 2,254 a Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents married for the first time before reaching the beginning of the age group Men marry at a later age than women; whereas 17 percent of women age 25-49 have been married by age 20, only 5 percent of men age 25-49 have married by age 20. Table 6.4 shows differences in the median age at first marriage among women age 30-49 by background characteristics. Because of late marriage, little data are available on women younger than 30 years and they have been omitted because less than half of the respondents in the younger age groups were married before entering the age group. Comparison of the median age at first marriage for women age 30-49 in the 2000 NDHS (MoHSS, 2003) and in the 2006-07 NDHS indicates that women are marrying an average of two years later (26.2 years in 2000 and 28.2 years in 2006-07). Urban women marry almost two years later than their rural counter parts (29.1 years and 27.4 years, respectively). By region, the median age at first marriage ranges from 21.9 years in Caprivi to 29.9 years in Khomas. Other Proximate Determinants of Fertility | 79 Table 6.4 Median age at first marriage Median age at first marriage among women by five-year age groups, age 20-49 and age 25-49, according to background characteristics, Namibia 2006-07 Women Background characteristic 30-34 35-39 40-44 45-49 Total 30-49 Residence Urban 29.4 30.0 28.7 25.1 29.1 Rural 28.4 28.3 27.2 24.8 27.4 Region Caprivi 22.4 28.8 21.0 20.1 21.9 Erongo 26.4 28.1 25.8 25.3 26.2 Hardap 28.5 27.5 26.2 26.8 27.0 Karas 28.2 27.2 28.8 24.5 27.1 Kavango 22.5 20.2 24.5 20.7 22.1 Khomas 29.3 32.9 33.2 24.9 29.9 Kunene 22.2 24.3 22.0 24.2 23.0 Ohangwena a 30.5 27.8 24.4 29.1 Omaheke 29.4 26.9 29.6 26.9 28.0 Omusati a a 33.6 30.8 a Oshana a 34.8 29.4 27.6 a Oshikoto a 33.0 29.9 26.3 a Otjozondjupa 25.5 24.6 26.6 21.8 24.8 Education No education/preschool 24.5 23.9 25.4 23.5 24.3 Incomplete primary 25.5 27.7 25.9 24.4 26.0 Complete primary 27.6 28.2 30.4 27.8 28.2 Incomplete secondary a 32.4 31.1 23.4 a Complete secondary 29.0 30.6 28.5 23.5 28.6 More than secondary 28.2 28.1 27.4 28.1 27.9 Wealth quintile Lowest 26.1 30.0 26.0 23.9 26.6 Second a 31.7 27.3 25.0 29.3 Middle 29.1 27.4 30.3 24.7 28.3 Fourth 29.8 29.8 29.1 26.2 29.4 Highest 28.4 28.0 26.8 24.1 27.2 Total 29.2 29.4 27.8 24.9 28.2 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group 6.4 AGE AT FIRST SEXUAL INTERCOURSE While age at first marriage is often used as a proxy for first exposure to intercourse, the two events do not necessarily occur at the same time. Women and men may have sexual relations prior to marriage, especially if they are postponing the age at which they marry. The 2006-07 NDHS asked women and men how old they were when they first had sexual intercourse. Table 6.5 shows that men initiate sex at an earlier age than women. The median age at first intercourse for women and men age 20-49 years is 18.9 years and 18.0 years, respectively. Furthermore, only 5 percent of women and 12 percent of men reported having sexual intercourse by age 15. By age 18, which is the legal age for marriage, four in ten women (36 percent) and half of men (49 percent) have had sexual intercourse. 80 | Other Proximate Determinants of Fertility Table 6.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first intercourse, according to current age, Namibia 2006-07 Percentage who had first sexual intercourse by exact age: Current age 15 18 20 22 25 Percentage who never had intercourse Number Median age at first intercourse WOMEN 15-19 7.4 na na na na 56.7 2,246 a 20-24 6.5 43.8 72.7 na na 11.2 1,855 18.3 25-29 4.9 38.4 64.4 79.1 85.6 4.0 1,623 18.7 30-34 4.8 32.1 54.8 71.8 79.4 1.4 1,417 19.4 35-39 3.8 33.3 56.6 71.3 80.1 1.1 1,045 19.2 40-44 4.3 30.0 50.6 63.7 73.6 0.7 928 19.9 45-49 4.1 27.5 48.3 63.3 73.2 0.8 689 20.2 20-49 5.0 35.8 60.4 74.4 81.1 4.2 7,558 18.9 25-49 4.5 33.2 56.4 na na 1.9 5,703 19.3 15-24 7.0 na na na na 36.1 4,101 19.0 MEN 15-19 19.2 na na na na 48.2 910 a 20-24 16.6 58.4 81.5 na na 8.2 750 17.4 25-29 15.7 55.6 78.9 89.6 94.6 2.2 702 17.5 30-34 10.6 45.5 71.8 84.4 90.7 1.0 586 18.2 35-39 9.2 47.0 69.3 86.4 91.7 0.6 400 18.2 40-44 6.5 38.0 61.7 77.6 84.9 0.7 331 18.7 45-49 5.1 32.0 58.2 76.3 82.5 2.3 235 19.0 20-49 12.2 49.4 73.4 85.9 90.6 3.1 3,005 18.0 25-49 10.8 46.4 70.7 na na 1.4 2,254 18.2 15-24 18.0 na na na na 30.1 1,661 17.7 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Comparing median age at first sex by age group for both women and men indicates that the trend is toward initiating sexual intercourse at younger ages. However, younger men are more sexually active than younger women. For example, men age 15-19 are almost three times as likely as women the same age to have initiated sexual intercourse by age 15 (19 percent and 7 percent, respectively). There has been no change in age at first sexual intercourse among women over the past decade; the median has been 19 years since 1992. Differentials in age at first sex by background characteristics are shown in Table 6.6. Women and men in urban areas have their first sexual experience at slightly younger ages than their rural counterparts. For women, age at first sex generally increases with level education and wealth status. For men, the relationship is less clear. For both women and men age 25-49, the median age at first sex is lowest in Kavango and highest in Omusati. Other Proximate Determinants of Fertility | 81 Table 6.6 Median age at first intercourse Median age at first sexual intercourse among women age 20-49 by five-year age groups, and median age at first intercourse for women and men age 20-49 and age 25-49, according to background characteristics, Namibia 2006-07 Age Women Men Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 20-49 25-49 Residence Urban 18.5 18.8 19.6 19.1 19.4 19.8 19.0 19.2 18.1 18.3 Rural 18.1 18.7 19.2 19.2 20.3 20.5 18.9 19.4 17.9 18.1 Region Caprivi 16.9 17.7 17.9 18.5 18.0 19.3 17.7 18.0 16.6 17.0 Erongo 18.4 18.5 18.9 18.7 19.0 19.5 18.7 18.9 18.5 18.5 Hardap 18.8 18.1 19.5 19.7 19.0 20.1 18.9 19.0 18.3 18.4 Karas 18.8 19.2 20.2 19.4 20.6 19.3 19.5 19.9 18.2 18.2 Kavango 16.7 16.9 17.6 17.7 18.1 20.0 17.2 17.5 16.5 16.6 Khomas 18.6 19.2 19.9 19.0 19.6 20.3 19.2 19.5 18.2 18.4 Kunene 17.8 17.0 17.7 17.6 17.0 18.6 17.7 17.6 18.0 18.1 Ohangwena 18.6 19.0 20.6 19.6 21.5 21.3 19.7 20.2 18.2 18.3 Omaheke 17.7 18.3 18.2 18.8 19.7 18.1 18.4 18.6 17.6 18.2 Omusati 19.0 20.0 20.9 21.0 24.0 22.8 a 21.0 18.0 19.0 Oshana 19.2 19.9 19.9 20.6 20.4 20.7 19.9 20.2 18.5 18.6 Oshikoto 18.4 19.1 19.1 19.1 20.5 21.0 19.2 19.6 18.3 18.4 Otjozondjupa 17.5 18.1 18.0 18.4 17.8 19.1 18.1 18.2 17.7 17.9 Education No education 16.8 17.5 18.1 17.8 18.3 18.7 17.8 18.1 18.4 18.6 Incomplete primary 16.9 17.5 18.1 18.4 19.0 20.2 18.3 18.5 18.3 18.4 Complete primary 17.2 17.9 18.6 18.6 19.0 20.5 18.4 18.7 17.6 18.0 Incomplete secondary 18.3 18.7 19.7 19.6 19.9 19.7 18.8 19.2 17.7 17.9 Complete secondary 19.0 19.7 21.0 20.5 21.1 20.5 19.8 20.3 18.0 18.1 More than secondary a 20.9 20.1 22.2 23.1 22.0 a 21.1 18.3 18.5 Wealth quintile Lowest 17.3 18.4 18.7 18.6 20.3 21.1 18.5 18.9 17.9 18.2 Second 18.3 18.8 19.3 19.1 20.6 20.5 19.1 19.5 17.9 18.2 Middle 18.0 18.3 18.7 19.2 19.9 20.5 18.6 18.8 18.0 18.3 Fourth 18.4 18.6 19.3 18.9 18.9 19.6 18.8 18.9 18.0 18.0 Highest 19.0 19.6 20.2 20.3 20.3 20.0 19.8 20.0 18.2 18.4 Total 18.3 18.7 19.4 19.2 19.9 20.2 18.9 19.3 18.0 18.2 a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group 6.5 RECENT SEXUAL INTERCOURSE In the absence of contraception, the probability of becoming pregnant is related to the frequency of intercourse. Thus, information on sexual activity can be used to refine measures of exposure to the risk of pregnancy. All women and men were asked how long ago they last had sexual intercourse. Tables 6.7.1 and 6.7.2 show the percent distribution of women and men by recent sexual activity. Overall, 16 percent of women age 15-49 years have never had sex, 38 percent of women were sexually active in the four weeks preceding the survey, and 28 percent had had sexual intercourse within the past year, but not in past four weeks. The proportion of women who were sexually active in the past four weeks increases with age, from 15 percent at age 15-19 to 51 percent at age 30-39, and decreases to 46 percent at age 45-49. Women who are married or living together are the most likely to have recently engaged in sexual intercourse (70 percent), while women who have never been in a marital union are only slightly more likely to be sexually active than those who are divorced, separated, or widowed (21 percent compared with 19 percent). There are small variations in the proportion of women who were sexually active in the four weeks preceding the survey. Recent sexual activity is relatively lower among women in rural areas (34 percent) than among women in urban areas (44 percent). More than half of women in Erongo, Kunene, and Otjozondjupa regions are sexually active, compared with about one in four women in Ohangwena, Omusati, and Oshana. The relationship between level of education and recent sexual activity presents a u-shaped pattern; women who have no education and women with more than secondary education are much more likely than women who have some primary education to be sexually active. The percentage of sexually active women increases with wealth quintile. 82 | Other Proximate Determinants of Fertility Table 6.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Namibia 2006-07 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Never had sexual intercourse Total Number of women Age 15-19 14.8 20.5 7.2 0.8 56.7 100.0 2,246 20-24 36.7 37.2 13.6 1.4 11.2 100.0 1,855 25-29 45.4 33.6 15.1 1.9 4.0 100.0 1,623 30-34 50.6 28.4 15.6 4.1 1.4 100.0 1,417 35-39 50.5 26.5 19.8 2.1 1.1 100.0 1,045 40-44 48.5 24.2 24.7 1.9 0.7 100.0 928 45-49 45.9 18.5 30.9 4.0 0.8 100.0 689 Marital status Never married 21.1 31.2 18.2 1.5 28.0 100.0 5,673 Married or living together 70.4 22.8 4.0 2.8 0.0 100.0 3,451 Divorced/separated/widowed 19.2 24.8 53.1 2.7 0.1 100.0 678 Marital duration2 Married only once 70.1 23.1 3.9 2.9 0.0 100.0 3,000 0-4 years 71.1 23.8 2.6 2.5 0.0 100.0 923 5-9 years 70.7 24.0 3.2 2.1 0.0 100.0 814 10-14 years 67.4 25.7 4.0 2.9 0.0 100.0 455 15-19 years 69.1 23.8 5.0 2.1 0.0 100.0 384 20-24 years 73.1 16.2 6.7 4.0 0.0 100.0 224 25+ years 67.0 17.0 7.4 8.6 0.0 100.0 200 Married more than once 72.6 20.7 4.5 2.2 0.0 100.0 453 Residence Urban 43.5 25.9 13.7 2.7 14.1 100.0 4,772 Rural 33.5 29.6 17.4 1.4 18.2 100.0 5,032 Region Caprivi 47.6 24.7 18.2 2.3 7.2 100.0 474 Erongo 51.2 22.2 7.7 6.6 12.3 100.0 688 Hardap 40.3 28.7 14.0 2.0 15.1 100.0 315 Karas 45.8 22.7 16.2 2.8 12.4 100.0 318 Kavango 40.5 29.6 21.7 0.9 7.3 100.0 934 Khomas 43.5 25.0 14.0 2.7 14.7 100.0 2,218 Kunene 52.7 28.2 9.8 2.2 7.2 100.0 259 Ohangwena 24.2 30.8 18.0 1.3 25.6 100.0 1,043 Omaheke 48.0 30.2 10.2 1.1 10.4 100.0 373 Omusati 25.3 26.3 20.4 2.1 25.9 100.0 975 Oshana 25.6 33.3 16.9 0.5 23.7 100.0 819 Oshikoto 29.6 33.3 15.5 0.7 21.0 100.0 837 Otjozondjupa 53.3 26.8 11.1 0.9 7.9 100.0 550 Education No education/preschool 48.0 26.2 20.6 2.3 3.0 100.0 651 Incomplete primary 43.9 26.4 19.3 1.4 9.0 100.0 1,699 Complete primary 34.2 29.5 16.2 0.9 19.2 100.0 736 Incomplete secondary 32.1 29.3 14.8 1.6 22.2 100.0 4,751 Complete secondary 45.3 26.1 12.0 4.0 12.6 100.0 1,286 More than secondary 50.6 24.2 12.9 3.8 8.4 100.0 682 Wealth quintile Lowest 32.7 30.3 20.0 1.3 15.7 100.0 1,621 Second 32.2 26.9 18.8 1.4 20.8 100.0 1,668 Middle 37.9 31.1 14.8 1.5 14.8 100.0 1,885 Fourth 43.0 29.5 13.6 1.8 12.2 100.0 2,292 Highest 42.6 22.5 12.8 3.8 18.3 100.0 2,338 Total 38.4 27.8 15.6 2.0 16.2 100.0 9,804 Note: Total includes three women with information missing on marital status. 1 Excludes women who had sexual intercourse within the past 4 weeks 2 Excludes women who are not currently married Table 6.7.2 shows that a slightly higher proportion of men than women age 15-49 have recently engaged in sexual intercourse (40 percent compared with 38 percent). Three in ten men had sexual intercourse in the year before the survey but not in the month prior to the survey, while 16 percent had not been sexually active for one year or more. Fourteen percent of men said they have never had sex. As with women, sexual activity among men increases with age and peaks between age 35 and 44. Men in union are much more likely to be sexually active than those not in union. There is little variation in recent sexual activity by marital duration. Men in urban areas (42 percent) are more likely to be sexually active in the recent past than those in rural areas (38 percent). Other Proximate Determinants of Fertility | 83 Table 6.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Namibia 2006-07 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Never had sexual intercourse Total Number of men Age 15-19 12.0 25.5 14.1 0.3 48.2 100.0 910 20-24 33.6 34.0 24.0 0.2 8.2 100.0 750 25-29 44.3 36.1 16.3 1.2 2.2 100.0 702 30-34 55.9 27.6 14.0 1.5 1.0 100.0 586 35-39 60.6 26.3 10.6 1.9 0.6 100.0 400 40-44 59.9 25.4 12.0 2.0 0.7 100.0 331 45-49 53.6 22.8 18.9 2.3 2.3 100.0 235 Marital status Never married 25.8 31.2 21.4 0.6 20.9 100.0 2,545 Married or living together 69.1 24.6 4.5 1.9 0.0 100.0 1,205 Divorced/separated/widowe d 46.4 32.6 19.3 1.7 0.0 100.0 163 Marital duration2 Married only once 66.9 27.5 3.9 1.7 0.0 100.0 791 0-4 years 62.4 31.9 3.8 1.9 0.0 100.0 230 5-9 years 66.5 29.5 3.6 0.4 0.0 100.0 226 10-14 years 78.4 18.4 2.4 0.8 0.0 100.0 159 15-19 years 63.7 27.4 5.8 3.0 0.0 100.0 96 20-24 years 60.8 30.6 2.2 6.4 0.0 100.0 61 25+ years 67.0 16.1 17.0 0.0 0.0 100.0 19 Married more than once 75.4 18.5 4.6 1.5 0.0 100.0 301 Residence Urban 41.9 32.5 14.7 1.6 9.4 100.0 1,962 Rural 38.1 26.0 17.6 0.5 17.9 100.0 1,953 Region Caprivi 53.9 28.3 9.8 2.5 5.5 100.0 189 Erongo 39.3 41.3 8.4 3.2 7.8 100.0 362 Hardap 50.7 15.1 16.3 1.5 16.4 100.0 132 Karas 42.0 28.5 13.0 0.2 16.3 100.0 157 Kavango 55.0 26.0 6.4 0.7 12.0 100.0 331 Khomas 37.5 33.7 18.6 1.4 8.7 100.0 984 Kunene 51.9 31.4 6.6 1.9 8.2 100.0 92 Ohangwena 20.6 16.0 28.9 0.0 34.6 100.0 306 Omaheke 51.3 28.2 12.8 0.3 7.5 100.0 188 Omusati 28.5 25.2 28.3 0.0 18.1 100.0 320 Oshana 41.2 21.1 18.8 0.3 18.5 100.0 270 Oshikoto 34.8 33.3 11.4 0.6 19.9 100.0 322 Otjozondjupa 44.3 32.1 14.9 0.3 8.5 100.0 262 Education No education/preschool 39.0 29.9 22.4 0.6 8.1 100.0 360 Incomplete primary 37.0 28.0 17.3 1.1 16.6 100.0 856 Complete primary 32.4 25.6 14.1 0.0 27.8 100.0 252 Incomplete secondary 36.5 30.9 16.5 1.1 15.0 100.0 1,604 Complete secondary 47.8 30.5 11.8 1.0 8.8 100.0 538 More than secondary 60.6 23.9 12.4 2.1 1.1 100.0 305 Wealth quintile Lowest 35.3 25.4 17.9 0.4 21.1 100.0 560 Second 36.0 24.6 18.7 1.1 19.7 100.0 607 Middle 41.6 26.2 19.5 0.5 12.2 100.0 875 Fourth 41.6 33.8 14.8 0.6 9.2 100.0 963 Highest 42.4 32.8 11.4 2.4 11.0 100.0 911 Total 15-49 40.0 29.2 16.1 1.0 13.6 100.0 3,915 Note: Total includes one man with information missing on marital status. 1 Excludes men who had sexual intercourse within the past 4 weeks 2 Excludes men who are not currently married 84 | Other Proximate Determinants of Fertility Regional variation for men shows patterns similar to those of women. At least half of the men in Caprivi, Hardap, Kavango, Kunene, and Omaheke reported being sexually active in the past month compared with only 21 percent of men in Ohangwena. The relationship of level of education and wealth quintile with recent sexual activity among men is the same as for women; men with no education and men with more than secondary education are much more likely than men with other levels of education to have engaged in recent sexual activity. Recent sexual activity increases with wealth quintile. 6.6 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea is the interval between the birth of a child and the resumption of menstruation, during which the risk of pregnancy is much reduced. Postpartum protection from conception depends on the intensity and duration of breastfeeding. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. A woman is considered insusceptible if she is not exposed to the risk of pregnancy, either because she is amenorrhoeic or because she is abstaining from sexual intercourse following a birth. In the 2006-07 NDHS, information was obtained about the duration of amenorrhoea and the duration of sexual abstinence following childbirth for births in the three years preceding the survey. Postpartum protection from conception can be prolonged by breastfeeding, which lengthens the duration of amenorrhoea. Delaying the resumption of sexual relations also prolongs protection. As shown in Table 6.8, the majority of women are amenorrhoeic for at least 4-5 months after delivering, with a median of 5.5 months. By 8-9 months after the birth, 36 percent of women are amenorrhoeic, 56 percent are insusceptible to pregnancy, and 38 percent are abstaining from sexual relations. The median duration of postpartum abstinence is 6.8 months. Combining these two factors, the median duration of postpartum insusceptibility to pregnancy is 13.1 months. Table 6.8 Postpartum amenorrhoea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Namibia 2006-07 Percentage of births for which the mother is: Months since birth Amenorrhoeic Abstaining Insusceptible1 Number of births < 2 72.0 86.8 89.3 127 2-3 67.3 73.8 91.3 182 4-5 53.7 58.2 77.5 198 6-7 44.5 53.5 69.8 215 8-9 35.9 38.2 56.0 160 10-11 33.2 39.9 60.4 181 12-13 26.8 32.0 48.1 205 14-15 25.2 35.4 50.5 174 16-17 11.5 23.8 31.5 169 18-19 14.0 20.1 26.6 149 20-21 7.7 16.9 20.3 163 22-23 6.9 14.5 18.8 171 24-25 7.9 19.1 23.9 156 26-27 5.2 19.1 22.0 161 28-29 6.0 17.1 21.7 166 30-31 1.3 10.2 11.2 149 32-33 8.7 10.6 15.1 154 34-35 3.5 14.3 15.4 204 Total 24.3 32.7 42.4 3,085 Median 5.5 6.8 13.1 na Mean 9.0 12.0 15.3 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth Other Proximate Determinants of Fertility | 85 Comparing the current data with the 2000 NDHS data indicates that the median and mean durations for all three variables have decreased (MoHSS, 2003). For example, the current median duration of postpartum amenorrhoea (5.5 months) is 4.2 months shorter than it was in the 2000 NDHS (9.7 months), and the median duration of postpartum abstinence decreased from 7.9 months to 6.8 months. Table 6.9 shows the median durations of postpartum amenorrhoea, abstinence, and insusceptibility by background characteristics. The median duration of insusceptibility is shorter among women age 30 and older than among younger women, and is five months longer for rural women than for urban women. Across regions, the median duration of insusceptibility ranges from 6.1 months in Khomas to 17.1 months in Caprivi. Postpartum amenorrhoea and insusceptibility generally decrease with the level of education and wealth quintile. Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Namibia 2006-07 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 5.2 8.2 13.8 30-49 6.0 5.0 11.7 Residence Urban 3.1 6.2 9.0 Rural 7.6 7.8 14.2 Region Caprivi 13.0 9.3 17.1 Erongo 0.7 5.4 9.5 Hardap 0.7 5.7 9.2 Karas 2.3 8.2 13.5 Kavango 12.4 5.2 16.6 Khomas 0.5 5.2 6.1 Kunene 6.7 5.4 9.4 Ohangwena 8.4 9.0 13.7 Omaheke 1.9 7.9 9.8 Omusati 4.8 11.8 14.0 Oshana 5.0 10.1 12.1 Oshikoto 6.0 8.5 13.5 Otjozondjupa 4.1 6.9 9.3 Education No education/preschool 7.8 3.9 9.5 Incomplete primary 9.9 7.7 13.4 Complete primary 5.9 9.4 15.5 Incomplete secondary 4.0 8.7 13.8 Complete secondary 3.8 4.9 8.1 More than secondary 0.6 0.6 0.6 Wealth quintile Lowest 9.6 8.6 15.5 Second 9.1 6.6 13.3 Middle 3.7 9.1 14.5 Fourth 3.1 6.8 9.7 Highest 0.5 4.5 4.6 Total 5.5 6.8 13.1 Note: Medians are based on the status at the time of the survey (current status). 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth 86 | Other Proximate Determinants of Fertility 6.7 MENOPAUSE The risk of becoming pregnant declines with age. The term infecundity, the inability to produce a live child, denotes a process rather than a well-defined event. Although the onset of infecundity is difficult to determine for an individual woman, it is possible to estimate it for groups of women. Table 6.10 presents data on menopause, an indicator of decreasing exposure to the risk of pregnancy. In this report, women are considered menopausal if they are neither pregnant nor postpartum amenorrhoeic and have not had a menstrual period for at least six months preceding the survey. Overall, 12 percent of women age 30-49 are menopausal. The extent of menopause increases with age from 5 percent for women age 30-34 to 43 percent for women age 48-49. The proportion of women age 48-49 who are menopausal declined from 47 percent in the 2000 NDHS to 43 percent in the 2006-07 NDHS. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Namibia 2006-07 Age Percentage menopausal1 Number of women 30-34 4.9 1,417 35-39 7.0 1,045 40-41 13.1 392 42-43 13.5 383 44-45 19.0 297 46-47 25.7 311 48-49 42.6 236 Total 11.8 4,080 1 Percentage of all women who are not pregnant and not postpartum amenor- rhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 87 FERTILITY PREFERENCES 7 Analysis and interpretation of the need for contraception as assessed by whether or not respondents want another child, their preferred interval between children, and the number of children they consider ideal have revealed important implications for the planning and implementation of family planning programmes. Therefore in the 2006-07 NDHS, as in the previous NDHS surveys, women and men were asked a series of questions to ascertain fertility preferences. These data are used in this chapter to quantify fertility preferences and, in combination with data on contraceptive use, permit estimation of unmet need for family planning both for spacing and limiting births. 7.1 DESIRE FOR MORE CHILDREN Women in the 2006-07 NDHS sample were asked, “Would you like to have (a/another) child or would you prefer not to have any (more) children?” Respondents who said that they would like to have more children were asked, “How long would you like to wait from now before the birth of (a/another) child?” Unlike the 2000 NDHS, in which these questions were asked to all men, in the 2006-07 NDHS questions on fertility preferences were only asked to men who were living with one or more wives or partners. Responses to these questions for all women age 15-49 are presented in Table 7.1 by number of living children. Table 7.2 presents the same information for currently married women and men age 15-49. Table 7.1 Fertility preferences by number of living children: all women Percent distribution of all women age 15-49 by desire for children, according to number of living children, Namibia 2006-07 Number of living children1 Total 15-49 Desire for children 0 1 2 3 4 5 6+ Have another soon2 9.1 13.3 9.2 6.0 5.8 5.7 3.5 8.9 Have another later3 36.1 25.4 16.6 10.9 7.6 6.2 3.6 22.3 Have another, undecided when 29.4 9.8 4.5 1.3 2.6 1.1 0.4 13.0 Undecided 9.3 7.4 6.8 5.2 3.3 3.2 4.3 7.0 Want no more 12.7 41.3 55.8 62.4 67.4 67.5 68.3 41.4 Sterilized4 0.2 1.1 5.2 12.3 10.6 15.6 17.7 5.1 Declared infecund 2.3 1.0 1.2 1.5 1.3 0.6 2.0 1.6 Missing 0.9 0.8 0.6 0.3 1.4 0.0 0.2 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,266 1,981 1,688 1,149 714 429 577 9,804 1 Includes current pregnancy for women 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization Overall, the proportion of women who either do not want another child or are sterilized has increased from 47 percent in the 2000 NDHS to 49 percent in the 2006-07 NDHS. Forty-four percent of women want to have another child; 9 percent want to have a child within two years, 22 percent want to wait for two or more years, and 13 percent want to have a child but are undecided when (Figure 7.1). The desire to limit childbearing increases with the number of living children the woman has. Thirteen percent of women with no children say they do not want to have any children, compared with 68 percent of women with six or more children. 88 | Fertility Preferences There have been no significant changes in fertility preferences among women since 2000; the proportion of women who wanted to have another child was 45 percent in 2000 (MoHSS, 2003) and 44 percent in 2006-07. Table 7.2 shows the fertility preferences of married women and men age 15-49 by number of living children. Six in ten women either do not want another child (49 percent) or have been sterilized (11 percent). One in three women want to have another child—14 percent want the child within two years, 16 percent want to wait two years or more, and 3 percent are undecided when they want to have a child. The remaining women (6 percent) are undecided. Men show a different pattern: 47 percent do not want any more children, 42 percent want another child, and 6 percent are undecided. In general, men tend to want more children than women. The percentage of men who want more children is higher than that for women, regardless of the number of living children they already had. For example, 4 percent of women with six or more children want to have another child soon, compared with 13 percent of men. NDHS 2006-07 Figure 7.1 Fertility Preferences of Women Age 15-49 Want no more children 46% Declared infecund 2% Want child soon (<2 years) 9% Want child later (2+ years) 22% Want child, unsure when 13% Undecided 7% Note: “Want no more” includes sterilized women Fertility Preferences | 89 Table 7.2 Fertility preferences by number of living children: currently married women and men Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Namibia 2006-07 Number of living children Total 15-49 Desire for children 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 45.6 25.1 13.6 8.7 7.9 6.8 4.2 14.2 Have another later3 19.4 25.4 19.9 14.0 10.2 7.2 4.3 15.6 Have another, undecided when 6.6 5.0 2.6 1.1 2.4 1.0 0.6 2.6 Undecided 6.0 6.4 8.0 5.8 3.8 3.3 4.6 5.9 Want no more 14.6 34.1 46.1 52.9 62.1 63.5 63.6 48.9 Sterilized4 1.2 1.9 8.2 15.5 11.2 17.7 20.5 10.7 Declared infecund 3.8 1.5 1.0 1.5 0.5 0.5 2.0 1.4 Missing 2.8 0.6 0.7 0.5 1.8 0.0 0.3 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 211 596 844 676 433 286 405 3,451 MEN5 Have another soon2 43.9 19.6 14.5 14.3 16.6 7.5 12.6 16.9 Have another later3 16.0 42.5 25.0 19.0 10.8 17.9 10.7 20.9 Have another, undecided when 6.9 3.0 4.6 4.6 3.8 4.7 3.9 4.3 Undecided 4.6 5.0 3.5 6.2 9.0 8.7 9.3 6.4 Want no more 13.3 23.7 40.6 49.1 50.0 57.3 60.0 43.4 Sterilized4 1.9 1.3 8.0 3.7 3.1 2.1 0.6 3.4 Declared infecund 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Missing 13.4 4.9 3.7 3.1 6.7 1.8 3.0 4.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 94 174 267 202 161 99 208 1,205 1 Includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 5 Includes one additional child if wife is pregnant (or if any wife is pregnant for men with more than one wife) 7.2 DESIRE TO LIMIT CHILDBEARING The desire to stop childbearing by residence, region, education, and wealth index is shown in Table 7.3 for all women and men. Overall, the desire to stop childbearing increases with parity. Forty- two percent of women with one living child want no more children compared with 86 percent of women with six or more children (Figure 7.2). Urban women (47 percent) are only slightly more likely to want to stop childbearing than rural women (46 percent). The desire to limit childbearing varies widely across regions, from 34 percent in Ohangwena to 69 percent in Omaheke. There appears to be a negative relationship between desire to limit childbearing and women’s education. Women with no education are more likely than the highest educated women to want to stop childbearing (59 percent compared with 41 percent). The relationship between wealth and desire to limit childbearing has an inverted U-shaped pattern; low for women in the poorest and wealthiest households, and high for women in the middle quintile. Table 7.3 shows that some of the patterns for men are different from those of women. For example, urban men are more likely than rural men to want no more children (19 percent and 11 percent, respectively. And, while men in Ohangwena (like women) are least likely to want to stop having children (5 percent), men in Kunene and Otjozondjupa regions are the most likely to want no more children (24 percent). For men, the desire to limit childbearing rises with increasing access to resources. Men in the highest wealth quintile are more likely to want to limit childbearing than those in the poorest households (24 percent compared with 7 percent). 90 | Fertility Preferences Overall, the desire to have no more children among men has decreased from 27 percent in the 2000 NDHS to 15 percent in the 2006-07 NDHS. Table 7.3 Desire to limit childbearing: All women and men Percentage of all women age 15-49 who want no more children by number of living children and percentage of all men age 15-49 who want no more children, according to background characteristics, Namibia 2006-07 Background characteristic Number of living children1 Total women Total men 0 1 2 3 4 5 6+ Residence Urban 12.8 42.7 64.6 83.6 84.7 90.5 91.2 47.4 18.6 Rural 13.0 42.0 57.2 65.8 72.3 79.0 84.2 45.7 11.0 Region Caprivi 8.3 28.9 42.8 48.3 59.2 76.3 93.1 35.8 9.3 Erongo 15.3 46.1 77.9 92.6 86.5 96.9 100.0 57.0 21.8 Hardap 24.9 57.5 77.5 83.6 74.6 83.1 93.5 60.5 16.2 Karas 16.5 53.6 74.3 76.0 91.4 82.0 93.8 58.0 19.1 Kavango 19.6 46.9 51.4 53.1 66.8 67.2 78.3 47.1 12.0 Khomas 11.4 38.1 60.7 87.1 90.6 99.4 89.0 43.8 18.6 Kunene 18.9 38.8 63.9 58.4 71.4 58.3 68.8 49.3 23.6 Ohangwena 6.1 24.8 47.4 64.5 67.9 75.7 73.2 34.0 4.5 Omaheke 36.0 60.1 77.8 82.7 82.7 94.7 100.0 68.7 19.1 Omusati 10.0 41.8 54.5 70.1 64.4 85.6 84.8 38.9 7.5 Oshana 15.8 47.5 70.9 83.4 81.5 85.9 95.1 48.6 7.6 Oshikoto 9.4 44.3 57.4 76.3 84.5 81.7 87.7 45.7 9.6 Otjozondjupa 13.0 50.4 64.3 70.2 81.7 86.0 89.6 56.7 23.8 Education No education/preschool 27.1 41.8 52.9 52.7 70.4 71.7 81.4 59.4 19.3 Incomplete primary 14.7 44.7 52.7 69.1 69.8 80.5 85.5 57.6 14.0 Complete primary 15.6 44.4 63.7 78.0 78.1 89.1 91.5 53.0 10.3 Incomplete secondary 13.5 46.2 63.8 78.5 85.2 91.5 88.8 42.8 11.8 Complete secondary 8.8 32.1 61.7 89.0 81.4 82.4 100.0 38.0 16.0 More than secondary 7.4 36.0 63.1 72.5 87.7 87.2 100.0 41.4 29.4 Wealth quintile Lowest 12.4 41.5 52.1 58.0 58.5 71.3 78.9 44.7 7.4 Second 13.9 36.3 57.9 70.1 76.3 78.1 85.4 45.0 8.9 Middle 14.2 48.0 56.7 74.3 78.5 89.4 87.4 50.0 12.5 Fourth 13.7 47.8 66.3 78.8 90.5 91.3 97.8 50.8 16.0 Highest 11.2 35.6 66.7 86.4 83.8 96.4 90.4 41.8 24.2 Total 12.9 42.4 61.1 74.8 78.0 83.1 86.1 46.5 14.8 Note: Women who have been sterilized are considered to want no more children. 1 Includes current pregnancy Table 7.4 shows the desire to limit childbearing among married women and men. Thirty-six percent of women with one living child want no more children compared with 84 percent of women with six or more children. The desire to limit childbearing varies across subgroups of women. Women in urban areas are more likely than women in rural areas to want no more children. The desire to stop having children varies widely across regions, from 37 percent in Caprivi to 76 percent in Omaheke. The relationship between women’s education and desire to limit childbearing has an inverted U-shaped pattern; low for women with no education and those with the highest level of education (57 percent) and high for women with complete primary (65 percent). Women in the poorest households are the least likely to want to stop childbearing (50 percent), while women in the fourth wealth quintile are most likely (67 percent). Table 7.4 indicates that the desire to limit childbearing among married men is not very different than among married women; however, it is higher among urban men than rural men, among better educated men than less educated men, and among men in wealthier households (Figure 7.2). Fertility Preferences | 91 Table 7.4 Desire to limit childbearing: Currently married women and men Percentage of currently married women age 15-49 who want no more children by number of living children, and percentage of currently married men age 15-49 who want no more children, according to background characteristics, Namibia 2006-07 Background characteristic Number of living children1 Total women Total men 0 1 2 3 4 5 6+ Residence Urban 16.5 37.0 58.8 79.0 80.6 89.2 90.2 61.7 50.3 Rural 14.7 34.8 47.8 55.7 67.4 76.2 82.1 57.6 41.9 Region Caprivi 6.5 27.3 26.6 37.1 48.0 60.8 90.4 36.5 19.7 Erongo 17.7 38.0 78.1 91.2 85.6 95.9 100.0 71.8 47.6 Hardap 14.1 39.4 75.3 87.6 69.6 85.9 91.5 71.2 47.7 Karas 13.6 60.6 71.9 75.9 88.9 81.1 91.3 72.1 59.6 Kavango 10.5 36.6 43.3 40.4 55.1 60.4 75.8 46.8 29.6 Khomas 17.2 35.9 52.5 82.4 85.9 99.2 90.8 59.1 54.9 Kunene 15.8 33.8 67.7 53.4 64.9 58.9 64.2 52.4 48.8 Ohangwena 0.0 20.8 33.9 46.4 70.9 70.1 74.8 55.3 36.1 Omaheke 43.2 47.5 73.2 82.6 73.2 91.0 100.0 76.4 65.6 Omusati 0.0 36.2 41.0 62.7 60.9 91.4 77.7 56.9 46.4 Oshana 23.5 25.0 70.0 73.5 77.6 88.4 92.9 68.8 37.4 Oshikoto 23.0 20.6 45.1 69.0 78.2 85.8 83.3 63.1 40.6 Otjozondjupa 17.0 42.5 55.3 59.7 86.9 81.0 90.0 64.2 58.8 Education No education/preschool 23.9 33.8 34.0 45.9 68.9 65.2 81.3 57.0 43.6 Incomplete primary 12.3 37.4 43.6 58.2 63.2 79.0 81.5 61.0 42.0 Complete primary 14.9 39.3 57.6 71.5 64.2 86.2 91.4 65.3 43.5 Incomplete secondary 17.4 42.3 54.4 71.1 84.5 90.2 90.0 60.8 47.7 Complete secondary 11.5 22.5 61.0 88.5 74.2 80.1 100.0 55.3 48.1 More than secondary 14.9 30.7 65.7 70.5 81.4 88.9 100.0 57.0 57.0 Wealth quintile Lowest 7.7 34.9 41.7 39.8 44.3 70.5 74.4 49.5 24.8 Second 17.8 36.0 37.8 55.3 74.9 70.7 84.3 57.6 37.7 Middle 7.9 40.0 48.1 68.2 73.9 86.7 84.0 59.9 43.5 Fourth 20.8 39.6 61.3 74.4 89.8 90.9 97.0 66.5 48.7 Highest 18.0 30.5 63.0 83.8 79.5 95.2 96.3 61.1 60.5 Total 15.8 36.0 54.3 68.4 73.3 81.1 84.0 59.6 46.9 Note: Women who have been sterilized are considered to want no more children. 1 Includes current pregnancy Figure 7.2 Desire to Limit Childbearing Among Women 15-49 and Men 15-49, by Number of Living Children 1 9 29 37 43 42 53 13 42 61 75 78 83 86 1 2 3 4 5 6 7 0 20 40 60 80 100 Women Men NDHS 2006-07Note: Includes those who want no more children and those who are sterilized Percent 92 | Fertility Preferences 7.3 UNMET NEED FOR FAMILY PLANNING The proportion of women who want to stop childbearing or who want to space their next birth is a broad measure of the need for family planning, given that not all of these women are exposed to the risk of pregnancy and some may already be using a contraceptive method. This section discusses the levels of unmet need and the potential demand for family planning. Women who want to postpone their next birth for two or more years or who want to stop childbearing altogether but are not using a contraceptive method are said to have an unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted. Similarly, amenorrhoeic women are categorized as having an unmet need if their last birth was mistimed or unwanted. Women who are currently using family planning are said to have a met need for family planning. The total demand for family planning includes those in the met need and unmet need categories. Table 7.5 presents data on unmet need, met need, and the total demand for family planning for all women, currently married women, and women who are not currently married. Table 7.5 shows that the overall unmet need for family planning among all women in Namibia is 9 percent, 4 percent for spacing births and 5 percent for limiting births. This unmet need varies somewhat by age and residence. Urban women have lower unmet need than rural women (7 percent compared with 11 percent). Women in Kunene have the highest level of unmet need (7 percent), while women in Khomas have the lowest (6 percent). Access to education and economic resources is negatively associated with unmet need for family planning. This is seen by comparing the rates for women with no education (20 percent) and with more than secondary education (7 percent). Table 7.5 Unmet need and the demand for family planning among all women Percentage of all women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics; percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning and the percentage of the demand for contraception that is satisfied, and percentage of women who are not currently married age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning and the percentage of the demand for contraception that is satisfied, Namibia 2006-07 Background characteristic Unmet need for family planning1 Met need for family planning2 (currently using) Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 3.2 0.9 4.0 17.9 7.3 25.2 21.1 8.2 29.3 86.2 2,246 20-24 4.8 2.6 7.4 32.9 19.6 52.6 37.7 22.2 60.0 87.7 1,855 25-29 5.3 3.8 9.1 31.3 26.5 57.8 36.6 30.3 66.9 86.4 1,623 30-34 5.5 7.6 13.1 23.2 31.5 54.7 28.7 39.1 67.8 80.6 1,417 35-39 5.3 10.6 15.9 12.5 40.1 52.6 17.8 50.7 68.5 76.7 1,045 40-44 3.3 7.8 11.2 4.8 46.4 51.2 8.1 54.3 62.4 82.1 928 45-49 1.6 10.2 11.8 1.7 40.2 41.9 3.3 50.4 53.7 78.1 689 Residence Urban 3.1 4.1 7.2 25.2 30.7 55.8 28.3 34.8 63.1 88.6 4,772 Rural 5.5 5.8 11.3 16.6 21.2 37.8 22.1 27.1 49.1 77.0 5,032 Region Caprivi 8.3 4.4 12.7 25.2 16.2 41.4 33.5 20.6 54.1 76.5 474 Erongo 2.4 4.7 7.1 20.9 39.2 60.1 23.3 43.9 67.2 89.4 688 Hardap 4.6 6.7 11.3 12.9 37.2 50.0 17.5 43.8 61.3 81.6 315 Karas 4.3 6.1 10.4 16.9 36.7 53.6 21.2 42.9 64.1 83.7 318 Kavango 9.1 6.4 15.5 19.3 18.6 37.9 28.4 24.9 53.3 71.0 934 Khomas 2.0 3.6 5.6 27.8 29.6 57.4 29.8 33.2 63.0 91.1 2,218 Kunene 8.5 8.3 16.8 17.5 31.6 49.1 26.0 39.9 65.9 74.6 259 Ohangwena 4.5 4.9 9.4 16.2 12.0 28.2 20.7 16.9 37.6 74.9 1,043 Omaheke 2.6 8.3 10.9 11.8 38.4 50.2 14.4 46.7 61.1 82.2 373 Omusati 3.9 3.1 7.0 18.0 19.4 37.4 21.9 22.5 44.5 84.2 975 Oshana 2.6 5.2 7.8 20.3 23.6 43.9 22.9 28.8 51.7 84.9 819 Oshikoto 4.8 4.8 9.6 19.5 23.0 42.5 24.3 27.8 52.2 81.5 837 Otjozondjupa 5.7 7.2 13.0 21.3 35.7 57.0 27.0 42.9 70.0 81.5 550 Continued… Fertility Preferences | 93 Table 7.5—Continued Background characteristic Unmet need for family planning1 Met need for family planning2 (currently using) Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Education No education/ preschool 9.1 11.0 20.1 9.2 21.9 31.0 18.3 32.9 51.2 60.7 651 Incomplete primary 7.1 8.6 15.6 12.6 27.7 40.3 19.6 36.2 55.9 72.0 1,699 Complete primary 4.4 7.7 12.1 12.5 25.6 38.0 17.0 33.3 50.3 75.9 736 Incomplete secondary 3.1 3.4 6.4 22.0 25.2 47.2 25.0 28.7 53.7 88.0 4,751 Complete secondary 3.3 2.1 5.4 32.6 26.6 59.2 36.9 28.2 65.1 91.6 1,286 More than secondary 3.2 4.2 7.4 30.1 28.3 58.3 33.3 32.5 65.8 88.7 682 Wealth quintile Lowest 8.3 6.4 14.7 14.3 15.9 30.2 22.6 22.3 44.9 67.3 1,621 Second 4.5 5.8 10.3 17.5 20.0 37.6 22.0 25.8 47.8 78.5 1,668 Middle 4.8 6.5 11.3 17.6 26.0 43.6 22.5 32.5 55.0 79.4 1,885 Fourth 3.4 4.4 7.8 24.9 33.2 58.1 28.4 37.6 65.9 88.1 2,292 Highest 1.9 2.9 4.7 26.0 29.6 55.6 27.9 32.4 60.3 92.1 2,338 All women 4.3 5.0 9.3 20.8 25.8 46.6 25.1 30.8 55.9 83.3 9,804 Currently married women 9.1 11.5 20.6 17.6 37.5 55.1 26.6 49.0 75.6 72.8 3,451 Women not currently married 1.7 1.5 3.2 22.5 19.5 42.0 24.2 21.0 45.2 92.9 6,353 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed; amenorrhoeic women who are not using family planning and whose last birth was mistimed, or whose last birth was unwanted but now say they want more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted; amenorrhoeic women who are not using family planning, whose last child was unwanted and who do not want any more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and who want no more children. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. Comparison with data from the 2000 NDHS shows that there has been a decline in unmet need for family planning among all women, from 13 percent to 9 percent. Over the same period, the total demand for family planning satisfied increased from 75 percent to 83 percent. If all demand were satisfied, the current level of contraceptive prevalence would be 56 percent instead of 47 percent. Unmet need for family planning among currently married women (21 percent) is double that for all women: 9 percent for spacing births and 12 percent for limiting births. Comparison with the 2000 NDHS indicates that there has been a decrease in unmet need for family planning among married women, from 25 percent to 21 percent. Over the same period, the total demand for family planning satisfied increased from 64 percent to 73 percent. If all demand were satisfied, the current level of contraceptive prevalence among currently married women would be 76 percent instead of 55 percent. Table 7.5 also shows unmet need for family planning among women who are not currently married. Total unmet need is 3 percent. Compared with the 2000 NDHS, there has been a decline in unmet need among women who are not currently married, from 5 percent to 3 percent. 94 | Fertility Preferences 7.4 IDEAL NUMBER OF CHILDREN To ascertain what Namibian women and men consider to be the ideal number of children, a number of questions were asked. Respondents who had no living children were asked: “If you could choose exactly the number of children to have in your whole life, how many would that be?” For respondents who had children, the question was: “If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?” The distribution of respondents by ideal number of children is presented in Table 7.6. Table 7.6 Ideal number of children Percent distribution of all women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to number of living children, Namibia 2006-07 Ideal number of children Number of living children 0 1 2 3 4 5 6+ Total WOMEN1 0 9.2 5.5 4.3 5.8 5.2 4.6 7.9 6.6 1 9.2 15.0 4.7 5.2 4.7 1.8 0.9 8.0 2 42.5 34.9 34.8 16.4 17.1 12.8 10.9 31.6 3 22.2 21.5 18.5 27.8 6.3 8.4 9.1 19.5 4 11.5 15.0 25.6 23.1 33.7 13.3 13.2 17.8 5 3.0 3.8 5.3 9.9 11.1 24.1 7.6 6.2 6+ 1.6 3.7 6.1 11.4 21.1 33.0 45.4 9.3 Non-numeric responses 0.8 0.6 0.7 0.3 0.9 2.0 5.1 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,266 1,981 1,688 1,149 714 429 577 9,804 Mean ideal number of children for:2 All women 2.4 2.6 3.1 3.5 4.0 4.9 5.5 3.1 Number 3,240 1,970 1,676 1,145 707 420 547 9,706 Currently married women 2.4 2.8 3.2 3.7 4.0 4.9 5.5 3.7 Number 211 591 837 673 428 281 383 3,404 MEN3 0 8.4 2.2 6.7 3.0 3.4 4.1 3.2 6.3 1 5.2 12.6 1.0 3.3 0.7 0.0 0.2 4.8 2 29.3 26.5 28.7 8.3 8.7 14.3 10.4 24.5 3 22.7 23.6 17.2 25.5 4.1 6.9 4.8 19.8 4 16.2 17.7 21.7 21.3 30.1 12.4 9.8 17.6 5 8.3 7.6 10.1 18.8 13.0 23.0 10.9 10.1 6+ 8.3 9.0 12.7 17.9 38.3 36.6 55.9 15.1 Non-numeric responses 1.5 0.9 2.0 1.8 1.7 2.6 4.7 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,080 519 444 293 200 139 240 3,915 Mean ideal number of children for: 2 All men 3.1 3.5 3.7 4.4 5.9 5.1 8.1 3.9 Number 2,048 514 435 288 196 136 229 3,846 Currently married men 2.9 3.0 3.4 4.4 6.0 5.3 7.8 4.7 Number 93 171 264 197 158 96 197 1,177 1 Includes current pregnancy 2 Means do not include respondents who gave non-numeric responses. 3 Includes one additional child if wife is pregnant (or if any wife is pregnant for men with more than one wife) The mean ideal number of children is 3.1 for all women age 15-49 and 3.7 for currently married women. Men are considerably more pronatalist than women. The corresponding mean for all men age 15-49 is 3.9, and 4.7 for married men, about one child more than the ideal number reported by women. There is a positive correlation between the actual and ideal number of children for both women and men. For instance, the mean ideal number of children increases from 2.4 for childless Fertility Preferences | 95 women to 5.5 for women with six or more living children. Likewise, the mean ideal number of children for men with no children is 3.1 to 8.1 for men with six or more living children. The increasing mean ideal number of children is partly due to the fact that respondents who have more children may be reluctant to say that they might have wanted fewer children. Further, those who want more children are also more likely to have them. 7.5 MEAN IDEAL NUMBER OF CHILDREN BY BACKGROUND CHARACTERISTICS Table 7.7 shows the mean ideal number of children by age and background characteristics for all women. The mean ideal number of children increases with age and is higher for women in rural areas than those in urban areas. The mean varies substantially by region, with Hardap showing the lowest mean ideal number of 2.4 children and Ohangwena having the highest mean of 3.8 children. The mean ideal number of children decreases with increasing level of education and wealth quintile. 7.6 FERTILITY PLANNING STATUS The issue of unplanned and unwanted pregnancies (unwanted fertility) was further investigated in the 2006-07 NDHS by asking women who had births during the five years before the survey whether the births were wanted at the time (planned), wanted but at a later time (mistimed), or not wanted at all (unwanted). For women who were pregnant at the time of the interview, this question was asked with reference to the current pregnancy. The procedure required respondents to recall their wishes at one or more times in the past five years. Care should be used in interpreting the results because an unwanted conception may have resulted in a cherished child, thus leading to rationalisation of responses to the questions. Table 7.8 gives the percent distribution of births in the five years preceding the survey (and current pregnancies) by fertility planning status, according to birth order and mother’s age at birth. Nearly half of births in the five years before the survey (46 percent) were wanted by the respondents at the time they were conceived, while 27 percent were wanted later and 27 percent were not wanted at all. These figures show that more than half of births in the past five years were unplanned, either born too soon or not wanted at all. The proportion of births reported as unplanned increased from 45 percent in 2000 to 53 percent in 2006-07. The increase is evenly shared by an increase in mistimed and unwanted births. Table 7.7 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Namibia 2006-07 Background characteristic Mean Number of women1 Age 15-19 2.3 2,231 20-24 2.5 1,844 25-29 3.0 1,609 30-34 3.3 1,403 35-39 3.7 1,039 40-44 4.2 907 45-49 4.5 673 Residence Urban 2.8 4,739 Rural 3.3 4,967 Region Caprivi 3.5 471 Erongo 2.8 684 Hardap 2.4 313 Karas 2.7 317 Kavango 3.6 916 Khomas 2.7 2,201 Kunene 3.7 249 Ohangwena 3.8 1,024 Omaheke 3.0 371 Omusati 3.3 963 Oshana 2.9 814 Oshikoto 2.8 834 Otjozondjupa 3.2 549 Education No education/preschool 4.5 627 Incomplete primary 3.9 1,677 Complete primary 3.2 729 Incomplete secondary 2.7 4,721 Complete secondary 2.6 1,279 More than secondary 2.8 672 Wealth quintile Lowest 3.8 1,588 Second 3.4 1,649 Middle 3.1 1,868 Fourth 2.9 2,283 Highest 2.5 2,317 Total 3.1 9,706 1 Women who gave a numeric response 96 | Fertility Preferences Table 7.8 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancy), by planning status of the birth, according to birth order and mother's age at birth, Namibia 2006-07 Planning status of birth Birth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 40.9 32.4 26.3 0.4 100.0 1,753 2 50.4 26.8 22.7 0.1 100.0 1,412 3 49.7 22.7 26.9 0.7 100.0 898 4+ 46.6 21.7 31.6 0.2 100.0 1,468 Mother's age at birth <20 34.0 34.6 31.2 0.2 100.0 857 20-24 39.8 33.6 26.3 0.2 100.0 1,547 25-29 52.0 23.3 24.3 0.5 100.0 1,304 30-34 52.3 22.5 25.0 0.2 100.0 1,004 35-39 56.1 15.7 28.0 0.2 100.0 602 40-44 51.6 14.0 33.7 0.7 100.0 200 45-49 * * * * 100.0 17 Total 46.3 26.5 26.9 0.3 100.0 5,531 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. In the 2006-07 NDHS, the percentage of mistimed births declines with increasing birth order, from 32 percent for first births to 22 percent for the fourth or higher birth order. The proportion of unwanted children rises with increasing birth order. The proportion of children born to mothers under age 20 at the time of the birth is evenly distributed across categories, i.e., one-third wanted then, one- third wanted later, and almost one-third wanted no more. The proportion of wanted children rises with increasing age, from 34 percent for women age 15-19 to 52 percent for women age 40-44. The percentage of mistimed births declines with increasing age, from 35 to 14 percent, while the percentage of unwanted births varies between 24 and 34 percent. 7.7 WANTED FERTILITY RATES Using information on whether births occurring in the five years before the survey were wanted or not, a total “wanted” fertility rate has been calculated. The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. The wanted fertility rate is calculated in the same manner as the conventional total fertility rate, except that unwanted births are excluded. A birth is considered wanted if the number of living children at the time of conception was less than the ideal number of children reported by the respondent. The gap between wanted and actual fertility shows how successful women are in achieving their reproductive intentions. A comparison of the total wanted fertility rate and the total fertility rate for the three years preceding the survey is presented in Table 7.9 by background characteristics. Overall, the total wanted fertility rate is 25 percent lower (0.9 children lower) than the actual total fertility rate. Thus, if all unwanted births were prevented, the total fertility rate for Namibia would be 2.7 children per woman, which is 0.4 children lower than the mean ideal number of children (3.1). In the 2000 NDHS, the total wanted fertility rate was 3.4 children per woman, 19 percent lower than the total fertility rate at that time. Fertility Preferences | 97 The difference between the wanted and actual fertility rate is 0.6 children in urban areas and 1.0 children in rural areas. However, the gap between actual and wanted fertility rates is 19 percent in both rural and urban areas. Regionally, the wanted total fertility rates range from 1.9 children in Khomas to 4.1 children in Kavango; whereas the actual total fertility rates for these regions are 2.6 and 4.9 children, respectively. The total wanted fertility rate decreases with increasing level of education and wealth quintile. Comparing wanted and actual fertility, women with the highest level of education and women in the wealthiest households are the most likely to achieve their fertility desires. Table 7.9 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Namibia 2006-07 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 2.2 2.8 Rural 3.3 4.3 Region Caprivi 3.0 3.6 Erongo 2.3 2.8 Hardap 2.2 3.3 Karas 2.5 3.2 Kavango 4.1 4.9 Khomas 1.9 2.6 Kunene 3.7 4.7 Ohangwena 3.5 4.3 Omaheke 3.5 5.1 Omusati 3.0 3.7 Oshana 2.4 3.0 Oshikoto 2.6 4.0 Otjozondjupa 3.2 4.5 Education No education/preschool 4.8 6.3 Incomplete primary 3.5 4.7 Complete primary 3.1 4.0 Incomplete secondary 2.5 3.2 Complete secondary 2.3 2.8 More than secondary 1.8 2.1 Wealth quintile Lowest 3.9 5.1 Second 3.4 4.3 Middle 3.0 4.1 Fourth 2.1 2.8 Highest 1.9 2.4 Total 2.7 3.6 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Infant and Child Mortality | 99 INFANT AND CHILD MORTALITY 8 This chapter presents levels, trends, and differentials in neonatal, postneonatal, infant, child, and perinatal mortality. The information is relevant both for understanding population trends—for example, the mortality rates can be used in population projections—and for the planning and evaluation of health policies and programmes. Information on child mortality serves the needs of the health sector by identifying population groups that are at high risk. Because the government of Namibia through the Ministry of Health and Social Services is undertaking a number of interventions aimed at reducing child mortality in the country, the analysis in this report provides an opportunity to evaluate the performance of such programmes. The data for mortality estimation is collected in the birth history section of the Women’s Questionnaire. The birth history section begins with questions about the respondent’s experience with childbearing (i.e., the number of sons and daughters living with the mother, the number who live elsewhere, and the number who have died). These questions are followed by a retrospective birth history in which the respondent is asked to list each of her births, starting with the first birth. For each birth, data are obtained on sex, month and year of birth, survivorship status, and current age, or if the child is dead, age at death. This information is used to directly estimate mortality. Age-specific mortality rates are categorized and defined as follows: Neonatal mortality (NN): the probability of dying within the first month of life Postneonatal mortality (PNN): the difference between infant and neonatal mortality Infant mortality (1q0): the probability of dying before the first birthday Child mortality (4q1): the probability of dying between the first and fifth birthday Under-five mortality (5q0): the probability of dying between birth and fifth birthday. All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. 8.1 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Table 8.1 shows neonatal, postneonatal, infant, child, and under-five mortality rates for successive five-year periods before the survey. For the five years immediately preceding the survey (approximately calendar years 2002-2006), the infant mortality rate is 46 per 1,000 live births, and the under-five mortality rate is 69 per 1,000 live births. For the same period, neonatal mortality is 24 deaths per 1,000 live births and child mortality is 24 deaths per 1,000 children surviving to their first birthday. Table 8.1 shows that neonatal mortality decreased from 28 to 24 deaths per 1, 000 live births between the periods 1997-2001 and 2002-2006. At the same time, infant mortality decreased from 51 to 46 deaths per 1,000 live births and under-five mortality remained steady. These downward trends contrast with the previous period 1992-96 to 1997-2001 when neonatal, infant, and under-five mortality rates increased slightly. 100 | Infant and Child Mortality Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Namibia 2006-07 Years preceding the survey Approximate time period of rates Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 2002-2006 24 22 46 24 69 5-9 1997-2001 28 24 51 18 68 10-14 1992-1996 26 18 44 21 64 1 Computed as the difference between the infant and neonatal mortality rates Figure 8.1 shows the infant and under-five mortality rates for each of the three five-year periods preceding the 2006-07 NDHS, 2000 NDHS, and 1992 NDHS. 8.2 DATA QUALITY The quality of mortality estimates calculated from retrospective birth histories depends upon the completeness with which births and deaths are reported and recorded. One factor that affects childhood mortality estimates is the quality of reporting of age at death, which may distort the age pattern of mortality. If age at death is misreported, it will bias the estimates, especially if the net effect of the age misreporting results in transference from one age bracket to another. For example, a net transfer of deaths from the less than one month category to a higher age will affect estimates of neonatal and postneonatal mortality. To minimize errors in reporting of age at death, interviewers were instructed to record age at death in days if the death took place in the month following the birth, in months if the child died before age two, and in years if the child was at least two years of age. They were also asked to probe for deaths reported at one year to determine a more precise age at death in terms of months. The distribution of deaths among children under two years during the 20 years prior to the survey by month shows that there is heaping at 12 months of age (Table C.6). 32 25 57 38 83 20 18 38 25 62 24 22 46 24 69 Neonatal mortality Postneonatal mortality Infant mortality Child mortality Under-five mortality 0 20 40 60 80 100 Percent 1992 NDHS 2000 NDHS 2006-07 NDHS Figure 8.1 Trends in Infant and Child Mortallity Namibia 1992 to 2006-07 Infant and Child Mortality | 101 Another potential data quality problem is the selective omission from birth histories of births that did not survive, which can lead to underestimation of mortality rates. When selective omission of childhood deaths occurs, it is usually more severe for deaths occurring early in infancy. One way such omissions can be detected is by examining the proportion of neonatal deaths to infant deaths. Generally, if there is substantial underreporting of deaths, the result is an abnormally low ratio of neonatal deaths to infant deaths. An examination of the Namibia ratios indicates that no significant number of early infants deaths were omitted in the 2006-07 NDHS (see Tables C.5 and C.6). The proportion of neonatal deaths occurring in the first month of life was 86 percent. This proportion fluctuates between 78 and 87 percent over the 20 years preceding the survey. The proportion of infant deaths occurring before the first birthday ranges from 51 to 61 percent over the same period. Another potential data quality problem is displacement of birth dates, which can distort trends in mortality. In the 2006-07 NDHS questionnaire, the cut-off year for these questions was 2001. The overall sex ratio for deaths is 121, which is higher than expected, indicating that there may be overreporting of male deaths or underreporting of female deaths. The number of deaths recorded during the year 2000 was 101, almost double the number of deaths reported in 2001 (53) (Table C.4). This might be an indication that some interviewers exaggerated the number of deaths occurring in 2000, perhaps to avoid having to ask additional questions. 8.3 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Mortality differentials by residence, region, mother’s level of education, and household wealth are presented in Table 8.2. Rates are presented for the ten-year period preceding the survey (approximately 1998 to 2007) so there would be a sufficient number of births to study differentials across population subgroups. Differentials by residence show that all mortality rates are higher in rural areas than in urban areas. For example, infant mortality in rural areas is 52 deaths per 1,000 live births compared with 43 deaths per 1,000 live births in urban areas. Child mortality in rural areas is 25 per 1,000 live births compared with 17 deaths per 1,000 in urban areas. Across regions, the infant mortality rate is highest in Caprivi (78 deaths per 1,000 live births) and lowest in Kunene (27 deaths per 1,000 live births). The under-five mortality rate is highest in Ohangwena (95 deaths per 1,000 live births) and Caprivi (93 deaths per 1,000 live births), while Kunene has the lowest rate (49 deaths per 1,000 live births.) Table 8.2 also shows that higher education among mothers is associated with lower childhood mortality. For example, children born to mothers with no education have a higher probability of dying before age five (78 deaths per 1,000 births) than those born to mothers who completed secondary school (27 deaths per 1,000 births). There is a significant relationship between household wealth and mortality. Children born to mothers in the lowest wealth quintile are at much higher risk of dying before the fifth birthday (92 deaths per 1,000 births) than those born to mothers in the highest wealth quintile (29 deaths per 1,000 births). 102 | Infant and Child Mortality Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, Namibia 2006-07 Background characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 24 19 43 17 60 Rural 27 26 52 25 76 Region Caprivi 39 39 78 17 93 Erongo 18 30 48 17 65 Hardap 25 22 48 27 73 Karas 20 25 45 15 59 Kavango 21 28 49 19 67 Khomas 28 12 40 12 52 Kunene 10 17 27 23 49 Ohangwena 37 25 62 36 95 Omaheke 21 15 37 27 63 Omusati 31 18 49 29 76 Oshana 29 20 49 26 74 Oshikoto 17 31 48 17 64 Otjozondjupa 19 30 49 19 67 Mother's education No education/preschool 30 27 56 23 78 Incomplete primary 33 29 62 34 94 Complete primary 35 20 56 19 74 Incomplete secondary 25 25 49 17 66 Complete secondary 5 12 17 11 27 More than secondary 14 5 19 4 23 Wealth quintile Lowest 29 31 60 34 92 Second 28 25 54 21 73 Middle 24 21 45 25 69 Fourth 29 26 55 18 72 Highest 16 8 23 6 29 1 Computed as the difference between the infant and neonatal mortality rates 8.4 DEMOGRAPHIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY The demographic characteristics of both mother and child have been found to play an important role in the survival probability of children. Table 8.3 presents early childhood mortality rates by demographic characteristics (i.e., sex of child, mother’s age at birth, birth order, previous birth interval, and birth size). In general, female children experience lower mortality than male children at all ages, with under-five mortality rates of 58 and 79 deaths per 1,000, respectively. The mother’s age at birth is associated with a child’s chances of survival. Children born to younger mothers (under 20 years of age) and older mothers (40 years and older) have higher levels of mortality. This U-shaped pattern by age is seen for neonatal and infant mortality. Child mortality rates, however, increase from 13 per 1,000 live births for children of mothers under age 20 to 26 deaths per 1,000 live births for children of mothers age 40-49. Similarly, under-five mortality for children of mothers age 40-49 is double the rate for children born to mothers under age 20 years. Mortality rates increase with increasing birth order. Children of birth order four and higher have substantially higher mortality rates than children of birth order one to three. Short birth intervals also substantially reduce a child’s chances of survival. For example, children born within two years of a preceding birth are more than twice as likely to die within the first year of life as children born three or more years after an older sibling. The child’s size at birth has a bearing on childhood mortality. For example, neonatal mortality among children whose birth size is “small” or “very small” is 40 deaths per 1,000 live births, compared with 18 deaths per 1,000 live births for children with “average or larger” birth size. Infant and Child Mortality | 103 Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Namibia 2006-07 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 32 25 57 24 79 Female 19 21 40 19 58 Mother's age at birth <20 28 22 50 13 63 20-29 22 21 43 22 63 30-39 25 28 53 25 76 40-49 74 23 97 26 121 Birth order 1 19 19 38 15 52 2-3 23 19 42 21 62 4-6 32 34 65 30 93 7+ 57 29 86 26 109 Previous birth interval2 <2 years 59 33 92 38 126 2 years 27 22 50 24 72 3 years 25 20 45 20 64 4+ years 17 26 43 21 63 Birth size3 Small/very small 40 30 70 na na Average or larger 18 21 39 na na na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey 8.5 DIFFERENTIALS IN INFANT AND CHILD MORTALITY BY WOMEN’S STATUS Women’s ability to access information, make decisions, and act effectively on their own behalf, or the behalf of those who depend on them, is essential to the empowerment of women. When women, the primary caretakers of children, are empowered, the health and survival of their infants is enhanced. In fact, mother’s empowerment fits into Mosley and Chen’s framework on child survival as an individual-level variable that affects child survival through the proximate determinants (Mosley and Chen, 1984). Table 8.4 presents mortality rates by three indicators of women’s status: participation in household decisionmaking, attitude towards a wife’s right to refuse to have sex with her husband, and attitude towards wife beating. These indicators are described in Chapter 3. Contrary to expectation, the data show that children of women who do not have a say in any decisions in the household have lower infant mortality rates (42 deaths per 1,000) than those who do have a say in some decisions in the household (56 deaths per 1,000). Likewise, infant mortality is lower for children of women who did not agree with any of the reasons given for refusing to have sexual intercourse with their husband (35 deaths per 1,000) and higher for children of women who agreed with all three reasons (56 deaths per 1,000). In contrast, the third women’s status indicator, number of reasons for which wife beating is justified, showed mixed results, but with infant mortality lower for children of women who did not agree with any of the reasons justifying wife beating (52 deaths per 1,000) and higher for children of women who agreed with all five reasons justifying wife beating (63 deaths per 1,000). Thus, the results point to two women’s status indicators suggesting that infant mortality is higher for children of women who are more empowered, while the third women’s status indicator points to infant mortality being higher among children of less empowered women. 104 | Infant and Child Mortality Table 8.4 Early childhood mortality rates by women's status Infant, child, and under-five mortality rates for the 10-year period preceding the survey, by indicators of women's status, Namibia 2006-07 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which women participate1 0 42 7 49 1-2 41 28 67 3-4 56 19 73 Number of reasons given for refusing to have sexual intercourse with husband2 0 35 11 46 1-2 45 23 67 3 56 19 73 Number of reasons for which wife beating is justified3 0 52 14 66 1-2 49 25 72 3-4 50 22 71 5 63 42 103 1 Restricted to currently married women. See Table 14.5.1 for the list of decisions. 2 See Table 14.6.1 for the list of reasons 3 See Table 14.7.1 for the list of reasons 8.6 PERINATAL MORTALITY Pregnancy losses occurring after seven completed months of gestation (stillbirths) plus deaths to live births within the first seven days of life (early neonatal deaths) constitute perinatal deaths. The distinction between a stillbirth and an early neonatal death may be a fine one, often depending on observing and then remembering sometimes faint signs of life after delivery. The causes of stillbirths and early neonatal deaths are closely linked and examining just one or the other can understate the true level of mortality around delivery. For this reason, deaths around delivery are combined into the perinatal mortality rate. The perinatal mortality rate is derived by dividing the number of perinatal deaths by the total number of pregnancies reaching seven months of gestation. Table 8.5 presents the number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey. Out of 5,046 reported pregnancies of at least seven months duration, 46 were stillbirths and 101 were early neonatal deaths, with an overall perinatal mortality rate of 29 per 1,000 pregnancies. Compared with data from the 2000 NDHS, perinatal mortality appears to have slightly increased from 27 to 29 deaths per 1,000 pregnancies. However, this analysis is hampered by the fact that the estimate has a large sampling error because of the small number of stillbirths and early neonatal deaths. Perinatal mortality is significantly higher among births to women age 40–49 than those to women who gave birth at a younger age. There is no significant difference in perinatal deaths between urban and rural areas. Perinatal mortality is highest for births occurring less than 15 months after a preceding birth (56 deaths per 1,000 live births) and lowest among births occurring after an interval of 15 to 26 months (18 deaths per 1,000 live births). Caprivi region has the highest perinatal mortality rate (58 deaths per 1,000 live births), while Kunene region has the lowest rate (14 deaths per 1,000 live births). The perinatal mortality rate varies according to mother’s level of education, but the relationship is unclear. Perinatal mortality does not vary much by wealth quintile. Infant and Child Mortality | 105 Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Namibia 2006-07 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 2 25 34 796 20-29 22 46 26 2,602 30-39 15 25 28 1,445 40-49 7 6 59 204 Previous pregnancy interval (in months)4 First pregnancy 9 31 25 1,599 <15 4 4 56 155 15-26 3 9 18 660 27-38 7 25 38 841 39+ 22 32 30 1,792 Residence Urban 20 44 31 2,097 Rural 26 56 28 2,949 Region Caprivi 4 12 58 273 Erongo 3 5 25 308 Hardap 0 3 24 149 Karas 0 4 29 146 Kavango 8 12 32 618 Khomas 10 19 31 929 Kunene 3 0 14 191 Ohangwena 4 9 23 575 Omaheke 2 4 26 236 Omusati 4 12 35 456 Oshana 3 8 30 363 Oshikoto 2 8 22 450 Otjozondjupa 3 4 20 351 Mother's education No education/preschool 4 8 22 557 Incomplete primary 14 23 35 1,070 Complete primary 6 11 45 384 Incomplete secondary 15 49 30 2,177 Complete secondary 6 3 16 599 More than secondary 0 6 24 260 Wealth quintile Lowest 11 20 29 1,083 Second 9 19 29 963 Middle 8 26 30 1,129 Fourth 13 22 33 1,053 Highest 5 14 23 818 Total 46 101 29 5,046 1 Foetal deaths in pregnancies of seven or more months duration 2 Deaths at age 0-6 days among live-born children 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months duration, expressed per 1,000 4 Categories correspond to birth intervals of <24, 24-35, 36-47, and 48+ months. 106 | Infant and Child Mortality 8.7 HIGH-RISK FERTILITY BEHAVIOUR Findings from scientific studies have confirmed that there is a strong relationship between children’s chances of dying and certain fertility behaviours. Typically, the probability of dying in early childhood is much greater if children are born to mothers who are too young or too old, if they are born after a short preceding birth interval, or if they are high parity births. Very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. Older women may also experience age-related problems during pregnancies and delivery. In this analysis, a mother is considered to be “too young” if she is under age 18 and “too old” if she is over age 34 at the time of delivery. A “short birth interval” is a birth occurring within 24 months of a previous birth. Table 8.6 shows the distribution of children born in the five years preceding the survey by risk category. While first births to women age 18-34 are considered an unavoidable risk, they are included in the analysis and are shown as a separate risk category. The first column in Table 8.6 shows the percentage of births occurring in the five years before the survey that fall into the various risk categories. One in three births in Namibia are in a “risk-free” category and 41 percent are at an elevated risk of dying that is considered avoidable. First births, which make up 26 percent of births, are in the unavoidable risk category. Twenty-seven percent of births are in a single high-risk category, and 14 percent are in a multiple high-risk category. The most common single high-risk category is births of order 3 and higher (13 percent), while the most common multiple high-risk category is births to mothers older than 34 years and births of order 3 and above (10 percent). The risk ratios in the second column of Table 8.6 denote the relationship between risk factors and mortality. Births to women under age 18, births after an interval of less than 24 months, and births of order 3 or higher are at the same level of elevated risk, i.e., 12 to 17 percent higher risk than births not in any high-risk category. The most vulnerable births are those to women under age 18 that occur less than 24 months after a preceding birth. They are more than three times as likely to die as births that are not in any high-risk category. The last column in Table 8.6 looks to the future and addresses the question of how many currently married women have the potential for having a high-risk birth. The results were obtained by simulating the risk category into which a birth to a currently married woman would fall if she were to become pregnant at the time of the survey. Thirty percent of currently married women have no elevated risk; 5 percent have unavoidable risk. The survey indicates that of the 65 percent of currently married women who are at an elevated risk for having a high-risk birth, 28 percent fall under the single high-risk category, and 37 percent are in the multiple high-risk category. Infant and Child Mortality | 107 Table 8.6 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of dying and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Namibia 2006-07 Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women1 Not in any high-risk category 32.6 1.00 30.3a Unavoidable risk category First-order births between ages 18 and 34 years 26.0 0.72 5.0 Single high-risk category Mother’s age <18 6.1 1.12 0.5 Mother’s age >34 3.2 0.66 10.5 Birth interval <24 months 5.1 1.13 7.7 Birth order >3 12.8 1.17 9.2 Subtotal 27.3 1.09 28.0 Multiple high-risk category Age <18 and birth interval <24 months2 0.3 3.51 0.3 Age >34 and birth interval <24 months 0.0 0.00 0.6 Age >34 and birth order >3 10.1 1.46 25.5 Age >34 and birth interval <24 months and birth order >3 1.2 0.81 3.9 Birth interval <24 months and birth order >3 2.5 1.70 6.5 Subtotal 14.1 1.48 36.7 In any avoidable high-risk category 41.4 1.23 64.7 Total 100.0 na 100.0 Number of births/women 5,004 na 3,451 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women Adult and Maternal Mortality | 109 ADULT AND MATERNAL MORTALITY 9 In an earlier chapter of this report, estimates of mortality during the first years of life were presented and discussed. This chapter presents information on adult mortality and maternal mortality. Two aspects of the dynamics of adult mortality deserve close attention. First, given the sharp rise in the prevalence of HIV infection and AIDS over the past 20 years, Namibia is expected to experience increases in both female and male adult mortality in the near term. Second, mortality related to pregnancy and childbearing (maternal mortality) is as an important indicator for monitoring women’s health programmes in the country. For a number of reasons, little is known about adult mortality in Namibia compared with infant and child mortality. First, while early childhood mortality can be estimated through the birth history approach, there is no equivalent for measuring adult mortality. Second, death rates are much lower among adults than young children, and hence estimates for particular adult age groups are associated with large sampling errors. Third, there is usually limited information available about the characteristics of adults who have died. While much the same can be said about data on childhood mortality, it is reasonable to expect that the characteristics of the parents will directly influence their children’s chances of survival. 9.1 DATA To estimate adult mortality, the 2006-07 NDHS included a sibling history in the Women’s Questionnaire. Each female respondent was asked to list all children born to her biological mother, excluding herself. These included all siblings who living and those who had died. For brothers and sisters who were alive, only the age at the last birthday was asked. For brothers who had died, only the number of years since death and age at death were asked. For sisters who had died at age 12 years or older, three questions were asked to determine whether the death was maternity related: “Was [NAME OF SISTER] pregnant when she died?” and, if negative, “Did she die during childbirth?” and, if negative, “Did she die within two months after the end of a pregnancy or childbirth?” The data are aggregated to determine the number of person-years of exposure to mortality risk and the number of sibling deaths occurring in defined calendar periods. Rates of maternal and adult mortality are obtained by dividing maternal deaths or all adult female or adult male deaths by person- years of exposure (Rutenberg and Sullivan, 1991). The procedure first calculates rates for each of the five-year age groups and then aggregates the estimates for the total 15-49 age range, weighting the age-specific estimates using the observed age structure of the population. Adult and maternal mortality estimation by either direct or indirect methods requires accurate reporting of the number of siblings the respondent ever had, the number who died, and the number of sisters who died of maternal-related causes (for maternal mortality). Although there is no definitive procedure for establishing the completeness of retrospective data on sibling survivorship, Table 9.1 presents several indicators that can be used to measure the quality of sibling survivorship data. The data do not show any obvious defects that would indicate poor data quality or significant underreporting. A total of 51,256 siblings were recorded in the maternal mortality section of the 2006- 07 NDHS questionnaires. The sex ratio of the siblings (the ratio of brothers to sisters) is 97.3, which is lower than the expected value of 100. This suggests that there is an underreporting of brothers. However, data from the 2000 NDHS and the 1991 and 2001 Population Census indicate that the sex ratio in the general population is relatively low (92, 95, and 94 males per 100 females, respectively). 110 | Adult and Maternal Mortality Table 9.1 Data on siblings Number of siblings reported by survey respondents and completeness of the reported data on age, age at death, and years since death, Namibia 2006-07 Sisters Brothers Total Siblings Number Percent Number Percent Number Percent Living siblings 22,573 100.0 21,006 100.0 43,580 100.0 Age reported 22,324 98.9 20,805 99.0 43,130 99.0 Age missing 249 1.1 201 1.0 450 1.0 Dead siblings 3,359 100.0 4,243 100.0 7,602 100.0 AD and YSD reported 3,199 95.2 4,030 95.0 7,228 95.1 AD missing 74 2.2 96 2.3 170 2.2 YSD missing 21 0.6 24 0.6 45 0.6 AD and YSD missing 65 1.9 94 2.2 159 2.1 All siblings 25,979 100.0 25,278 100.0 51,256 100.0 Living 22,573 86.9 21,006 83.1 43,580 85.0 Dead 3,359 12.9 4,243 16.8 7,602 14.8 Status unknown 46 0.2 28 0.1 74 0.1 AD = Age at death YSD = Years since death The survival status of 74 siblings (less than 1 percent) was not reported. For the surviving siblings, current age was not reported for only 450 (1 percent). Both the age at death and years since death were missing for 2 percent of deceased siblings. Rather than exclude the siblings with missing data from further analysis, information on the birth order of siblings in conjunction with other information was used to impute the missing data.1 The sibling survivorship data, including cases with imputed values, have been used in the direct estimation of adult and maternal mortality. 9.2 DIRECT ESTIMATES OF ADULT MORTALITY One way to assess the quality of data used to estimate maternal mortality is to evaluate the plausibility and stability of overall adult mortality. It is reasoned that if the rates for overall adult mortality are implausible, rates based on a subset of deaths—maternal mortality in particular—are also likely to have serious problems. This is important because levels and trends in overall adult mortality have important implications for health and social programmes in Namibia, especially with regard to the potential impact of the AIDS epidemic. Direct estimation of adult mortality is calculated using the reported ages at death and years since death of respondents’ brothers and sisters. Table 9.2 presents age-specific mortality rates for women and men age 15-49 for the ten-year period preceding the survey, which roughly corresponds to 1998-2007. The rates from the 2006-07 NDHS show the expected increases in mortality for both sexes with increasing age. Female and male mortality rates for age group 15-29 do not differ much; however, above age 25, male mortality exceeds female mortality by increasingly wider margins in older age groups. 1 The imputation procedure is based on the assumption that the reported birth order of siblings in the history is correct. The first step is to calculate birth dates. For each living sibling with a reported age and each dead sibling with complete information on both age at death and years since death, the birth date was calculated. For a sibling missing these data, a birth date was imputed within the range defined by the birth dates of the bracketing siblings. In the case of living siblings, an age at the time of the survey was then calculated from the imputed birth date. In the case of dead siblings, if either the age at death or years since death was reported, that information was combined with the birth date to produce the missing information. If both pieces of information were missing, the distribution of the ages at death of siblings for whom years since death was unreported, but age at death was reported, was used as a basis for imputing the age at death. Adult and Maternal Mortality | 111 Table 9.2 Adult mortality rates Direct estimates of age-specific mortality rates for women and men age 15-49, for the period 0-9 years prior to the 2000 NDHS and 2006-07 NDHS 2006-07 NDHS 2000 NDHS Age Deaths Exposure (person years) Mortality rates/ 1,0001 Mortality rates/ 1,0001 WOMEN 15-19 88 32,923 2.66 1.73 20-24 155 35,342 4.40 3.61 25-29 268 32,555 8.23 5.23 30-34 312 26,412 11.82 5.54 35-39 270 19,426 13.91 5.15 40-44 149 12,691 11.72 5.19 45-49 124 7,348 16.82 7.32 15-49 1,365 166,697 8.29 4.29a MEN 15-19 63 30,655 2.07 1.62 20-24 115 34,002 3.37 3.29 25-29 228 30,856 7.40 5.22 30-34 369 24,448 15.11 8.90 35-39 333 17,545 18.98 10.34 40-44 251 10,805 23.25 13.18 45-49 145 6,252 23.21 11.89 15-49 1,505 154,562 10.38 6.31a 1 Mortality rates are expressed per 1,000 population a Age-adjusted rate The mortality rates derived from the 2006-07 NDHS data are higher for males than females (10 and 8 deaths per 1,000 population, respectively). A comparison of mortality rates for the 2006-07 NDHS and the 2000 NDHS (MoHSS, 2003) shows an increase in adult mortality for both females and males. The summary measure of mortality for age group 15-49 shows that between the two surveys female mortality doubled and male mortality increased by 65 percent. Overall, female mortality rates from the 2006-07 NDHS are higher than those from the 2000 NDHS, especially for females over age 25 (Figure 9.2). The same pattern is seen for males (Figure 9.3). ' ' ' ' ' ' ' & & & & & & & 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 5 10 15 20 25 Rates per 1,000 Women Men& ' Figure 9.1 Adult Mortality Rates in Namibia by Age and Sex 1998-2007 23 17 12 2 12 7 14 3 23 19 15 8 43 112 | Adult and Maternal Mortality 9.3 ESTIMATES OF MATERNAL MORTALITY Two survey methods are generally used to estimate maternal mortality in developing countries: the sisterhood method (Graham et al., 1989) and a direct variant of the sisterhood method (Rutenberg and Sullivan, 1991). In this report, the direct estimation procedure is applied. Age-specific mortality rates are calculated by dividing the number of maternal deaths by woman-years of exposure. To remove the effect of truncation bias (the upper boundary of eligibility for women interviewed in the 2006-07 NDHS is 49 years), the overall rate for women age 15-49 was standardized by the age distribution of the survey respondents. A maternal death is any death that occurs during pregnancy, ' ' ' ' ' ' ' & & & & & & & 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 5 10 15 20 Rates per 1,000 2000 NDHS 2006-07 NDHS& ' Figure 9.2 Female Mortality Rates in Namibia by Age 2000 NDHS and 2006-07 NDHS 2 12 7 5 55 6 4 3 17 14 12 8 4 ' ' ' ' ' ' ' & & & & & & & 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 5 10 15 20 25 Rates per 1,000 2000 NDHS 2006-07 NDHS& ' Figure 9.3 Male Mortality Rates in Namibia by Age 2000 NDHS and 2006-07 NDHS 23 19 15 7 3 3 2 2 12 13 10 9 5 23 Adult and Maternal Mortality | 113 childbirth, or during the two months after the birth or termination of pregnancy.2 Estimates of maternal mortality are therefore based solely on the timing of the death in relation to the pregnancy. Table 9.3 presents direct estimates of maternal mortality for the ten-year period preceding the survey. The data indicate that for the entire childbearing period (age 15-49) during the 10-year period before the survey (1998-2007), the rate of mortality associated with pregnancy and childbearing is 0.52 maternal deaths per 1,000 woman-years of exposure. The estimated age-specific mortality rates show a plausible pattern, being higher during the peak childbearing years (twenties and thirties) and lower for younger and older age groups. Table 9.3 Direct estimates of maternal mortality Direct estimates of maternal mortality rates and the maternal mortality ratio, for the period 0-9 years prior to the 2000 NDHS and 2006-07 NDHS 2006-07 NDHS 2000 NDHS Age Deaths Exposure (person years) Mortality rates/ 1,0001 Mortality rates/ 1,0001 WOMEN 15-19 9 32,923 0.06 0.14 20-24 19 35,342 0.10 0.39 25-29 15 32,555 0.07 0.71 30-34 19 26,412 0.11 0.60 35-39 10 19,426 0.05 0.42 40-44 6 12,691 0.04 0.18 45-49 9 7,348 0.09 0.00 15-49 86 166,697 0.52 0.38 General fertility rate (GFR) 0.12 0.14 Maternal mortality ratio (MMR)1 449 271 1 Per 100,000 live births, calculated as the maternal mortality rate divided by the general fertility rate The maternal mortality rate can be converted to a maternal mortality ratio and expressed per 100,000 live births by dividing the rate by the general fertility rate. This general fertility rate that prevailed during this period was 0.117. Using this procedure, the maternal mortality ratio during the 10-year period before the survey is estimated at 449 maternal deaths per 100,000 live births. This figure should be viewed with caution because the number of female deaths that occurred during pregnancy, at delivery, or within two months of delivery is small (86). As a result, the maternal mortality estimates are subject to large sampling errors; the 95 percent confidence intervals indicate that the maternal mortality ratio varies from 325 to 572. Maternal mortality ratios have been estimated for comparable 10-year periods preceding the 1992 and 2000 NDHS surveys. The maternal mortality ratio appears to have increased substantially since the mid-1980s. Over the past seven years it increased from 271 maternal deaths per 100,000 live births for the period 1991-2000 to 449 for the period 1998-2007. The methodology used and the sample sizes implemented in these three surveys do not allow for precise estimates of maternal mortality, so the sampling errors around each of the estimates are large. While the confidence intervals around the estimates from the 1992 and 2000 NDHS surveys overlap with the confidence interval around the estimate from the 2006-07 NDHS survey, additional statistical testing makes it possible to say with reasonable confidence that maternal mortality in Namibia increased in the recent past. 2 This time-dependent definition includes all deaths that occurred during pregnancy and two months after pregnancy, even if the death was due to nonmaternal causes. However, this definition is unlikely to result in overreporting of maternal deaths because most deaths to women during the two-month period are due to maternal causes, and maternal deaths are more likely to be underreported than overreported. Maternal Health │ 115 MATERNAL HEALTH 10 The health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child. This chapter presents findings on several areas of importance to maternal health: antenatal, delivery, and postnatal care, and problems in accessing health care. These findings are important to policymakers and programme implementers in formulating programmes and policies, and in designing appropriate strategies and interventions to improve maternal and child health care services. Information on antenatal, delivery and postnatal care is important for identifying subgroups of women who do not utilize these services. It is also useful for planning improvements in maternity care. This chapter presents the 2006-07 NDHS findings on providers of maternity care services, where the services are received, timing of ANC visits, components of antenatal care (ANC) including coverage of tetanus toxoid vaccinations, problems women face in accessing health care, and men’s participation in the health care for their family. 10.1 ANTENATAL CARE Antenatal care (ANC) coverage can be described according to the type of provider, number of ANC visits, and stages of pregnancy at the time of the first visit as well as content of services and information provided during antenatal care. One of the major goals of antenatal care is to identify and treat problems that may occur during pregnancy such as anaemia, high blood pressure, and genital infections. It is during ANC visits that screening for complications is done and advice is given on a range of issues including place of delivery and referral of women with complications. In the 2006-07 NDHS, information on ANC coverage was obtained from women who had a birth in the five years preceding the survey. For women with two or more live births during the five-year period, data refer to the most recent birth only. Table 10.1 shows the percent distribution of mothers who had a birth in the five years preceding the survey by provider of antenatal care received during pregnancy, according to selected characteristics. Women were asked to report all persons seen for antenatal care for the last birth. For purposes of this analysis, if the woman saw more than one provider, only the provider with the highest qualifications is considered. A large majority (95 percent) of mothers received antenatal care from a health professional for their most recent birth in the five years preceding the survey, 16 percent from a doctor and 79 percent from a nurse/midwife. Just 1 percent of mothers received antenatal care from a traditional birth attendant (trained or untrained) while 4 percent received no antenatal care for births in the past five years. Differences in antenatal care by women’s age at birth are not large. Differences by birth order, however, are more pronounced. Mothers are more likely to receive care from a health professional for first births (97 percent) than for births of order six and higher (88 percent). There are differences in the type of provider of the antenatal care services between urban and rural women. In urban areas, 27 percent of mothers receive antenatal care from a doctor compared with 7 percent of women in rural areas. On the other hand, nurses and midwives provide antenatal care for 86 percent of mothers in rural areas but only 69 percent of mothers in urban areas. 116 │ Maternal Health There are regional differences in the type of provider of antenatal care; 81 percent of mothers in Kunene received antenatal care from a health professional, compared with 99 percent of mothers in Karas and Oshana. Table 10.1 Antenatal care provider Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Namibia 2006-07 Antenatal care provider Background characteristic Doctor Nurse/ midwife Traditional birth attendant Other No one Missing Total Percentage receiving antenatal care from a skilled provider1 Number of women Mother's age at birth <20 9.2 85.4 0.8 0.3 4.3 0.1 100.0 94.6 590 20-34 17.3 78.3 0.7 0.3 3.1 0.4 100.0 95.6 2,701 35-49 17.1 73.3 2.1 0.0 6.7 0.8 100.0 90.4 607 Birth order 1 16.0 80.6 0.4 0.2 2.7 0.1 100.0 96.6 1,224 2-3 19.2 76.4 0.9 0.1 3.0 0.4 100.0 95.6 1,646 4-5 12.6 79.4 1.2 0.4 5.8 0.5 100.0 92.1 643 6+ 8.3 80.0 2.6 0.6 7.6 1.0 100.0 88.3 385 Residence Urban 27.4 68.7 0.4 0.2 2.9 0.5 100.0 96.1 1,711 Rural 7.2 86.2 1.4 0.3 4.6 0.3 100.0 93.4 2,188 Region Caprivi 2.9 90.8 1.4 0.0 4.1 0.9 100.0 93.6 217 Erongo 23.4 69.5 0.2 0.0 6.8 0.0 100.0 93.0 257 Hardap 22.1 73.4 0.0 0.9 3.1 0.5 100.0 95.5 121 Karas 23.1 75.6 0.0 0.0 0.9 0.3 100.0 98.8 119 Kavango 9.5 82.2 0.6 0.9 5.9 0.9 100.0 91.6 481 Khomas 38.3 58.5 0.4 0.0 2.4 0.4 100.0 96.8 737 Kunene 8.7 72.6 10.1 0.7 7.4 0.4 100.0 81.4 136 Ohangwena 1.9 93.8 2.0 0.0 2.3 0.0 100.0 95.7 422 Omaheke 18.0 73.5 1.1 0.2 6.5 0.7 100.0 91.5 171 Omusati 7.1 89.8 1.0 0.3 1.5 0.3 100.0 96.9 365 Oshana 7.4 91.1 0.0 0.0 1.2 0.3 100.0 98.5 271 Oshikoto 4.3 91.0 0.0 0.0 4.5 0.3 100.0 95.3 340 Otjozondjupa 25.3 68.1 0.0 0.2 6.4 0.0 100.0 93.4 261 Mother's education No education/preschool 9.4 69.6 4.9 0.7 14.9 0.6 100.0 79.0 372 Incomplete primary 4.9 88.6 1.2 0.5 4.3 0.6 100.0 93.5 784 Complete primary 7.2 89.4 0.3 0.0 2.9 0.2 100.0 96.6 303 Incomplete secondary 14.8 82.2 0.5 0.1 2.0 0.3 100.0 97.0 1,739 Complete secondary 31.8 65.6 0.0 0.0 2.0 0.6 100.0 97.4 494 More than secondary 56.6 40.6 0.0 0.0 2.8 0.0 100.0 97.2 205 Wealth quintile Lowest 3.4 86.9 2.2 0.4 6.6 0.5 100.0 90.3 788 Second 5.1 88.2 2.0 0.2 4.2 0.3 100.0 93.2 711 Middle 11.8 83.9 0.7 0.1 3.2 0.3 100.0 95.7 855 Fourth 17.2 79.8 0.1 0.3 2.3 0.3 100.0 97.0 856 Highest 45.7 50.9 0.0 0.1 2.8 0.5 100.0 96.6 688 Total 16.1 78.6 1.0 0.2 3.8 0.4 100.0 94.6 3,898 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor and nurse/midwife Maternal Health │ 117 The type of provider of ANC services is directly related to the mother’s level of education. Fifteen percent of women with no education received no antenatal care compared with 4 percent or less of women with some education. On the other hand, 94 to 97 percent of women with some education received antenatal care from a health professional compared with 79 percent of women with no education. There is also a positive relationship between increasing wealth quintile and receiving antenatal care from a health professional. Comparison with the 2000 NDHS data shows an overall improvement in the proportion of pregnant women who received ANC services from a health provider. The proportion of women living in rural areas who received ANC services from a skilled health care provider increased from 88 percent in 2000 to 93 percent in 2006-07. Among regions, the greatest improvement was in Omaheke (19 percentage points), and Kavango and Caprivi (10 percentage points, each). On the other hand, Kunene and Erongo showed a decline in ANC coverage by a skilled provider of 4 and 2 percentage points, respectively. 10.2 PLACE OF ANTENATAL CARE Table 10.2 shows the percent distribution of women with a live birth in the past five years who received antenatal care, by place where ANC was received, according to background characteristics. Nine in ten women in Namibia went to a public health facility to receive antenatal care for their most recent birth in the five years preceding the survey. Only 8 percent of women went to a private sector facility for antenatal care and just 1 percent received care at home. The proportion of mothers who go to a public health facility for antenatal care decreases with women’s age, while the proportion receiving care at a private facility increases with women’s age. For example, 97 percent of mothers under 20 received ANC at a public health facility compared with 88 percent of mothers age 35-49. There are differences in the place where antenatal care services were received between urban and rural women. Urban mothers are less likely to go to a public health facility than rural mothers (84 percent compared with 95 percent), while they are more likely to go to a private facility than rural mothers (15 percent compared with 2 percent). There are some regional differences in the source of antenatal care; for example, 76 percent of mothers in Khomas received antenatal care from a public health facility, compared with 98 percent of mothers in Caprivi and Oshikoto. On the other hand, one in five women (22 percent) in Khomas went to a private health facility for ANC compared to less than 1 percent of women in Kavango and Caprivi. Education has an impact on the source of ANC. Mothers with a higher education are generally more likely to use private health facilities for ANC and less likely to use public facilities than mothers with no or little education. For example, over half of women (52 percent) with higher-than-secondary education received ANC from a private health facility compared with 1 percent or less of mothers with no education or primary education. There is a positive relationship between increasing wealth quintile and receiving antenatal care from a private health facility while the opposite is true for public facilities. 118 │ Maternal Health Table 10.2 Place of antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey and saw someone for antenatal care, by place of antenatal care (ANC) during pregnancy for the most recent birth, according to background characteristics, Namibia 2006-07 Health facility Background characteristic Public sector Private sector Home Other Missing Total Number of women Mother's age at birth <20 97.2 1.6 0.8 0.2 0.2 100.0 564 20-34 89.1 8.9 1.3 0.1 0.7 100.0 2,609 35-49 88.1 9.2 2.1 0.0 0.6 100.0 562 Birth order 1 90.5 8.3 0.5 0.1 0.5 100.0 1,189 2-3 87.3 10.5 1.3 0.0 0.8 100.0 1,591 4-5 94.3 3.9 1.3 0.0 0.5 100.0 603 6+ 94.7 1.3 4.0 0.0 0.0 100.0 352 Residence Urban 83.7 14.7 0.6 0.1 0.9 100.0 1,653 Rural 95.2 2.4 1.9 0.1 0.4 100.0 2,081 Region Caprivi 97.7 0.9 0.7 0.0 0.6 100.0 206 Erongo 84.9 13.2 0.6 0.0 1.2 100.0 240 Hardap 89.9 8.1 1.5 0.0 0.5 100.0 116 Karas 82.2 15.3 0.0 0.0 2.6 100.0 117 Kavango 97.2 0.0 2.3 0.0 0.6 100.0 449 Khomas 76.1 22.0 0.6 0.0 1.3 100.0 716 Kunene 85.7 1.8 11.1 0.9 0.5 100.0 125 Ohangwena 96.6 1.8 1.6 0.0 0.0 100.0 412 Omaheke 87.8 10.0 1.8 0.4 0.0 100.0 159 Omusati 92.9 5.3 1.3 0.0 0.5 100.0 359 Oshana 96.7 3.0 0.0 0.3 0.0 100.0 267 Oshikoto 98.4 1.6 0.0 0.0 0.0 100.0 324 Otjozondjupa 91.9 7.0 0.8 0.0 0.3 100.0 244 Mother's education No education/preschool 92.3 1.0 6.2 0.2 0.3 100.0 315 Incomplete primary 96.3 0.9 2.4 0.0 0.4 100.0 746 Complete primary 98.2 1.1 0.4 0.0 0.3 100.0 294 Incomplete secondary 94.5 4.6 0.5 0.1 0.2 100.0 1,698 Complete secondary 76.7 20.5 0.0 0.1 2.7 100.0 481 More than secondary 46.8 51.6 0.9 0.0 0.7 100.0 200 Wealth quintile Lowest 96.6 0.5 2.4 0.1 0.3 100.0 732 Second 95.5 1.9 2.2 0.1 0.4 100.0 679 Middle 97.0 1.7 1.2 0.0 0.1 100.0 825 Fourth 93.7 5.5 0.5 0.1 0.2 100.0 834 Highest 64.6 32.6 0.4 0.1 2.3 100.0 665 Total 90.1 7.9 1.3 0.1 0.6 100.0 3,734 10.3 NUMBER AND TIMING OF ANC VISITS Antenatal care is more beneficial in preventing pregnancy outcomes when it is sought early in the pregnancy and is continued through to delivery. Health professionals recommend that the first antenatal care visit should occur within the first three months of pregnancy and continue on a monthly basis through the twenty-eighth week of pregnancy and every two weeks up to the thirty-sixth week (or until birth). Under normal circumstances, the World Health Organization (WHO) recommends that a woman without complications have at least four ANC visits, the first of which should take place during the first trimester. It is possible during these visits to detect health problems associated with a pregnancy. In the event of any complications, more frequent visits are advisable and admission to a health facility may be necessary. Maternal Health │ 119 In Namibia, the recommended protocol for antenatal care calls for a woman with a normal pregnancy to visit an ANC clinic at monthly intervals until the twenty-eighth week of pregnancy, then fortnightly until the thirty- sixth week and then weekly until labour begins. This implies that 12-13 visits should be made during the entire pregnancy. Table 10.3 shows that seven in ten women make four or more antenatal care visits during their pregnancy. There is some variation between women in urban areas (73 percent) and those in rural areas (68 percent). Sixteen percent of women make fewer than four ANC visits, while 4 percent do not have any ANC visits at all. One in three women make their first antenatal care visit before the fourth month of pregnancy. The median duration of pregnancy for the first antenatal care visit is 4.7 months. This indicates that in Namibia, women start antenatal care somewhat late in their pregnancy. There has been a slight increase in the timing of the first visit over the past five years; 69 percent of women received ANC before the sixth month of pregnancy in 2000 compared with 71 percent in 2006-07. These results indicate that more programme interventions should be designed to encourage pregnant women to attend ANC clinics in the first trimester of pregnancy. 10.4 COMPONENTS OF ANTENATAL CARE Observing the content of antenatal care is essential for assessing the quality of the services offered. Pregnancy complications are a primary source of maternal and child morbidity and mortality. Therefore, ensuring that pregnant women receive information on the signs of complications and testing them for complications should be routinely included in all antenatal care visits. To help assess ANC services, respondents were asked about whether they had been advised of complications or received certain screening tests during at least one of the antenatal visits. Table 10.4 presents information on the percentage of women who took iron tablets and intestinal parasite drugs during their last pregnancy in the five years preceding the survey. For women who received antenatal care, the table shows the percentage of women who were informed about the signs of pregnancy complications and the percentage who received routine antenatal care services. Among women with a live birth in the past five years, eight in ten took iron tablets or syrup while pregnant with the last birth. There are few variations by age at birth and birth order. However, there are some variations by residence, region, education, and wealth quintile, with urban women, women in Karas and Hardap, and better educated women and wealthier women much more likely to have taken iron supplements. Although Namibia does not have a policy on the prescription of intestinal parasite drugs, 7 percent of women took intestinal parasite drugs during their pregnancy. Variations by background characteristics are small. Table 10.3 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit; and among women with ANC, median months pregnant at first visit, according to residence, Namibia 2006-07 Residence Number and timing of ANC visits Urban Rural Total Number of ANC visits None 2.9 4.6 3.8 1 1.3 2.0 1.7 2-3 11.5 15.7 13.9 4+ 73.0 68.4 70.4 Don't know/missing 11.3 9.4 10.2 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 2.9 4.6 3.8 <4 36.5 29.5 32.6 4-5 35.6 40.4 38.3 6-7 20.2 21.2 20.8 8+ 3.2 2.1 2.6 Don't know/missing 1.7 2.3 2.0 Total 100.0 100.0 100.0 Number of women 1,711 2,188 3,898 Median months pregnant at first visit (for those with ANC) 4.6 4.8 4.7 Number of women with ANC 1,662 2,088 3,749 120 │ Maternal Health Table 10.4 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy for the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Namibia 2006-07 Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Among women who received antenatal care for their most recent birth in the past five years, the percentage who received specific services: Background characteristic Took iron tablets or syrup Took intestinal parasite drugs Number of women with a live birth in the past five years Informed of signs of pregnancy complications Weighed Blood pressure measured Urine sample taken Blood sample taken Number of women with ANC for their most recent birth Mother's age at birth <20 79.8 9.8 590 54.4 97.4 95.3 91.9 96.9 564 20-34 80.7 6.9 2,701 60.4 98.4 97.9 94.1 97.6 2,609 35-49 75.5 7.4 607 51.9 97.4 96.7 93.6 97.1 562 Birth order 1 81.4 7.8 1,224 59.7 98.5 97.8 94.0 97.8 1,189 2-3 81.3 7.6 1,646 60.8 98.3 97.4 94.0 97.5 1,591 4-5 76.8 6.5 643 53.5 98.2 98.2 94.9 97.7 603 6+ 73.0 6.9 385 49.4 96.0 93.7 89.2 95.1 352 Residence Urban 84.2 7.0 1,711 61.2 99.3 99.3 98.4 98.2 1,653 Rural 76.3 7.7 2,188 55.9 97.2 95.7 90.0 96.7 2,081 Region Caprivi 73.4 14.3 217 81.2 99.1 98.1 91.8 97.9 206 Erongo 79.6 3.5 257 49.2 98.4 99.7 98.4 97.7 240 Hardap 91.2 3.6 121 58.5 98.9 99.0 98.4 99.1 116 Karas 91.7 2.6 119 61.1 99.1 99.6 99.6 99.1 117 Kavango 82.1 23.9 481 61.1 98.1 91.3 90.1 95.8 449 Khomas 84.8 6.1 737 63.6 99.6 99.9 99.8 98.6 716 Kunene 77.8 3.9 136 41.1 87.1 87.3 87.6 85.5 125 Ohangwena 70.0 2.0 422 44.3 98.3 98.1 86.7 97.8 412 Omaheke 80.6 4.8 171 34.9 93.6 96.1 96.0 95.4 159 Omusati 74.9 6.1 365 71.6 98.2 98.3 86.8 98.9 359 Oshana 82.9 4.0 271 76.3 100.0 98.2 93.9 98.3 267 Oshikoto 74.0 6.2 340 46.2 97.9 96.6 92.7 96.7 324 Otjozondjupa 83.0 1.9 261 48.9 98.3 99.2 99.0 98.7 244 Mother's education No education/preschool 67.0 8.8 372 47.0 91.1 89.4 85.6 90.1 315 Incomplete primary 76.5 9.2 784 50.0 97.7 96.7 90.3 97.4 746 Complete primary 78.5 5.0 303 56.6 97.9 95.0 92.9 96.1 294 Incomplete secondary 81.6 6.6 1,739 60.9 99.0 98.8 94.9 98.7 1,698 Complete secondary 86.1 5.6 494 61.5 99.9 98.6 98.0 99.0 481 More than secondary 86.3 12.3 205 77.6 99.1 100.0 99.5 95.6 200 Wealth quintile Lowest 71.9 10.8 788 59.5 96.3 93.7 85.5 95.0 732 Second 74.0 7.3 711 54.9 96.5 95.6 90.0 96.7 679 Middle 82.1 6.6 855 53.0 98.5 97.9 94.9 98.1 825 Fourth 83.3 5.5 856 59.6 99.7 99.5 97.8 98.8 834 Highest 87.4 7.0 688 64.8 99.4 99.5 99.8 98.0 665 Total 79.8 7.4 3,898 58.2 98.1 97.3 93.7 97.4 3,734 About six in ten mothers (58 percent) who received antenatal care reported that they were informed about pregnancy complications during their visits. Weight and blood pressure were measured on 98 percent and 97 percent of mothers, respectively. More than nine in ten mothers gave urine (94 percent) and blood samples (97 percent). The quality of antenatal care received is related to mother’s level of education, household wealth quintile, residence, and region. For example, women with secondary or higher education, women in the highest wealth quintile, and urban women are more likely than women with no education, women in the lowest wealth quintile, and rural women to be informed about pregnancy Maternal Health │ 121 complications. There are regional variations in the proportion of women informed about pregnancy complications during their ANC visits ranging from 35 percent among women in Omaheke to 81 percent in Caprivi. Patterns observed for the other routine ANC tests and procedures were not as pronounced. 10.5 TETANUS TOXOID INJECTIONS Neonatal tetanus is a leading cause of death among children less than one month of age in developing countries where a high proportion of deliveries are conducted at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) immuni- zation is given to pregnant women to prevent neonatal tetanus. If a woman has received no previous TT injections, two doses of TT are required during pregnancy for full protection. For a woman to have lifetime protection, a total of five doses are required. However, if a woman was fully immunized before she became pregnant, she may require only one TT injection during the current pregnancy, depending on the number of injections she has ever received and the timing of the last injection. For the last live birth in the five years preceding the survey, the 2006-07 NDHS collected information on whether the woman received at least two TT injections during pregnancy and whether the pregnancy was protected against neonatal tetanus. Table 10.5 shows that one-third (33 percent) of the women had two or more TT injections during the last pregnancy and six in ten women (57 percent) had their last births protected against neonatal tetanus. This information indicates that births to women in Namibia are not routinely protected against neonatal tetanus. Births to relatively younger mothers (age 20-34) and first births are slightly more likely to be protected against tetanus than births to older mothers and higher order births. Although TT protection for women age 35-49 is 8 percentage points lower than the national average, there has been an increase of 16 percentage points since the 2000 NDHS. There are no urban-rural variations in the protection of births against tetanus; however, the proportion of births protected against tetanus does vary by region. Tetanus Table 10.5 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid (TT) injections during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Namibia 2006-07 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last live birth was protected against neonatal tetanus1 Number of mothers Mother's age at birth <20 43.0 58.5 590 20-34 32.1 58.1 2,701 35-49 26.3 49.3 607 Birth order 1 38.5 60.0 1,224 2-3 30.7 55.8 1,646 4-5 29.4 56.4 643 6+ 29.6 51.7 385 Residence Urban 32.3 59.6 1,711 Rural 33.3 54.6 2,188 Region Caprivi 58.2 87.1 217 Erongo 20.7 66.8 257 Hardap 27.6 57.6 121 Karas 45.2 66.0 119 Kavango 35.5 43.2 481 Khomas 29.0 54.5 737 Kunene 36.9 68.5 136 Ohangwena 21.6 44.5 422 Omaheke 45.7 69.4 171 Omusati 27.7 49.7 365 Oshana 31.1 55.2 271 Oshikoto 25.6 48.3 340 Otjozondjupa 52.5 76.6 261 Mother's education No education/preschool 35.3 53.1 372 Incomplete primary 35.0 54.1 784 Complete primary 38.2 60.7 303 Incomplete secondary 35.4 60.3 1,739 Complete secondary 24.3 53.7 494 More than secondary 11.6 45.7 205 Wealth quintile Lowest 32.8 50.9 788 Second 31.9 50.5 711 Middle 37.4 60.4 855 Fourth 36.1 67.4 856 Highest 24.1 52.3 688 Total 32.9 56.8 3,898 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth. 122 │ Maternal Health toxoid coverage is lowest among mothers in Kavango and Ohangwena (43 percent and 45 percent, respectively) and highest among mothers in Caprivi (87 percent). Births to women with more than secondary education (46 percent) are the least likely to be protected against tetanus while births to women with completed primary education are the most likely to be protected (61 percent). It should be noted, however, that TT coverage has increased since the 2000 NDHS for mothers with all levels of education. 10.6 PLACE OF DELIVERY Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that may cause the death or serious illness of the mother and child. Hence, an important component in the effort to reduce the health risks of mothers and children is to increase the proportion of babies delivered in a safe and clean environment and under the supervision of health professionals. Table 10.6 shows the percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. A large majority of births (81 percent) in the five years before the survey were delivered in a health facility, an increase of 6 percentage points since the 2000 NDHS. Seventy-six percent of births were delivered in a public facility and 5 percent were delivered in a private facility. Almost one in five births (19 percent) were delivered at home. Delivery at a health facility is generally more common among younger mothers (age less than 35), mothers with a first-order birth, and mothers who have had at least four antenatal visits. Children born in urban areas are more than four times as likely to be delivered in a health facility as children born in rural areas. The proportion of births delivered in a health facility varies from 54 percent in Kunene to 95 percent in Khomas. There is a strong association between mother’s education and place of delivery. About half the births among uneducated mothers are delivered in a health facility compared with almost all the births among mothers with secondary and higher education. Births to mothers in the highest wealth quintile (97 percent) are much more likely to be delivered in a health facility than births to mothers in the lowest two wealth quintiles (59 percent and 73 percent, respectively). Table 10.6 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Namibia 2006-07 Place of delivery Health facility Background characteristic Public sector Private sector Home Other Missing Total Percentage delivered in a health facility Number of births Mother's age at birth <20 80.4 0.8 18.5 0.3 0.0 100.0 81.2 793 20-34 76.7 5.4 17.3 0.2 0.4 100.0 82.1 3,482 35-49 69.7 4.7 25.0 0.3 0.4 100.0 74.4 728 Birth order 1 83.2 5.6 10.7 0.2 0.3 100.0 88.8 1,608 2-3 76.8 6.0 16.9 0.1 0.3 100.0 82.8 2,064 4-5 71.4 1.5 26.6 0.3 0.2 100.0 72.9 833 6+ 60.1 0.4 38.4 0.6 0.5 100.0 60.5 498 Antenatal care visits1 None 37.2 2.9 58.9 1.0 0.0 100.0 40.1 149 1-3 69.3 1.7 28.5 0.4 0.2 100.0 71.0 606 4+ 81.5 5.8 12.5 0.2 0.1 100.0 87.2 2,745 Don't know/missing 74.6 6.6 17.9 0.0 0.8 100.0 81.3 398 Residence Urban 84.6 8.9 6.1 0.1 0.3 100.0 93.5 2,077 Rural 70.3 1.5 27.6 0.3 0.3 100.0 71.9 2,926 Continued… Maternal Health │ 123 Table 10.6—Continued Place of delivery Health facility Background characteristic Public sector Private sector Home Other Missing Total Percentage delivered in a health facility Number of births Region Caprivi 77.7 0.3 21.8 0.2 0.0 100.0 78.0 269 Erongo 80.3 11.6 7.4 0.7 0.0 100.0 91.9 306 Hardap 87.1 3.1 8.7 0.0 1.1 100.0 90.2 149 Karas 81.8 10.1 7.1 0.7 0.3 100.0 91.9 146 Kavango 62.3 0.2 36.1 0.5 0.9 100.0 62.5 610 Khomas 83.1 11.9 4.9 0.1 0.0 100.0 95.0 920 Kunene 52.7 0.9 45.6 0.3 0.5 100.0 53.6 189 Ohangwena 69.9 0.9 28.7 0.0 0.4 100.0 70.9 571 Omaheke 72.7 4.0 22.7 0.0 0.7 100.0 76.7 234 Omusati 84.5 3.1 11.8 0.2 0.3 100.0 87.6 452 Oshana 86.3 2.5 11.2 0.0 0.0 100.0 88.8 360 Oshikoto 75.1 2.7 21.7 0.3 0.2 100.0 77.8 449 Otjozondjupa 77.2 3.0 19.5 0.2 0.2 100.0 80.2 348 Mother's education No education/preschool 49.0 0.2 49.7 0.5 0.5 100.0 49.2 553 Incomplete primary 66.6 0.1 32.5 0.5 0.3 100.0 66.8 1,058 Complete primary 80.5 0.0 19.2 0.1 0.2 100.0 80.5 378 Incomplete secondary 87.3 1.8 10.5 0.1 0.4 100.0 89.1 2,162 Complete secondary 82.3 15.2 2.4 0.1 0.0 100.0 97.5 593 More than secondary 62.2 37.5 0.3 0.0 0.0 100.0 99.7 260 Wealth quintile Lowest 58.4 0.1 40.6 0.6 0.2 100.0 58.6 1,072 Second 72.1 0.8 26.6 0.2 0.4 100.0 72.9 956 Middle 84.7 0.7 14.2 0.1 0.4 100.0 85.4 1,121 Fourth 89.5 3.8 6.1 0.1 0.5 100.0 93.3 1,041 Highest 76.0 21.3 2.5 0.2 0.0 100.0 97.3 813 Total 76.3 4.6 18.6 0.2 0.3 100.0 80.8 5,003 1 Includes only the most recent birth in the five years preceding the survey 10.7 ASSISTANCE DURING DELIVERY Obstetric care by a trained provider during delivery is recognized as critical for the reduction of maternal and neonatal mortality. Births delivered at home are usually less likely to be delivered with assistance from a trained health professional than births delivered at a health facility. Table 10.7 shows the type of assistance received during delivery by background characteristics. More than eight in ten births (81 percent) are delivered with assistance from a trained health professional, that is a doctor, nurse, or midwife. This is an increase from 76 percent in the 2000 NDHS. Seven percent of births are delivered by a traditional birth attendant, while about one in ten births (11 percent) are attended by a relative or some other person. Less than 1 percent of births are delivered without any assistance at all. Births to young mothers (less than 35 years) and first births are more likely to be assisted by trained health professionals. A higher percentage of births in urban areas are assisted by a trained health professional than births in rural areas (94 percent versus 73 percent). Additionally, 17 percent of births among women in rural areas are delivered with the help of a relative or some other person, compared with 4 percent of births among women in urban areas. In most regions, the proportion of births assisted by a trained health professional is quite high (70 percent or higher). However, 54 percent of births in Kunene and 64 percent of births in Kavango are delivered by a trained health professional. 124 │ Maternal Health Table 10.7 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider and percentage delivered by caesarean-section, according to background characteristics, Namibia 2006-07 Person providing assistance during delivery Background characteristic Doctor Nurse/ midwife Traditional birth attendant Relative/ other No one Don't know/ missing Total Percentage delivered by a skilled provider1 Percentage delivered by C-section Number of births Mother's age at birth <20 10.3 71.2 5.6 12.3 0.4 0.2 100.0 81.5 8.3 793 20-34 20.2 62.6 6.0 10.4 0.4 0.2 100.0 82.9 13.5 3,482 35-49 19.5 54.4 9.9 13.8 1.8 0.5 100.0 74.0 13.5 728 Birth order 1 20.4 68.6 3.7 6.9 0.1 0.3 100.0 89.0 14.8 1,608 2-3 20.6 62.6 5.7 10.3 0.4 0.3 100.0 83.3 14.2 2,064 4-5 15.2 59.4 8.7 15.7 0.9 0.1 100.0 74.6 8.3 833 6+ 9.6 50.5 15.5 21.7 2.4 0.2 100.0 60.1 6.5 498 Place of delivery Health facility 22.9 76.8 0.0 0.2 0.0 0.1 100.0 99.7 15.7 4,045 Elsewhere 0.4 3.3 34.7 58.7 2.8 0.1 100.0 3.6 0.0 943 Missing 0.0 28.4 0.0 0.0 12.8 58.9 100.0 28.4 0.0 15 Residence Urban 32.0 61.9 2.0 3.7 0.2 0.2 100.0 93.9 20.7 2,077 Rural 9.0 63.4 9.8 16.6 0.9 0.3 100.0 72.5 7.0 2,926 Region Caprivi 3.7 76.3 6.3 13.3 0.4 0.0 100.0 80.0 2.2 269 Erongo 32.2 60.4 2.4 5.0 0.0 0.0 100.0 92.6 23.4 306 Hardap 21.3 69.2 0.5 7.9 0.0 1.1 100.0 90.5 12.2 149 Karas 33.7 59.9 0.0 6.1 0.0 0.3 100.0 93.7 16.5 146 Kavango 6.9 56.7 10.5 23.4 1.9 0.7 100.0 63.5 5.4 610 Khomas 42.1 53.2 1.0 3.6 0.0 0.0 100.0 95.3 26.0 920 Kunene 8.0 46.3 13.7 31.4 0.0 0.5 100.0 54.4 3.5 189 Ohangwena 5.4 65.9 14.2 13.7 0.5 0.2 100.0 71.3 4.9 571 Omaheke 21.6 54.6 2.2 20.3 0.2 1.1 100.0 76.2 18.8 234 Omusati 10.5 77.1 7.5 3.6 1.0 0.3 100.0 87.6 11.1 452 Oshana 11.6 77.2 4.8 5.9 0.5 0.0 100.0 88.8 11.6 360 Oshikoto 8.1 70.3 11.4 9.0 0.9 0.2 100.0 78.5 6.2 449 Otjozondjupa 25.1 55.3 4.0 14.4 1.2 0.0 100.0 80.4 12.6 348 Mother's education No education/preschool 9.1 41.2 14.2 32.8 2.2 0.5 100.0 50.3 5.0 553 Incomplete primary 9.3 58.3 13.2 18.5 0.6 0.2 100.0 67.5 6.9 1,058 Complete primary 7.9 72.4 6.4 12.1 1.0 0.2 100.0 80.4 6.3 378 Incomplete secondary 16.4 73.2 3.6 6.1 0.4 0.4 100.0 89.5 11.9 2,162 Complete secondary 39.5 58.4 1.1 1.0 0.0 0.0 100.0 97.9 26.8 593 More than secondary 62.2 37.3 0.3 0.2 0.0 0.0 100.0 99.4 35.5 260 Wealth quintile Lowest 4.7 55.2 15.3 23.7 1.0 0.2 100.0 59.8 4.1 1,072 Second 6.7 66.6 10.0 14.9 1.5 0.3 100.0 73.3 5.2 956 Middle 13.5 72.0 4.6 9.1 0.4 0.4 100.0 85.5 9.8 1,121 Fourth 24.5 69.2 1.0 5.0 0.0 0.3 100.0 93.7 16.5 1,041 Highest 50.1 47.6 0.7 1.5 0.1 0.0 100.0 97.7 31.7 813 Total 18.6 62.8 6.5 11.2 0.6 0.3 100.0 81.4 12.7 5,003 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. 1 Skilled provider includes doctor and nurse/midwife As expected, mother’s education has a positive relationship with delivery care. Half of births to women with no education receive delivery assistance from a health professional compared with almost all births to women with secondary or higher education. Similarly, assistance by a trained health professional varies by economic status. Births to women in the highest wealth quintile (98 percent) are much more likely to be assisted by trained health professionals than births to women in the lowest wealth quintile (60 percent). Table 10.7 shows that deliveries by caesarean section occur in 13 percent of births in Namibia. Caesarean section occurs most frequently in births to highly educated women (36 percent), women in the highest wealth quintile (32 percent), urban women (21 percent), and women in Erongo (23 percent) and Khomas (26 percent) regions. Maternal Health │ 125 10.8 POSTNATAL CARE A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Thus, postnatal care is important for both the mother and the child. Postnatal care treats complications arising from the delivery and provides the mother with information on how to care for herself and her child. It is recommended that all women receive a check-up within two days of delivery. To assess the extent of postnatal care utilization, respondents were asked, referencing the last birth in the five years preceding the survey, whether they had received a health check-up after the delivery, the timing of the first check-up, and the type of health provider performing the postnatal check-up. This information is presented according to background characteristics in Tables 10.8 and 10.9. Table 10.8 shows that more than six in ten mothers (65 percent) received postnatal care within the critical first two days after the delivery, while about one in five (22 percent) received no postnatal care at all. Table 10.8 Timing of first postnatal check-up Among women age 15-49 with a birth in the five years preceding the survey, the percent distribution of mother's first postnatal check-up for the last live birth by time after delivery, according to background characteristics, Namibia 2006-07 Timing after delivery of mother's first postnatal check-up Background characteristic Less than 4 hours 4-23 hours 1-2 days 3-41 days Other responses Don't know/ missing No postnatal check-up1 Total Number of women Mother's age at birth <20 30.3 10.5 21.1 8.7 0.0 2.6 26.8 100.0 590 20-34 35.7 10.9 19.8 9.7 0.2 3.9 19.8 100.0 2,701 35-49 31.5 10.6 20.0 9.8 0.1 3.5 24.4 100.0 607 Birth order 1 35.0 12.2 19.7 8.8 0.1 3.6 20.7 100.0 1,224 2-3 36.2 11.1 20.9 10.4 0.3 3.1 18.1 100.0 1,646 4-5 32.9 7.9 20.6 11.3 0.0 4.2 23.0 100.0 643 6+ 25.8 9.2 16.5 5.7 0.3 5.2 37.3 100.0 385 Residence Urban 38.0 14.0 20.5 10.1 0.3 3.9 13.2 100.0 1,711 Rural 31.3 8.2 19.7 9.2 0.1 3.4 28.1 100.0 2,188 Region Caprivi 41.2 17.3 9.0 8.7 0.0 2.4 21.5 100.0 217 Erongo 40.3 22.0 18.7 7.4 0.0 3.0 8.6 100.0 257 Hardap 32.2 10.4 17.3 16.2 0.0 4.4 19.5 100.0 121 Karas 34.8 9.5 18.5 22.2 0.0 4.5 10.6 100.0 119 Kavango 19.8 2.6 17.2 6.4 0.0 4.1 50.0 100.0 481 Khomas 40.8 13.9 22.8 11.3 0.5 3.0 7.8 100.0 737 Kunene 19.8 6.0 16.9 6.0 0.0 2.7 48.6 100.0 136 Ohangwena 18.5 7.6 23.2 7.7 0.0 5.2 37.8 100.0 422 Omaheke 36.2 9.9 17.7 10.0 0.0 1.7 24.5 100.0 171 Omusati 41.9 7.0 18.7 14.6 0.3 3.3 14.1 100.0 365 Oshana 39.3 18.8 23.3 5.5 0.0 5.2 7.8 100.0 271 Oshikoto 36.6 9.6 24.9 6.4 0.0 3.9 18.5 100.0 340 Otjozondjupa 43.9 7.9 19.8 10.7 0.8 3.0 13.9 100.0 261 Education No education/preschool 24.4 5.5 14.0 7.0 0.0 2.8 46.2 100.0 372 Incomplete primary 29.7 9.2 16.0 9.1 0.1 3.3 32.7 100.0 784 Complete primary 35.6 9.7 19.2 8.7 0.2 2.1 24.4 100.0 303 Incomplete secondary 36.7 10.7 23.0 9.1 0.3 3.7 16.5 100.0 1,739 Complete secondary 32.9 18.1 23.2 12.3 0.0 4.9 8.6 100.0 494 More than secondary 50.1 10.8 15.0 14.9 0.0 4.7 4.4 100.0 205 Wealth quintile Lowest 28.1 6.4 14.4 6.8 0.2 2.8 41.4 100.0 788 Second 30.7 6.4 21.3 8.5 0.0 4.9 28.2 100.0 711 Middle 32.1 12.3 22.4 11.6 0.0 3.3 18.3 100.0 855 Fourth 37.7 13.9 22.9 9.4 0.5 3.6 12.0 100.0 856 Highest 43.3 14.5 18.6 11.7 0.1 3.7 8.1 100.0 688 Total 34.2 10.8 20.0 9.6 0.2 3.6 21.6 100.0 3,898 1 Includes women who received a check-up after 41 days 126 │ Maternal Health There are no marked variations by mother’s age in the utilization of postnatal care services within the first two days after the birth. A slightly higher percentage of mothers who delivered for the first time received postnatal care within the first two days than mothers with two or more children. Seventy-three percent of mothers in urban areas received postnatal care within two days of the birth compared with 59 percent of mothers in rural areas. Regional utilization of timely postnatal care ranges from 40 percent among mothers in Kavango to 81 percent in Erongo and Oshana regions. Similarly, mother’s education influences the utilization of postnatal care services. Forty-four percent of mothers with no education received timely postnatal care, compared with 70 percent of mothers with at least some secondary education. There are significant differences among women in receipt of postnatal care within two days by wealth quintile, with about half of women (49 percent) in the lowest wealth quintile receiving timely postnatal care compared with more than three-fourths of women (76 percent) in the highest wealth quintile. Table 10.9 presents information on the type of postnatal care provider by background characteristics. Health professionals provided postnatal care to three-fourths of the mothers; 34 percent received care from a doctor and 41 percent from a nurse or midwife. Just 3 percent of mothers received postnatal care from a traditional birth attendant. Health professionals are somewhat more likely to provide postnatal care to mothers with lower order births (births 1-3), mothers with secondary or higher education, and mothers in the highest wealth quintile. Likewise, mothers in urban areas and those in Khomas and Oshana are more likely to have received postnatal care from a health professional. Table 10.9 Postnatal care provider Percent distribution of women age 15-49 with a birth in the five years preceding the survey by type of provider of mother's first postnatal check-up for last live birth, according to background characteristics, Namibia 2006-07 Provider of mother's first postnatal check-up Background characteristic Doctor Nurse/ midwife Tradi- tional birth attendant Other Don't know/ missing No postnatal check-up1 Total Number of women Mother's age at birth <20 28.7 41.9 1.8 0.4 0.3 26.8 100.0 590 20-34 35.3 41.0 2.6 0.4 0.9 19.8 100.0 2,701 35-49 30.0 40.1 4.1 0.4 1.0 24.4 100.0 607 Birth order 1 37.5 40.0 1.3 0.4 0.2 20.7 100.0 1,224 2-3 36.6 41.5 2.3 0.4 1.1 18.1 100.0 1,646 4-5 25.2 45.6 4.8 0.3 1.0 23.0 100.0 643 6+ 21.2 34.3 5.3 0.6 1.2 37.3 100.0 385 Residence Urban 48.6 35.7 1.0 0.3 1.1 13.2 100.0 1,711 Rural 21.6 45.2 4.1 0.5 0.6 28.1 100.0 2,188 Region Caprivi 26.3 50.6 0.7 0.0 0.9 21.5 100.0 217 Erongo 50.9 37.8 2.5 0.2 0.0 8.6 100.0 257 Hardap 33.6 44.4 0.6 0.9 1.0 19.5 100.0 121 Karas 39.4 49.0 0.0 1.0 0.0 10.6 100.0 119 Kavango 18.6 24.8 4.9 0.7 1.1 50.0 100.0 481 Khomas 62.0 27.9 0.2 0.3 1.8 7.8 100.0 737 Kunene 21.8 27.7 1.5 0.0 0.4 48.6 100.0 136 Ohangwena 20.5 36.7 4.5 0.2 0.3 37.8 100.0 422 Omaheke 39.4 34.7 0.8 0.3 0.2 24.5 100.0 171 Omusati 18.2 63.1 3.0 0.4 1.2 14.1 100.0 365 Oshana 23.9 63.8 3.5 0.5 0.6 7.8 100.0 271 Oshikoto 23.8 50.2 7.0 0.3 0.3 18.5 100.0 340 Otjozondjupa 33.3 49.5 2.1 0.9 0.3 13.9 100.0 261 Continued… Maternal Health │ 127 Table 10.9 —Continued Provider of mother's first postnatal check-up Background characteristic Doctor Nurse/ midwife Tradi- tional birth attendant Other Don't know/ missing No postnatal check-up1 Total Number of women Education No education/preschool 15.5 31.5 5.6 0.4 0.8 46.2 100.0 372 Incomplete primary 20.9 39.3 5.5 0.5 1.1 32.7 100.0 784 Complete primary 28.7 41.5 4.5 0.7 0.2 24.4 100.0 303 Incomplete secondary 36.2 45.0 1.4 0.3 0.7 16.5 100.0 1,739 Complete secondary 50.1 38.8 0.8 0.1 1.6 8.6 100.0 494 More than secondary 58.3 35.8 0.3 1.2 0.0 4.4 100.0 205 Wealth quintile Lowest 13.2 38.1 6.1 0.7 0.6 41.4 100.0 788 Second 19.2 46.3 5.0 0.5 0.9 28.2 100.0 711 Middle 34.0 45.5 1.5 0.1 0.6 18.3 100.0 855 Fourth 41.1 44.4 0.9 0.3 1.2 12.0 100.0 856 Highest 61.3 29.1 0.2 0.4 0.8 8.1 100.0 688 Total 33.5 41.0 2.7 0.4 0.8 21.6 100.0 3,898 1 Includes women who received a check-up after 41 days 10.9 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers women may face in seeking care during pregnancy and at the time of delivery. In the 2006-07 NDHS, women were asked whether each of the following factors would be a big problem or not a big problem in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to a health facility, having to take transportation, not wanting to go alone, concern that there may not be a female health provider, and concern that there may not be a health provider available. The results are shown in Table 10.10. The most reason given for not seeking health care was concern that there may not be a health provider available (44 percent). Concern about getting money for treatment, concern about distance to a health facility, and concern about having to take transport are cited by about four in ten women. Not wanting to go alone is perceived as big problems by more than one in four women; concern about the availability of a female provider is cited by about one in six women; and getting permission to go for treatment is cited by about one in ten women. Younger women, women with more than two living children, women who were divorced, separated or widowed, unemployed women, and women employed, but not for cash, are more likely to report at least one serious problem in accessing health care than their counterparts. Women in rural areas and those residing in Caprivi and Kavango regions are more likely than urban women and women residing in the other regions to report at least one concern in accessing health care. Women with no education and those in the lowest wealth quintile are more likely than other women to report at least one of the specified problems in accessing health care. As expected, more than twice as many rural women (57 percent) as urban women (26 percent) consider having to take transport to be a big problem. 128 │ Maternal Health Table 10.10 Problems accessing health care Percentage of women age 15-49 who reported that they have serious problems accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Namibia 2006-07 Problems accessing health care Background characteristic Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern no female provider available Concern no provider available At least one problem accessing health care Number of women Age 15-19 11.6 38.3 42.4 42.2 32.4 19.2 44.2 74.9 2,246 20-34 10.0 39.0 41.3 40.9 24.1 15.2 43.1 69.6 4,895 35-49 9.0 39.2 41.0 42.7 23.6 16.4 44.4 68.2 2,663 Number of living children 0 10.6 34.1 38.1 37.3 28.4 16.8 41.5 68.9 3,419 1-2 9.7 38.3 39.4 40.6 22.5 14.4 43.2 69.2 3,620 3-4 9.3 42.6 44.9 44.4 24.4 17.2 45.6 71.2 1,789 5+ 10.9 50.7 54.7 56.2 32.1 21.5 49.5 79.0 976 Marital status Never married 10.0 37.0 40.1 39.8 26.8 15.2 42.3 70.4 5,673 Married or living together 10.1 39.3 42.3 42.6 24.5 18.0 44.8 69.3 3,451 Divorced/separated/widowed 10.3 53.1 48.7 52.8 24.7 18.8 49.0 76.4 678 Employed past 12 months Not employed 11.9 46.0 47.8 48.6 30.4 20.5 47.6 78.0 4,573 Employed for cash 7.8 26.8 30.5 30.0 17.8 11.9 39.0 59.0 3,738 Employed not for cash 10.3 47.6 49.8 50.0 32.5 15.3 43.1 75.8 1,467 Residence Urban 8.7 29.4 24.7 25.9 16.3 12.6 37.7 57.3 4,772 Rural 11.4 47.9 57.4 56.7 34.9 20.1 49.3 82.9 5,032 Region Caprivi 22.8 75.1 64.6 68.2 51.1 14.9 59.2 92.8 474 Erongo 5.2 26.4 23.9 28.3 13.1 17.4 68.5 78.0 688 Hardap 11.4 41.2 39.8 40.6 17.7 16.0 50.9 73.4 315 Karas 8.0 26.8 28.6 31.9 9.6 14.0 34.2 54.7 318 Kavango 13.6 73.9 52.9 55.3 36.1 41.9 60.8 89.9 934 Khomas 9.7 26.2 23.7 23.4 15.3 9.1 28.3 49.3 2,218 Kunene 5.8 60.6 63.5 63.1 39.5 26.2 40.6 82.8 259 Ohangwena 5.6 36.1 55.6 56.5 37.3 18.1 65.6 88.7 1,043 Omaheke 5.5 41.6 55.3 55.5 20.1 17.4 45.3 78.5 373 Omusati 17.6 40.0 48.1 45.6 37.1 11.5 37.3 76.4 975 Oshana 5.4 27.8 32.2 27.5 19.5 8.0 29.4 57.1 819 Oshikoto 10.1 35.6 53.7 52.3 28.1 13.2 33.1 68.5 837 Otjozondjupa 8.2 33.2 40.9 43.0 21.3 22.8 40.5 67.5 550 Education No education/preschool 14.0 68.0 66.6 67.0 41.1 29.3 54.9 88.8 651 Incomplete primary 13.3 53.3 56.8 55.5 33.6 23.0 50.7 84.1 1,699 Complete primary 10.7 47.7 51.2 51.5 30.6 20.1 48.1 81.0 736 Incomplete secondary 10.0 36.8 39.7 39.7 25.7 15.0 43.7 70.5 4,751 Complete secondary 6.9 22.5 22.1 24.6 13.9 9.8 36.1 53.7 1,286 More than secondary 4.4 11.1 17.9 18.4 11.1 6.9 24.8 38.2 682 Wealth quintile Lowest 12.5 65.5 67.1 68.7 43.6 24.1 54.9 91.6 1,621 Second 11.4 47.8 57.6 54.8 35.4 19.0 48.4 83.4 1,668 Middle 11.8 43.3 49.8 50.0 28.8 18.9 49.8 80.8 1,885 Fourth 9.0 33.3 31.0 31.3 18.3 14.1 40.8 63.1 2,292 Highest 7.1 16.1 15.8 17.0 11.8 9.6 30.3 45.3 2,338 Total 10.1 38.9 41.5 41.7 25.9 16.5 43.7 70.4 9,804 Note: Total includes 3 women with information missing on marital status and 19 women with information missing on employment in past 12 months. Maternal Health │ 129 10.10 PARTICIPATION OF MEN IN FAMILY HEALTH CARE This section presents information on men’s involvement in the health care of their wives and children. In the 2006-07 NDHS, men’s involvement in the family health care was measured by asking male respondents whether they were present during antenatal check-ups for the pregnancy of their young- est child and whether the youngest child was born in a health facility. This information is presented in Table 10.11. Almost one-third (31 percent) of men were present during their wife’s ANC visits for the pregnancy of their youngest child and 85 percent of fathers reported that their last child was born in the health facility. There are no significant variations in men’s participation in their wife’s antenatal care visits by men’s age or marital status. On the other hand, men living in urban areas are much more likely to attend their wife’s ANC visits than men living in rural areas (39 percent versus 23 percent). Only one in ten men in Ohangwena participate in the ante- natal care of their wives compared with almost half of men in Hardap and Omaheke regions. Men’s participation in the antenatal care of their wives increases with the level of education and wealth quintile. Men who had a child born in the three years preceding the 2006-07 NDHS were asked whether the child was delivered in a hospital or health facility. If the child was not born in a health facility, the father was asked the reason. The number of men whose last child was not born in a health facility was too small to allow meaningful analysis. In the 2006-07 NDHS, men who had ever had a child were asked about their knowledge of diarrhoea treatment. Only one in four men gave the correct response, i.e., giving more than the usual amount of liquids to a child with diarrhoea. More than four in ten men said that a child with diarrhoea should be given less than the usual amount to drink or no liquids at all (Table 10.12). Table 10.11 Participation of men in antenatal care visit Percentage of men who reported that they were present during their wife's antenatal care (ANC) visits for the youngest child and percentage whose youngest child was born in a health facility, according to background characteristics, Namibia 2006-07 Background characteristic Percentage present during any ANC visit Percentage whose last child was born in a health facility Number of men Age 15-19 * * 12 20-24 26.8 86.4 140 25-29 28.0 87.6 262 30-34 38.0 84.6 260 35-39 30.9 85.3 166 40-44 31.0 75.8 122 45-49 24.6 80.9 66 Marital status Never married 25.4 88.9 352 Married or living together 35.0 82.4 625 Divorced/separated/widowed 30.0 81.8 49 Residence Urban 38.6 93.8 551 Rural 23.1 74.1 477 Region Caprivi 19.2 69.2 72 Erongo 30.6 93.9 113 Hardap 47.2 91.8 32 Karas 42.6 91.9 45 Kavango 17.7 61.6 92 Khomas 41.7 94.5 269 Kunene (28.7) (55.4) 27 Ohangwena 9.8 82.3 63 Omaheke 45.5 83.1 54 Omusati 19.5 89.4 60 Oshana 32.3 84.8 61 Oshikoto 22.9 75.8 65 Otjozondjupa 35.8 88.5 76 Education No education/preschool 22.4 65.5 134 Incomplete primary 19.2 74.5 251 Complete primary 35.3 82.2 63 Incomplete secondary 29.4 90.4 347 Complete secondary 47.5 98.5 133 More than secondary 57.2 98.9 100 Wealth quintile Lowest 12.8 53.7 148 Second 24.2 78.3 141 Middle 22.9 86.1 243 Fourth 33.6 91.9 279 Highest 55.4 98.9 217 Total 31.4 84.6 1,028 Note: Total includes one man with information missing on marital status. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 130 │ Maternal Health Table 10.12 Knowledge about diarrhoea treatment Percent distribution of men age 15-49 who have ever had a child by how much they think a child with diarrhoea should be given to drink, according to background characteristics, Namibia 2006-07 Amount to drink Background characteristic More than usual About the same Less than usual Nothing to drink Don't know/ missing Total Number of men Age 15-19 * * * * * 100.0 12 20-24 22.5 34.1 22.9 18.6 2.0 100.0 140 25-29 25.7 25.8 21.2 24.7 2.7 100.0 262 30-34 23.2 22.6 18.5 31.1 4.5 100.0 260 35-39 32.2 29.1 11.7 21.6 5.4 100.0 166 40-44 29.6 28.7 16.6 19.2 5.8 100.0 122 45-49 9.1 33.8 35.1 19.6 2.4 100.0 66 Marital status Never married 21.7 28.9 19.9 28.5 0.9 100.0 352 Married or living together 27.1 26.6 19.8 21.1 5.3 100.0 625 Divorced/separated/widowed 25.7 26.2 16.8 26.6 4.7 100.0 49 Residence Urban 27.5 25.8 20.8 22.4 3.6 100.0 551 Rural 22.4 29.1 18.7 25.7 4.1 100.0 477 Region Caprivi 51.7 16.9 20.3 8.6 2.4 100.0 72 Erongo 9.5 19.1 22.7 41.9 6.7 100.0 113 Hardap (3.7) (40.0) (25.6) (27.8) (3.0) 100.0 32 Karas (35.1) (15.7) (5.7) (43.6) (0.0) 100.0 45 Kavango 9.5 32.8 15.6 27.8 14.3 100.0 92 Khomas 35.1 26.8 20.7 15.5 2.0 100.0 269 Kunene (11.2) (38.7) (11.2) (38.9) (0.0) 100.0 27 Ohangwena 0.5 55.3 16.6 25.6 2.1 100.0 63 Omaheke 5.6 30.7 31.0 22.0 10.7 100.0 54 Omusati 55.4 23.1 5.7 15.9 0.0 100.0 60 Oshana 48.8 16.1 1.2 33.9 0.0 100.0 61 Oshikoto 16.1 41.5 30.9 8.5 3.1 100.0 65 Otjozondjupa 14.8 16.4 37.6 29.4 1.8 100.0 76 Education No education/preschool 7.8 37.0 18.0 33.7 3.4 100.0 134 Incomplete primary 20.3 28.3 22.3 24.3 4.8 100.0 251 Complete primary 21.3 33.9 20.4 23.9 0.6 100.0 63 Incomplete secondary 28.2 26.6 17.8 23.3 4.2 100.0 347 Complete secondary 33.1 23.4 24.1 16.3 3.2 100.0 133 More than secondary 42.3 15.5 17.2 21.9 3.2 100.0 100 Wealth quintile Lowest 20.0 30.7 18.0 26.2 5.1 100.0 148 Second 24.3 28.9 20.7 21.4 4.8 100.0 141 Middle 21.4 33.9 16.6 23.4 4.6 100.0 243 Fourth 23.3 25.8 24.0 25.8 1.1 100.0 279 Highest 35.8 18.6 18.8 22.0 4.8 100.0 217 Total 25.2 27.3 19.8 23.9 3.8 100.0 1,028 Note: Total includes one man with information missing on marital status. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Knowledge of correct treatment of diarrhoea increases with age and peaks at age 35-39, after which it declines to a low of 10 percent for men age 45-49. Urban men are more knowledgeable about diarrhoea treatment than rural men (28 percent compared with 22 percent). Across regions, this knowledge is 10 percent or less in Erongo, Hardap, Kavango, and Omaheke. Less than 1 percent of men in Ohangwena know the correct treatment for diarrhoea. The proportion of men who say that children with diarrhoea should be given more to drink increases with level of education, from 8 percent among men with no education to 42 percent among men with more than secondary education. Maternal Health │ 131 10.11 PAYMENT FOR DELIVERY The high costs for the delivery of a child can be a problem in accessing health care. In the 2006-07 NDHS, women who had a live birth in the five years preceding the survey and who delivered in a health facility were asked whether they paid for the services during delivery and how much. The findings are presented in Table 10.13. A large majority of the delivery costs (86 percent) were paid in cash. For 85 percent of the births, delivery cost less than 50 Namibian dollars. This amount does not vary much by background characteristics. For a small percentage of births, delivery costs were higher. For 35 percent of births to women with more than secondary education and 22 percent of births to women in the highest wealth quintile, delivery costs were 300 or more Namibian dollars. Table 10.13 Payment for delivery Percent distribution of live births in the five years preceding the survey delivered in a health facility by type of payment for the delivery, and among the live births with cash payment, percent distribution by cost of delivery, according to background characteristics, Namibia 2006-07 Payment for the delivery Cost of delivery1 Background characteristic Cash Goods/ services Free Missing Number of births in health facility <50 50-99 100-199 200-299 300+ Missing Number of births for which cash was paid for health facility delivery Mother's age at birth <20 83.0 0.9 15.8 0.4 625 89.9 8.9 0.1 0.0 1.0 0.0 518 20-34 86.7 2.2 11.0 0.2 2,509 84.6 6.1 1.1 0.6 6.4 1.2 2,175 35-49 86.9 3.1 10.0 0.0 432 80.0 8.3 0.5 2.3 7.0 1.9 376 Birth order 1 86.3 2.0 11.6 0.2 1,428 83.8 8.4 0.8 0.3 5.8 0.9 1,233 2-3 85.6 2.2 12.0 0.2 1,433 82.4 6.6 1.1 1.3 7.4 1.2 1,227 4-5 85.6 2.7 11.7 0.0 494 90.9 4.5 0.8 0.5 1.7 1.6 423 6+ 88.2 1.3 10.5 0.0 211 95.6 3.4 0.0 0.0 0.5 0.4 186 Residence Urban 83.7 2.9 13.2 0.1 1,733 73.5 12.0 1.4 1.2 9.9 2.0 1,451 Rural 88.2 1.3 10.2 0.2 1,834 95.2 2.2 0.4 0.3 1.6 0.2 1,618 Region Caprivi 76.1 1.5 22.1 0.2 193 98.2 0.5 0.0 0.0 1.2 0.0 147 Erongo 87.8 1.8 9.9 0.5 250 87.0 0.6 0.4 0.0 9.3 2.7 219 Hardap 88.2 0.5 11.3 0.0 116 90.2 3.1 0.6 0.0 4.4 1.7 103 Karas 79.3 2.3 17.2 1.2 115 81.5 0.8 2.4 0.0 7.9 7.4 91 Kavango 62.5 2.9 34.4 0.3 347 95.9 3.4 0.0 0.0 0.6 0.0 217 Khomas 82.2 5.2 12.7 0.0 791 55.5 24.6 2.4 2.2 13.7 1.6 650 Kunene 95.7 0.0 4.3 0.0 89 89.3 1.6 0.0 0.6 8.5 0.0 85 Ohangwena 95.4 1.5 2.8 0.4 347 97.2 0.7 0.1 0.7 0.8 0.5 331 Omaheke 88.6 0.8 10.6 0.0 152 83.2 10.0 0.7 0.2 5.8 0.0 134 Omusati 96.1 0.0 3.9 0.0 348 96.4 0.7 0.5 0.7 1.8 0.0 335 Oshana 94.3 1.7 4.0 0.0 290 92.5 2.4 0.9 0.6 2.0 1.6 274 Oshikoto 95.3 0.3 4.5 0.0 299 95.0 1.3 0.3 0.0 2.6 0.8 284 Otjozondjupa 86.4 0.4 12.7 0.5 229 91.0 3.2 0.8 0.2 4.8 0.0 198 Education No education/preschool 82.3 0.0 17.5 0.2 239 98.6 1.4 0.0 0.0 0.0 0.0 197 Incomplete primary 85.4 1.6 12.8 0.1 589 97.1 2.5 0.1 0.0 0.2 0.1 503 Complete primary 87.6 0.8 11.6 0.0 258 93.8 5.4 0.0 0.0 0.8 0.0 226 Incomplete secondary 88.8 0.7 10.3 0.2 1,727 88.5 7.1 0.6 0.2 2.8 0.8 1,534 Complete secondary 84.2 5.1 10.4 0.3 522 65.4 14.7 1.8 0.4 15.0 2.7 440 More than secondary 73.3 10.3 16.1 0.3 231 39.4 5.1 5.6 10.2 35.0 4.7 169 Wealth quintile Lowest 82.6 2.2 15.0 0.2 544 99.7 0.3 0.0 0.0 0.0 0.0 449 Second 87.1 1.0 11.8 0.1 596 98.4 0.4 0.2 0.0 0.9 0.0 519 Middle 88.7 0.6 10.7 0.0 844 95.0 4.0 0.2 0.0 0.8 0.0 749 Fourth 89.2 0.9 9.7 0.2 851 86.9 6.3 1.1 1.2 4.0 0.5 758 Highest 81.1 6.0 12.6 0.4 731 46.8 21.6 2.7 2.2 21.8 4.9 593 Total 86.0 2.1 11.7 0.2 3,567 84.9 6.8 0.9 0.7 5.6 1.1 3,069 1 Namibian dollars Child Health | 133 CHILD HEALTH 11 This chapter presents findings on several areas of importance to child health and survival including characteristics of the neonate (birth weight and size at birth), the vaccination status of young children, and treatment practices for childhood illnesses. The information presented on birth weight and birth size is important for designing and implementing programmes aimed at reducing neonatal and infant mortality. Many of the deaths in early childhood can be avoided by immunizing children against preventable diseases and by ensuring that children receive prompt and appropriate treatment when they become ill. Information on vaccination coverage focuses on age group 12-23 months. Data are presented on overall coverage for this age group at the time of the survey and coverage by 12 months of age. Additionally, the source of the vaccination information (whether a vaccination card or mother’s recall) is examined. Differences in vaccination coverage between subgroups of the popula- tion are discussed because this information is useful for programme planning. Information on treatment practices and contact with health services among children with the three most common childhood illnesses (acute respiratory infection, fever, and diarrhoea) help in the assessment of national programmes aimed at reducing the mortality impact of these illnesses. Information is provided on the prevalence of acute respiratory infection and its treatment with antibiotics, and the prevalence of fever and its treatment with anti-malarial drugs and antibiotics. Information on the treatment of diarrhoeal disease with oral rehydration therapy (including increased fluids) aids in the assessment of programmes that utilize such treatment. Appropriate sanitary practices can help prevent and reduce the severity of diarrhoeal disease so information is presented on the manner of disposing of children’s faecal matter. 11.1 CHILD’S SIZE AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to the risk of childhood illnesses and the chances of survival. Children whose birth weight is less than 2.5 kg, or children reported to be “very small” or “smaller than average” are considered to have a higher than average risk of early childhood death. For births in the five years preceding the survey, birth weight was recorded in the questionnaire if available from either a written record or the mother’s recall. Since birth weight may not be known for many babies, the mother’s estimate of the baby’s size at birth was also obtained. Even though the mother’s estimate is subjective, it can be a useful proxy for the weight of the child. Table 11.1 presents information on children’s weight and size at birth according to background characteristics. Three-quarters of children born in the five years preceding the survey had been weighed at birth, an increase of 9 percentage points since the 2000 NDHS. Among the children with a reported birth weight, 14 percent weighed less than 2.5 kg at birth. Birth weight is lower among children born to older women (age 35-49), children of higher birth order (6 and above), children of women with no education or some primary education, and children of women in the lowest wealth quintile. Birth weight does not vary by urban-rural residence but does vary by region. The proportion of children who were less than 2.5 kg at birth varies from 9 percent in Omaheke to 27 percent in Hardap. 134 | Child Health Table 11.1 Child's weight and size at birth Percent distribution of live births in the five years preceding the survey with a reported birth weight by birth weight; percentage of all births with a reported birth weight; and percent distribution of all live births in the five years preceding the survey by mother's estimate of child’s size at birth, according to background characteristics, Namibia 2006-07 Percent distribution of births with a reported birth weight1 Percent distribution of all live births by size of child at birth Background characteristic Less than 2.5 kg 2.5 kg or more Total Number of births Percentage of all births with a reported birth weight Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 13.5 86.5 100.0 578 72.9 5.7 13.3 78.1 2.9 100.0 793 20-34 13.5 86.5 100.0 2,639 75.8 5.2 9.8 83.1 1.9 100.0 3,482 35-49 17.5 82.5 100.0 536 73.7 5.8 8.5 82.7 3.1 100.0 728 Birth order 1 13.6 86.4 100.0 1,290 80.2 5.4 11.2 81.5 1.9 100.0 1,608 2-3 12.7 87.3 100.0 1,589 77.0 5.4 10.2 82.7 1.8 100.0 2,064 4-5 15.6 84.4 100.0 572 68.7 5.9 8.6 82.4 3.2 100.0 833 6+ 20.2 79.8 100.0 302 60.6 4.3 9.2 82.7 3.7 100.0 498 Residence Urban 14.4 85.6 100.0 1,735 83.5 4.8 10.6 82.9 1.7 100.0 2,077 Rural 13.8 86.2 100.0 2,018 69.0 5.7 9.8 81.8 2.6 100.0 2,926 Region Caprivi 15.7 84.3 100.0 208 77.2 6.7 17.2 72.8 3.3 100.0 269 Erongo 14.5 85.5 100.0 262 85.8 3.4 12.8 82.1 1.7 100.0 306 Hardap 26.5 73.5 100.0 128 86.2 11.3 12.5 74.6 1.6 100.0 149 Karas 11.4 88.6 100.0 129 88.5 2.8 11.8 84.7 0.6 100.0 146 Kavango 15.7 84.3 100.0 365 59.8 4.7 6.8 85.5 3.0 100.0 610 Khomas 13.4 86.6 100.0 783 85.1 5.5 11.4 82.4 0.7 100.0 920 Kunene 17.4 82.6 100.0 79 42.0 11.6 11.4 73.5 3.5 100.0 189 Ohangwena 11.9 88.1 100.0 369 64.6 5.2 11.7 80.8 2.4 100.0 571 Omaheke 9.4 90.6 100.0 170 72.7 11.1 9.8 75.5 3.5 100.0 234 Omusati 12.2 87.8 100.0 368 81.4 1.7 5.0 91.5 1.9 100.0 452 Oshana 12.3 87.7 100.0 304 84.4 3.1 9.8 83.9 3.2 100.0 360 Oshikoto 13.8 86.2 100.0 330 73.4 3.7 7.8 86.8 1.6 100.0 449 Otjozondjupa 17.0 83.0 100.0 258 74.0 7.5 10.7 77.8 4.0 100.0 348 Mother's education No education/preschool 16.3 83.7 100.0 244 44.2 9.5 9.0 76.1 5.3 100.0 553 Incomplete primary 16.9 83.1 100.0 656 62.0 5.3 10.0 81.7 2.9 100.0 1,058 Complete primary 13.3 86.7 100.0 285 75.4 4.6 10.4 82.4 2.6 100.0 378 Incomplete secondary 13.8 86.2 100.0 1,787 82.7 4.7 10.9 83.1 1.3 100.0 2,162 Complete secondary 10.9 89.1 100.0 538 90.8 5.1 9.4 83.9 1.5 100.0 593 More than secondary 13.4 86.6 100.0 243 93.4 3.4 8.8 86.3 1.4 100.0 260 Wealth quintile Lowest 15.8 84.2 100.0 602 56.2 5.3 8.5 82.5 3.7 100.0 1,072 Second 13.8 86.2 100.0 666 69.7 5.6 9.6 82.3 2.5 100.0 956 Middle 14.1 85.9 100.0 864 77.0 5.9 11.6 80.9 1.7 100.0 1,121 Fourth 13.5 86.5 100.0 861 82.7 4.4 11.2 81.9 2.4 100.0 1,041 Highest 13.4 86.6 100.0 760 93.5 5.5 9.7 84.2 0.6 100.0 813 Total 14.0 86.0 100.0 3,753 75.0 5.3 10.2 82.3 2.2 100.0 5,003 1 Based on written record or mother's recall In the absence of birth weight, a mother’s subjective assessment of the size of the baby at birth, may be useful. One in twenty births were reported to be very small and one in ten were reported as smaller than average. Children of mothers in rural areas and mothers with no education are slightly more likely to be described as very small at birth than children of urban mothers and mothers with education. More than one in ten births (11-12 percent) in Hardap, Kunene, and Omaheke regions were reported to be very small. Child Health | 135 11.2 VACCINATION COVERAGE Universal immunization of children against the six vaccine-preventable diseases (namely tuberculosis, diphtheria, whooping cough (pertussis), tetanus, polio, and measles) is crucial to reducing infant and child mortality. Differences in vaccination coverage among subgroups of the population are useful for programme planning and targeting resources to the areas most in need. Additionally, information on immunization coverage is important for monitoring and evaluation of the Expanded Programmes on Immunization (EPI). The 2006-07 NDHS collected information on vaccinations for all living children born in the five years preceding the survey. According to the guidelines developed by the World Health Organization, children are considered fully vaccinated when they have received a vaccination against tuberculosis (BCG), three doses each of the DPT and polio vaccines, and a measles vaccination by 12 months of age. BCG should be given at birth or at first clinical contact, DPT and polio require three vaccinations at approximately 6, 10, and 14 weeks of age, and measles vaccination should be given at or soon after reaching 9 months of age. Information on vaccination coverage was collected in two ways in the 2006-07 NDHS: from vaccination cards shown to the interviewer and from mothers’ verbal reports. If the cards were available, the interviewer copied the vaccination dates directly onto the questionnaire. When there was no vaccination card for the child, or if a vaccination had not been recorded on the card. The respondent was asked to recall the vaccinations given to the child. Table 11.2 shows the percentage of children age 12-23 months who have received various vaccinations by source of information (vaccination card or mother’s report). This is the youngest cohort of children who have reached the age by which they should be fully vaccinated. Data show that 69 percent of children age 12-23 months had been fully vaccinated at the time of the survey, an increase from 65 percent in the 2000 NDHS. The level of coverage for BCG, for the first dose DPT, and the first dose polio exceeds 90 percent, similar to the 2000 NDHS results. Coverage for those who have received the third dose of DPT and polio is lower (83 percent and 79 percent, respectively). Eighty-four percent of children age 12-23 months have received the measles vaccination, a slight increase from 80 percent reported in the 2000 NDHS. Only 2 percent of children age 12-23 months have not received any vaccinations. Table 11.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Namibia 2006-07 DPT Polio1 Source of information BCG 1 2 3 0 1 2 3 Measles All basic vaccina- tions 2 No vaccina- tions Number of children Vaccinated at any time before survey Vaccination card 72.5 72.6 70.6 68.2 72.4 72.6 70.6 68.2 63.2 61.9 0.0 724 Mother's report 22.5 22.1 18.7 15.0 18.5 22.8 18.9 10.4 20.6 6.7 2.2 262 Both sources 95.0 94.7 89.4 83.2 90.9 95.4 89.5 78.6 83.8 68.7 2.2 987 Vaccinated by 12 months of age 3 94.7 93.4 88.2 81.0 90.6 94.1 88.4 76.5 78.0 63.8 2.8 987 1 Polio 0 is the polio vaccination given at birth 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination Table 11.3 shows vaccination coverage for children age 12-23 months by background characteristics. This information gives an indication of the success of the immunization programme in reaching out to all population subgroups. The results indicate that females have somewhat higher 136 | Child Health vaccination coverage than males (71 percent versus 67 percent), a pattern similar to that observed in the 2000 NDHS. Births of order 6 and above have lower vaccination coverage than other births. There are differences in vaccination coverage by urban-rural residence; children living in urban areas are somewhat more likely to be fully immunized than children in rural areas (72 percent versus 67 percent). Similarly, there are substantial differences in the coverage by region. The percentage of children fully immunized ranges from 35 percent in Kunene to 81 percent in Omusati.). Kunene also had the lowest coverage in the 2000 NDHS (49 percent). Table 11.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to vaccination card or mother's report), and percentage with a vaccination card, by background characteristics, Namibia 2006-07 DPT Polio1 Background characteristic BCG 1 2 3 1 2 3 4 Measles All basic vaccina- tions No vaccina- tions 2 Percentage with a vaccination card seen Number of children Sex Male 96.6 94.8 89.6 84.1 90.3 96.7 90.7 78.6 82.8 66.9 1.7 73.9 513 Female 93.4 94.5 89.2 82.2 91.5 94.1 88.2 78.6 84.8 70.5 2.9 73.0 474 Birth order 1 97.5 95.3 90.1 83.9 89.9 95.8 91.4 77.7 85.8 67.1 1.6 66.3 305 2-3 95.9 96.9 91.7 87.1 93.9 98.0 91.0 82.9 86.2 72.0 1.2 74.8 422 4-5 92.1 94.2 87.9 80.3 89.0 94.9 90.1 78.3 79.9 68.9 3.8 81.5 162 6+ 88.6 83.7 79.4 68.8 84.2 84.2 76.1 63.2 73.0 58.7 6.0 76.3 97 Residence Urban 96.5 95.1 91.2 86.1 92.0 97.0 91.8 80.5 86.1 71.5 1.1 69.7 394 Rural 94.1 94.4 88.1 81.3 90.2 94.4 87.9 77.4 82.2 66.8 3.0 75.9 592 Region Caprivi 96.0 96.8 93.6 89.5 95.1 95.9 92.8 77.0 89.5 70.2 3.2 76.7 61 Erongo 97.3 96.4 96.4 96.4 92.4 97.3 97.3 91.0 84.4 76.3 0.0 60.8 57 Hardap 94.1 99.0 94.1 84.9 82.9 99.0 92.1 82.8 88.0 66.3 0.0 64.6 33 Karas (96.6) (96.0) (94.4) (86.6) (93.7) (98.6) (91.3) (74.3) (95.4) (67.9) (1.4) (68.9) 26 Kavango 89.5 87.8 81.6 72.1 86.9 88.3 83.2 72.5 55.0 47.7 7.7 74.7 136 Khomas 98.7 96.1 91.0 87.9 95.0 98.5 94.5 81.7 86.6 75.5 0.2 75.6 176 Kunene 79.1 74.0 59.4 51.5 64.2 86.4 71.3 40.9 60.9 35.3 13.6 49.1 36 Ohangwena 93.2 95.3 84.2 78.5 84.1 90.7 81.6 75.7 91.8 70.4 1.5 72.2 114 Omaheke 96.5 95.3 88.0 80.6 85.9 99.2 97.0 81.4 89.1 69.8 0.8 74.1 53 Omusati 96.9 99.6 98.3 90.6 95.9 99.6 93.4 88.5 94.5 81.0 0.4 83.0 85 Oshana 97.4 97.7 93.2 83.6 98.7 95.3 82.7 75.4 97.7 74.1 0.0 71.5 64 Oshikoto 97.7 97.4 96.3 89.1 95.2 97.4 96.1 83.3 83.9 72.2 1.3 78.5 81 Otjozondjupa 96.7 96.2 89.6 84.7 97.4 99.4 88.7 81.6 90.0 76.2 0.6 77.4 65 Mother's education No education/ preschool 81.7 82.2 68.8 61.6 75.7 84.4 73.0 59.4 56.8 44.3 10.5 71.6 121 Incomplete primary 96.4 96.5 92.8 81.1 91.7 96.6 90.5 80.5 81.2 67.5 0.6 80.3 185 Complete primary 96.0 96.6 88.5 81.7 94.2 94.7 83.8 77.8 80.6 69.4 2.7 78.0 83 Incomplete secondary 96.5 95.4 91.2 86.1 92.5 96.9 92.0 79.0 89.4 70.9 1.2 68.4 446 Complete secondary 99.7 99.7 97.3 95.2 94.6 99.3 97.3 94.3 94.2 86.3 0.3 81.6 121 More than secondary (97.4) (97.4) (95.1) (95.1) (100.0) (97.4) (97.4) (76.6) (91.6) (68.1) (0.0) (67.4) 30 Wealth quintile Lowest 90.9 89.8 83.4 74.0 88.3 90.4 83.2 69.5 70.1 58.8 6.4 76.5 220 Second 95.2 97.5 89.9 83.6 88.7 95.3 89.2 80.9 89.8 69.2 0.9 71.3 199 Middle 93.3 94.1 85.5 78.6 91.2 96.1 87.2 75.1 80.2 62.7 2.1 74.2 217 Fourth 98.5 95.3 94.4 90.2 92.0 97.8 95.0 84.3 88.5 76.1 0.4 74.4 213 Highest 98.8 98.2 96.7 93.8 96.2 98.8 95.2 86.6 95.3 81.6 0.6 69.0 137 Total 95.0 94.7 89.4 83.2 90.9 95.4 89.5 78.6 83.8 68.7 2.2 73.4 987 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) The percentage of children fully immunized increases steadily with mother’s level of education. Forty-four percent of children of mothers with no education are fully immunized, compared with 86 percent of children of mothers with at least some secondary education. Children of mothers in the lowest wealth quintile are less likely to have been fully immunized than children of mothers in the highest wealth quintile. Child Health | 137 Table 11.3 shows that a vaccination card was seen for 73 percent of children age 12-23 months. The actual percentage of children with a vaccination card may be higher, however, because vaccination cards are sometimes kept by the health care provider and not by mothers. Cards are more likely to have been seen for second- or higher-order births, children living in rural areas, children in Omusati, children of mothers with at least some secondary education, and children of mothers in the lowest wealth quintile. 11.3 TRENDS IN VACCINATION COVERAGE One way of measuring trends in vaccination coverage is to compare coverage among children in different age cohorts. Table 11.4 shows the percentage of children who received vaccinations during the first year of life by age. This information provides insight into trends in vaccination coverage in the recent past. The data indicate that the proportion of children fully vaccinated by 12 months of age has increased over the past five years from less than half of children age 36-47 months and 48-59 months (47 percent) to almost two-thirds of children age 12-23 months (64 percent). Likewise, the proportion of children who have not received any vaccinations by age 12 months has decreased, from 9 percent among children in the two oldest groups to 3 percent among children in the two youngest groups. Vaccination cards were seen for 73 percent of children age 12-23 months but only for 46 percent of children age 48-59 months. This could be because vaccination cards for older children may have been lost or discarded. Table 11.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Namibia 2006-07 DPT Polio1 Age in months BCG 1 2 3 0 1 2 3 Measles All basic vaccina- tions No vaccina- tions2 Percentage with a vaccination card seen Number of children 12-23 94.7 93.4 88.2 81.0 90.6 94.1 88.4 76.5 78.0 63.8 2.8 73.4 987 24-35 94.5 93.0 88.2 79.0 89.8 94.5 86.6 68.1 80.9 54.5 2.9 56.9 949 36-47 88.1 84.7 79.2 71.7 82.2 85.6 78.4 61.5 70.0 46.7 9.2 50.4 930 48-59 88.0 86.7 81.6 71.0 80.9 87.1 78.8 60.6 75.0 46.9 8.9 46.1 816 Total 91.7 89.8 84.7 76.1 86.3 90.7 83.5 67.2 76.7 53.6 5.5 57.3 3,681 Note: Information was obtained from the vaccination card or if there was no written record, from the mother. For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) Trends in vaccination coverage can also be seen by examining comparable data from the 2000 NDHS and the 2006-07 NDHS. The results indicate that vaccination coverage in Namibia has improved over the past five years. The percentage of children age 12-23 months fully vaccinated at the time of the survey increased slightly from 65 percent in 2000 to 69 percent in 2006-07, while the percentage who received none of the basic vaccinations decreased from 5 percent in 2000 to 2 percent in 2006-07. 11.4 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths caused by ARI. In the 2006-07 NDHS, the prevalence of ARI was estimated by asking mothers whether their children under age five had been ill in the two weeks preceding the 138 | Child Health survey, with a cough accompanied by short, rapid breathing that the mother considered to be chest- related. These symptoms are compatible with ARI. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Table 11.5 shows that 4 percent of children under five years of age showed symptoms of ARI within the two weeks preceding the survey. Since the number of cases of ARI varies seasonally, the time of year that survey fieldwork is conducted should be considered when interpreting the find- ings. Prevalence of ARI varies by age of child. Children age 6-11 months are most likely to show symptoms of ARI (6 percent) compared with chil- dren in all other age groups. Differences by gender are small (5 percent for males and 4 percent for females). Children living in households that use wood/straw for cooking fuel are more likely to exhibit symptoms of ARI than children living in households with other sources of cooking fuel. Cough and rapid breathing were reported to be slightly higher among rural children (5 percent) than children in urban areas (3 percent). By region, prevalence of ARI ranges from a high of 12 percent among children under five living in Caprivi to a low of 2 percent among children living in Erongo, Khomas, and Oshana. ARI prevalence is lower for children whose mothers have at least some second- ary education and live in households in the highest wealth quintile. About three-quarters of children with symp- toms of ARI were taken for treatment to a health facility or provider (data not shown because of small numbers). Fewer children were reported to have ARI in the 2006-07 NDHS compared with the 2000 NDHS (4 percent compared with 18 percent). 11.5 FEVER Fever is a major manifestation of malaria and other acute infections in children. Malaria and fever contribute to high levels of malnutrition and death. While fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors should be taken into account when interpreting fever as an indicator of malaria prevalence. Since malaria is a major con- tributor to death in infancy and childhood in many developing countries, the so-called presumptive treatment of fever with anti-malarial medication is advocated in many countries where malaria is endemic. Malaria is discussed in greater detail in Chapter 12. Table 11.5 Prevalence of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, by background characteristics, Namibia 2006-07 Among children under age five Background characteristic Percentage with symptoms of ARI1 Number of children Age in months <6 4.0 496 6-11 5.7 542 12-23 5.0 987 24-35 4.9 949 36-47 3.3 930 48-59 2.9 816 Sex Male 4.8 2,402 Female 3.7 2,317 Cooking fuel Electricity or gas 1.9 1,558 Wood/straw2 5.5 3,021 Other fuel 5.2 139 Residence Urban 2.6 1,970 Rural 5.4 2,749 Region Caprivi 11.8 243 Erongo 1.6 287 Hardap 2.6 139 Karas 3.2 136 Kavango 6.6 574 Khomas 1.8 889 Kunene 3.9 179 Ohangwena 3.4 532 Omaheke 8.5 227 Omusati 5.9 422 Oshana 2.3 337 Oshikoto 3.9 424 Otjozondjupa 3.8 330 Mother's education No education/preschool 5.7 526 Incomplete primary 5.5 983 Complete primary 4.6 350 Incomplete secondary 4.0 2,034 Complete secondary 2.2 576 More than secondary 3.1 251 Wealth quintile Lowest 7.0 1,000 Second 5.4 897 Middle 4.5 1,048 Fourth 2.6 987 Highest 1.4 787 Total 4.3 4,719 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related) is considered a proxy for pneumonia 2 Includes grass, shrubs, crop residues Child Health | 139 Table 11.6 shows the percentage of children under five with fever during the two weeks preceding the survey and the percentage who received various treatments, by selected background characteristics. Because the number of cases of febrile illness varies seasonally, the time of year that the survey fieldwork was conducted should be considered when interpreting the findings, even where malaria is not present. Table 11.6 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage for whom treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who took antibiotic drugs, by background characteristics, Namibia 2006-07 Among children under age five with fever: Among children under age five: Background characteristic Percentage with fever Number of children Percentage for whom treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 16.7 496 52.1 6.0 18.0 83 6-11 23.0 542 61.1 9.9 10.5 125 12-23 21.5 987 55.4 12.8 18.3 213 24-35 16.9 949 54.6 6.0 21.6 160 36-47 14.0 930 58.3 11.5 6.6 130 48-59 10.4 816 51.1 10.4 14.0 85 Sex Male 15.8 2,402 55.8 10.5 16.5 380 Female 17.9 2,317 55.8 9.1 14.3 416 Residence Urban 16.2 1,970 57.2 8.2 16.7 320 Rural 17.3 2,749 54.9 10.8 14.4 476 Region Caprivi 37.7 243 53.0 15.6 8.8 92 Erongo 12.3 287 (64.0) (5.7) (9.6) 35 Hardap 13.6 139 (55.5) (0.0) (10.8) 19 Karas 13.6 136 * * * 19 Kavango 18.2 574 61.2 10.9 16.3 104 Khomas 17.9 889 51.7 7.5 19.3 159 Kunene 15.5 179 (48.3) (10.0) (2.0) 28 Ohangwena 15.2 532 56.0 10.2 9.6 81 Omaheke 26.5 227 47.7 7.5 26.4 60 Omusati 18.3 422 65.3 12.0 19.8 77 Oshana 7.7 337 (56.9) (26.5) (9.9) 26 Oshikoto 10.0 424 (56.0) (13.3) (13.2) 42 Otjozondjupa 16.1 330 57.3 0.0 11.5 53 Mother's education No education/preschool 18.3 526 62.7 5.4 12.3 96 Incomplete primary 16.7 983 53.0 10.2 11.0 164 Complete primary 20.0 350 53.2 8.4 20.5 70 Incomplete secondary 16.6 2,034 56.3 10.8 18.0 338 Complete secondary 16.9 576 48.0 8.6 9.6 97 More than secondary 12.0 251 * * * 30 Wealth quintile Lowest 20.4 1,000 53.6 9.5 12.8 204 Second 16.0 897 58.3 15.4 12.4 143 Middle 17.3 1,048 60.4 8.5 16.1 181 Fourth 14.5 987 50.2 5.9 12.2 143 Highest 15.7 787 56.2 10.1 25.3 124 Total 16.9 4,719 55.8 9.8 15.3 795 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes pharmacy, shop, and traditional practitioner 140 | Child Health Seventeen percent of children under five were reported to have had fever in the two weeks preceding the survey. Prevalence varies by age. Children age 6-11 months and 12-23 months are more often sick with fever (23 and 22 percent, respectively) than other children. There are no significant variations in the prevalence of fever by sex of child, place of residence (urban-rural), or household wealth quintile. The prevalence of fever among children under five varies by region, from 8 percent in Oshana to 38 percent in Caprivi. The prevalence of fever is also high among children in Omaheke (27 percent). More than half (56 percent) of children with fever were taken to a health facility or provider for treatment; one in ten were given antimalarial drugs, and one in seven received antibiotics. The numbers were too small to make meaningful comparisons by background characteristics. 11.6 PREVALENCE OF DIARRHOEA Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children and the condition can be easily treated with oral rehydration therapy (ORT). Exposure to diarrhoeal-causing agents is frequently re- lated to use of contaminated water and un- hygienic practices related to food prepara- tion and disposal of excreta. In interpreting the findings of the 2006-07 NDHS on diarrhoea, it should be noted that the preva- lence of diarrhoea varies seasonally. Table 11.7 shows the percentage of children under five with diarrhoea in the two weeks pre- ceding the survey, by background character- istics. Overall, 12 percent of all children under five had diarrhoea in the two weeks preceding the survey and 2 percent had diarrhoea with blood. The prevalence of diarrhoea varies by age. Young children age 6-23 months are more prone to diarrhoea than children in the other age groups. There are slight variations in the prevalence of diarrhoea by child’s sex, with females being more likely to have diarrhoea than males (13 percent versus 11 percent). Children living in households with an improved source of drinking water have a lower prevalence of diarrhoea (12 percent) than children living in households with a not-improved source (16 percent). The prevalence of diarrhoea varies by region. Children in Oshana and Oshikoto Table 11.7 Prevalence of diarrhoea Percentage of children under age five who had diarrhoea in the two weeks preceding the survey, by background characteristics, Namibia 2006-07 Diarrhoea in the two weeks preceding the survey Background characteristic All diarrhoea Diarrhoea with blood Number of children Age in months <6 11.7 1.8 496 6-11 19.6 2.2 542 12-23 20.0 2.5 987 24-35 12.6 2.7 949 36-47 6.3 1.1 930 48-59 4.5 0.9 816 Sex Male 11.4 1.8 2,402 Female 13.0 2.0 2,317 Source of drinking water1 Improved 11.6 1.4 4,035 Not improved 15.7 4.4 683 Toilet facility2 Improved, not shared 11.7 1.0 1,313 Non-improved or shared 12.5 2.2 3,395 Residence Urban 12.3 1.6 1,970 Rural 12.2 2.1 2,749 Region Caprivi 13.4 2.7 243 Erongo 9.0 0.0 287 Hardap 9.2 0.0 139 Karas 11.8 1.8 136 Kavango 20.5 3.5 574 Khomas 13.5 2.3 889 Kunene 9.9 0.0 179 Ohangwena 8.7 1.8 532 Omaheke 19.1 2.8 227 Omusati 11.4 2.9 422 Oshana 6.8 0.7 337 Oshikoto 7.2 1.1 424 Otjozondjupa 12.9 1.0 330 Mother's education No education/preschool 15.4 2.0 526 Incomplete primary 11.4 2.5 983 Complete primary 13.7 2.4 350 Incomplete secondary 12.9 2.2 2,034 Complete secondary 10.9 0.1 576 More than secondary 4.4 0.0 251 Wealth quintile Lowest 13.4 2.6 1,000 Second 11.4 2.1 897 Middle 13.0 2.1 1,048 Fourth 11.8 1.7 987 Highest 11.2 0.5 787 Total 12.2 1.9 4,719 Note: Total includes 11 children with information missing on toilet facility 1 See Table 2.7 for definition of categories 2 See Table 2.8 for definition of categories Child Health | 141 (7 percent each) have the lowest prevalence of diarrhoea, while Kavango (21 percent) and Omaheke (19 percent) have the highest. Mother’s level of education is related to the prevalence of diarrhoea among children; 15 percent of children of uneducated mothers had diarrhoea in the past two weeks compared with 4 percent of children of mothers with higher than secondary education. The prevalence of diarrhoea with blood follows a pattern similar to that observed for diarrhoea in general. 11.7 DIARRHOEA TREATMENT In the 2006-07 NDHS, mothers of children who had diarrhoea were asked what was done to treat the illness. Table 11.8 shows the percentage of children with diarrhoea who received specific treatments, by background characteristics. Six in ten children with diarrhoea were taken to a health provider. Children age 6-23 months old were somewhat more likely than other children to be taken to a health provider. Notable differences are seen by place of residence and type of diarrhoea. The proportion of children taken to a health facility in urban areas is 64 percent compared with 58 percent of children in rural areas. A significantly higher proportion of children with bloody diarrhoea (75 percent) were taken to a health provider than children with non-bloody diarrhoea (58 percent). There are slight variations between regions, but the numbers are too small for meaningful comparison (data not shown). Mother’s level of education is directly correlated with seeking treatment for children with diarrhoea; 66 percent of children of mothers with some secondary or higher education were taken to a health provider compared with 46 percent of children of uneducated mothers. Table 11.8 Diarrhoea treatment Among children under age five who had diarrhoea in the two weeks preceding the survey, the percentage who were taken for treatment to a health provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Namibia 2006-07 Oral rehydration therapy (ORT) Other treatments Background characteristic Percentage of children with diarrhoea taken to a health provider1 ORS packets Salt- sugar solution Either ORS or SSS Increased fluids ORT or increased fluids Anti- biotic drugs Home remedy/ other No treatment Number of children Age in months <6 59.6 58.4 28.9 66.2 9.1 73.3 11.7 7.1 18.4 58 6-11 67.4 66.8 17.3 73.8 15.4 76.5 16.2 16.5 16.9 106 12-23 64.0 66.2 24.2 73.2 16.8 74.6 21.9 17.1 13.7 197 24-35 55.4 60.2 17.1 63.8 23.5 73.2 25.8 19.9 12.9 120 36-47 52.8 59.8 19.0 67.4 12.4 68.0 22.3 8.5 20.9 59 48-59 49.9 58.5 12.4 60.8 8.8 60.8 3.7 15.7 31.9 37 Sex Male 61.8 62.7 18.9 67.1 14.5 70.4 21.0 14.6 16.5 275 Female 59.0 63.5 22.2 71.3 17.7 75.4 18.1 16.5 16.5 302 Type of diarrhoea Non-bloody 57.9 61.3 21.3 68.4 15.1 71.6 19.3 14.6 18.0 485 Bloody 74.7 73.4 18.0 74.2 22.6 80.9 21.4 20.9 9.1 88 Residence Urban 64.2 67.3 22.0 72.8 20.0 78.3 25.9 13.1 13.0 243 Rural 57.5 60.1 19.7 66.7 13.4 69.1 14.9 17.4 19.1 334 Mother's education No education/preschool 46.0 55.5 16.4 60.7 10.2 63.7 15.0 27.1 15.8 81 Incomplete primary 58.0 61.6 22.0 67.2 10.6 69.1 9.7 16.2 18.5 112 Complete primary 55.2 57.4 22.6 67.2 11.8 68.6 10.5 22.6 21.9 48 Incomplete secondary 66.1 66.0 18.8 72.3 18.2 78.1 23.6 9.2 14.7 262 Complete secondary 63.2 69.4 33.1 75.1 21.5 75.6 34.4 23.5 15.2 63 More than secondary * * * * * * * * * 11 Wealth quintile Lowest 52.1 49.9 17.0 55.2 7.0 56.9 9.7 21.0 28.4 134 Second 63.4 68.2 18.0 78.0 13.5 79.1 13.0 16.9 9.2 102 Middle 66.7 72.7 24.4 76.1 18.5 78.8 18.7 12.6 15.4 137 Fourth 57.4 66.2 17.6 73.3 15.5 78.9 23.1 9.1 14.7 116 Highest 63.3 58.5 27.5 64.6 30.6 73.6 38.6 19.1 11.0 88 Total 60.3 63.1 20.7 69.3 16.2 73.0 19.5 15.6 16.5 577 Note: ORT includes solution prepared from oral rehydration salt (ORS), pre-packaged ORS packet, and recommended home fluids (salt-sugar solution). Total includes 3 children with information missing on type of diarrhoea. An asterisk is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes pharmacy, shop, and traditional practitioner 142 | Child Health A large majority of children with diarrhoea (73 percent) were treated with oral rehydration therapy (ORT) or increased fluids; 63 percent were treated with oral rehydration salts (ORS) prepared from an ORS packet, 21 percent were given recommended home fluids (salt-sugar solution), and 16 percent were given increased fluids. One in five children received antibiotic drugs and 16 percent were given home remedies or other treatments. However, about one in six children with diarrhoea did not receive any treatment at all. Diarrhoea treatment does not vary much by age. Female children and children who had diarrhoea with blood were more likely to have received ORT than others. Seventy-eight percent of children in urban areas received ORT or increased fluids compared with 69 percent of children in rural areas. There are large variations in the treatment of children with diarrhoea by mother’s education and wealth quintile, with children of uneducated mothers and mothers in the lowest wealth quintile being the least likely to receive ORT compared with children in other subgroups. Data from the 2000 NDHS show that 51 percent of children with diarrhoea were taken for treatment to a health provider compared with 60 percent in the 2006-07 NDHS. On the other hand, a higher proportion of children with diarrhoea did not receive any treatment in the 2006-07 NDHS than in the 2000 NDHS (17 percent versus 12 percent). 11.8 FEEDING PRACTICES For children with diarrhoea, mothers are encouraged to continue feeding normally and to increase the amount of fluids given. These practices help to reduce dehydration and minimize the adverse consequences of diarrhoea on children’s nutritional status. Mothers were asked whether their children with diarrhoea were given less, the same amount, or more fluids and food than usual. Tables 11.9.1 and 11.9.2 show the percent distribution of children under five who had diarrhoea in the past two weeks by feeding practices (amount of liquids/solids received, according to background characteristics. Sixteen percent of children who had diarrhoea were given more liquids than usual and 42 percent were given the same as usual. Fourteen percent of children with diarrhoea were given somewhat less liquids than usual, 22 percent were given much less than usual, and 4 percent of children with diarrhoea were given no liquids at all. Overall, one in ten children were given increased fluids and continued feeding during the diarrhoea episode, while seven in ten continued feeding but were also given ORT or increased fluids. Regarding the amount of solid food offered to children with diarrhoea, 8 percent were given more food than usual, 39 percent were given the same as usual, 21 percent received somewhat less than usual, 23 percent were given much less than usual, and 3 percent did not receive any solid food during their illness, presumably because these children had not yet started eating solid food. Children age 24-35 months with diarrhoea are the most likely to be offered more liquids than usual, while those 6-11 months are most likely to be offered the same amount of liquids as usual, compared with other age groups. Children with bloody diarrhoea are more likely than those with non- bloody diarrhoea to be offered more liquids than usual, while children with non-bloody diarrhoea are more likely than those with bloody diarrhoea to be given the same amount of liquids as usual. Urban children receive more or the same amount of fluids when they have diarrhoea, compared with rural children. Overall, children of more educated mothers and children living in households in the highest wealth quintile are more likely to receive more liquids than usual during episodes of diarrhoea than other children. Child Health | 143 Table 11.9.1 Feeding practices during diarrhoea: liquids Percent distribution of children under age five who had diarrhoea in the two weeks preceding the survey by amount of liquids offered compared with normal practice, the percentage of children given increased fluids and continued feeding during the diarrhoea episode, and the percentage of children who continued feeding and were given ORT and/or increased fluids during the diarrhoea episode, by background characteristics, Namibia 2006-07 Amount of liquids offered Background characteristic More Same as usual Some- what less Much less None Don't know/ missing Total Percentage given increased fluids and continued feeding1,2 Percentage who continued feeding and were given ORT and/or increased fluids Number of children with diarrhoea Age in months <6 9.1 48.4 14.8 21.1 5.6 1.1 100.0 6.6 54.0 58 6-11 15.4 49.6 14.7 15.9 2.5 2.0 100.0 11.1 41.9 106 12-23 16.8 36.7 14.5 25.6 4.4 2.0 100.0 10.1 45.4 197 24-35 23.5 32.9 12.6 23.7 4.1 3.3 100.0 16.5 54.6 120 36-47 12.4 39.3 14.1 27.2 4.4 2.5 100.0 4.7 45.5 59 48-59 (8.8) (67.0) (11.3) (5.8) (4.8) (2.3) 100.0 (7.1) (50.9) 37 Sex Male 14.5 45.8 15.3 18.6 2.5 3.4 100.0 10.0 47.5 275 Female 17.7 37.8 12.6 24.9 5.7 1.3 100.0 11.0 48.2 302 Type of diarrhoea Non-bloody 15.1 44.4 12.8 21.1 4.2 2.4 100.0 11.5 48.8 485 Bloody 22.6 27.7 19.5 26.2 4.0 0.0 100.0 5.6 43.4 88 Residence Urban 20.0 45.9 8.5 20.3 2.5 2.8 100.0 14.3 51.5 243 Rural 13.4 38.6 17.8 23.0 5.3 1.8 100.0 7.8 45.3 334 Mother's education No education/preschool 10.2 41.3 12.5 29.8 3.6 2.6 100.0 9.4 40.5 81 Incomplete primary 10.6 45.5 19.5 17.5 4.4 2.5 100.0 4.1 41.4 112 Complete primary 11.8 33.5 25.1 27.3 0.0 2.3 100.0 9.6 49.4 48 Incomplete secondary 18.2 42.3 13.6 20.0 4.9 1.0 100.0 9.8 54.3 262 Complete secondary 21.5 40.0 0.8 26.2 4.3 7.1 100.0 19.1 39.5 63 More than secondary * * * * * * 100.0 * * 11 Wealth quintile Lowest 7.0 40.9 13.4 27.3 10.0 1.4 100.0 3.8 32.1 134 Second 13.5 37.9 21.4 19.2 4.3 3.8 100.0 8.7 54.6 102 Middle 18.5 38.0 17.3 23.8 1.9 0.6 100.0 9.7 48.2 137 Fourth 15.5 49.8 12.9 18.8 1.4 1.7 100.0 12.3 60.7 116 Highest 30.6 42.2 2.1 17.9 2.1 5.1 100.0 21.7 47.0 88 Total 16.2 41.6 13.9 21.9 4.1 2.3 100.0 10.5 47.9 577 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppresses. Total includes 3 children with information missing on diarrhoea. 1 Equivalent to the UNICEF/WHO indicator "Home management of diarrhoea." 2 Continue feeding practices includes children who were given more, same as usual, or somewhat less food during the diarrhoea episode When looking at the amount of solids offered, youngest children (less than 6 months old) are more likely to be offered more or the same amount of solids as usual compared with older children. Furthermore, children with non-bloody diarrhoea are more likely than those with bloody diarrhoea to be offered more or the same amount of solids as usual, while the children with bloody diarrhoea are more likely than those with non-bloody diarrhoea to be offered somewhat less or much less solid food than usual. Children in the higher wealth quintiles are more likely to receive more or the same amount of solids as usual during the diarrhoea episode compared with children in the lower quintiles. 144 | Child Health Table 11.9.2 Feeding practices during diarrhoea: solid food Percent distribution of children under age five who had diarrhoea in the two weeks preceding the survey by amount of food offered compared with normal practice, according to background characteristics, Namibia 2006-07 Amount of food offered Background characteristic More Same as usual Some- what less Much less None Never gave food Don't know/ missing Total Number of children with diarrhoea Age in months <6 11.9 53.3 11.7 8.6 1.5 12.9 0.0 100.0 58 6-11 9.4 38.4 13.8 27.8 3.4 5.3 2.0 100.0 106 12-23 6.2 33.8 23.3 27.3 4.2 3.4 1.8 100.0 197 24-35 9.9 33.7 29.1 22.6 3.4 0.0 1.2 100.0 120 36-47 4.2 36.5 25.0 28.7 0.0 3.1 2.5 100.0 59 48-59 (5.4) (67.0) (13.2) (6.1) (1.5) (4.5) (2.3) 100.0 37 Sex Male 6.5 41.6 20.4 20.4 3.4 5.3 2.4 100.0 275 Female 9.1 36.6 21.8 25.9 2.7 2.9 1.0 100.0 302 Type of diarrhoea Non-bloody 8.9 41.8 19.5 22.3 3.0 3.0 1.5 100.0 485 Bloody 2.2 24.7 29.8 28.6 3.4 10.1 1.1 100.0 88 Residence Urban 11.0 41.4 16.4 24.3 1.0 4.0 1.8 100.0 243 Rural 5.6 37.2 24.5 22.6 4.5 4.1 1.5 100.0 334 Mother's education No education/preschool 9.6 38.2 17.6 29.4 3.8 1.5 0.0 100.0 81 Incomplete primary 3.3 36.2 22.1 24.5 7.3 3.2 3.4 100.0 112 Complete primary 6.8 29.6 38.6 22.0 1.9 1.1 0.0 100.0 48 Incomplete secondary 7.4 44.0 20.6 20.5 1.8 5.2 0.5 100.0 262 Complete secondary 8.7 32.3 15.2 28.6 1.1 6.9 7.1 100.0 63 More than secondary * * * * * * * 100.0 11 Wealth quintile Lowest 4.7 38.0 21.6 29.1 2.1 4.0 0.5 100.0 134 Second 8.6 30.7 27.5 20.2 6.9 3.1 3.1 100.0 102 Middle 4.3 41.2 20.8 22.4 3.6 7.4 0.3 100.0 137 Fourth 12.5 43.5 18.3 21.3 2.4 1.4 0.7 100.0 116 Highest 11.2 40.7 17.4 22.0 0.0 3.7 5.1 100.0 88 Total 7.9 39.0 21.1 23.3 3.0 4.1 1.6 100.0 577 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppresses. Total includes 3 children with information missing on diarrhoea. 11.9 KNOWLEDGE OF ORS PACKETS A simple and effective response to dehydration caused by diarrhoea is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy, which may include the use of a solution prepared from packets of oral rehydration salts (ORS). To ascertain how widespread knowledge of ORS is in Namibia, respondents were asked whether they had heard of ORS packets. Table 11.10 shows that nine in ten women (91 percent) who had a birth in the five years preceding the survey reported knowing about ORS packets. There are no significant differences in the knowledge of ORS packets by background characteristics. There has been a slight decline in the proportion of mothers who have heard about ORS, from 95 percent in 2000 to 91 percent in 2006-07. Child Health | 145 Table 11.10 Knowledge of ORS packets or pre- packaged liquids Percentage of mothers age 15-49 who gave birth in the five years preceding the survey who know about ORS packets or ORS pre-packaged liquids for treatment of diarrhoea, by background characteristics, Namibia 2006-07 Background characteristic Percentage of women who know about ORS packets or ORS pre- packaged liquids Number of women Age 15-19 89.3 282 20-24 90.2 985 25-34 91.3 1,767 35-49 91.2 864 Residence Urban 90.2 1,711 Rural 91.4 2,188 Region Caprivi 95.4 217 Erongo 92.6 257 Hardap 83.4 121 Karas 91.4 119 Kavango 89.0 481 Khomas 89.3 737 Kunene 89.0 136 Ohangwena 90.0 422 Omaheke 90.3 171 Omusati 94.1 365 Oshana 96.9 271 Oshikoto 92.9 340 Otjozondjupa 85.6 261 Education No education/preschool 85.5 372 Incomplete primary 90.1 784 Complete primary 93.3 303 Incomplete secondary 92.2 1,739 Complete secondary 91.4 494 More than secondary 86.9 205 Wealth quintile Lowest 90.8 788 Second 90.3 711 Middle 92.2 855 Fourth 93.3 856 Highest 86.7 688 Total 90.9 3,898 ORS = Oral rehydration salts 11.10 DISPOSAL OF CHILDREN’S STOOLS If human faeces are left uncontained, disease may spread by direct contact or by animal contact with the faeces. Hence, the proper disposal of children’s stool is extremely important in preventing the spread of disease. Table 11.11 presents information on the disposal of the stools of children under five by background characteristics. For one-third of children (32 percent), stools are left uncontained. Stools for 5 percent of children are put or rinsed into a drain or ditch, 11 percent are thrown into the garbage, and 16 percent are rinsed away. The stools of 67 percent of children are disposed of hygienically. Fourteen percent of children under five use a toilet or latrine, and 15 percent of children’s stools are disposed of in the 146 | Child Health toilet or latrine. The most common means of disposing of children’s stools (38 percent) is to bury them in the yard. Stools of older children (age 48-59 months) and children who live in households with improved, not shared toilet facilities, are more likely to be disposed of safely than stools of other children. There are regional differences in the way children’s faeces are disposed of. For example, the percentage of children whose stools are disposed of safely ranges from 52 percent in Kunene to 79 percent in Kavango. There are no substantial differences by mother’s education or wealth quintile in safe disposal of children’s stools. Table 11.11 Disposal of children's stools Percent distribution of youngest children under age five living with the mother by the manner of disposal of the child's last faecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Namibia 2006-07 Manner of disposal of children's stools Background characteristic Child used toilet or latrine Put/ rinsed into toilet or latrine Buried Put/ rinsed into drain or ditch Thrown into garbage Rinsed away Other Don’t know/ missing Total Percentage of children whose stools are disposed of safely Number of children Age in months <6 6.7 13.6 37.6 12.2 19.0 9.7 0.4 0.9 100.0 57.8 475 6-11 6.1 16.7 45.3 9.2 14.1 8.2 0.1 0.2 100.0 68.1 504 12-23 8.4 15.1 45.0 4.2 10.7 15.4 0.5 0.8 100.0 68.4 836 24-35 17.3 15.2 36.1 3.4 7.6 19.6 0.1 0.7 100.0 68.6 566 36-47 25.8 11.7 28.9 1.1 9.6 21.5 0.1 1.2 100.0 66.4 433 48-59 28.7 17.7 24.5 1.6 3.4 21.5 0.2 2.4 100.0 70.9 338 Toilet facility Improved, not shared1 29.4 29.6 11.2 6.4 18.0 4.3 0.0 1.0 100.0 70.2 913 Non-improved or shared 7.5 8.8 48.9 4.9 8.2 20.3 0.4 0.9 100.0 65.3 2,231 Residence Urban 24.9 25.9 15.9 6.4 17.2 8.4 0.2 1.1 100.0 66.7 1,297 Rural 6.3 7.2 53.3 4.6 6.7 20.7 0.3 0.8 100.0 66.8 1,855 Region Caprivi 3.3 0.8 67.6 16.6 5.4 6.3 0.0 0.0 100.0 71.7 195 Erongo 23.3 32.9 6.3 6.6 20.8 6.7 0.0 3.5 100.0 62.5 186 Hardap 21.9 17.3 18.8 7.3 14.7 19.0 0.0 0.9 100.0 58.0 101 Karas 25.0 23.3 12.2 10.8 22.8 5.8 0.0 0.0 100.0 60.6 96 Kavango 9.5 9.4 60.4 0.3 7.6 12.2 0.1 0.5 100.0 79.3 426 Khomas 34.3 27.7 5.1 6.7 21.0 4.8 0.1 0.3 100.0 67.1 568 Kunene 5.6 9.5 36.7 1.6 6.3 39.8 0.0 0.5 100.0 51.9 110 Ohangwena 5.0 8.2 57.3 5.0 4.1 18.5 0.0 1.9 100.0 70.5 338 Omaheke 5.3 11.9 38.2 6.5 8.6 28.5 0.0 1.1 100.0 55.4 149 Omusati 2.5 4.3 48.9 2.8 8.0 31.1 1.2 1.2 100.0 55.8 281 Oshana 6.6 8.1 47.9 2.4 9.9 21.7 1.4 2.1 100.0 62.6 205 Oshikoto 7.9 12.7 51.8 6.8 7.1 12.9 0.0 0.8 100.0 72.4 281 Otjozondjupa 15.8 23.2 29.2 3.1 6.4 21.6 0.7 0.0 100.0 68.2 217 Education No education/preschool 8.9 7.6 48.2 3.3 5.5 25.5 0.2 0.8 100.0 64.6 337 Incomplete primary 8.8 7.0 50.3 4.5 7.9 20.7 0.3 0.5 100.0 66.1 650 Complete primary 9.2 15.8 41.9 3.5 7.3 20.2 0.3 1.8 100.0 66.9 251 Incomplete secondary 13.1 15.7 38.5 6.3 10.7 14.2 0.2 1.2 100.0 67.3 1,351 Complete secondary 22.9 27.1 16.4 6.9 18.8 6.9 0.6 0.5 100.0 66.4 392 More than secondary 36.3 24.1 9.8 4.1 23.5 1.8 0.0 0.4 100.0 70.2 172 Wealth quintile Lowest 5.0 4.3 60.1 4.7 5.9 19.1 0.0 1.0 100.0 69.3 695 Second 4.6 4.6 56.1 2.5 6.4 24.1 0.8 1.0 100.0 65.3 597 Middle 6.8 8.5 44.9 5.6 10.2 23.1 0.4 0.5 100.0 60.2 683 Fourth 21.3 28.3 19.2 7.3 13.3 8.9 0.2 1.4 100.0 68.9 607 Highest 35.4 32.3 3.3 6.7 20.7 0.8 0.0 0.8 100.0 70.9 569 Total 13.9 14.9 37.9 5.4 11.0 15.6 0.3 0.9 100.0 66.8 3,151 Note: Total includes 3 children with information missing on type of toilet facility 1 Non-shared facilities that are of the types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; pit latrine with a slab; and a composting toilet. Nutrition of Children and Women | 147 NUTRITION OF CHILDREN AND WOMEN 12 This chapter covers nutritional concerns for children and women. Infant and young child feeding practices, including breastfeeding and feeding with solid/semisolid foods, are presented for children. Anthropometric assessment of nutritional status, diversity of foods consumed, micronutrient intake, and vitamin A deficiency are presented for both women and children under the age of five. Adequate nutrition is critical to child development. The period from birth to two years of age is important for optimal growth, health, and development. Unfortunately, this period is often marked by growth faltering, micronutrient deficiencies, and common childhood illnesses such as diarrhoea and acute respiratory infections (ARI). Optimal feeding practices reported in this chapter include early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding for up to two years of age and beyond, timely introduction of complementary feeding at six months of age, recommended frequency of feeding solid/semisolid foods, and the diversity of food groups fed to children age 6-23 months. A summary indicator that describes the quality of infant and young child (age 6-23 months) feeding practices (IYCF) is included. A woman’s nutritional status has important implications for both her health and that of her children. Malnutrition in women results in reduced productivity, increased susceptibility to infections, slow recovery from illness, and heightened risk of adverse pregnancy outcomes. For example, a woman who has poor nutritional status, as indicated by a low body mass index (BMI), short stature, anaemia, or other micronutrient deficiencies, has a greater risk of obstructed labour, having a baby with low birth weight, producing lower quality breast milk, and dying from postpartum haemorrhage. 12.1 NUTRITIONAL STATUS OF CHILDREN Anthropometric data on height and weight collected in the 2006-07 NDHS permit the measurement and evaluation of the nutritional status of young children in Namibia. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. The 2006-07 NDHS collected data on the nutritional status of children by measuring the height and weight of all children under five years of age. Data were collected with the aim of calculating three important indices—height-for-age, weight-for-height, and weight-for-age—taking into consideration age and sex. Weight measurements were obtained using lightweight, bathroom-type scales with a digital screen. Height measurements were carried out using a measuring board produced by Shorr Productions. Children younger than 24 months were measured lying down (recumbent length) on the board, while standing height was measured for older children. For the 2006-07 NDHS, the nutritional status of children is calculated using new growth standards published by the World Health Organization (WHO) in 2006. These new growth standards were generated using data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). The study, whose sample included 8,440 children in six countries, was designed to provide a description of how children should grow under optimal conditions. The WHO Child Growth Standards can therefore be used to assess children all over the world regardless of ethnicity, social and economic influences, and feeding practices. Each of the three nutritional status indicators described below is expressed in standard deviation units from the median of the Multicentre Growth Reference Study sample. It must be noted that the new WHO Child Growth Standards used in this report are not comparable to the previously used standards. The use of the new WHO standards results in higher stunting rates throughout childhood and higher wasting and underweight rates during infancy when 148 | Fertility compared with reports that used the old standards. Therefore, an analysis of the trends in the nutritional status of children is not done in this report. Each of these indices—height-for-age, weight-for-height, and weight-for-age—provides different information about growth and body composition, which is used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. Children who are more than two standard deviations (+2 SD) above the median for height-for-age are tall for their age. However, because being tall is not considered a health problem, the percentages are not shown in this chapter. The weight-for-height index measures body mass in relation to body height (or length) and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) are considered thin (wasted) and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) are considered severely wasted. Overweight and obesity are becoming problems for some children in developing countries. Children who are more than two standard deviations (+2 SD) above the median for weight-for-height are considered overweight or obese. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) are considered as severely underweight. The percentage of children more than two standard deviations (+2 SD) above the median for weight-for-age is presented in this chapter as a measure of overweight children for comparison with other data sources in Namibia that did not measure height. Measurement of height and weight were obtained for all children under age six living in the households selected for the 2006-07 NDHS sample. Although data were collected for all children under age six, for purposes of comparability, the analysis is limited to children under age five. Height and weight measurements were obtained for the total of 5,457 children under age of five who were present in NDHS households at the time of the survey. Of these children, 9 percent were considered to have implausibly high or low values for the height or weight measures or lacked data on age in months (data not shown). The following analysis focuses on 4,945 children for whom complete and plausible anthropometric and age data were collected. The results are shown in Table 12.1 and Figure 12.1. Table 12.1 shows that three in ten children under age five are stunted and one in ten is severely stunted. Eight percent of children under five are wasted and 2 percent are severely wasted. The weight- for-age indicator shows that 17 percent of children under five are underweight and 4 percent are severely underweight. At the same time, 4 percent of Namibian children are overweight or obese. Nutrition of Children and Women | 149 Table 12.1 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Namibia 2006-07 Height-for-age Weight-for-height Weight-for-age Background characteristic Per- centage below -3 SD Per- centage below -2 SD1 Mean Z-score (SD) Per- centage below -3 SD Per- centage below -2 SD1 Per- centage above +2 SD Mean Z-score (SD) Per- centage below -3 SD Per- centage below -2 SD1 Per- centage above +2 SD Mean Z-score (SD) Number of children Age in months <6 4.7 14.0 -0.5 4.4 11.1 12.5 0.0 3.3 11.2 1.9 -0.4 468 6-8 4.4 15.5 -0.5 1.4 5.1 5.4 0.0 1.9 6.9 3.5 -0.4 272 9-11 10.0 18.7 -0.8 2.1 9.4 7.2 -0.2 2.7 11.9 3.4 -0.6 244 12-17 12.5 32.0 -1.2 2.2 9.9 5.1 -0.3 4.0 17.0 1.9 -0.8 526 18-23 14.4 38.2 -1.5 3.1 9.0 2.0 -0.3 5.9 18.3 0.3 -1.0 505 24-35 13.5 36.4 -1.5 1.0 5.1 3.3 -0.2 2.6 16.6 1.5 -0.9 1,006 36-47 9.6 29.9 -1.4 1.3 6.4 2.8 -0.4 5.0 18.5 0.6 -1.1 1,010 48-59 6.4 27.3 -1.3 1.5 7.3 2.6 -0.5 3.6 20.0 0.6 -1.1 914 Sex Male 11.8 31.5 -1.3 1.7 7.3 4.5 -0.3 4.0 17.6 1.2 -0.9 2,466 Female 7.9 26.4 -1.1 2.1 7.6 4.2 -0.3 3.6 15.5 1.4 -0.8 2,479 Birth interval in months2 First birth 3 6.7 23.6 -1.0 1.7 7.3 5.4 -0.2 2.2 14.3 1.6 -0.7 1,101 <24 14.0 29.8 -1.4 1.8 9.3 3.9 -0.3 3.6 18.5 0.9 -1.0 328 24-47 12.2 34.0 -1.4 1.9 7.8 3.2 -0.3 4.4 18.7 0.8 -1.0 1,119 48+ 10.6 28.3 -1.2 2.8 7.1 6.1 -0.2 4.2 15.5 1.9 -0.8 1,040 Size at birth2 Very small 15.3 46.8 -1.7 2.5 9.8 2.0 -0.6 10.9 30.4 0.0 -1.4 172 Small 15.6 38.8 -1.5 2.0 8.2 2.9 -0.4 4.8 22.0 0.7 -1.1 377 Average or larger 9.1 26.4 -1.1 2.0 7.4 5.1 -0.2 3.0 14.8 1.5 -0.8 2,970 Missing 22.4 35.8 -1.7 4.7 7.9 11.3 -0.2 8.9 23.0 2.3 -1.1 50 Mother's interview status Interviewed 10.2 28.8 -1.2 2.1 7.6 4.8 -0.2 3.6 16.4 1.4 -0.9 3,587 Not interviewed but in household 4.9 29.1 -0.9 1.0 7.0 7.8 -0.1 1.8 11.5 2.3 -0.6 174 Not interviewed, and not in the household4 9.5 29.6 -1.2 1.5 7.1 2.4 -0.4 4.5 17.8 0.9 -1.0 1,177 Mother's nutritional status5 Thin (BMI<18.5) 18.4 42.8 -1.6 4.2 15.7 2.6 -0.8 9.8 30.8 0.3 -1.5 442 Normal (BMI 18.5-24.9) 10.0 30.0 -1.3 1.6 6.8 4.3 -0.3 3.0 16.0 1.1 -0.9 2,165 Overweight/obese (BMI ≥25) 6.6 19.6 -0.9 2.0 5.4 7.2 0.0 1.9 10.6 2.5 -0.5 1,050 Missing 9.0 34.5 -1.3 2.2 11.9 2.6 -0.2 6.1 14.2 0.0 -0.9 71 Residence Urban 7.6 23.8 -1.0 1.4 5.6 7.4 0.0 2.1 11.5 2.1 -0.6 1,600 Rural 10.9 31.4 -1.3 2.1 8.3 2.8 -0.4 4.6 19.0 0.9 -1.0 3,345 Region Caprivi 9.0 26.1 -1.2 1.9 5.3 4.3 -0.2 5.7 13.8 2.0 -0.8 275 Erongo 6.2 21.5 -1.0 1.1 3.2 11.3 0.2 1.4 6.5 3.6 -0.4 241 Hardap 10.1 30.0 -1.2 3.4 10.8 5.7 -0.4 5.7 20.3 2.3 -1.0 142 Karas 11.2 30.2 -1.3 1.5 7.7 7.7 -0.0 4.1 16.0 2.7 -0.7 133 Kavango 15.1 38.8 -1.6 1.8 6.9 6.5 -0.1 3.7 18.5 0.8 -1.0 607 Khomas 6.9 22.6 -0.9 0.9 5.3 5.5 -0.0 1.3 11.4 1.3 -0.5 658 Kunene 9.9 27.0 -1.1 1.1 5.2 3.8 -0.1 2.1 12.6 0.3 -0.7 205 Ohangwena 10.3 34.0 -1.4 1.7 6.9 2.7 -0.5 3.2 19.5 0.8 -1.1 636 Omaheke 8.8 21.6 -0.8 1.2 5.5 1.5 -0.3 2.9 14.2 2.1 -0.6 338 Omusati 9.0 27.7 -1.2 2.1 10.1 1.6 -0.5 4.4 18.3 0.9 -1.1 513 Oshana 8.7 28.3 -1.2 2.2 9.6 2.5 -0.6 5.3 21.2 1.0 -1.1 337 Oshikoto 10.7 32.3 -1.3 2.1 11.2 2.5 -0.6 5.7 21.9 0.6 -1.1 500 Otjozondjupa 10.2 27.1 -1.1 4.7 8.6 5.8 -0.3 5.3 15.4 1.4 -0.8 360 Mother's education6 No education/preschool 15.7 38.2 -1.5 2.4 8.6 4.1 -0.3 6.5 23.1 1.1 -1.1 475 Incomplete primary 13.4 36.6 -1.5 2.7 9.4 4.0 -0.4 5.1 20.9 0.7 -1.1 1,103 Complete primary 7.5 24.6 -1.1 1.7 6.9 4.9 -0.2 2.3 13.2 1.4 -0.7 1,972 Incomplete secondary 2.2 5.6 -0.2 1.4 2.5 12.0 0.3 0.2 3.9 6.0 0.1 205 Continued… 150 | Fertility Table 12.1—Continued Height-for-age Weight-for-height Weight-for-age Background characteristic Per- centage below -3 SD Per- centage below -2 SD1 Mean Z-score (SD) Per- centage below -3 SD Per- centage below -2 SD1 Per- centage above +2 SD Mean Z-score (SD) Per- centage below -3 SD Per- centage below -2 SD1 Per- centage above +2 SD Mean Z-score (SD) Number of children Wealth quintile Lowest 13.7 37.0 -1.5 2.1 8.0 3.9 -0.4 5.3 21.5 0.7 -1.1 1,164 Second 11.8 35.7 -1.4 2.3 9.3 2.1 -0.5 5.4 21.0 0.9 -1.2 1,133 Middle 9.4 27.9 -1.2 2.2 8.5 2.8 -0.3 3.7 16.0 0.9 -0.9 1,095 Fourth 7.9 24.0 -1.0 1.3 6.1 6.1 -0.2 1.7 12.7 1.1 -0.7 840 Highest 3.7 12.6 -0.6 1.2 3.5 8.8 0.2 1.5 6.9 3.6 -0.2 713 Total 9.9 29.0 -1.2 1.9 7.5 4.3 -0.3 3.8 16.6 1.3 -0.9 4,945 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 6 children with information missing on mother’s interview status. 1 Includes children who are below -3 standard deviations (SD) from the International Reference Population median 2 Excludes children whose mothers were not interviewed 3 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 4 Includes children whose mothers are deceased 5 Excludes children whose mothers were not weighed and measured. Mother's nutritional status in terms of BMI (Body Mass Index) is presented in Table 11.10. 6 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire Table 12.1 and Figure 12.1 show that stunting is apparent even among children less than 6 months of age (14 percent). Stunting increases with the age of the child, from 16 percent among children age 6-8 months to 38 percent among children age 18-23 months and 36 percent among children 24-35 months. The level then declines slowly to between 27 and 30 percent among children age three years and older. There is a difference in the level of stunting by gender; stunting is higher among male children (32 percent) than among females (26 percent). Stunting does not vary in a clear pattern by the birth interval, but size at birth is an important indicator of the nutritional status of children. Stunting is higher among children reported as very small at birth (47 percent) than children described as small, average, or larger in size at birth. Children whose biological mothers are thin (43 percent) are more likely to have better nutritional status than children of normal weight mothers (30 percent), or overweight or obese mothers (20 percent). Rural children are more stunted (31 percent) than urban children (24 percent). Regional variation in nutritional status of children is substantial. Stunting levels range from 22 percent in Omaheke and Erongo to 39 percent in Kavango. The percentage of children stunted decreases with increasing level of mother’s education and with increasing household wealth (wealth quintile). By age group, the prevalence of wasting is highest among children under 6 months (11 percent). The proportion of children wasted is also high among those who were very small at birth (10 percent) and among children of mothers who are thin (16 percent). Rural children are slightly more likely than urban children to be wasted (8 percent versus 6 percent). Wasting varies by region; it is highest in Oshikoto (11 percent) and lowest in Erongo (3 percent). Wasting decreases with increasing level of mother’s education and with increasing household wealth. The percentage of overweight or obese children is highest among children under 6 months (13 percent). As expected, children who were average or larger in size at birth are more likely than other children to be overweight or obese, as are children of overweight or obese mothers. Urban children are more likely to be overweight or obese than rural children (7 percent versus 3 percent). By region, the percentage of overweight or obese children ranges from 2 percent in Omaheke and Omusati to 11 percent in Erongo. Children in the highest wealth quintiles are more likely than other children to be overweight or obese. Nutrition of Children and Women | 151 Table 12.1 and Figure 12.1 show that the percentage of children underweight increases sharply from 7 percent among children under age 6-8 months to 12 percent among children age 9-11 months, and peaks at 20 percent among children age 48-59 months. This may be caused by inappropriate and/or inadequate feeding practices because increasing levels of underweight children by age coincides with the age at which complementary feeding normally starts. The percentage of underweight children varies by size at birth and is highest among those who were born very small. Furthermore, as expected, children of thin mothers are more likely than other children to be underweight. Children living in the rural areas are more likely than urban children to be underweight (19 percent versus 12 percent). The percentage of underweight children in Oshikoto (22 percent), Oshana (21 percent), Hardap and Ohangwena (20 percent each), Kavango (19 percent), and Omusati (18 percent) are above the national average (17 percent). There are differentials by mother’s level of education and household wealth quintile, with children of uneducated mothers and those in the lowest wealth quintiles more likely to be underweight than other children. 12.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged because it is important to the health of both mother and child. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the contraction of the uterus and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 12.2 shows the percentage of all children born in the five years before the survey by breastfeeding status and the timing of initial breastfeeding. Breastfeeding is nearly universal in Namibia, with 94 percent of children born in the five years preceding the survey having been breastfed at some time. By region, children ever breastfed ranges from 85 percent in Hardap to 97 percent in Kavango. However, the percentage of children ever breastfed does not vary much by most background characteristics. ( ( ( ( ( ( ( ( # # # # # # # # ) ) ) ) ) ) ) ) <6 6-8 9-11 12-17 18-23 24-35 36-47 48-59 Age in months 0 10 20 30 40 50 Percent Stunting Wasting Underweight) # ( NDHS 2006-07 Figure 12.1 Nutritional Status of Children by Age 11 7 27 30 36 38 32 14 19 16 9 5 11 7 12 17 18 17 19 20 10 9 5 6 152 | Fertility Table 12.2 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and for the last children born in the five years preceding the survey ever breastfed, the percentage who started breastfeeding within one hour and within one day of birth and the percentage who received a prelacteal feed, by background characteristics, Namibia 2006-07 Among last-born children ever breastfed: Breastfeeding among children born in past five years Background characteristic Percentage ever breastfed Number of children born in past five years Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 92.7 2,569 70.8 91.8 13.6 1,838 Female 94.9 2,434 71.9 92.5 14.6 1,840 Assistance at delivery Health professional 3 93.6 4,071 71.6 93.3 13.0 3,035 Traditional birth attendant 94.9 327 71.8 87.7 12.2 214 Other 93.8 562 71.2 87.4 22.8 397 No one (98.6) 30 (51.6) (79.0) (28.8) 26 Place of delivery Health facility 93.6 4,045 71.7 93.4 13.0 3,020 At home 94.3 933 71.1 87.2 19.2 644 Other * 10 * * * 8 Residence Urban 91.8 2,077 72.0 91.3 16.4 1,580 Rural 95.2 2,926 70.9 92.8 12.4 2,098 Region Caprivi 95.4 269 81.1 93.0 6.2 209 Erongo 93.7 306 63.7 93.1 22.4 241 Hardap 85.4 149 64.5 90.1 16.5 105 Karas 91.9 146 73.6 91.7 21.6 110 Kavango 96.9 610 67.5 81.6 24.0 465 Khomas 90.7 920 74.7 90.5 15.8 676 Kunene 91.9 189 76.8 89.8 33.3 128 Ohangwena 95.1 571 77.1 98.4 3.0 404 Omaheke 95.8 234 55.3 86.1 26.9 163 Omusati 95.6 452 62.7 97.1 9.2 350 Oshana 95.0 360 74.0 98.5 4.3 257 Oshikoto 96.3 449 73.7 95.9 9.0 329 Otjozondjupa 90.3 348 75.3 92.1 8.8 240 Mother's education No education/preschool 94.0 553 71.3 88.5 21.1 353 Incomplete primary 94.8 1,058 72.4 91.9 10.0 748 Complete primary 94.6 378 76.9 92.9 13.4 291 Incomplete secondary 93.9 2,162 69.8 92.8 13.6 1,637 Complete secondary 91.6 593 70.0 90.8 14.5 453 More than secondary 92.2 260 75.0 96.5 21.6 196 Wealth quintile Lowest 96.9 1,072 74.0 90.2 13.1 762 Second 95.0 956 73.5 95.8 9.7 683 Middle 94.4 1,121 69.2 92.4 12.2 814 Fourth 92.9 1,041 68.7 91.6 15.5 799 Highest 88.4 813 72.0 90.8 20.8 619 Total 93.8 5,003 71.3 92.1 14.1 3,678 Note: Table is based on births in the past five years whether the children are living or dead at the time of interview. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Total includes 8 children with information missing on assistance at delivery and 9 children with information missing on place of delivery. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse/midwife, or auxiliary midwife Nutrition of Children and Women | 153 Seven in ten children are breastfed within one hour of birth (71 percent) and more than nine in ten (92 percent) within one day of birth. Fourteen percent of children were given a prelacteal feed, that is, something other than breast milk during the first three days of life. The percentage of children who are breastfed early has decreased somewhat in the past five years, the decrease being more pronounced for children breastfed within one hour (91 percent in 2000 to 71 percent in 2006-07). There is no difference in the timing of initial breastfeeding by gender of child. However, other characteristics of the infant and mother, type of delivery assistance, and place of delivery have important influences on early breastfeeding practices. Initiation of breastfeeding within one day of birth is more common among children whose mothers were assisted by a health professional and who delivered at a health facility than among those whose mothers were assisted by a traditional birth attendant or other person, and those who were delivered at home. Urban children are slightly more likely than rural children to start breastfeeding within one hour of birth (72 percent and 71 percent, respectively), while rural children are somewhat more likely than urban children to start breastfeeding within one day of birth (91 percent and 87 percent, respectively). Initiation of breastfeeding within the first hour is lowest in Omaheke (55 percent) and highest in Caprivi (81 percent), while initiation of breastfeeding within the first day is lowest in Kavango (82 percent) and highest in Oshana (99 percent). There is no clear pattern of early breastfeeding by mother’s level of education or wealth quintile. 12.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first 6 months of life and that children be given solid or semisolid complementary foods in addition to continued breastfeeding from six months on (WHO and UNICEF, 1998). Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of life. In addition, the mother's antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for several reasons. First, it exposes infants to pathogens and increases their risk of infection and disease. Second, it decreases infants’ intake of breast milk and therefore suckling, which reduces breast milk production. Third, in a limited socioeconomic environment, supplementary food is often nutritionally inferior. Information on supplementation was obtained by asking mothers about the current breast- feeding status of all children under five years of age, and foods (liquids or solids) given the day before the survey to the youngest child born in the three years before the survey and living with the mother. Table 12.3 shows the percent distribution of youngest children under three years living with the mother by breastfeeding status and percentage of children under three years using a bottle with a nipple, according to age in months. The data presented in Table 12.3 and Figure 12.2 show that not all children under 6 months are exclusively breastfed. Contrary to WHOs recommendations, only about half of children under 2 months of age are exclusively breastfed, 10 percent receive breast milk and plain water, 11 percent receive breast milk and other non-milk liquids, and 9 percent receive breast milk and other milk. Three percent of children under 2 months are given complementary foods. The proportion of children exclusively breastfed drops off to 6 percent by age 4-5 months and continues to decline thereafter. Bottle-feeding is discouraged at any age. It is usually associated with increased risk of illness and especially diarrhoeal disease, because of the difficulty in sterilizing the nipples properly. Bottle- feeding also shortens the period of postpartum amenorrhoea and increases the risk of pregnancy. The practice of bottle-feeding with a nipple is relatively widespread in Namibia. The proportion of children who are bottle-fed is 22 percent among children under 2 months, which increases to 50 percent among children age 6-8 months, then declines to 15 percent among children age 24-35 months. 154 | Fertility Table 12.3 Breastfeeding status by age Percent distribution of youngest children under three years who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under three years using a bottle with a nipple, according to age in months, Namibia 2006-07 Breastfeeding and consuming: Age in months Not breast- feeding Exclusively breastfed Plain water only Non-milk liquids/ juice Other milk Comple- mentary foods Total Percentage currently breast- feeding Number of youngest children under three years Percentage using a bottle with a nipple Number of children under three years <2 13.6 53.6 10.0 11.0 8.5 3.4 100.0 86.4 118 22.4 125 2-3 10.2 22.9 12.0 19.8 16.4 18.7 100.0 89.8 172 39.3 176 4-5 7.4 5.7 7.5 9.6 11.0 58.8 100.0 92.6 184 47.1 194 6-8 20.4 1.0 1.1 5.0 3.0 69.6 100.0 79.6 266 50.1 278 9-11 22.5 0.2 0.9 1.1 0.7 74.6 100.0 77.5 238 46.2 264 12-17 33.0 0.7 0.4 1.1 0.4 64.3 100.0 67.0 472 37.0 527 18-23 64.5 0.0 0.4 0.0 0.0 35.1 100.0 35.5 365 26.2 459 24-35 91.1 0.7 0.0 0.1 0.0 8.2 100.0 8.9 566 14.6 949 0-3 11.5 35.4 11.2 16.2 13.2 12.5 100.0 88.5 291 32.3 301 0-5 9.9 23.9 9.7 13.6 12.3 30.4 100.0 90.1 475 38.1 496 6-9 20.2 0.8 0.8 3.8 2.8 71.5 100.0 79.8 344 48.6 363 12-15 31.5 1.0 0.3 1.1 0.6 65.4 100.0 68.5 331 39.1 363 12-23 46.8 0.4 0.4 0.6 0.3 51.6 100.0 53.2 836 32.0 987 20-23 71.6 0.0 0.6 0.0 0.0 27.8 100.0 28.4 249 25.3 320 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and non-milk liquids and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years Figure 12.3 presents breastfeeding status of children 0-5 months and 6-9 months for the years 2000 and 2006-07. Exclusive breastfeeding declined slightly among children under 6 months while complementary feeding increased between the two surveys. Figure 12.2 Infant Feeding Practices by Age <2 2-3 4-5 6-8 9-11 12-17 18-23 24-35 Age in months 0 20 40 60 80 100 Exclusively breastfed Breast milk and plain water Breast milk and non-milk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding NDHS 2006-07 Percent Nutrition of Children and Women | 155 12.4 DURATION AND FREQUENCY OF BREASTFEEDING Table 12.4 shows the median duration of breastfeeding by background characteristics. The estimates of mean and median duration of breastfeeding are based on current status data, that is, the proportion of last-born children in the three years preceding the survey who were being breastfed at the time of the survey. The median duration of breastfeeding is 16.8 months, while the mean duration is 15.4 months. There is little difference in the duration of breastfeeding by sex of child. Rural children are breastfed for twice as long as urban children (18.8 months versus 9.8 months). Children living in Kavango (20.6 months) and Caprivi (20 months) are breastfed longer than children in other regions. Highly educated mothers and those in the higher wealth quintiles breastfeed their children for a shorter time than mothers with little or no education and mothers in the lowest wealth quintiles. Both duration and frequency of breastfeeding can affect the length of postpartum amenorrhoea. Table 12.4 shows that the overwhelming majority (95 percent) of children under 6 months of age were breastfed 6 or more times in the 24 hours preceding the survey. In line with expectations, breastfeeding is slightly more frequent in the daytime than at night, with the mean number of feeds in the daytime being 7.9 compared with 6.1 at night. Figure 12.3 Infant and Young Child Feeding Practices 2000 NDHS and 2006-07 NDHS 0-05 6-09 0-05 6-09 0 20 40 60 80 100 Percent Not breastfeeding Exclusively breastfed Plain water only Nonmilk liquids/juice Other milk Complementary foods 0-5 6-9 0-5 6-9 Age in months 2000 NDHS 2006-07 NDHS Age in months 156 | Fertility Table 12.4 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Namibia 2006-07 Frequency of breastfeeding among children under six months2 Median duration (months) of breastfeeding among children born in the past three years 1 Background characteristic Any breast- feeding Exclusive breast- feeding Predominant breast- feeding3 Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 16.5 0.7 2.0 95.1 8.0 6.2 220 Female 17.1 0.9 2.0 94.8 7.8 6.1 209 Residence Urban 9.8 0.7 1.2 91.7 8.1 6.7 153 Rural 18.8 0.9 2.5 96.7 7.8 5.8 276 Mother's education No education/preschool 19.1 0.9 1.7 91.6 8.1 6.1 50 Incomplete primary 20.2 0.7 2.3 97.6 8.3 6.0 83 Complete primary 17.5 1.8 2.6 (100.0) (6.7) (5.0) 38 Incomplete secondary 15.6 0.8 2.3 97.5 8.3 6.5 193 Complete secondary (8.7) (0.6) (0.6) (86.7) (7.4) (6.2) 43 More than secondary * * * * * * 22 Wealth quintile Lowest 19.9 1.3 2.8 96.5 8.3 6.5 111 Second 18.7 0.7 2.4 96.4 8.6 5.9 85 Middle 17.3 0.7 2.2 93.5 7.8 5.5 110 Fourth 9.9 1.5 2.0 98.6 7.5 6.3 83 Highest (0.6) (0.4) (0.4) (83.8) (6.8) (7.2) 39 Total 16.8 0.7 2.0 94.9 7.9 6.1 429 Mean for all children 15.4 2.2 3.6 - - - - Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding 2 Excludes children without a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only 12.5 TYPES OF SUPPLEMENTAL FOODS Table 12.5 provides information on the types of foods given to the youngest child under three years of age living with the mother, in the day and night preceding the survey, according to breastfeeding status. The introduction of other liquids such as water, juice, and formula takes place earlier than the recommended age of about 6 months. Even among the youngest breastfeeding children (<2 months), 17 percent received other liquids and 10 percent drank milk other than breast milk. Consumption of liquids other than milk increases gradually with age, and by age 24-35 months about three-fourths of children received liquid supplements other than milk. Consumption of milk other than breast milk and infant formula peaks at 9-11 months (35 percent) and then declines. Supplementing with infant formula occurs in about one in ten breastfeeding children and two in ten nonbreastfeeding children under age in Namibia. WHO recommends the introduction of solid food to infants around the age of 6 months because by that age, breast milk by itself is no longer sufficient to maintain a child’s optimal growth. The percentage of children receiving solid or semisolid food increases gradually; by age 2, most children are fed solid or semisolid foods. Nevertheless, it is disconcerting to note that even at 6-8 months of age, only one in two children are receiving solid or semisolid foods. Nutrition of Children and Women | 157 At age 6-23 months, children are more likely to be given foods made from grains (90 percent) than any other type of solid or semisolid food. Four in ten children age 6-23 months received vitamin A-rich foods in the day and night preceding the survey. Meat, fish, poultry, and eggs contain bodybuilding substances essential to good health including nutrients that are important for balanced physical and mental development. More than half of children age 6-23 months received meat, fish, shellfish, poultry, or eggs in the 24 hours preceding the survey. Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under three years of age who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Namibia 2006-07 Solid or semi-solid foods Liquids Age in months Infant formula Other milk1 Other liquids2 Fortified baby foods 3 Food made from grains Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry, and eggs Cheese, yogurt, other milk product Any solid or semi- solid food Food made with oil, fat and butter Sugary foods Number of children BREASTFEEDING CHILDREN <2 7.8 10.0 17.3 0.0 2.4 1.5 2.2 0.0 0.0 1.5 0.8 4.0 1.7 1.5 102 2-3 12.7 21.2 44.4 3.2 12.9 3.8 0.5 1.3 0.6 3.6 2.7 20.2 3.0 0.7 155 4-5 19.0 22.6 56.7 17.2 54.6 17.5 8.0 9.0 2.6 13.8 6.7 62.8 16.3 8.6 170 6-8 17.8 25.2 70.2 26.3 82.8 27.5 14.0 20.2 13.1 37.7 16.2 87.4 29.1 25.7 212 9-11 11.8 34.7 75.9 17.8 94.2 40.6 21.8 17.2 9.1 64.4 13.0 96.0 43.7 35.5 184 12-17 6.9 31.8 80.9 13.0 91.3 42.4 21.2 18.3 12.6 56.4 13.4 95.7 48.3 42.0 316 18-23 6.4 26.5 83.3 9.3 95.1 48.0 15.1 19.8 17.5 53.5 6.7 98.8 38.7 35.1 130 24-35 0.7 15.0 72.9 6.1 83.9 36.4 21.0 18.1 14.1 56.8 5.7 91.2 36.1 36.7 51 6-23 10.6 30.0 77.5 16.8 90.4 39.1 18.6 18.8 12.7 53.0 13.0 94.2 41.0 35.4 841 Total 11.4 25.9 66.1 13.6 69.6 29.2 13.9 14.0 9.1 38.3 9.7 74.3 30.1 25.3 1,319 NONBREASTFEEDING CHILDREN 6-8 76.3 67.5 71.1 65.4 95.3 33.6 20.0 31.1 6.9 31.5 30.8 95.9 32.3 22.5 54 9-11 52.8 59.4 70.2 57.7 98.8 50.2 22.7 26.9 12.9 74.0 42.7 99.3 58.7 39.8 53 12-17 30.0 55.2 85.6 32.0 98.4 38.6 33.9 35.3 18.0 80.9 20.0 98.8 54.9 43.8 156 18-23 14.2 41.2 88.9 15.2 96.9 46.0 34.6 29.2 20.1 77.2 25.1 99.0 60.1 44.2 235 24-35 7.8 37.5 83.0 10.7 95.7 46.8 29.8 24.0 17.0 71.0 17.8 97.3 57.9 46.9 515 6-23 30.0 50.4 83.9 30.4 97.4 42.8 31.5 31.1 17.2 73.0 26.0 98.6 55.3 41.2 499 Total 20.6 45.4 82.4 20.4 94.3 43.2 30.2 26.6 16.7 69.6 21.7 95.7 54.9 42.9 1,061 Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and last night). 1 Other milk includes fresh, tinned, and powdered milk 2 Doesn't include plain water 3 Includes fortified baby food 4 Includes pumpkin, red or yellow yams or squash, carrots, sweet potatoes, dark green leafy vegetables, mangoes, and papaya. Table 12.6 and Figure 12.4 present a combined indicator of appropriate feeding practices for children age 6-23 months. This indicator is calculated taking into account guidelines for the number of food groups1 a child should receive and the number of times per day a child should eat. The guidelines for appropriate feeding practices change depending on age of the child and whether not the child is breastfed. According to WHO, breastfed children should receive foods from three or more food groups every day to obtain all of the micronutrients they need. Breastfed children who are age 6-8 months should be fed solid or semisolid foods at least 2-3 times per day. Children age 9-23 months should be fed at least 3-4 times per day (PAHO/WHO, 2003). Nonbreastfed children should receive foods from at least four food groups and should receive solid or semisolid food 4-5 times a day (WHO, 2005a). 1 Food groups used in the assessment of minimum standard of feeding practices include: infant formula, milk other than breast milk, cheese, or yogurt or other milk products; foods made from grains, roots, and tubers including porridge and fortified baby food from grains; fruits and vegetables rich in vitamin A; other fruits and vegetables; eggs; meat, poultry, fish, and shellfish (and organ meats); beans, peas, and nuts; and foods made with oil, fat, or butter. 158 | Fertility Table 12.6 looks at feeding practices by age, breastfeeding status, and background charac- teristics. Use of appropriate feeding practices with young children is low in Namibia. Overall, only one in four (26 percent) children age 6-23 months receive appropriate feeding Figure 12.4). Those age 6-8 months are most likely to receives appropriate feeding (33 percent). Use of appropriate feeding practices decreases with age to 17 percent among children 18-23 months. Inadequate number of feedings is the most common problem with feeding practices. Only four in ten children age 6-23 months are fed solid or semisolid foods the minimum recommended number of times each day. Girls Table 12.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night preceding the survey, by background characteristics, Namibia 2006-07 Among breastfed children 6-23 months, percentage fed: Among non-breastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: Background characteristic 3+ food groups1 Mini- mum times or more2 Both 3+ food groups and minimum times or more Number of breast- fed children 6-23 months Milk or milk prod- ucts3 4+ food groups 4+ times or more With 3 IYCF prac- tises4 Number of non- breast-fed children 6-23 months Breast milk or milk prod- ucts3 3+ or 4+ food groups5 Mini- mum times or more6 With all 3 IYCF prac- tises Number of all children 6-23 months Age 6-8 45.4 67.2 38.5 212 88.3 34.8 19.3 9.7 54 97.6 43.3 57.4 32.6 266 9-11 71.8 39.3 32.6 184 80.1 68.3 23.0 19.9 53 95.5 71.0 35.6 29.7 238 12-17 66.9 44.9 33.2 316 64.8 61.1 26.7 14.3 156 88.4 65.0 38.9 27.0 472 18-23 62.4 39.6 31.9 130 51.2 62.3 25.9 8.6 235 68.6 62.4 30.8 16.9 365 Sex Male 61.9 49.5 35.4 446 61.1 58.9 25.7 14.2 245 86.2 60.9 41.1 27.9 692 Female 61.8 47.3 32.8 395 64.0 60.2 24.5 9.4 253 85.9 61.2 38.4 23.6 648 Residence Urban 66.9 55.0 43.7 245 72.5 67.1 23.6 14.3 269 85.6 67.0 38.6 28.3 514 Rural 59.8 45.8 30.3 596 51.0 50.8 26.9 8.8 229 86.4 57.3 40.5 24.3 826 Region Caprivi 45.0 42.7 22.8 53 (74.2) (70.3) 11.4 (9.4) 25 91.7 53.1 32.6 18.5 78 Erongo (63.9) (66.3) (50.5) 27 (75.0) (64.7) 23.8 (10.8) 41 85.1 64.4 40.9 26.7 68 Hardap (59.5) (51.4) (40.9) 23 (84.2) (71.1) 28.9 (23.3) 19 92.8 64.8 41.1 32.8 42 Karas (60.8) (57.7) (46.7) 20 (79.6) (65.8) 36.1 (24.4) 18 90.3 63.2 47.4 36.0 38 Kavango 57.2 33.3 20.2 164 (39.4) (43.2) 20.7 (1.8) 32 90.1 54.9 31.2 17.2 196 Khomas 64.3 48.4 39.7 101 71.4 69.0 18.0 10.4 133 83.8 67.0 31.2 23.1 234 Kunene (50.1) (53.5) (23.6) 33 (69.1) (39.7) 24.9 (2.0) 16 89.8 46.7 44.1 16.5 49 Ohangwena 60.7 64.1 42.1 121 (29.2) (37.5) 24.3 (10.4) 36 83.6 55.4 54.9 34.8 157 Omaheke (56.7) (28.5) (17.0) 31 (74.7) (43.9) 29.8 (5.2) 32 87.1 50.2 29.2 10.9 62 Omusati 77.8 55.7 44.6 91 (39.5) (53.5) 47.2 (15.1) 38 82.0 70.6 53.1 35.8 129 Oshana 76.6 38.4 35.7 59 (52.1) (76.7) 21.0 (7.3) 27 84.8 76.6 32.9 26.7 86 Oshikoto 64.2 54.3 36.2 66 (42.4) (61.8) 20.6 (9.0) 39 78.5 63.3 41.7 26.0 105 Otjozondjupa 55.7 52.0 38.9 54 80.2 53.9 38.0 27.7 41 91.4 54.9 45.9 34.0 95 Mother's education No education/preschool 52.7 45.7 25.9 114 (63.7) (31.8) (31.1) (8.4) 39 90.7 47.3 42.0 21.4 153 Incomplete primary 55.9 42.5 28.7 206 34.4 48.9 11.6 5.7 57 85.8 54.4 35.8 23.8 263 Complete primary 55.3 33.3 21.2 75 (32.5) (32.6) (18.5) (7.5) 35 78.6 48.1 28.6 16.9 110 Incomplete secondary 67.8 53.7 40.6 359 64.5 63.5 28.0 13.2 235 85.9 66.1 43.5 29.8 594 Complete secondary 69.6 59.4 45.1 60 76.2 70.7 25.5 11.1 101 85.2 70.3 38.2 23.9 161 More than secondary * * * 27 (86.9) (78.6) (26.7) (22.3) 32 92.9 73.7 39.2 29.2 60 Wealth quintile Lowest 51.8 38.2 20.0 239 35.1 38.7 25.0 0.0 67 85.8 48.9 35.3 15.6 307 Second 63.4 51.1 37.1 196 43.8 52.0 28.0 13.1 72 84.9 60.4 44.9 30.6 268 Middle 65.4 45.3 33.8 199 53.3 48.4 19.2 3.7 104 84.0 59.6 36.3 23.5 303 Fourth 68.9 60.4 46.8 130 68.1 70.1 34.5 21.7 117 84.9 69.5 48.1 35.0 246 Highest 68.3 62.2 50.6 77 87.8 73.0 20.2 14.3 139 92.2 71.3 35.2 27.3 217 Total 61.9 48.5 34.2 841 62.6 59.6 25.1 11.7 499 86.1 61.0 39.8 25.8 1,340 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge, fortified baby food from grains; c. vitamin A-rich fruits and vegetables; d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts; h. foods made with oil, fat, butter. 2 At least twice a day for breastfed infants 6-8 months and at least three times a day for breastfed children 9-23 months 3 Includes commercial infant formula, fresh, tinned and powdered animal milk, and cheese, yogurt, and other milk products 4 Nonbreastfed children ages 6-23 months are considered to be fed with three appropriate feeding practices if they receive other milk or milk products and are fed at least the minimum number of times per day with at least the minimum number of food groups. 5 3+ food groups for breastfed children and 4+ food groups for non-breastfed children 6 Fed solid or semi-solid food at least twice a day for infants 6-8 months, 3+ times for other breastfed children, and 4+ times for non-breastfed children Nutrition of Children and Women | 159 are somewhat less likely to have appropriate feeding practices than boys (24 percent compared with 28 percent) and rural children are somewhat less likely to have appropriate feeding practices than urban children (24 percent compared with 28 percent). Use of appropriate feeding practices is lowest in Omaheke (11 percent) and highest in Hardap and Omusati (36 percent each). The association of appropriate feeding practices with mother’s level of education and household wealth quintile does not show a clear pattern. 12.6 MICRONUTRIENT INTAKE AMONG CHILDREN A serious contributor to childhood morbidity and mortality is micronutrient deficiency. Children can receive micronutrients from foods, food fortification, and direct supplementation. Table 12.7 looks at measures relating to intake of several key micronutrients by children. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency (VAD) can cause eye damage. VAD can also increase severity of infections, such as measles and diarrhoeal diseases in children, and slows recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Periodic dosing (usually every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD. 34 12 26 66 88 74 Breastfed (3+ food groups) Non-breastfed (4+ food groups) All (3+ or 4+ food groups) 0 20 40 60 80 100 Percent of children 6-23 months Fed with all IYCF practices Not fed with all IYCF practices Figure 12.4 Infant and Young Child Feeding Practices NDHS 2006-07 160 | Fertility The NDHS collected information on the consumption of vitamin A-rich foods and the coverage of supplements. Table 12.7 shows that 76 percent of last-born children age 6-35 months living with the mother consumed vitamin A-rich foods in the 24-hour period before the survey. Consumption of vitamin A-rich foods increases from 49 percent among children age 6-8 months to 83 percent among children age 18-23 and 81 percent among those 24-35 months. There is no significant gender difference in the consumption of vitamin A-rich foods and no discernible difference by birth order. Not surprisingly, breastfed children are much less likely to consume vitamin A-rich foods than nonbreastfed children. Urban children are somewhat more likely to consume vitamin A-rich foods than rural children. Children living in Kunene are least likely to consume vitamin A-rich foods compared with children in other regions, while children in Oshana are most likely. Children born to teenage mothers and mothers with at least some secondary education are more likely to have received foods rich in vitamin A than children born to older mothers and mothers with little or no education. Children living in the wealthiest households are much more likely to receive vitamin A-rich foods than children in poorer households. Sixty-three percent of young children receive foods rich in iron. There are substantial differences by background characteristics in the consumption of iron-rich foods. Consumption of iron- rich foods increases from 37 percent among children age 6-8 months to peak at 70 percent among children age 18-23 months. A significantly higher proportion of urban children than rural children receives iron-rich foods (72 percent versus 58 percent). Breastfeeding children are much less likely to consume iron-rich foods than nonbreastfeeding children (58 percent versus 72 percent). As with vitamin A consumption, children born to younger mothers and mothers with at least some secondary education are more likely to consume iron-rich foods than children born to older mothers and mothers with little or no education. Finally, children living in the wealthiest households are more likely to consume iron-rich foods than children living in other households. More than one in two (52 percent) children age 6-59 months received a vitamin A supplement in the six months before the survey. Differences in the consumption of vitamin A supplements by gender and breastfeeding status of mother are small. The urban-rural difference in vitamin A intake is marked, with rural children more likely to receive vitamin A supplements than children in urban areas (56 percent versus 46 percent). By region, children in Khomas are least likely to receive vitamin A supplements. Vitamin A supplementation is generally higher for children of more educated women and it is higher among children of women age 40-49 years old. Nutrition of Children and Women | 161 Table 12.7 Micronutrient intake among children Among youngest children age 6-35 months who are living with their mother, the percentages who consumed vitamin A-rich and iron- rich foods in the day or night preceding the survey, and among all children 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, who were given iron supplements in the past seven days, and who were given deworming medication in the six months preceding the survey, and among all children age 6-59 months who live in households that were tested for iodized salt, the percentage who live in households with adequately iodized salt, by background characteristics, Namibia 2006-07 Among youngest children age 6-35 months living with the mother: Among all children age 6-59 months: Background characteristic Percentage who consumed foods rich in vitamin A in past 24 hours1 Percentage who consumed foods rich in iron in past 24 hours2 Number of children Percentage given vitamin A supplements in past 6 months Percentage given iron supplements in past 7 days Percentage given deworm- ing medica- tion in past 6 months3 Number of children Age in months 6-8 48.8 36.5 266 37.3 11.1 8.6 278 9-11 77.0 66.6 238 57.1 16.8 11.2 264 12-17 77.5 64.5 472 60.4 12.7 8.4 527 18-23 83.4 68.8 365 56.5 14.6 8.9 459 24-35 81.0 69.7 566 53.6 12.0 9.3 949 36-47 na na na 48.5 8.9 9.9 930 48-59 na na na 47.0 10.2 8.0 816 Sex Male 74.4 63.5 971 51.7 11.4 8.9 2,149 Female 76.9 62.9 935 51.3 11.7 9.3 2,074 Breastfeeding status Breastfeeding 68.4 53.2 892 55.4 13.9 9.1 919 Not breastfeeding 81.8 71.5 990 50.7 10.4 8.9 3,150 Missing * * 24 45.6 20.5 13.0 154 Residence Urban 79.2 72.0 751 45.8 12.1 8.9 1,783 Rural 73.3 57.5 1,154 55.7 11.2 9.3 2,440 Region Caprivi 72.7 56.7 120 60.3 9.3 12.1 222 Erongo 77.7 73.3 102 45.2 4.0 5.5 261 Hardap 74.0 69.3 60 61.7 12.4 6.1 127 Karas 82.7 73.1 64 59.8 9.8 7.3 122 Kavango 81.0 47.3 258 52.7 31.1 24.0 496 Khomas 78.2 73.2 332 40.8 12.9 7.2 816 Kunene 46.8 44.7 65 46.3 8.1 10.1 167 Ohangwena 72.3 55.5 213 60.7 4.9 5.6 475 Omaheke 63.9 60.5 87 45.0 21.1 5.6 194 Omusati 82.4 71.2 178 56.2 10.8 7.2 377 Oshana 83.5 75.8 124 52.8 5.5 5.8 301 Oshikoto 75.8 63.6 167 59.6 4.3 5.6 371 Otjozondjupa 67.6 60.5 137 45.1 6.6 9.8 293 Mother's education No education/preschool 67.1 44.4 209 43.9 11.8 8.8 471 Incomplete primary 68.6 48.7 388 53.9 10.3 8.8 883 Complete primary 75.8 61.6 153 48.3 12.6 9.5 311 Incomplete secondary 77.5 68.9 822 52.7 10.7 8.0 1,810 Complete secondary 86.6 81.7 238 49.6 13.8 9.9 520 More than secondary 78.7 70.6 95 57.2 16.4 16.7 228 Mother's age at birth 15-19 80.8 69.4 283 50.5 10.7 9.8 666 20-29 74.3 63.7 962 49.9 12.1 9.4 2,198 30-39 75.8 61.3 575 53.3 11.3 8.0 1,195 40-49 72.4 50.2 86 64.3 10.2 10.4 164 Wealth quintile Lowest 71.5 44.2 427 55.5 14.3 13.2 878 Second 72.4 56.9 372 53.9 9.3 8.0 801 Middle 75.5 68.9 418 51.6 11.0 6.4 922 Fourth 75.2 69.7 346 51.7 9.4 8.2 895 Highest 84.6 80.2 343 43.6 14.3 9.8 727 Total 75.6 63.2 1,906 51.5 11.6 9.1 4,223 Note: Information on vitamin A and iron supplements and deworming medication is based on the mother's recall. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, sweet potatoes, dark green leafy vegetables, mango, papaya, oranges, and other locally grown fruits and vegetables that are rich in vitamin A 2 Includes meat, (including organ meat), fish, poultry and eggs 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 162 | Fertility 12.7 NUTRITIONAL STATUS OF WOMEN The 2006-07 NDHS collected information on the height and weight of women of reproductive age (15-49). The data are used to derive a measure of adult nutritional status known as body mass index (BMI). In this report, two anthropometric indices are presented for women—height and body mass index (BMI). A woman’s height is related to past socioeconomic status and nutritional status during childhood and adolescence. A woman’s height is used to predict the risk of difficulty in delivery because small stature is often associated with small pelvis size and the potential for obstructed labour. The risk of giving birth to a low-birth-weight baby is influenced by the mother’s nutritional status. The cut-off point for height, below which mothers are considered at risk, varies between populations but normally falls between 140 and 150 centimetres. For comparative purposes, DHS surveys use the same cut-off point (145 cm). The index used to measure thinness and obesity is known as the body mass index (BMI), or the Quetelet index. BMI is defined as weight in kilogrammes divided by height in metres squared (kg/m2). A cut-off point of 18.5 is used to define thinness or acute under- nutrition while a BMI of 25 or above usually indicates overweight or obesity. Table 12.8 presents the mean values of the two anthropometric indicators and the proportion of women falling into various high-risk categories, according to background characteristics. Women for whom there was no information on height and/or weight and for whom a BMI could not be estimated are excluded from this analysis. The data analysis on BMI is based on 8,803 women, while the height analysis is based on 9,943 women age 15-49 years. Overall, 1 percent of women are shorter than 145 cm. The highest proportion of women below the cutoff is in Hardap (4 percent). Women with no education are more likely to be shorter than 145 cm, compared with women in the highest education category (4 percent versus <1 percent). Table 12.8 shows that the average BMI for women in Namibia is 23, which is within the normal BMI range of 18.5-24.9. Overall, 56 six percent of women are within this range. There are large differentials across background characteristics in the percentage of women assessed as malnourished or “thin” (BMI less than 18.5) and overweight (BMI 25 or higher). Sixteen percent of women are chronically malnourished (BMI less than 18.5), while 16 percent are overweight and 12 percent are obese. Three in ten women age 15-19 are thin or undernourished. There are variations in BMI between urban and rural women. More women in rural areas have a BMI less than 18.5 (20 percent) than women in urban areas (12 percent). The percentage of overweight or obese women is, however, higher in urban areas (21 and 16 percent, respectively) than in rural areas (12 percent and 7 percent, respectively). Ohangwena (22 percent) and Oshana (21 percent) have the highest percentage of undernourished women, while Caprivi has the lowest percentage (8 percent). The percentage of undernourished women decreases with increasing educational level and with increasing wealth quintile, while the opposite pattern is seen among overweight and obese women. Nutrition of Children and Women | 163 Table 12.8 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Namibia 2006-07 Body Mass Index Height Background characteristic Percent- age under 145 cm Number of women Mean Body Mass Index (BMI) 18.5- 24.9 (total normal) <18.5 (total thin) 17.0- 18.4 (mildly thin) <17 (moder- ately and severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of women Age 15-19 1.4 2,159 20.2 62.6 30.4 18.0 12.4 7.1 5.5 1.5 2,070 20-29 0.7 3,371 22.5 63.1 14.3 10.2 4.1 22.6 15.4 7.3 3,053 30-39 0.8 2,373 24.9 49.7 8.1 5.3 2.8 42.2 24.4 17.8 2,167 40-49 1.2 1,540 25.9 42.1 10.5 6.7 3.8 47.4 21.7 25.7 1,513 Residence Urban 0.7 4,514 24.4 50.8 11.8 7.9 4.0 37.3 20.9 16.4 4,246 Rural 1.2 4,929 22.0 60.9 19.7 12.4 7.3 19.4 12.2 7.2 4,557 Region Caprivi 0.4 462 23.1 68.2 7.5 4.7 2.9 24.3 15.2 9.1 421 Erongo 0.6 655 25.5 46.9 8.5 5.4 3.1 44.6 24.3 20.3 610 Hardap 4.0 302 23.9 45.8 19.5 10.0 9.4 34.7 15.7 19.0 278 Karas 2.3 304 25.2 42.3 14.0 7.9 6.1 43.7 21.5 22.2 288 Kavango 0.9 916 21.5 64.2 20.1 15.1 5.0 15.7 10.7 5.0 839 Khomas 0.3 2,052 24.4 51.2 10.5 7.2 3.3 38.4 21.9 16.5 1,947 Kunene 0.8 249 24.1 48.1 15.5 9.3 6.2 36.4 21.3 15.1 224 Ohangwena 1.0 1,017 21.1 65.0 22.3 14.0 8.3 12.7 8.5 4.2 944 Omaheke 2.7 357 24.5 43.9 17.6 10.5 7.1 38.5 18.3 20.2 327 Omusati 0.5 960 21.6 63.9 19.5 12.2 7.4 16.6 12.5 4.1 911 Oshana 0.8 799 22.4 55.4 21.0 12.8 8.2 23.6 15.0 8.6 757 Oshikoto 1.1 832 22.1 62.7 19.2 12.2 7.0 18.1 11.6 6.5 770 Otjozondjupa 1.8 538 24.8 46.9 12.5 8.0 4.4 40.7 21.3 19.4 488 Education No education/preschool 3.0 628 22.4 58.4 20.1 12.0 8.1 21.5 12.9 8.6 569 Incomplete primary 1.6 1,658 22.9 56.0 19.0 11.3 7.6 25.1 13.5 11.6 1,535 Complete primary 1.3 722 22.7 53.9 20.1 11.4 8.6 26.0 14.9 11.2 668 Incomplete secondary 0.6 4,604 22.8 58.5 16.5 11.0 5.4 25.1 15.2 9.8 4,311 Complete secondary 0.4 1,220 24.2 53.3 11.0 7.0 3.9 35.7 21.8 13.9 1,140 More than secondary 0.5 612 26.2 43.7 4.3 3.9 0.4 51.9 27.1 24.8 580 Wealth quintile Lowest 0.9 1,595 20.8 69.0 22.2 13.5 8.7 8.9 6.5 2.4 1,454 Second 1.6 1,634 21.6 60.7 22.6 14.4 8.1 16.7 11.9 4.8 1,528 Middle 1.0 1,834 22.9 57.8 15.8 9.9 5.8 26.4 16.0 10.4 1,687 Fourth 0.8 2,210 24.2 53.0 11.2 7.4 3.8 35.8 19.5 16.3 2,070 Highest 0.7 2,171 25.1 45.1 11.4 7.8 3.6 43.5 23.8 19.6 2,064 Total 1.0 9,443 23.2 56.0 15.9 10.2 5.7 28.0 16.4 11.7 8,803 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding 2 months 12.8 FOODS CONSUMED BY MOTHERS Adequate nutrition is important for women’s health and child survival. Because of women’s childbearing and nurturing roles, pre- and postnatal care and adequate nutrition are important factors in of the development of the foetus and the survival of the newborn, in addition to women’s own health needs. Table 12.9 presents the diversity of food groups consumed by mothers who gave birth in the past three years, providing important information on maternal eating patterns. Data show that overall, seven in ten (71 percent) mothers with a child under age three years living with them consumed meat, fish, shellfish, poultry, or eggs in the preceding 24 hours; about six in ten (57 percent) ate foods made from grains; and more than half (54 percent) ate foods made with oil, fat, or butter. Furthermore, about half of women (47 percent) consumed vitamin A-rich fruits and vegetables, and one in four ate 164 | Fertility other foods or vegetables (24 percent) or foods made from roots or tubers (25 percent). Finally, about one in six women ate foods made from legumes and one in seven ate cheese or yogurt in the preceding 24-hour period. One in four women consumed milk in the day and night preceding the survey, while more than half (55 percent) had tea or coffee. The consumption of each of the specified solid or semisolid foods, as well as milk and tea or coffee, varies by background characteristics. A higher percentage of urban women than rural women consumed each of the specified foods or liquids. Consumption of foods and liquids generally increases with women’s level of education and wealth quintile. Table 12.9 Foods consumed by mothers in the day or night preceding the interview Among mothers age 15-49 with a child under age three years living with them, the percentage who consumed specific types of foods in the day or night preceding the interview, by background characteristics, Namibia 2006-07 Background characteristic Foods made from grains Foods made from roots/ tubers Foods made from legumes Meat/ fish/ shellfish/ poultry/ eggs Cheese/ yogurt Vitamin A-rich fruits/ vege- tables1 Other fruits/ vege- tables Foods made with oil/ fat/ butter Any other solid or semi- solid food Sugary foods Milk Tea/ coffe Other liquids Number of mothers Age 15-19 47.3 22.8 13.9 75.5 12.5 45.1 17.6 51.8 74.7 37.9 25.0 52.5 71.9 221 20-29 58.7 24.4 19.1 71.3 14.2 46.0 23.2 53.8 74.1 40.1 26.4 54.5 74.2 1,216 30-39 60.0 27.6 17.4 72.4 17.1 48.1 29.6 56.5 76.5 36.5 25.1 59.4 75.4 784 40-49 44.1 15.1 16.8 56.8 17.4 49.1 18.7 51.7 77.3 30.8 23.9 46.6 76.1 160 Residence Urban 81.1 37.3 20.0 85.0 27.9 48.9 41.6 66.2 69.6 50.4 30.4 74.9 81.3 927 Rural 41.8 16.6 16.5 62.1 7.1 45.5 13.5 46.8 78.7 30.2 22.6 43.0 70.2 1,453 Region Caprivi 45.4 18.7 11.6 67.1 5.1 56.4 12.9 42.5 81.4 33.3 27.5 38.1 46.7 141 Erongo 84.1 43.3 16.3 83.8 26.0 40.9 44.2 55.0 57.5 46.0 30.5 81.8 76.3 127 Hardap 77.6 31.6 15.0 77.4 28.3 33.7 31.2 48.9 49.4 39.1 36.3 87.2 70.8 72 Karas 85.9 45.3 19.1 83.0 26.8 49.3 32.8 52.8 53.2 40.5 42.0 87.2 63.9 77 Kavango 26.5 15.9 21.5 56.1 9.5 78.4 10.4 38.9 83.3 41.1 19.2 25.8 81.7 332 Khomas 85.9 37.9 18.3 87.5 31.1 45.4 44.0 69.7 62.3 49.7 29.1 74.5 82.9 401 Kunene 34.6 10.3 11.3 59.9 7.0 9.9 15.6 50.5 86.7 27.3 35.2 62.6 77.1 76 Ohangwena 46.5 11.3 10.1 58.2 2.3 37.8 12.8 45.3 85.7 30.1 14.2 25.8 73.3 268 Omaheke 56.1 28.3 12.0 64.8 15.7 24.1 15.2 50.8 87.4 26.2 47.1 81.6 77.6 118 Omusati 60.8 17.5 23.5 70.5 8.7 47.1 17.4 48.8 75.0 28.9 9.4 41.4 73.9 222 Oshana 64.7 33.7 29.8 79.0 19.3 49.0 32.9 82.6 87.5 56.7 22.0 56.1 73.9 158 Oshikoto 39.7 15.9 22.7 67.4 5.5 45.6 18.9 52.3 82.0 25.2 19.1 49.3 72.3 218 Otjozondjupa 54.6 26.6 11.9 74.5 19.3 35.4 31.0 62.8 68.1 38.5 44.9 85.5 71.7 170 Education No education/preschool 25.4 8.7 11.1 52.6 5.9 39.6 10.7 35.0 81.4 21.8 27.0 42.1 69.6 261 Incomplete primary 38.7 12.9 12.7 55.6 6.2 47.8 14.5 45.9 77.4 29.8 20.5 40.3 69.2 482 Complete primary 51.9 17.4 14.8 68.3 10.0 41.0 17.4 48.5 76.6 39.2 16.7 49.9 71.0 191 Incomplete secondary 64.7 28.7 20.8 76.8 15.7 46.0 24.3 58.6 75.7 42.3 25.9 59.9 76.8 1,040 Complete secondary 79.0 40.3 16.3 86.0 29.4 46.1 43.9 67.4 65.1 47.1 31.4 70.4 80.8 291 More than secondary 89.9 46.9 37.6 92.5 43.1 78.0 61.0 72.4 70.4 47.6 42.1 79.0 77.3 115 Wealth quintile Lowest 27.2 11.3 16.4 50.6 4.2 56.5 8.3 37.9 80.5 26.3 16.1 19.8 69.6 545 Second 42.8 14.3 17.2 60.8 5.8 43.6 12.1 46.2 79.9 32.0 20.8 44.3 69.7 463 Middle 58.0 22.2 18.4 76.0 12.3 35.9 21.3 54.0 79.1 36.1 25.6 65.0 72.6 538 Fourth 76.4 34.1 15.3 81.1 20.8 43.9 37.3 66.2 72.3 49.7 31.5 80.0 79.0 436 Highest 92.4 48.1 22.8 93.1 39.1 55.3 51.0 73.8 60.1 51.4 38.0 77.1 84.5 399 Total 57.1 24.7 17.9 71.0 15.2 46.8 24.4 54.3 75.2 38.1 25.6 55.4 74.5 2,381 Note: Foods consumed in the past 24-hour period (yesterday and last night). 1 Includes pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, green leafy vegetables, mangoes, papayas, oranges, and other locally grown fruits and vegetables that are rich in vitamin A Nutrition of Children and Women | 165 12.9 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate nutrition during pregnancy is important both for the well-being of the mother. Table 12.10 shows micronutrient intake among mothers with a child under age 3 living with her. Vitamin A and iron are important micronutrients for women’s health in general and especially for the health of pregnant women. The data show that a large majority of women in Namibia (83 percent) consumed vitamin A-rich foods in the 24 hours preceding the survey, and more than seven in ten (71 percent) ate iron-rich foods. Consumption of vitamin A-rich foods and iron-rich foods decreases with women’s age and is substantially higher among urban women than rural women. Women’s level of education and household wealth status have a direct impact on these micronutrient indicators: the consumption of vitamin A-rich foods and iron-rich foods increases with mother’s educational attainment and increasing household wealth. Night blindness is an indicator of severe vitamin A deficiency (VAD), and pregnant women are especially prone to suffer from it. Table 12.10 shows that 8 percent of women reported having night blindness during the pregnancy for their last child born in the five years preceding the survey. After adjusting for women who also reported vision problems during the day, an estimated 3 percent of Namibian women suffered from night blindness. Rural women, those living in Ohangwena and Omaheke, uneducated women and those with incomplete primary education, and women in the lowest wealth quintile have the highest rates of night blindness. Iron-deficiency anaemia is a major threat to maternal health; it contributes to low birth weight in infants, lowered resistance to infection in both mother and child, poor cognitive development in children, and decreased work capacity in adulthood. Further, anaemia increases the risk of death from infection because it adversely affects the body’s immune respons systeme. In the 2006-07 NDHS, women who had a birth in the five years preceding the survey were asked whether they received or purchased any iron tablets during the pregnancy for their last birth. If the woman did receive/purchase iron tablets, she was asked to report the number of days the tablets were actually taken during that pregnancy. Table 12.10 shows that about one in five (19 percent) women did not take any iron tablets or syrups during the pregnancy. Three in ten women reported taking iron supplements during the pregnancy for the recommended minimum of 90 days. The percentage taking iron supplements for 90 or more days is highest among women in urban areas, those living in Erongo, women with at least some secondary education, and those in the highest wealth quintile. In Namibia, 7 percent of women with a child born in the past five years took deworming medication during pregnancy for the last birth. Variations by background characteristics are small, although about one in four women in Kavango (24 percent) took the medication during pregnancy. 166 | Fertility Table 12.10 Micronutrient intake among mothers Among women age 15-49 with a child under age three years living with her, the percentages who consumed vitamin A-rich and iron-rich foods in the 24 hours preceding the survey; among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child; among mothers age 15-49 who during the pregnancy of the last child born in the five years prior to the survey, the percentage who suffered from night blindness, the percentage who took iron tablets or syrup for specific numbers of days, and the percentage who took deworming medication; and among women age 15-49 with a child born in the past five years, who live in households that were tested for iodized salt, the percentage who live in households with adequately iodized salt, by background characteristics, Namibia 2006-07 Among women with a child under three years living with her Number of days women took iron tablets or syrup during pregnancy of last birth Percentage who suffered night blindness during pregnancy of last birth Background characteristic Percentage consumed vitamin A rich foods1 Percentage consumed iron-rich foods2 Number of women Percentage who received vitamin A dose post- partum3 Reported Adjusted4 None <60 60-89 90+ Don’t know/ missing Percent- age of women who took deworm- ing medi- cation during pregnancy of last birth Number of women Age 15-19 86.3 75.5 221 48.2 6.5 1.9 18.2 31.1 6.4 31.4 12.9 10.2 282 20-29 82.0 71.3 1,216 52.4 7.6 3.3 18.7 27.5 6.4 30.3 17.1 7.3 1,947 30-39 84.1 72.4 784 48.8 7.5 1.9 17.3 24.5 6.5 31.9 19.8 6.8 1,320 40-49 77.4 56.8 160 54.1 11.1 3.6 24.7 22.3 4.3 31.5 17.2 8.2 349 Residence Urban 89.0 85.0 927 48.1 6.3 2.2 14.7 20.0 7.4 40.7 17.2 7.0 1,711 Rural 78.8 62.1 1,453 53.3 8.9 3.2 21.9 31.1 5.4 23.4 18.1 7.7 2,188 Region Caprivi 83.5 67.1 141 68.7 8.9 2.0 24.3 62.1 2.0 3.5 8.1 14.3 217 Erongo 85.8 83.8 127 48.7 7.8 3.0 20.4 11.3 8.1 54.8 5.5 3.5 257 Hardap 78.7 77.4 72 61.3 5.0 2.7 8.3 37.8 9.1 23.8 21.1 3.6 121 Karas 89.3 83.0 77 43.9 3.0 0.6 8.0 18.6 9.0 47.1 17.3 2.6 119 Kavango 90.7 56.1 332 60.7 10.3 1.0 16.0 31.3 1.9 13.7 37.0 23.9 481 Khomas 89.3 87.5 401 37.3 5.3 2.7 13.7 16.2 7.6 44.4 18.0 6.1 737 Kunene 60.4 59.9 76 45.0 3.2 0.2 21.2 25.6 9.3 34.7 9.2 3.9 136 Ohangwena 75.7 58.2 268 41.8 9.9 4.4 28.2 33.4 6.1 11.1 21.1 2.0 422 Omaheke 67.6 64.8 118 48.6 9.8 3.9 18.3 25.7 3.8 46.1 6.1 4.8 171 Omusati 83.8 70.5 222 67.3 7.8 2.9 19.9 20.8 9.5 37.5 12.3 6.1 365 Oshana 86.6 79.0 158 62.1 9.3 2.7 16.8 20.5 6.7 36.3 19.6 4.0 271 Oshikoto 78.4 67.4 218 47.2 10.2 4.9 25.2 35.1 4.7 14.8 20.2 6.2 340 Otjozondjupa 80.8 74.5 170 48.9 5.1 2.4 17.0 19.5 6.8 47.7 9.0 1.9 261 Education No education/preschool 72.7 52.6 261 42.9 11.0 3.9 31.9 28.1 3.0 19.1 17.9 8.8 372 Incomplete primary 77.5 55.6 482 52.2 12.1 3.8 21.5 28.0 6.0 24.0 20.4 9.2 784 Complete primary 80.9 68.3 191 54.6 7.2 3.0 19.6 29.5 3.9 29.8 17.2 5.0 303 Incomplete secondary 85.1 76.8 1,040 52.6 6.6 2.1 17.1 27.2 7.2 32.5 16.0 6.6 1,739 Complete secondary 88.9 86.0 291 47.9 4.3 3.2 12.6 17.7 8.7 44.3 16.7 5.6 494 More than secondary 94.2 92.5 115 50.4 4.5 0.6 11.3 23.8 2.9 37.1 24.9 12.3 205 Wealth quintile Lowest 78.2 50.6 545 52.5 11.9 3.5 25.5 35.0 4.5 14.3 20.7 10.8 788 Second 77.2 60.8 463 54.6 8.4 2.8 24.1 28.3 4.5 22.9 20.1 7.3 711 Middle 81.7 76.0 538 52.0 6.7 2.8 16.8 27.7 6.7 32.3 16.4 6.6 855 Fourth 85.8 81.1 436 53.7 7.5 2.7 16.1 20.8 9.5 39.8 13.9 5.5 856 Highest 93.8 93.1 399 41.2 4.0 1.8 11.2 19.1 5.3 46.1 18.3 7.0 688 Total 82.8 71.0 2,381 51.0 7.8 2.7 18.7 26.3 6.2 31.0 17.7 7.4 3,898 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, mango, papaya, oranges, and other locally grown fruits and vegetables that are rich in vitamin A. 2 Includes meat (and organ meat), fish, poultry, and eggs 3 In the first two months after delivery of last birth 4 Women who reported night blindness but did not report difficulty with vision during the day Malaria and Other Health Issues │ 167 MALARIA AND OTHER HEALTH ISSUES 13 Malaria is a major public health problem in Namibia. The disease was the leading cause of illness and death from 1999 to 2002 and still remains one of the top five diseases of public health concern in the country. Malaria is endemic in Caprivi, Kavango, Kunene, Ohangwena, Omusati, Oshana, Oshikoto, and part of Otjozondjupa and Omaheke regions, where 65 percent of the Namibian population live and are at risk of malaria. In Namibia, malaria is seasonal but with a propensity for epidemic outbreaks related to high rainfall and the warm climate. The following sections present the findings of the 2006-07 NDHS collected at the household level regarding ownership of mosquito nets and use of mosquito nets by children under five and by pregnant women. In the women’s questionnaire, women with children born since January 2001 were asked about prophylactic use of anti-malarial drugs and the use of intermittent preventive treatment (IPT) by women during pregnancy; prevalence and prompt treatment of their children’s fevers; the type and timing of administering anti-malarial drugs; knowledge of signs of malaria; action taken when malaria occurs; and action taken to prevent malaria. 13.1 OWNERSHIP OF MOSQUITO NETS The National Roll Back Malaria Strategic Plan envisions that by 2007 at least 70 percent of women mothers and children under the age of five will be sleeping under a mosquito net. The use of insecticide- treated nets (ITNs) is one of the primary health interventions to reduce malaria transmission. The Ministry of Health and Social Services through the National Malaria Control Programme has been distributing long-lasting ITNs (LLITNs) free to pregnant women and children under the age of five. Social marketed ITNs are also available to the general public at a reduced cost. Mosquito nets in Namibia are distributed through three main distribution channels: health facilities, mass distributions, and National Immunization Days (NIDs). Table 13.1 shows the percentage of households with at least one and with more than one mosquito net (treated or untreated, ever-treated mosquito net, and insecticide-treated net) and the average number of nets per household by background characteristics. The data show that 25 percent of households in Namibia own at least one mosquito net (treated or untreated) and 10 percent have more than one net. Most of the nets owned by these households were treated with insecticide at some time (21 percent), and the majority of nets still provide adequate protection against mosquitoes (20 percent). Overall, the average number of any type of mosquito net per household is 0.4 and the average number of ITNs per household is 0.3. Households in Caprivi have the highest average number of mosquito nets (1.2). The percentage of households with at least one mosquito net is higher in the rural areas (34 percent) than in the urban areas (14 percent). Ownership of at least one mosquito net varies across regions, from 2 percent in Erongo to 65 percent in Caprivi. Households in the northern regions (Caprivi, Ohangwena, Omusati, Oshana, Oshikoto, and Kavango) are more likely to have mosquito nets than other regions. Ownership of mosquito nets varies across socio-economic groups, with the two lowest income groups having the highest proportion of ownership of at least one net. 168 │ Malaria and Other Health Issues Table 13.1 Ownership of mosquito nets Percentage of households with at least one and with more than one mosquito net (treated or untreated), ever-treated mosquito net, and insecticide- treated net (ITN), and the average number of nets per household, by background characteristics, Namibia 2006-07 Ever-treated mosquito net1 Any type of mosquito net Insecticide-treated mosquito nets (ITNs)2 Background characteristic Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ever- treated nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Number of households Residence Urban 14.3 5.2 0.2 11.1 3.9 0.2 10.3 3.5 0.2 4,260 Rural 33.9 14.7 0.6 30.1 12.5 0.5 28.7 11.8 0.5 4,940 Region Caprivi 64.8 33.1 1.2 57.2 27.5 1.0 54.4 26.3 1.0 514 Erongo 2.3 0.7 0.0 1.2 0.5 0.0 0.9 0.3 0.0 837 Hardap 6.3 1.4 0.1 4.7 1.3 0.1 4.0 1.1 0.1 328 Karas 5.5 1.9 0.1 3.0 0.8 0.0 2.5 0.5 0.0 382 Kavango 34.8 13.9 0.6 32.8 12.5 0.5 32.2 12.3 0.5 750 Khomas 8.3 2.5 0.1 5.5 1.6 0.1 4.4 1.1 0.1 1,950 Kunene 17.5 3.5 0.2 11.4 2.1 0.1 11.4 2.1 0.1 305 Ohangwena 41.4 18.2 0.7 38.3 16.0 0.6 37.8 15.8 0.6 829 Omaheke 22.9 9.4 0.3 21.0 8.7 0.3 20.5 8.2 0.3 426 Omusati 34.8 15.7 0.6 29.5 12.8 0.5 26.6 11.3 0.4 855 Oshana 43.6 20.1 0.7 39.0 17.5 0.6 37.7 16.1 0.6 663 Oshikoto 36.0 14.2 0.6 31.6 11.1 0.5 29.8 10.7 0.5 745 Otjozondjupa 19.4 5.5 0.3 14.2 3.8 0.2 13.8 3.4 0.2 615 Wealth quintile Lowest 32.9 10.9 0.5 29.4 9.3 0.4 27.6 8.8 0.4 1,691 Second 35.3 16.5 0.6 31.6 14.3 0.5 30.7 13.5 0.5 1,528 Middle 27.5 12.6 0.5 24.3 10.8 0.4 23.2 10.1 0.4 1,803 Fourth 19.6 7.5 0.3 16.6 5.8 0.3 16.1 5.6 0.3 2,104 Highest 13.5 6.1 0.2 9.3 4.4 0.2 8.0 3.7 0.1 2,073 Total 24.8 10.3 0.4 21.3 8.5 0.3 20.2 8.0 0.3 9,200 1 An ever-treated net is a pretreated net or a non-pretreated which has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment or 2) a pretreated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. 13.2 USE OF MOSQUITO NETS BY CHILDREN Table 13.2 shows the use of mosquito nets by children under five years of age. Twelve percent of children under five slept under a mosquito net the night before the survey, and the majority of these children (11 percent) slept under an ITN. Use of a mosquito net by children varies by the child’s age, rural-urban residence, region, and wealth status. Younger children, rural children, and children in the lowest wealth quintile are more likely to sleep under a mosquito net than other children. Children in Caprivi are the most likely to sleep under a mosquito bednet (48 percent). Malaria and Other Health Issues │ 169 Table 13.2 Use of mosquito nets by children Percentage of children under five years of age who slept under a mosquito net (treated or untreated), an ever-treated mosquito net, and an insecticide-treated net (ITN) the night before the survey, by background characteristics, Namibia 2006-07 Background characteristic Percentage who slept under any net the past night Percentage who slept under an ever-treated net the past night Percentage who slept under an ITN the past night Number of children Age in years <1 17.3 15.2 14.8 1,104 1 14.1 12.6 12.2 1,122 2 11.1 10.3 9.9 1,078 3 8.9 8.2 7.9 1,106 4 8.9 8.0 7.6 1,042 Sex Male 12.5 11.5 11.2 2,729 Female 11.7 10.4 9.8 2,723 Residence Urban 8.4 7.2 6.9 1,841 Rural 14.0 12.8 12.4 3,613 Region Caprivi 47.9 43.8 41.0 297 Erongo 0.4 0.4 0.4 274 Hardap 2.8 1.9 1.1 162 Karas 1.3 1.3 1.3 154 Kavango 21.4 19.6 18.8 657 Khomas 3.1 2.3 2.2 782 Kunene 5.5 3.9 3.9 224 Ohangwena 10.0 9.8 9.8 695 Omaheke 7.5 7.3 7.3 357 Omusati 11.3 10.3 10.0 545 Oshana 24.0 22.0 21.1 366 Oshikoto 9.7 8.0 7.8 532 Otjozondjupa 9.0 7.4 7.1 408 Wealth quintile Lowest 15.7 14.4 14.3 1,257 Second 13.2 12.1 11.8 1,227 Middle 12.9 11.4 10.3 1,209 Fourth 10.7 10.1 9.7 934 Highest 5.4 4.1 4.0 826 Total 12.1 10.9 10.5 5,453 Note: Total includes one child with information missing on sex 1 An ever-treated net is a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment or 2) a pretreated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. 13.3 USE OF MOSQUITO NETS BY PREGNANT WOMEN The danger of malaria for pregnant women has prompted many advocacy campaigns to educate not only pregnant women, but also the general public on the importance of preventing malaria during pregnancy. Table 13.3 shows the percentage of all women age 15-49 and the percentage of pregnant women age 15-49 who slept under a treated or untreated net, an ever-treated mosquito net, and an insecticide-treated net the night before the survey. Eight percent of women slept under a bed net, and most of these women slept under an ever-treated net or an ITN (7 percent each). 170 │ Malaria and Other Health Issues Table 13.3 Use of mosquito nets by pregnant women Percentage of all women age 15-49 and pregnant women age 15-49 who slept under a mosquito net (treated or untreated), an ever-treated mosquito net, and an insecticide-treated net (ITN) the night before the survey, by background characteristics, Namibia 2006-07 Percentage of all women age 15-49 who: Percentage of pregnant women age 15-49 who: Background characteristic Slept under any net the past night Slept under an ever- treated net the past night Slept under an ITN the past night Number of women Slept under any net the past night Slept under an ever- treated net the past night Slept under an ITN the past night Number of women Residence Urban 5.0 4.2 4.0 5,177 7.4 5.9 5.9 221 Rural 10.6 9.7 9.3 5,448 12.9 11.2 10.8 321 Region Caprivi 40.8 36.4 35.2 515 (43.1) (39.1) (36.1) 36 Erongo 0.4 0.2 0.1 749 (0.0) (0.0) (0.0) 37 Hardap 1.1 1.1 0.9 344 (1.4) (1.4) (1.4) 22 Karas 0.8 0.6 0.6 346 * * * 13 Kavango 19.6 18.5 18.1 1,009 35.2 33.6 33.6 60 Khomas 1.8 1.3 1.3 2,403 (0.0) (0.0) (0.0) 89 Kunene 4.8 3.3 3.3 281 (8.1) (6.0) (6.0) 27 Ohangwena 7.0 6.4 6.4 1,130 6.3 6.3 6.3 56 Omaheke 2.5 2.5 2.5 404 (0.0) (0.0) (0.0) 28 Omusati 7.7 7.0 6.8 1,055 (4.8) (3.0) (3.0) 50 Oshana 13.4 11.7 10.6 886 (21.4) (12.8) (12.8) 34 Oshikoto 5.9 5.3 4.8 907 8.3 6.1 6.1 48 Otjozondjupa 4.0 2.7 2.6 594 3.2 1.3 1.3 41 Education No education/preschool 8.4 7.2 6.8 765 4.6 2.4 2.4 66 Incomplete primary 10.2 9.2 9.0 2,051 16.4 14.2 14.2 122 Complete primary 8.5 7.3 7.3 762 (8.8) (8.8) (8.8) 29 Incomplete secondary 8.0 7.3 7.0 4,897 11.2 9.2 8.8 225 Complete secondary 5.1 4.2 4.0 1,354 4.2 4.2 4.2 64 More than secondary 5.3 3.8 3.8 796 (11.4) (11.4) (11.4) 34 Wealth quintile Lowest 12.0 11.0 10.8 1,750 14.7 11.9 11.0 117 Second 10.4 9.3 8.8 1,813 14.7 14.7 14.7 97 Middle 10.0 8.7 8.2 2,036 15.7 11.4 11.4 122 Fourth 6.6 6.2 6.1 2,449 3.7 3.7 3.7 119 Highest 3.0 2.2 2.1 2,578 2.7 2.7 2.7 86 Total 7.9 7.0 6.8 10,626 10.6 9.0 8.8 541 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 An ever-treated net is a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment or 2) a pretreated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. Overall, 11 percent of pregnant women slept under a net the night before the survey and 9 percent slept under an ITN. Mosquito net usage among pregnant women is higher in rural areas (13 percent) than in urban areas (7 percent). Analysis of regional differentials is not possible because of the small number of pregnant women in each region. Use of a mosquito net also varies across socio- economic groups, with the two lowest income groups having the highest use of mosquito nets. 13.4 MALARIA PROPHYLAXIS IN PREGNANCY In line with the National Malaria Policy (MoHSS, 2005a), chemoprophylaxis is only recommended for persons who are at risk of contracting malaria, non-immune travellers, and individuals living in malaria-endemic areas for short periods, such as labour force, police, and army. Non-immune travellers to malaria-endemic areas are advised to take chemoprophylaxis before they make the trip. The recommended prophylaxis for travellers to Namibia and people from non-malaria- endemic areas within Namibia who visit malaria-endemic areas is mefloquine. The risk of severe or Malaria and Other Health Issues │ 171 fatal malaria is greatest in areas of unstable transmission and can cause maternal death, abortion, still birth, premature delivery, and low birth weight in infants. Sulphadoxine/pyrimethamine (SP) is recommended for intermittent preventive treatment during the first and second pregnancies. This regimen is beneficial in low- and high-transmission areas. Chemoprophylaxis is not recommended for third and subsequent pregnancies, as it does not confer additional protection against malaria. In areas where the prevalence of HIV is documented to be greater than 10 percent, a third dose of SP is given four weeks after the second dose. Table 13.4 shows the prophylactic use of anti-malarial drugs and intermittent preventive treatment (IPT) by women during pregnancy. The table shows that 30 percent of all pregnant women took an anti-malarial drug to prevent malaria and most of these women (28 percent) took SP. Table 13.4 further shows that 11 percent of women took two or more doses of the drug. One in five pregnant women (20 percent) received SP/Fansidar during an antenatal care visit, and half of these women received two more doses of SP/Fansidar during an antenatal care visit. Table 13.4 Prophylactic use of anti-malarial drugs and use of intermittent preventive treatment (IPT) by women during pregnancy Percentage of women who took any anti-malarial drugs for prevention of malaria, percentage who took SP/Fansidar, and percentage who received intermittent preventive treatment (IPT) during the pregnancy for their last live birth in the two years preceding the survey, by background characteristics, Namibia 2006-07 Intermittent Preventive Treatment (IPT)1 SP/Fansidar Background characteristic Percentage who took any anti-malarial drug Percentage who took any SP/Fansidar Percentage who took 2+ doses Percentage who received any SP/Fansidar during an ANC visit Percentage who received 2+ doses, at least one during an ANC visit Number of women Residence Urban 18.7 17.7 6.8 13.0 6.0 824 Rural 38.0 34.6 13.1 23.9 12.6 1,230 Region Caprivi 53.4 50.8 4.4 30.0 4.4 110 Erongo 3.6 2.7 1.8 2.7 1.8 111 Hardap 3.0 3.0 1.6 1.4 0.0 62 Karas 4.6 3.6 0.0 0.0 0.0 57 Kavango 44.0 34.1 20.8 29.0 19.6 291 Khomas 8.2 7.0 3.3 4.4 2.2 365 Kunene 7.5 7.5 4.4 4.2 3.6 73 Ohangwena 35.1 32.8 9.1 17.1 9.0 235 Omaheke 4.6 4.6 2.9 3.9 2.9 106 Omusati 50.9 49.3 22.8 37.8 21.9 193 Oshana 51.9 51.3 14.6 38.0 13.3 136 Oshikoto 46.6 44.8 14.5 29.9 14.5 172 Otjozondjupa 38.1 38.1 14.3 28.7 14.3 144 Education No education/preschool 23.9 22.8 14.0 18.3 12.9 223 Incomplete primary 34.9 30.2 10.3 19.0 10.1 407 Complete primary 34.4 32.5 10.4 19.7 9.9 170 Incomplete secondary 31.2 29.2 10.8 20.9 10.0 921 Complete secondary 24.6 22.1 8.7 18.0 8.0 244 More than secondary 22.7 22.7 6.9 15.6 6.9 91 Wealth quintile Lowest 41.8 35.8 14.2 24.8 13.5 455 Second 40.1 38.3 14.1 25.4 13.9 401 Middle 30.5 28.9 10.8 20.9 10.0 472 Fourth 22.5 21.3 8.4 16.5 7.3 417 Highest 10.7 9.8 3.3 6.5 3.3 310 Total 30.3 27.8 10.6 19.6 10.0 2,054 1 Treatment with SP/Fansidar during an antenatal care (ANC) visit 172 │ Malaria and Other Health Issues Pregnant women in rural areas are twice as likely as those in urban areas to take anti-malarial medication (38 percent and 19 percent, respectively). The percentage of pregnant women who took any anti-malarial drug is highest in the northern regions, ranging from 35 percent in Ohangwena to 53 percent in Caprivi, while in Erongo, Hardap, Karas, and Omaheke, less than 5 percent of pregnant women took any anti-malarial drug. Use of anti-malarial drugs has a negative relationship with wealth status: 42 percent among women in the lowest wealth quintile compared with 11 percent for women in the highest wealth quintile. 13.5 MALARIA DIAGNOSIS AND TREATMENT Prevalence of Fever Fever is the primary manifestation of malaria. Although fever occurs year-round, malaria is most prevalent during the rainy season. Therefore, temporal factors must be taken into account when interpreting the occurrence of fever as an indicator of malaria prevalence. The National Malaria Control Programme through The Global Fund to Fight AIDS, Tuberculosis and Malaria project envisions that by 2010, 80 percent of all uncomplicated malaria will receive correct treatment within 24 hours. In interpreting the results of the 2006-07 NDHS on prevalence of fever, it should be borne in mind that the data were not collected during the peak malaria season, which is from March to June. Table 13.5 shows the percentage of children under age five with fever in the two weeks preceding the survey, and among children with fever, the percentage who took anti-malarial drugs the same or next day following the onset of fever. Overall, 17 percent of children under five had a fever in the two weeks preceding the survey. The highest proportion of fever cases (22 percent) was reported for children age 12-23 months. The prevalence of fever among children under five declines as mother’s level of education increases. For example, 18 percent of children whose mothers have no education had fever compared with 12 percent of children whose mothers have incomplete secondary education. The relationship between prevalence of fever and wealth status is less clear, although children in the lowest quintile have the highest prevalence and children in the higher quintiles have lower prevalence. One in ten children with fever in the two weeks preceding the survey received anti-malarial drugs. The likelihood that a child with fever received anti-malarial drugs varies slightly across subgroups, except by region of residence and mother’s education. Children whose mothers have no education are the least likely to receive anti-malarial drugs during a fever episode. Malaria and Other Health Issues │ 173 Table 13.5 Prevalence of fever and treatment with anti-malarial drugs Percentage of children under age five with fever in the two weeks preceding the survey, and among children with fever, the percentage who received anti- malarial drugs, by background characteristics, Namibia 2006-07 Among children under age five: Among children under age five with fever: Background characteristic Percentage with fever in the two weeks preceding the survey Number of children Percentage who received anti-malarial drugs Number of children Age (in months) <12 20.0 1,038 8.4 208 12-23 21.5 987 12.8 213 24-35 16.9 949 6.0 160 36-47 14.0 930 11.5 130 48-59 10.4 816 10.4 85 Residence Urban 16.2 1,970 8.2 320 Rural 17.3 2,749 10.8 476 Region Caprivi 37.7 243 15.6 92 Erongo 12.3 287 (5.7) 35 Hardap 13.6 139 (0.0) 19 Karas 13.6 136 * 19 Kavango 18.2 574 10.9 104 Khomas 17.9 889 7.5 159 Kunene 15.5 179 (10.0) 28 Ohangwena 15.2 532 10.2 81 Omaheke 26.5 227 7.5 60 Omusati 18.3 422 12.0 77 Oshana 7.7 337 (26.5) 26 Oshikoto 10.0 424 (13.3) 42 Otjozondjupa 16.1 330 0.0 53 Mother's education No education/preschool 18.3 526 5.4 96 Incomplete primary 17.5 1,333 9.7 234 Complete primary 16.7 2,609 10.3 435 Incomplete secondary 12.0 251 * 30 Wealth quintile Lowest 20.4 1,000 9.5 204 Second 16.0 897 15.4 143 Middle 17.3 1,048 8.5 181 Fourth 14.5 987 5.9 143 Highest 15.7 787 10.1 124 Total 16.9 4,719 9.8 795 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 13.6 TREATMENT OF FEVER Prompt and effective treatment of malaria within 24 hours of onset of symptoms has been highlighted as one of the key objectives in the Namibian Malaria Policy (MoHSS, 2005a). Most child deaths caused by malaria can be avoided through prompt recognition of symptoms and treatment with anti-malarial drugs. Table 13.6 shows the proportion of children under five with fever in the two weeks preceding the survey who received specific anti-malarial drugs. 174 │ Malaria and Other Health Issues Table 13.6 Anti-malarial drugs received by children Among children under age five with fever in the two weeks preceding the survey, percentage who received specific anti-malarial drugs, by background characteristics, Namibia 2006-07 Percentage of children who received anti-malarial drug Background characteristic SP/Fansidar Quinine Arthemether Lumefantrine (AL) Other anti- malarial Percentage who received pill/syrup Number of children with fever Age (in months) <12 3.7 2.3 0.0 2.9 13.5 208 12-23 4.1 1.5 3.6 4.4 18.3 213 24-35 4.7 0.0 0.9 0.3 21.6 160 36-47 6.0 0.0 5.5 1.6 6.6 130 48-59 5.8 1.5 3.2 3.7 14.0 85 Residence Urban 2.9 0.3 1.9 3.7 16.7 320 Rural 5.8 1.7 2.7 2.0 14.4 476 Region Caprivi 5.8 1.4 8.0 1.7 8.8 92 Erongo (0.0) (0.0) (0.0) (5.7) (9.6) 35 Hardap (0.0) (0.0) (0.0) (0.0) (10.8) 19 Karas * * * * * 19 Kavango 8.2 1.0 3.3 1.7 16.3 104 Khomas 1.8 0.0 2.4 3.3 19.3 159 Kunene (0.0) (0.0) (0.0) (10.0) (2.0) 28 Ohangwena 4.1 0.0 3.0 4.6 9.6 81 Omaheke 7.5 0.0 0.0 0.0 26.4 60 Omusati 6.2 2.7 1.5 1.6 19.8 77 Oshana (16.5) (10.0) (0.0) (4.2) (9.9) 26 Oshikoto (7.1) (5.0) (0.0) (3.9) (13.2) 42 Otjozondjupa 0.0 0.0 0.0 0.0 11.5 53 Mother's education No education/preschool 1.3 1.9 1.5 1.4 12.3 96 Incomplete primary 6.1 0.9 1.6 2.5 13.8 234 Complete primary 4.5 1.2 3.2 2.3 16.2 435 Incomplete secondary * * * * * 30 Wealth quintile Lowest 3.7 2.0 4.0 1.3 12.8 204 Second 8.9 2.4 3.1 2.8 12.4 143 Middle 4.2 1.0 0.6 3.4 16.1 181 Fourth 3.7 0.0 1.0 2.2 12.2 143 Highest 2.7 0.0 3.1 4.2 25.3 124 Total 4.6 1.1 2.4 2.7 15.3 795 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. The table indicates that when a child has fever, the most frequent treatment is pill or syrup (15 percent). Among anti-malarial drugs, SP/Fansidar is the most frequently given (5 percent), followed by other anti-malarial drugs (3 percent). Children with fever in rural areas are more likely to be given specific anti-malarial drugs such as SP/Fansidar, Quinine or Arthemether Lumenfantrine than children in urban areas. For example, 6 percent of rural children were given SP/Fansidar compared with 3 percent of urban children. Urban children are more likely to take other anti-malarial drugs and pill or syrup. Malaria and Other Health Issues │ 175 13.7 KNOWLEDGE AND SIGNS OF MALARIA In line with National Roll Back Malaria Strategic Plan, community education on the signs and symptoms of malaria is conducted regularly, especially during the annual malaria awareness week and campaign. Table 13.7.1 shows the percentage of women age 15-49 who know specific signs and symptoms according to knowledge of signs of malaria. Headache is the most commonly mentioned symptom of malaria (61 percent), followed by increased body temperature (49 percent), and chills and body pain (27 percent and 26 percent, respectively). Knowledge of symptoms of malaria varies somewhat across subgroups of women. Better educated women and women in the highest wealth quintile are the most likely to mention chills and high temperature. Table 13.7.1 Knowledge of signs of malaria: Women Percentage of women age 15-49 who know specific signs and symptoms of malaria, by background characteristics, Namibia 2006-07 Background characteristic Headache Chills High temperature Body pain Loss of energy Other Don't know/ missing Number of women Age 15-19 57.1 20.5 39.6 19.6 18.6 8.5 12.0 2,246 20-24 60.5 28.5 48.8 22.6 20.5 6.8 7.8 1,855 25-29 63.1 27.3 50.7 29.5 18.7 8.8 5.3 1,623 30-34 64.9 31.5 51.3 28.8 22.0 7.6 5.7 1,417 35-39 63.8 27.9 51.8 30.0 17.5 9.1 7.5 1,045 40-44 62.7 33.3 55.3 31.4 18.7 7.9 5.5 928 45-49 59.5 27.1 53.8 27.1 17.3 9.4 8.7 689 Residence Urban 61.6 30.3 50.1 26.6 23.5 9.4 7.8 4,772 Rural 60.9 24.3 47.3 25.2 15.2 7.0 7.9 5,032 Region Caprivi 85.4 27.9 83.7 35.9 39.6 7.3 2.8 474 Erongo 54.6 26.9 48.6 34.1 32.9 15.2 7.3 688 Hardap 64.8 21.4 42.4 29.9 27.3 7.3 15.7 315 Karas 41.4 14.8 34.9 12.7 21.6 4.2 36.7 318 Kavango 50.3 20.0 48.4 21.0 17.3 5.1 4.0 934 Khomas 60.0 33.7 46.9 24.1 19.8 10.3 9.1 2,218 Kunene 81.2 28.3 51.2 46.6 27.7 2.9 4.9 259 Ohangwena 55.8 20.6 40.5 16.6 4.9 5.7 6.7 1,043 Omaheke 71.4 22.2 45.4 27.0 14.7 3.9 8.6 373 Omusati 60.7 24.5 40.2 27.8 10.7 6.3 7.2 975 Oshana 61.3 19.7 57.8 16.8 17.9 4.0 4.5 819 Oshikoto 63.5 47.4 54.7 34.6 22.6 11.5 6.4 837 Otjozondjupa 74.1 23.9 46.1 31.7 18.5 14.7 4.8 550 Education No education/preschool 56.8 20.0 36.4 30.7 13.1 6.8 12.0 651 Incomplete primary 58.8 24.1 45.5 26.8 13.5 8.4 8.6 1,699 Complete primary 58.0 24.1 42.3 26.9 16.2 7.0 11.3 736 Incomplete secondary 61.6 27.9 49.1 24.8 20.6 7.2 7.9 4,751 Complete secondary 63.7 29.6 54.3 25.1 21.5 11.0 6.2 1,286 More than secondary 68.7 35.9 61.5 27.0 29.5 11.6 1.5 682 Wealth quintile Lowest 61.2 20.4 46.2 25.8 14.5 7.4 7.1 1,621 Second 58.8 25.3 46.3 24.7 13.3 6.9 7.4 1,668 Middle 60.7 24.2 47.0 27.4 15.8 7.1 7.1 1,885 Fourth 63.3 31.1 48.2 25.9 22.5 8.0 8.9 2,292 Highest 61.6 31.8 53.8 25.6 26.5 10.7 8.3 2,338 Total 61.3 27.2 48.6 25.9 19.3 8.2 7.9 9,804 Table 13.7.2 shows the percentage of men age 15-49 who know specific signs and symptoms of malaria. The levels are similar to those among women. The symptom of malaria most often cited by men is headache (62 percent) followed by increased body temperature (50 percent). However, unlike women, rural men are more likely than urban men to mention headache as a sign of malaria (67 percent compared with 58 percent, respectively). Men are more likely than women to mention loss of energy (33 percent compared with 19 percent, respectively). Knowledge of the symptoms of malaria varies little across subgroups of men. 176 │ Malaria and Other Health Issues Table 13.7.2 Knowledge of signs of malaria: Men Percentage of men age 15-49 who know specific signs and symptoms of malaria, by background characteristics, Namibia 2006-07 Background characteristic Headache Chills High temperature Body pain Loss of energy Other Don't know/ missing Number of men Age 15-19 56.6 28.8 39.3 19.5 32.9 6.4 10.1 910 20-24 63.1 35.6 49.9 22.9 33.3 8.5 5.2 750 25-29 61.1 34.3 51.3 27.1 31.4 7.9 5.1 702 30-34 66.0 40.4 57.5 28.4 31.1 9.5 4.3 586 35-39 70.0 35.3 57.2 29.5 31.3 8.8 5.4 400 40-44 60.2 42.4 50.0 27.9 30.3 7.5 3.8 331 45-49 68.9 38.3 58.3 29.5 40.8 6.7 3.9 235 Residence Urban 58.0 33.2 50.8 23.8 34.8 10.3 8.0 1,962 Rural 67.0 37.2 49.4 26.6 30.2 5.5 4.0 1,953 Region Caprivi 73.9 35.9 60.0 21.2 26.8 9.8 0.0 189 Erongo 61.6 19.4 47.8 13.4 30.4 17.2 6.6 362 Hardap 59.9 38.4 49.0 41.4 38.6 9.0 16.7 132 Karas 53.5 16.9 50.3 16.2 32.7 5.8 16.6 157 Kavango 72.7 42.2 64.1 11.9 45.5 5.8 0.6 331 Khomas 49.4 39.3 45.0 24.3 32.7 11.0 10.2 984 Kunene 75.2 68.3 54.3 54.3 37.5 10.8 0.6 92 Ohangwena 66.1 29.7 43.8 31.6 42.5 1.4 1.4 306 Omaheke 62.9 45.2 57.0 32.8 35.6 11.8 6.4 188 Omusati 82.3 52.0 65.6 16.9 29.7 3.2 3.4 320 Oshana 58.2 10.1 37.8 29.9 22.7 1.3 6.3 270 Oshikoto 64.9 34.1 38.1 44.3 23.6 5.2 1.9 322 Otjozondjupa 66.8 36.0 57.0 19.8 28.2 4.5 3.8 262 Education No education/preschool 58.6 41.5 47.4 31.7 29.7 4.9 6.6 360 Incomplete primary 63.7 34.4 44.6 27.6 32.1 5.3 5.7 856 Complete primary 58.1 35.7 38.8 22.7 30.2 5.8 9.3 252 Incomplete secondary 61.4 34.3 50.7 22.2 32.9 8.7 6.6 1,604 Complete secondary 64.0 34.6 55.1 21.6 32.3 12.1 4.9 538 More than secondary 70.5 35.5 65.8 34.5 37.5 8.7 2.2 305 Wealth quintile Lowest 67.5 36.2 48.1 25.8 33.2 4.4 2.1 560 Second 70.3 37.8 52.5 24.5 34.1 4.4 3.1 607 Middle 61.9 38.5 47.1 27.2 27.3 6.5 6.5 875 Fourth 61.3 35.0 52.3 25.9 32.6 8.0 7.5 963 Highest 56.1 29.9 50.2 22.5 35.9 13.5 8.3 911 Total 62.5 35.2 50.1 25.2 32.5 7.9 6.0 3,915 13.8 KNOWLEDGE OF CAUSES OF MALARIA Table 13.8.1 shows knowledge of the causes of malaria among women age 15-49. Virtually all women (95 percent) correctly identified mosquito bites as the cause of malaria. This proportion varies little across subgroups of women. While rural women are less likely than urban women to mention mosquito bites as the cause of malaria (96 percent and 93 percent, respectively), they are more likely than urban women to mention rain (15 percent and 10 percent, respectively). There are marked differences in the perception of rain as a cause of malaria across regions. While 28 percent of women in Kunene mentioned the rains as the cause for malaria, less than 2 percent of women in Hardap share this belief. Malaria and Other Health Issues │ 177 Table 13.8.1 Knowledge of causes of malaria: Women Percentage of women age 15-49 who report specific causes of malaria, by background characteristics, Namibia 2006- 07 Background characteristic Mosquito bites Rain Unhygienic environment Sleeping with someone who has malaria Other Don't know/ missing Number of women Age 15-19 91.6 13.4 10.1 0.4 1.6 3.7 2,246 20-24 95.3 11.7 11.4 0.5 1.4 2.5 1,855 25-29 95.5 12.5 9.9 0.6 1.3 2.2 1,623 30-34 94.3 11.6 11.3 0.3 1.1 3.1 1,417 35-39 96.2 12.9 11.3 0.7 1.2 2.1 1,045 40-44 96.6 11.7 10.7 0.5 1.4 2.0 928 45-49 93.8 12.7 12.9 0.4 0.9 3.8 689 Residence Urban 96.1 9.9 10.8 0.4 0.9 1.8 4,772 Rural 92.9 14.8 10.9 0.5 1.7 3.8 5,032 Region Caprivi 97.9 13.6 35.4 0.3 0.5 1.4 474 Erongo 96.8 6.3 18.5 0.1 0.6 0.6 688 Hardap 95.3 1.6 0.4 0.1 0.2 1.2 315 Karas 89.4 8.8 5.0 0.4 0.0 9.1 318 Kavango 87.6 7.3 9.7 0.9 1.8 7.7 934 Khomas 95.9 8.4 8.3 0.3 0.9 1.7 2,218 Kunene 88.6 27.8 23.6 4.0 1.4 7.5 259 Ohangwena 93.4 18.7 4.6 0.2 1.5 2.5 1,043 Omaheke 95.5 13.0 11.5 0.2 0.5 3.0 373 Omusati 96.0 14.7 9.8 0.1 3.4 2.2 975 Oshana 96.0 13.5 10.0 0.7 1.9 2.0 819 Oshikoto 95.1 21.1 12.9 0.2 0.6 1.6 837 Otjozondjupa 94.9 13.3 7.2 1.3 2.0 2.5 550 Education No education/preschool 80.6 12.6 6.3 1.6 1.9 11.6 651 Incomplete primary 90.9 14.1 11.1 0.4 1.6 5.1 1,699 Complete primary 93.8 18.4 12.1 0.6 1.3 2.8 736 Incomplete secondary 96.2 12.2 11.3 0.4 1.4 1.7 4,751 Complete secondary 98.2 8.9 10.0 0.1 0.6 0.6 1,286 More than secondary 97.8 9.2 11.9 0.5 0.9 0.7 682 Wealth quintile Lowest 90.1 15.5 11.6 0.6 1.2 5.7 1,621 Second 93.2 15.3 11.0 0.6 2.0 3.1 1,668 Middle 93.9 13.4 10.2 0.8 1.7 3.2 1,885 Fourth 95.9 12.8 11.3 0.4 1.3 2.2 2,292 Highest 97.4 7.0 10.4 0.1 0.6 0.8 2,338 Total 94.5 12.4 10.9 0.5 1.3 2.8 9,804 Table 13.8.2 shows knowledge of the causes of malaria among men age 15-49. Men show a an equally high level of knowledge of the cause of malaria: 96 percent say that mosquito bite is the cause of malaria. Across regions, men in Kavango are the most likely to say that malaria is caused by the rains and an unhygienic environment (48 percent each). Men in the wealthiest households are much less likely to mention rain and an unhygienic environment (5 and 7 percent, respectively) as causes of malaria compared with men in the lowest wealth quintile (26 and 22 percent, respectively). 178 │ Malaria and Other Health Issues Table 13.8.2 Knowledge of causes of malaria: Men Percentage of men age 15-49 who report specific causes of malaria, by background characteristics, Namibia 2006-07 Background characteristic Mosquito bites Rain Unhygienic environment Sleeping with someone who has malaria Other Don't know/ missing Number of men Age 15-19 92.3 19.5 14.5 1.4 5.9 1.8 910 20-24 96.2 15.1 13.6 0.2 7.1 0.5 750 25-29 96.2 13.0 12.1 0.3 4.5 1.8 702 30-34 96.7 11.0 11.0 0.4 2.2 2.2 586 35-39 98.1 16.2 13.6 0.5 5.2 0.4 400 40-44 98.3 11.3 8.7 0.7 5.0 0.5 331 45-49 94.7 15.1 13.0 0.0 4.1 1.2 235 Residence Urban 97.0 10.1 10.3 0.3 2.7 1.5 1,962 Rural 94.2 19.8 15.1 0.9 7.5 1.2 1,953 Region Caprivi 96.5 2.5 4.2 0.0 1.8 0.3 189 Erongo 97.6 8.3 9.0 1.4 5.2 0.9 362 Hardap 96.4 4.7 5.5 0.0 1.4 1.1 132 Karas 96.0 3.6 4.9 0.0 1.0 0.9 157 Kavango 96.5 48.4 48.0 0.4 14.0 1.2 331 Khomas 96.1 6.7 5.9 0.0 2.1 2.4 984 Kunene 92.1 3.1 6.7 0.0 12.4 3.7 92 Ohangwena 89.3 37.0 16.2 1.0 0.0 1.0 306 Omaheke 94.7 17.7 3.5 1.3 3.0 0.8 188 Omusati 98.0 10.4 13.2 2.3 21.0 0.4 320 Oshana 95.7 14.6 7.1 0.7 5.1 0.2 270 Oshikoto 94.5 24.1 25.0 0.5 2.6 1.5 322 Otjozondjupa 96.5 4.9 8.0 0.0 0.3 1.4 262 Education No education/preschool 89.3 21.1 15.1 0.9 5.7 3.5 360 Incomplete primary 93.0 20.0 15.2 0.9 7.3 2.2 856 Complete primary 93.6 15.4 18.9 0.7 5.3 1.6 252 Incomplete secondary 97.2 14.3 12.0 0.4 5.2 0.8 1,604 Complete secondary 98.2 8.2 8.4 0.5 2.2 0.8 538 More than secondary 99.0 8.2 8.8 0.4 2.5 0.0 305 Wealth quintile Lowest 92.9 26.1 22.1 0.6 8.6 1.5 560 Second 94.8 22.1 16.6 1.5 9.2 0.9 607 Middle 94.0 16.5 11.9 0.4 5.5 1.7 875 Fourth 97.7 12.3 11.1 0.2 3.3 0.8 963 Highest 97.2 4.6 6.7 0.5 1.8 1.7 911 Total 95.6 14.9 12.7 0.6 5.1 1.3 3,915 13.9 ACTION TAKEN IN CASE OF MALARIA Respondents in the 2006-07 NDHS were asked what action they would take if they suspected that they had malaria. Almost all women and men, regardless of background characteristics (94-96 percent), gave the same response: go to a health facility/health professional (Tables 13.9.1 and 13.9.2). Less than 1 percent said that they would go to a traditional healer. Malaria and Other Health Issues │ 179 Table 13.9.1 Action taken in case of malaria: Women Among women age 15-49, percentage who said they would take specific actions if they suspected they had malaria, by background characteristics, Namibia 2006-07 Background characteristic Nothing Go to a health facility/ personnel Go to a traditional healer Other Don't know/ missing Number of women Age 15-19 1.3 94.5 0.4 0.1 2.3 2,246 20-24 0.9 96.2 0.2 0.4 1.5 1,855 25-29 0.3 96.8 0.4 0.2 1.3 1,623 30-34 0.4 96.9 0.2 0.0 1.7 1,417 35-39 0.6 97.5 0.1 0.4 0.9 1,045 40-44 0.9 97.0 0.3 0.3 1.1 928 45-49 0.7 95.7 0.1 0.3 1.7 689 Residence Urban 0.6 96.8 0.2 0.2 1.2 4,772 Rural 0.9 95.6 0.3 0.3 2.0 5,032 Region Caprivi 0.3 98.1 0.0 0.5 0.5 474 Erongo 0.9 97.6 0.4 0.0 0.2 688 Hardap 1.7 92.4 0.0 0.2 2.5 315 Karas 0.5 88.7 0.5 0.5 8.4 318 Kavango 0.5 96.3 0.3 0.5 1.6 934 Khomas 0.8 95.9 0.3 0.4 1.3 2,218 Kunene 1.4 97.2 0.4 0.0 0.8 259 Ohangwena 0.1 97.4 0.3 0.1 1.4 1,043 Omaheke 0.9 93.2 0.3 0.0 4.6 373 Omusati 0.8 96.7 0.5 0.0 1.4 975 Oshana 0.4 97.8 0.2 0.1 1.1 819 Oshikoto 1.9 96.1 0.3 0.3 1.0 837 Otjozondjupa 0.5 96.3 0.4 0.2 1.7 550 Education No education preschool 0.9 89.3 0.6 0.3 4.9 651 Incomplete primary 0.8 95.1 0.5 0.4 2.2 1,699 Complete primary 1.2 95.6 0.1 0.2 2.2 736 Incomplete secondary 0.7 96.8 0.2 0.2 1.3 4,751 Complete secondary 0.7 98.0 0.3 0.3 0.5 1,286 More than secondary 0.4 98.3 0.2 0.0 0.2 682 Wealth quintile Lowest 0.7 96.6 0.3 0.3 1.6 1,621 Second 1.0 95.4 0.5 0.3 1.7 1,668 Middle 0.8 94.5 0.3 0.3 2.7 1,885 Fourth 0.6 96.9 0.2 0.2 1.4 2,292 Highest 0.7 97.0 0.3 0.1 0.9 2,338 Total 0.8 96.2 0.3 0.2 1.6 9,804 180 │ Malaria and Other Health Issues Table 13.9.2 Action taken in case of malaria: Men Among men age 15-49, percentage who said they would take specific actions if they suspected they had malaria, by background characteristics, Namibia 2006-07 Background characteristic Nothing Go to a health facility/ personnel Go to a traditional healer Other Don't know/ missing Number of men Age 15-19 7.5 87.6 0.1 0.5 0.9 910 20-24 3.5 94.7 0.2 0.0 0.4 750 25-29 2.3 94.2 0.2 0.2 0.2 702 30-34 1.4 95.8 0.0 0.1 0.1 586 35-39 0.9 97.9 0.0 0.0 0.4 400 40-44 1.7 97.3 0.0 0.3 0.0 331 45-49 3.8 93.1 0.5 0.4 0.3 235 Residence Urban 0.6 96.9 0.1 0.3 0.2 1,962 Rural 6.4 90.2 0.2 0.1 0.6 1,953 Region Caprivi 0.2 96.1 0.0 0.6 1.0 189 Erongo 0.3 96.6 0.1 1.2 0.3 362 Hardap 0.0 97.9 0.0 0.0 0.2 132 Karas 1.1 96.5 0.0 0.0 0.0 157 Kavango 0.0 97.8 0.3 0.3 0.0 331 Khomas 0.0 96.7 0.2 0.1 0.5 984 Kunene 0.5 95.8 0.0 0.0 0.0 92 Ohangwena 39.1 56.6 0.0 0.0 0.0 306 Omaheke 0.6 96.0 0.0 0.0 1.0 188 Omusati 0.4 97.3 0.8 0.0 0.6 320 Oshana 3.3 94.5 0.0 0.0 1.3 270 Oshikoto 0.3 97.6 0.0 0.0 0.0 322 Otjozondjupa 0.9 96.5 0.0 0.4 0.0 262 Education No education/preschool 2.0 91.3 0.3 0.2 0.1 360 Incomplete primary 4.7 90.2 0.3 0.5 1.0 856 Complete primary 9.2 87.9 0.2 0.4 0.2 252 Incomplete secondary 3.4 94.8 0.1 0.0 0.4 1,604 Complete secondary 2.2 96.4 0.0 0.0 0.0 538 More than secondary 0.4 98.5 0.0 0.3 0.0 305 Wealth quintile Lowest 6.6 89.2 0.2 0.2 0.6 560 Second 9.5 88.1 0.2 0.2 0.2 607 Middle 3.9 92.2 0.3 0.1 0.5 875 Fourth 0.7 97.5 0.0 0.3 0.3 963 Highest 0.2 97.0 0.0 0.3 0.3 911 Total 3.5 93.6 0.1 0.2 0.4 3,915 13.10 ACTION TAKEN TO PREVENT MALARIA Control of malaria vectors is the best way to protect communities against malaria infection. Vector control measures, such as indoor residual spraying of houses (IRS) and insecticide-treated nets, have the ability to reduce malaria incidence and prevalence. Other protective measures include using repellents, mosquito coils, and burning of leaves. The National Roll Back Malaria Strategic Plan envisions 80 percent coverage of targeted structures with indoor residual spraying in order to achieve a significant reduction in malaria transmission. Malaria and Other Health Issues │ 181 In the 2006-07 NDHS, respondents were asked what they would do to prevent getting malaria. Tables 13.10.1 and 13.10.2 show that the action most often cited by women and men is using a mosquito net (75 percent for women and 67 percent for men). Spraying the house is mentioned by 23 percent of women and 26 percent of men, and the use of a mosquito coil is cited by 19 percent of women and 24 percent of men. The use of repellents is mentioned by 20 percent of women and 23 percent of men. As expected, respondents in the malaria-endemic areas are more likely than those in other areas to mention various ways to prevent getting malaria. For example, 95 percent of women and 90 percent of men in Caprivi mentioned the use of mosquito nets, compared with 49 percent of women and 46 percent of men in Erongo. The proportion of women and men who mentioned appropriate ways of preventing malaria increases with level of education and wealth quintile, while the proportion who mentioned burning leaves decreases. Table 13.10.1 Action taken to prevent malaria: Women Percentage of women age 15-49 who said they would take specific actions to prevent getting malaria, by background characteristics, Namibia 2006-07 Background characteristic Spray house Use repellents Use mosquito net Use mosquito coil Burn leaves Other Don't know/ missing Number of women Age 15-19 19.8 17.1 77.2 17.1 11.4 8.4 5.6 2,246 20-24 22.2 19.9 75.9 18.9 11.5 10.4 5.4 1,855 25-29 24.0 21.4 78.7 20.9 13.2 7.5 4.8 1,623 30-34 25.2 20.2 75.2 18.2 11.5 7.6 5.8 1,417 35-39 21.8 19.4 75.8 19.2 13.1 9.9 5.5 1,045 40-44 22.3 23.5 71.1 21.7 17.1 9.9 4.4 928 45-49 27.0 20.2 65.9 17.4 14.6 9.5 9.6 689 Residence Urban 26.4 29.8 72.1 24.6 7.5 8.5 6.5 4,772 Rural 19.1 10.4 78.5 13.5 17.5 9.3 4.8 5,032 Region Caprivi 41.0 18.1 95.4 45.2 9.8 6.5 1.5 474 Erongo 33.5 20.4 49.3 27.5 8.5 13.7 22.0 688 Hardap 18.3 31.4 50.8 40.3 7.5 5.9 7.3 315 Karas 18.2 29.1 65.6 15.0 0.6 6.3 7.8 318 Kavango 9.9 6.4 83.3 12.7 4.3 10.4 5.7 934 Khomas 25.3 39.3 68.3 22.5 7.5 6.7 6.0 2,218 Kunene 39.0 14.2 70.7 16.3 14.5 5.0 11.9 259 Ohangwena 7.5 5.1 80.6 8.3 24.5 10.7 3.5 1,043 Omaheke 28.0 19.6 62.1 29.4 4.5 7.7 5.2 373 Omusati 21.3 7.2 88.2 5.9 15.5 9.8 2.6 975 Oshana 18.8 10.3 85.2 11.9 14.6 8.3 1.6 819 Oshikoto 24.6 12.2 84.0 17.9 33.3 11.0 2.3 837 Otjozondjupa 32.2 32.5 76.8 20.9 8.1 10.0 2.2 550 Education No education/preschool 19.1 9.3 60.2 10.2 12.8 8.4 11.6 651 Incomplete primary 18.6 11.3 72.2 13.1 16.8 8.4 7.4 1,699 Complete primary 21.6 14.1 76.6 15.6 13.7 6.4 6.5 736 Incomplete secondary 22.9 19.0 78.6 20.4 12.7 8.7 4.2 4,751 Complete secondary 26.6 31.3 74.3 23.1 8.8 10.7 5.8 1,286 More than secondary 28.4 41.5 76.4 27.0 8.3 10.9 3.8 682 Wealth quintile Lowest 17.4 6.7 79.7 10.6 18.9 8.6 5.6 1,621 Second 15.3 6.7 79.2 11.3 20.0 10.2 4.8 1,668 Middle 21.9 12.1 76.8 16.8 11.1 8.7 5.5 1,885 Fourth 25.8 24.0 74.7 23.7 10.4 7.0 5.7 2,292 Highest 29.1 40.6 69.3 27.1 6.6 10.2 6.2 2,338 Total 22.7 19.8 75.4 18.9 12.7 8.9 5.6 9,804 182 │ Malaria and Other Health Issues Table 13.10.2 Action taken to prevent malaria: Men Percentage of men age 15-49 who said they would take specific actions to prevent getting malaria, by background characteristics, Namibia 2006-07 Background characteristic Spray house Use repellents Use mosquito net Use mosquito coil Burn leaves Other Don't know/ missing Number of men Age 15-19 23.5 21.0 67.8 23.6 9.6 9.1 5.7 910 20-24 25.9 19.5 69.2 24.6 9.4 9.9 5.6 750 25-29 24.4 21.6 65.5 23.9 8.2 11.9 6.3 702 30-34 24.0 24.5 69.2 22.6 7.8 6.4 4.4 586 35-39 27.4 27.0 62.4 30.2 8.5 6.9 7.5 400 40-44 28.2 24.3 68.3 19.9 6.7 7.1 6.1 331 45-49 33.2 25.2 55.1 29.7 12.9 7.8 9.2 235 Residence Urban 22.1 31.1 59.9 23.5 5.2 8.4 7.2 1,962 Rural 29.0 13.8 73.3 25.3 12.6 9.4 4.8 1,953 Region Caprivi 9.4 18.3 90.0 15.6 6.1 11.0 0.6 189 Erongo 27.2 21.6 45.5 15.2 10.9 7.5 23.6 362 Hardap 34.7 24.3 24.8 14.5 2.3 6.1 15.3 132 Karas 24.2 41.5 79.8 15.4 2.9 5.3 2.9 157 Kavango 54.6 12.6 93.4 35.6 6.1 16.1 2.6 331 Khomas 16.2 39.0 50.1 22.3 3.4 10.5 5.3 984 Kunene 35.1 55.8 64.5 33.8 8.2 15.9 12.8 92 Ohangwena 22.4 9.1 81.3 33.9 22.4 0.2 0.3 306 Omaheke 20.4 29.0 57.5 30.0 8.3 7.3 6.5 188 Omusati 59.2 3.9 96.2 27.8 9.3 11.3 1.1 320 Oshana 12.2 8.6 63.7 19.1 10.4 1.5 6.9 270 Oshikoto 20.0 11.0 62.7 31.5 21.2 15.4 2.7 322 Otjozondjupa 13.6 15.3 82.0 21.9 6.7 3.1 2.6 262 Education No education/preschool 22.5 13.4 57.5 25.8 10.9 6.7 9.5 360 Incomplete primary 26.7 12.5 66.8 25.6 12.9 7.7 6.6 856 Complete primary 25.7 23.6 66.1 23.8 10.2 7.9 5.7 252 Incomplete secondary 25.6 23.6 69.0 22.7 8.3 8.8 5.3 1,604 Complete secondary 24.3 30.8 63.0 26.1 4.7 10.6 5.7 538 More than secondary 28.2 39.6 70.3 25.7 4.3 12.8 5.0 305 Wealth quintile Lowest 32.3 9.3 75.4 25.3 15.6 9.5 3.5 560 Second 30.8 10.8 74.9 28.5 14.9 10.1 3.9 607 Middle 25.1 17.3 71.1 20.9 8.0 8.2 6.6 875 Fourth 24.0 29.6 66.0 27.0 7.4 8.5 5.6 963 Highest 20.2 35.8 51.9 21.7 3.2 8.7 8.9 911 Total 25.6 22.5 66.6 24.4 8.9 8.9 6.0 3,915 13.11 HEALTH INSURANCE COVERAGE Health insurance in Namibia is far from satisfactory because it reaches only 28 percent of the population. Most of the people who lack health insurance coverage are poor and live in rural areas. The Social Security Commission and the Government Medical Aid Scheme provide health insurance for those who work and are able to contribute to the fund. Private health insurance is available to people who can pay the premiums. Overall, only 18 percent of women age 15-49 are covered by health insurance, 9 percent have employer-based insurance, and 5 percent have social security coverage (Table 13.11.1). Other health insurance schemes are mutual health organization/community-based insurance (4 percent) and privately-purchased commercial insurances (3 percent). Younger women are less likely than older women to be insured. For example, 10 percent of women age 15-19 are covered compared with 29 percent of women age 45-49. Rural women are more likely to be uninsured (92 percent) than urban women (71 percent). Malaria and Other Health Issues │ 183 Women in Caprivi, Kavango, and Ohangwena regions are more likely to lack insurance coverage than the women in other regions. Khomas has the lowest percentage of women without insurance coverage (65 percent). Women in Karas (23 percent), Khomas (19 percent), and Erongo (15 percent) are the most likely to have employer-based insurance. As expected, education influences level of insurance coverage: women with higher education are more likely to have health insurance than women with less education. For example, 73 percent of women with more than secondary education have insurance coverage compared with 4 percent of women with no education. The same pattern is seen according to increasing wealth quintile. Table 13.11.1 Health insurance coverage: Women Percentage of women age 15-49 with specific types of health insurance coverage, according to background characteristics, Namibia 2006-07 Background characteristic Social security Other employer- based insurance Mutual health organization/ community- based insurance Privately purchased commercial insurance Other None Number of women Age 15-19 1.1 4.4 2.4 1.8 0.9 89.6 2,246 20-24 2.0 5.6 1.9 1.9 0.5 88.4 1,855 25-29 5.7 9.1 3.0 2.3 0.6 81.4 1,623 30-34 5.5 11.2 3.7 4.4 0.6 78.1 1,417 35-39 7.4 11.7 4.1 2.4 0.6 76.1 1,045 40-44 8.3 15.5 7.8 2.1 0.8 70.2 928 45-49 8.1 14.6 7.3 4.2 0.3 70.6 689 Residence Urban 6.5 15.0 4.9 4.3 1.1 71.1 4,772 Rural 2.6 3.2 2.5 0.9 0.2 91.9 5,032 Region Caprivi 2.5 1.0 1.2 1.6 0.1 95.2 474 Erongo 5.1 14.6 2.4 6.9 0.9 71.6 688 Hardap 3.3 7.1 6.6 3.7 1.0 79.9 315 Karas 1.4 22.6 3.5 3.4 0.5 69.8 318 Kavango 2.9 2.6 1.6 0.8 0.2 93.2 934 Khomas 7.7 18.5 5.7 4.0 1.7 64.9 2,218 Kunene 3.8 8.6 3.1 2.7 0.0 84.5 259 Ohangwena 2.6 2.1 2.6 0.8 0.5 92.2 1,043 Omaheke 4.1 5.8 1.0 2.3 0.2 88.0 373 Omusati 3.8 4.5 3.2 1.4 0.1 89.3 975 Oshana 3.9 3.9 5.5 1.7 0.1 86.8 819 Oshikoto 3.9 6.0 3.6 1.6 0.0 88.3 837 Otjozondjupa 5.3 9.0 3.0 1.7 0.6 83.4 550 Education No education/preschool 0.9 1.0 1.6 0.0 0.1 96.3 651 Incomplete primary 1.7 1.5 1.9 0.3 0.2 94.9 1,699 Complete primary 3.9 2.7 2.0 0.7 0.1 92.1 736 Incomplete secondary 3.6 5.6 2.9 1.9 0.5 86.7 4,751 Complete secondary 7.7 20.0 6.6 5.3 1.3 62.1 1,286 More than secondary 16.1 44.3 11.1 12.1 2.6 26.8 682 Wealth quintile Lowest 0.3 0.5 1.0 0.1 0.1 98.0 1,621 Second 1.0 1.1 1.3 0.5 0.2 96.4 1,668 Middle 4.0 2.6 2.4 0.7 0.1 91.2 1,885 Fourth 6.9 7.2 4.4 2.2 0.9 81.8 2,292 Highest 8.0 27.2 7.4 7.5 1.4 52.4 2,338 Total 4.5 8.9 3.6 2.5 0.6 81.8 9,804 Table 13.11.2 shows insurance coverage for men. Overall, 78 percent of men age 15-49 do not have any health insurance, 11 percent have employer-based insurance, and 6 percent have social security coverage. In addition, 5 percent of men have mutual health organization/community-based insurance and 5 percent have privately-purchased commercial insurance. Men in rural areas (90 percent) are less likely to have health insurance than men in urban areas (67 percent). Across regions, 184 │ Malaria and Other Health Issues men in Kavango, Ohangwena, and Caprivi regions are less likely to have insurance coverage than men in other regions. Men in Erongo have the highest coverage overall (41 percent), while men in Khomas (22 percent), Karas (19 percent), and Hardap (15 percent) have the highest proportions of men with employer-based insurance. As with women, men’s level of education is related to health insurance coverage. The higher the level of education, the more likely a man is to have health insurance. A similar pattern is seen by wealth quintile: men in the higher wealth quintile are more likely to have insurance coverage than men in the lower wealth quintiles. In general, the differences between women and men in health insurance coverage are small. Table 13.11.2 Health insurance coverage: Men Percentage of men age 15-49 with specific types of health insurance coverage, according to background characteristics, Namibia 2006-07 Background characteristic Social security Other employer- based insurance Mutual health organization/ community- based insurance Privately purchased commercial insurance Other None Number of men Age 15-19 0.4 4.8 2.1 5.3 0.4 87.6 910 20-24 2.3 5.5 1.4 3.0 0.2 88.7 750 25-29 5.0 10.5 4.1 2.6 0.2 81.5 702 30-34 10.8 13.7 5.1 5.1 0.3 71.2 586 35-39 9.2 17.6 8.4 6.8 0.0 68.0 400 40-44 11.3 23.8 9.2 5.6 0.6 59.9 331 45-49 13.3 25.0 10.3 7.5 0.2 60.2 235 Residence Urban 8.1 18.7 6.6 7.1 0.4 66.5 1,962 Rural 3.3 4.0 2.4 2.1 0.1 90.1 1,953 Region Caprivi 3.9 6.6 1.6 2.1 0.8 89.2 189 Erongo 18.3 14.4 10.1 13.0 1.0 59.2 362 Hardap 2.3 14.6 3.7 1.9 2.4 76.2 132 Karas 10.6 19.0 5.6 5.5 0.0 69.4 157 Kavango 2.3 3.2 0.0 0.0 0.0 94.7 331 Khomas 4.2 22.1 3.7 7.6 0.0 66.5 984 Kunene 2.0 4.4 2.8 1.5 0.6 88.6 92 Ohangwena 1.0 6.0 2.8 0.5 0.0 89.6 306 Omaheke 1.3 9.0 3.1 3.1 0.0 84.7 188 Omusati 4.3 2.7 2.9 3.0 0.1 88.1 320 Oshana 8.8 4.4 10.4 2.6 0.0 78.2 270 Oshikoto 7.1 6.0 7.8 4.8 0.2 86.0 322 Otjozondjupa 5.7 9.8 3.0 1.7 0.0 83.6 262 Education No education/preschool 2.9 2.1 1.8 1.3 0.0 93.9 360 Incomplete primary 5.2 4.3 3.2 2.0 0.0 89.1 856 Complete primary 2.4 6.3 2.3 3.1 0.0 88.2 252 Incomplete secondary 4.6 8.9 3.2 4.8 0.3 81.0 1,604 Complete secondary 8.6 19.1 7.8 6.3 0.7 63.8 538 More than secondary 14.2 46.2 14.4 13.7 0.4 32.2 305 Wealth quintile Lowest 0.9 0.6 0.4 0.0 0.0 98.2 560 Second 2.1 3.1 1.3 1.9 0.3 92.6 607 Middle 4.7 5.2 3.0 2.1 0.1 87.4 875 Fourth 9.5 11.9 6.4 3.8 0.2 75.2 963 Highest 8.1 29.0 8.7 12.7 0.7 51.0 911 Total 15-49 5.7 11.4 4.5 4.6 0.3 78.3 3,915 Malaria and Other Health Issues │ 185 13.12 KNOWLEDGE AND ATTITUDES CONCERNING TUBERCULOSIS Tuberculosis (TB) is a leading cause of death in the world and a major public health problem in the developing world. TB is caused by the bacteria mycobacterium tuberculosis whose transmission is mainly airborne through droplets coughed or sneezed out by infected persons. The infection is primarily concentrated in the lungs, but in some cases it can be transmitted to other areas of the body. Namibia reported 15,894 TB cases in 2005, a rate of 790 TB cases per 100,000 population. At this rate, Namibia has one of the world’s highest notification rates (MOHSS, 2005). The National TB Control Programme (NTCP) developed the Medium Term Plan I (MTP I) covering the period of 2004-2009 for the control of TB through the prevention and treatment efforts at the national, regional, and local levels. The treatment is provided free of charge in all Government and NGO health facilities. The implementation of the MTP 1 is based on, among others, the following strategies: advocacy and social mobilization, capacity building and training, supervision, expansion of the laboratory network for TB diagnosis, drug supply, and mobilization of resources (MoHSS, 2004). Namibia adopted the strategy recommended by WHO and the International Union against TB and Lung Diseases, better known as the Directly Observed Treatment-Short Course Strategy, or DOTS. By the end of the National Development Plan II in March 2006, Namibia achieved a treatment success rate of 70 percent for new smear-positive PTB cases started on treatment (MoHSS, 2007) The 2006-07 NDHS collected information from women and men of reproductive age on the level of awareness of TB. Specifically, respondents were asked whether they had ever heard of the illness, how it spreads from one person to another, whether it can be cured, and whether they would want to keep the information secret if a member of their family got TB. This information is useful in policy formulation and implementation of programmes designed to combat and limit the spread of the disease. The findings are presented in Table 13.12.1 and 13.12.2. Knowledge of TB among women and men age 15-49 is almost universal (98-99 percent). Seventy-five percent of women and 77 percent of men correctly responded that TB is spread through the air by coughing. There are small differences across subgroups of women and men who reported the means of TB transmission. In general, this knowledge increases with education and wealth status. More than nine in ten women and men (92 and 93 percent, respectively) believe that TB can be cured. There are small variations across subgroups of women and men. When asked whether they would want to keep a family member’s TB status a secret, only 15 percent of women and 18 percent of men responded positively. 186 │ Malaria and Other Health Issues Table 13.12.1 Knowledge and attitude concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Namibia 2006-07 Respondents who have heard of TB All respondents Background characteristic Percentage who have heard of TB Number of women Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member's TB kept secret Number of women Age 15-19 97.3 2,246 70.3 83.7 19.4 2,186 20-24 98.6 1,855 75.4 93.6 15.9 1,828 25-29 98.9 1,623 79.3 96.4 12.8 1,604 30-34 99.2 1,417 77.7 95.1 13.6 1,406 35-39 99.1 1,045 75.5 95.2 12.2 1,036 40-44 99.2 928 77.0 94.6 11.2 921 45-49 99.1 689 74.1 93.5 14.1 684 Residence Urban 98.7 4,772 80.9 93.4 12.3 4,711 Rural 98.5 5,032 70.0 91.3 17.4 4,955 Region Caprivi 98.3 474 84.1 90.8 24.7 466 Erongo 98.9 688 86.7 95.0 11.4 681 Hardap 97.1 315 82.7 93.2 16.0 306 Karas 99.7 318 74.8 89.7 17.9 317 Kavango 98.6 934 71.3 92.9 19.9 921 Khomas 98.4 2,218 81.7 92.1 11.4 2,183 Kunene 98.3 259 65.9 81.5 13.4 255 Ohangwena 99.6 1,043 61.7 91.2 15.3 1,039 Omaheke 97.2 373 77.1 87.1 29.5 363 Omusati 98.4 975 71.2 94.9 12.2 960 Oshana 98.9 819 66.6 95.7 7.3 810 Oshikoto 98.8 837 79.2 95.0 13.0 827 Otjozondjupa 98.1 550 73.8 88.0 23.4 539 Education No education/preschool 95.6 651 54.9 83.7 20.7 622 Incomplete primary 98.3 1,699 66.4 90.9 20.2 1,670 Complete primary 99.0 736 66.4 91.8 19.4 729 Incomplete secondary 98.8 4,751 77.6 92.8 14.7 4,694 Complete secondary 99.1 1,286 85.3 94.2 7.3 1,274 More than secondary 99.4 682 90.7 97.3 7.2 678 Wealth quintile Lowest 98.4 1,621 65.6 90.9 17.1 1,596 Second 98.9 1,668 66.0 92.2 16.7 1,649 Middle 97.9 1,885 73.4 91.0 18.1 1,846 Fourth 99.0 2,292 81.9 94.1 14.9 2,270 Highest 98.6 2,338 83.7 92.6 9.5 2,305 Total 98.6 9,804 75.3 92.3 14.9 9,665 Malaria and Other Health Issues │ 187 Table 13.12.2 Knowledge and attitude concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Namibia 2006-07 Respondents who have heard of TB All respondents Background characteristic Percentage who have heard of TB Number of men Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member's TB kept secret Number of men Age 15-19 97.1 910 78.7 86.5 21.8 884 20-24 98.9 750 76.2 93.5 18.9 742 25-29 97.8 702 72.3 94.4 20.1 686 30-34 99.2 586 78.2 95.2 13.0 581 35-39 99.5 400 79.6 93.6 14.5 398 40-44 98.7 331 77.6 96.9 13.1 327 45-49 99.0 235 72.1 92.5 11.7 233 Residence Urban 99.0 1,962 75.5 93.0 15.1 1,943 Rural 97.8 1,953 77.7 92.1 20.0 1,910 Region Caprivi 95.4 189 70.6 92.1 29.2 180 Erongo 99.1 362 77.5 94.3 14.0 359 Hardap 99.1 132 82.4 94.4 6.0 131 Karas 98.8 157 83.8 93.1 14.4 155 Kavango 98.8 331 85.0 95.2 6.9 327 Khomas 98.6 984 69.8 91.7 18.9 971 Kunene 98.9 92 81.9 89.4 12.7 91 Ohangwena 96.4 306 93.9 96.0 22.2 295 Omaheke 97.5 188 74.8 86.7 20.3 184 Omusati 99.4 320 89.4 94.2 15.5 318 Oshana 99.1 270 57.9 87.9 21.8 268 Oshikoto 99.4 322 77.0 94.1 27.7 320 Otjozondjupa 97.2 262 69.8 91.2 10.1 254 Education No education/preschool 96.3 360 65.7 89.8 21.4 346 Incomplete primary 98.0 856 72.2 91.3 23.5 839 Complete primary 98.3 252 76.9 89.9 21.9 248 Incomplete secondary 98.7 1,604 77.6 93.1 16.3 1,583 Complete secondary 99.4 538 82.2 93.7 13.3 534 More than secondary 98.8 305 86.0 96.8 6.3 301 Wealth quintile Lowest 96.3 560 79.0 92.0 22.7 539 Second 98.7 607 80.3 93.0 20.7 599 Middle 98.2 875 71.0 92.6 16.8 859 Fourth 99.4 963 76.1 93.2 16.1 957 Highest 98.6 911 78.5 91.8 14.5 898 Total 15-49 98.4 3,915 76.6 92.6 17.5 3,852 13.13 USE OF TOBACCO Tobacco smoking has negative effects on health and is associated with increased risk of lung and heart diseases. Women and men interviewed in the 2006-07 NDHS were asked about their smoking habits. Table 13.13.1 and 13.13.2 show the percentage of women and men who smoke cigarettes or tobacco and the percent distribution of cigarette smokers by number of cigarettes smoked in the preceding 24 hours, according to background characteristics. 188 │ Malaria and Other Health Issues Few women age 15-49 (5 percent) smoke cigarettes. Older women are more likely to smoke than younger women; 2 percent of women age 15-19 smoke cigarettes compared with 10 percent of women age 40-44. Women in the oldest age group are also more likely to use tobacco other than cigarette or pipe. One in five women in Hardap (20 percent) smoke cigarettes and 3 percent use tobacco in other forms. Two percent or less of women in Caprivi, Omusati, and Oshana use any type of tobacco. Women’s level of education and wealth status are related to their propensity to smoke. Women with no education and women in the highest wealth quintile are the most likely to use tobacco. Table 13.13.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics and maternity status, Namibia 2006-07 Number of cigarettes in past 24 hours Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of women 0 1-2 3-5 6-9 10+ Don't know/ missing Total Number of cigarette smokers Age 15-19 2.3 0.2 0.2 97.2 2,246 (20.9) (34.4) (23.8) (2.3) (17.9) (0.7) 100.0 52 20-24 3.9 0.3 0.9 94.9 1,855 2.1 10.0 45.7 19.2 21.6 1.4 100.0 72 25-29 5.2 0.4 1.2 93.1 1,623 0.5 18.2 36.3 6.0 37.9 1.2 100.0 85 30-34 5.8 0.4 1.8 91.9 1,417 7.5 18.4 36.1 14.7 21.9 1.4 100.0 82 35-39 7.8 1.0 3.8 87.4 1,045 0.8 22.1 34.5 17.1 25.4 0.0 100.0 82 40-44 9.6 1.1 5.2 84.2 928 0.6 7.6 24.4 21.2 45.2 1.1 100.0 89 45-49 8.8 1.8 10.4 79.1 689 0.0 5.8 25.6 24.0 44.5 0.0 100.0 60 Residence Urban 8.5 0.2 1.1 90.1 4,772 4.8 14.9 30.0 15.7 34.5 0.0 100.0 406 Rural 2.3 0.9 3.4 93.4 5,032 0.5 20.4 42.5 13.4 19.4 3.9 100.0 115 Region Caprivi 0.7 0.0 1.7 97.4 474 * * * * * * 100.0 3 Erongo 14.5 0.5 1.9 83.1 688 9.7 19.5 23.1 6.2 41.5 0.0 100.0 100 Hardap 19.8 0.1 2.7 77.4 315 0.0 11.3 54.4 13.7 20.6 0.0 100.0 62 Karas 15.2 1.0 1.8 82.1 318 0.0 15.8 35.8 16.0 32.4 0.0 100.0 48 Kavango 0.5 0.5 6.3 92.5 934 * * * * * * 100.0 4 Khomas 9.5 0.0 0.7 89.8 2,218 3.6 14.2 31.8 20.2 29.9 0.2 100.0 211 Kunene 7.3 3.0 4.7 85.0 259 (6.0) (16.3) (38.9) (9.7) (29.1) (0.0) 100.0 19 Ohangwena 0.0 1.8 1.8 96.4 1,043 * * * * * * 0.0 0 Omaheke 4.5 2.0 9.2 84.1 373 (0.0) (25.5) (25.0) (22.7) (26.8) (0.0) 100.0 17 Omusati 0.7 0.1 1.0 98.2 975 * * * * * * 100.0 7 Oshana 1.0 0.0 0.4 98.5 819 * * * * * * 100.0 8 Oshikoto 1.9 0.3 2.3 95.5 837 * * * * * * 100.0 16 Otjozondjupa 4.6 0.9 3.5 91.0 550 (0.0) (20.8) (44.1) (11.5) (23.6) (0.0) 100.0 25 Education No education/preschool 7.4 4.6 12.9 74.6 651 1.1 29.7 39.3 13.6 14.2 2.1 100.0 48 Incomplete primary 4.3 0.8 5.2 89.5 1,699 0.0 17.3 32.8 21.4 25.8 2.7 100.0 74 Complete primary 3.2 0.3 2.7 93.7 736 (2.3) (17.9) (41.7) (12.5) (25.6) (0.0) 100.0 24 Incomplete secondary 4.4 0.1 0.6 94.8 4,751 3.3 18.9 33.1 13.3 30.7 0.7 100.0 211 Complete secondary 9.9 0.1 0.2 89.8 1,286 6.5 7.2 32.1 13.4 40.7 0.0 100.0 127 More than secondary 5.6 0.0 0.3 94.1 682 10.1 9.6 19.1 23.8 37.3 0.0 100.0 38 Maternity status Pregnant 4.7 0.7 2.2 92.3 527 0.0 10.9 68.6 12.5 8.0 0.0 100.0 25 Breastfeeding (not pregnant) 3.5 0.8 3.1 92.4 1,351 0.0 29.0 43.0 14.2 11.6 2.1 100.0 47 Neither 5.7 0.5 2.2 91.6 7,925 4.5 15.0 29.7 15.5 34.5 0.8 100.0 450 Wealth quintile Lowest 0.5 1.3 5.6 92.5 1,621 * * * * * * 100.0 9 Second 2.0 1.0 2.6 94.3 1,668 (0.0) (27.6) (28.6) (12.5) (18.7) (12.6) 100.0 33 Middle 3.1 0.4 3.0 93.4 1,885 1.8 21.8 39.4 18.8 17.6 0.7 100.0 58 Fourth 7.6 0.2 1.4 90.8 2,292 3.0 18.3 42.0 12.7 23.9 0.0 100.0 175 Highest 10.6 0.1 0.2 89.2 2,338 5.6 10.9 25.2 17.1 41.3 0.0 100.0 247 Total 5.3 0.5 2.3 91.8 9,804 3.9 16.1 32.8 15.2 31.2 0.9 100.0 521 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Malaria and Other Health Issues │ 189 Among women who smoke, one in three smoked 3-5 cigarettes in the past 24 hours, 15 percent smoked 6-9 cigarettes, and 31 percent smoke 10 or more cigarettes. Older women are more likely to be heavy smokers (10 cigarettes or more in the past 24 hours) than younger women. Smoking is more popular among urban women than rural women. Urban women are also more likely than rural women to be heavy smokers (35 percent and 19 percent, respectively). Better educated women tend to smoke more than women with less education. Women in the highest wealth quintiles are more likely to be heavy smokers (23-41 percent). Smoking is more common among Namibian men than women (Table 13.13.2); 24 percent of men use tobacco, compared with 8 percent of women. The likelihood of a man using tobacco increases with age: 10 percent of men age 15-19, compared with 21 to 25 percent of older men. Across regions, men in Hardap are the most likely to use tobacco (45 percent). Men in Ohangwena and Omusati are the least likely to use tobacco (7 and 8 percent, respectively). Tobacco use among men does not vary much by level of education or wealth quintile. Table 13.13.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Namibia 2006-07 Number of cigarettes in past 24 hours Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of men 0 1-2 3-5 6-9 10+ Don't know/ missing Total Number of cigarette smokers Age 15-19 9.1 0.1 0.4 90.2 910 13.0 18.0 42.8 13.0 12.0 1.1 100.0 83 20-24 20.9 0.3 0.9 77.9 750 2.4 21.8 34.5 16.8 23.4 1.1 100.0 157 25-29 26.5 1.3 1.0 71.2 702 2.4 18.6 39.8 7.8 29.4 2.1 100.0 186 30-34 24.8 0.9 2.4 71.9 586 1.3 12.7 35.8 20.0 29.9 0.3 100.0 145 35-39 27.1 1.9 3.2 67.7 400 2.4 14.6 37.7 17.8 26.4 1.1 100.0 109 40-44 24.9 2.1 4.6 68.4 331 9.6 10.8 26.6 22.2 30.8 0.0 100.0 83 45-49 24.6 1.2 4.9 69.3 235 3.6 17.4 32.8 19.9 24.4 1.8 100.0 58 Residence Urban 23.4 0.1 0.5 76.0 1,962 3.5 13.3 36.5 15.8 30.3 0.6 100.0 459 Rural 18.5 1.7 3.1 76.6 1,953 4.9 21.1 36.0 15.8 20.4 1.7 100.0 361 Region Caprivi 30.8 0.6 5.1 63.6 189 8.4 29.6 40.7 11.4 10.0 0.0 100.0 58 Erongo 23.5 0.5 0.3 75.7 362 2.9 6.1 38.1 22.5 29.1 1.4 100.0 85 Hardap 43.3 0.6 1.2 54.9 132 1.6 17.0 35.9 21.8 23.7 0.0 100.0 57 Karas 32.4 2.3 1.4 63.8 157 2.3 19.2 27.2 21.1 30.2 0.0 100.0 51 Kavango 15.7 3.9 2.7 77.7 331 22.0 30.0 26.9 8.8 10.3 2.0 100.0 52 Khomas 24.7 0.0 0.6 74.7 984 3.1 10.4 36.4 15.7 34.4 0.0 100.0 243 Kunene 34.5 0.0 2.1 63.4 92 3.3 15.0 40.8 14.7 23.4 2.9 100.0 32 Ohangwena 3.7 1.1 2.1 92.8 306 * * * * * * 100.0 11 Omaheke 29.2 2.8 8.8 59.2 188 1.1 14.0 38.6 21.0 25.4 0.0 100.0 55 Omusati 6.9 0.0 1.5 91.6 320 * * * * * * 100.0 22 Oshana 14.1 0.0 0.3 85.6 270 1.9 22.5 52.9 11.9 8.2 2.5 100.0 38 Oshikoto 7.7 1.8 3.3 87.1 322 (0.0) (44.2) (34.1) (2.7) (15.3) (3.7) 100.0 25 Otjozondjupa 34.7 0.0 0.4 64.9 262 0.0 16.4 41.0 17.3 24.4 0.9 100.0 91 Education No education/preschool 23.1 2.9 8.3 65.7 360 0.0 18.9 45.8 14.5 20.3 0.6 100.0 83 Incomplete primary 19.7 1.5 2.2 76.6 856 2.7 21.6 36.3 17.2 21.7 0.5 100.0 169 Complete primary 15.3 0.3 2.7 81.7 252 (6.2) (13.3) (54.7) (5.7) (16.2) (3.9) 100.0 39 Incomplete secondary 22.1 0.6 0.8 76.5 1,604 5.9 16.1 37.0 17.6 22.9 0.5 100.0 354 Complete secondary 24.4 0.2 0.4 75.0 538 2.4 10.1 28.1 17.3 38.6 3.4 100.0 131 More than secondary 14.6 0.0 0.4 85.0 305 (5.6) (21.2) (21.5) (3.3) (48.4) (0.0) 100.0 45 Wealth quintile Lowest 15.0 2.9 5.5 76.7 560 11.1 29.3 34.5 12.6 9.8 2.7 100.0 84 Second 14.7 0.8 1.0 83.5 607 4.3 17.9 41.3 12.7 22.7 1.0 100.0 89 Middle 23.2 0.9 2.8 73.1 875 4.1 20.7 36.7 16.8 19.7 1.9 100.0 203 Fourth 21.3 0.5 1.0 77.0 963 0.6 14.9 43.3 18.0 22.8 0.5 100.0 205 Highest 26.2 0.1 0.0 73.7 911 4.5 9.9 28.7 15.4 40.9 0.5 100.0 239 Total 20.9 0.9 1.8 76.3 3,915 4.1 16.7 36.3 15.8 26.0 1.1 100.0 820 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 190 │ Malaria and Other Health Issues Among men who smoke cigarettes, 36 percent smoked 3-5 cigarettes within the past 24 hours, 16 percent smoked 6-9 cigarettes, and 26 percent smoked 10 or more cigarettes. Heavy smoking (10 cigarettes or more in the past 24 hours) is popular among the men age 20 and older. The survey shows that men in urban areas are more likely to be heavy smokers than men in rural areas (30 percent and 20 percent, respectively). While the proportion of men who smoke cigarettes in Caprivi is relatively high (31 percent), only 10 percent of smokers had 10 or more cigarettes in the past 24 hours. On the other hand, 43 percent of men in Hardap smoke cigarettes and more than half (56 percent) of these men smoked at least 6 cigarettes in the past 24 hours. Tobacco use among men varies somewhat by wealth status. Men in the two lowest wealth quintiles are the least likely to smoke cigarettes and the least likely to be heavy smokers. Men in the highest wealth quintile are most likely to smoke cigarettes (26 percent). HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 191 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 14 Acquired Immune Deficiency Syndrome (AIDS) is caused by a human immunodeficiency virus (HIV) that weakens the immune system, making the body susceptible to and unable to recover from other opportunistic diseases that lead to death through these secondary infections. The predomi- nant mode of HIV transmission is through heterosexual intercourse, followed by perinatal transmission, in which the mother passes the virus to the child during pregnancy, delivery, or breastfeeding. Other modes of transmission are through infected blood and unsafe injections. From the estimated rate of 4 percent in 1992, HIV prevalence rose rapidly to 22 percent in 2002. The national prevalence showed a small decline to 20 percent in 2004 and remains at this level, according to the 2006 HIV Sentinel Surveillance Report (MoHSS, 2007) (Figure 14.1). The Namibian response to HIV/AIDS has been aggressive and persistent. Namibia is in the third year of implementation of its third Medium Term Plan (MTP-III, 2004–2009) on HIV/AIDS. Since the launch of MPT-III in 2004, a number of important initiatives affecting Namibia’s expanded response to the epidemic have commenced in the country and globally. These initiatives include, at the global level, universal access to HIV/AIDS treatment, presented at the 2005 G8 Summit (G8, 2005), and the previous Universal Access Initiative and Political Declaration of the United Nations General Assembly (UN, 2001). At the continental level, the African Heads of States made a declaration on universal access in 2006 and emphasized the pre-eminence of prevention in the continent’s response to the epidemic (UNAIDS, 2006). The future course of Namibia’s AIDS epidemic depends on a number of factors including levels of HIV/AIDS-related knowledge among the general population, social stigmatization of people living with HIV/AIDS, risk behaviour modification, access to high-quality services for sexually transmitted infections (STI), provision and uptake of HIV counselling and testing, and access to care and antiretroviral therapy (ART), including prevention and treatment of opportunistic infections. ) ) ) ) ) ) ) ) 4 8 15 17 19 22 20 20 1992 1994 1996 1998 2000 2002 2004 2006 Year 0 5 10 15 20 25 HIV prevalence (percent) Figure 14.1 HIV Prevalence by Year of Survey Source: Report of the 2006 National HIV Sentinel Survey, MoHSS, 2007 192 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour The principal objective of this chapter is to examine levels of HIV/AIDS-related knowledge, perceptions, and the prevalence of risk behaviours related to HIV infection at the national level and for geographic and socioeconomic subgroups of the population. In this way, prevention programmes can target those persons most in need of information and most at risk for HIV infection. In this chapter, indicators for HIV/AIDS knowledge, attitudes, and related behaviour are presented for the adult population (age 15-49). The chapter also highlights HIV/AIDS knowledge and patterns of sexual behaviour among young people, because young adults are more likely than their older counterparts to be in the process of establishing patterns of sexual behaviour and hence are the main target of most prevention strategies. The prevalence of HIV in 2006 by age group and region shows a scattered picture indicating the need for a continued, strengthened, prevention-focused, and decentralized multi-sectoral response, to effectively contain the spread of HIV and reduce the impact of AIDS (MoHSS, 2007). To address the problems presented by the HIV/AIDS epidemic, substantial changes have taken place in Namibia over the past few years. These include: a) increased funding, b) increased involvement of organizations by the public, private, and civil society sectors, c) expanded geographic coverage for services and programmes, and d) increased coverage of the needs and demands of beneficiaries. Further, the monitoring and evaluation system utilized in Namibia has evolved and considerable amounts of data are being gathered. 14.1 KNOWLEDGE OF HIV/AIDS TRANSMISSION AND PREVENTION METHODS According to studies conducted by Nawa Life Trust and NASOMA, knowledge of HIV/AIDS in Namibia is high. However, the results of the sero-surveillance survey in 2006 and the KAP surveys indicate that there has been no significant change in sexual behaviour. New HIV prevention strategies are needed to effectively address the factors driving the epidemic (Nawa Life Trust, 2007). 14.1.1 Knowledge of AIDS In the 2006 NDHS, respondents were asked whether they had heard of AIDS. According to the findings presented in Table 14.1, knowledge of AIDS is almost universal (99 percent for both men and women age 15-49). This level of knowledge is similar to that recorded in the 2000 NDHS (98 percent of women and 99 percent of men). There are no significant differences in AIDS knowledge by urban-rural residence or region. Women without any formal education show the lowest level of knowledge (93 percent). HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 193 Table 14.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Namibia 2006-07 Women Men Background characteristic Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-24 98.4 4,101 98.8 1,661 15-19 98.3 2,246 98.4 910 20-24 98.6 1,855 99.3 750 25-29 99.3 1,623 99.0 702 30-39 98.9 2,462 99.7 986 40-49 99.2 1,618 99.2 567 Marital status Never married 98.9 5,676 98.9 2,547 Ever had sex 98.8 4,087 99.5 2,014 Never had sex 99.1 1,589 96.4 533 Married/living together 98.6 3,451 99.6 1,205 Divorced/separated/widowed 99.2 678 100.0 163 Residence Urban 98.9 4,772 99.6 1,962 Rural 98.8 5,032 98.6 1,953 Region Caprivi 97.8 474 97.3 189 Erongo 100.0 688 98.9 362 Hardap 99.3 315 100.0 132 Karas 99.5 318 98.6 157 Kavango 97.9 934 99.7 331 Khomas 98.6 2,218 99.9 984 Kunene 99.4 259 99.0 92 Ohangwena 99.1 1,043 97.4 306 Omaheke 97.3 373 100.0 188 Omusati 99.5 975 99.8 320 Oshana 99.1 819 99.8 270 Oshikoto 99.6 837 99.7 322 Otjozondjupa 97.3 550 96.0 262 Education No education/preschool 93.3 651 97.0 360 Incomplete primary 98.8 1,699 98.4 856 Complete primary 99.5 736 98.9 252 Incomplete secondary 99.1 4,751 99.7 1,604 Complete secondary 99.8 1,286 99.7 538 More than secondary 100.0 682 100.0 305 Wealth quintile Lowest 97.7 1,621 97.5 560 Second 98.8 1,668 98.7 607 Middle 98.9 1,885 99.3 875 Fourth 98.8 2,292 99.6 963 Highest 99.4 2,338 99.8 911 Total 15-49 98.8 9,804 99.1 3,915 14.1.2 Knowledge of HIV Prevention In Namibia, HIV is transmitted among adults primarily through heterosexual contact between an infected partner and a non-infected partner. Consequently, HIV prevention programmes focus their messages and efforts on promoting three specific behaviours: use of condoms, limiting the number of sexual partners or staying faithful to one uninfected sexual partner, and for young persons, delaying first sexual intercourse (sexual debut) through abstinence. Table 14.2 shows the percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by: a) using condoms every time they have sexual intercourse, b) having one sex partner who is not infected, and b) abstaining from sexual intercourse. 194 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is not infected and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Namibia 2006-07 Percentage of women who say HIV can be prevented by: Percentage of men who say HIV can be prevented by: Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Abstaining from sexual intercourse Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Abstaining from sexual intercourse Number of men Age 15-24 83.4 88.1 78.5 82.6 4,101 86.4 90.9 81.3 85.7 1,661 15-19 80.6 86.7 75.3 81.6 2,246 85.0 89.2 79.1 84.4 910 20-24 86.7 89.9 82.3 83.8 1,855 88.2 93.0 84.1 87.3 750 25-29 85.6 91.7 82.8 85.9 1,623 87.3 91.9 83.2 85.6 702 30-39 85.9 90.2 81.9 85.5 2,462 90.4 92.4 85.1 87.4 986 40-49 83.0 89.7 79.1 84.5 1,618 85.0 92.3 81.7 84.9 567 Marital status Never married 85.3 90.2 81.1 84.7 5,676 86.9 91.2 82.0 85.5 2,547 Ever had sex 86.8 90.8 82.7 85.2 4,087 88.3 92.4 83.4 86.3 2,014 Never had sex 81.6 88.7 77.0 83.6 1,589 81.4 86.7 76.6 82.3 533 Married/living together 82.8 88.6 79.1 83.0 3,451 87.7 92.5 83.7 86.8 1,205 Divorced/separated/widowed 83.6 88.2 77.6 85.8 678 92.0 92.7 85.5 88.6 163 Residence Urban 85.7 89.9 81.2 85.4 4,772 90.3 93.1 85.3 88.0 1,962 Rural 83.0 89.1 79.2 83.1 5,032 84.5 90.2 80.0 84.0 1,953 Region Caprivi 85.6 87.9 79.6 86.5 474 95.7 93.9 93.0 87.8 189 Erongo 78.1 84.2 69.9 75.5 688 89.4 88.4 82.0 84.7 362 Hardap 82.0 87.2 77.0 79.2 315 95.5 95.2 91.9 60.3 132 Karas 85.7 91.5 81.7 85.9 318 93.6 95.6 90.9 89.4 157 Kavango 75.3 83.0 70.5 75.7 934 89.0 96.6 87.6 90.4 331 Khomas 89.6 92.1 85.7 89.8 2,218 91.0 94.5 86.5 92.8 984 Kunene 70.7 73.6 64.2 77.7 259 87.4 84.2 77.3 79.6 92 Ohangwena 89.5 95.1 86.9 86.6 1,043 87.8 84.0 81.0 82.9 306 Omaheke 64.0 73.3 59.6 69.2 373 78.1 85.9 70.7 82.9 188 Omusati 85.8 94.0 83.4 84.7 975 95.4 94.2 90.6 92.9 320 Oshana 87.4 92.9 84.5 91.0 819 70.0 86.6 63.7 69.7 270 Oshikoto 87.2 93.8 83.7 87.4 837 77.7 94.0 75.4 92.8 322 Otjozondjupa 83.9 86.4 79.5 79.7 550 81.0 88.3 77.1 74.5 262 Education No education 64.2 71.4 59.1 68.8 651 77.6 83.5 70.8 75.7 360 Incomplete primary 81.1 87.2 76.2 82.2 1,699 84.1 90.3 79.7 82.4 856 Complete primary 81.7 88.2 78.3 81.6 736 86.8 90.0 80.9 84.2 252 Incomplete secondary 86.1 91.5 82.3 84.9 4,751 89.4 93.1 85.0 87.9 1,604 Complete secondary 90.3 92.2 85.5 89.4 1,286 90.0 93.5 85.3 89.4 538 More than secondary 90.8 95.1 87.0 92.4 682 93.0 95.5 89.3 94.1 305 Wealth quintile Lowest 80.6 86.5 76.6 81.3 1,621 81.4 88.6 77.3 82.4 560 Second 84.8 90.8 81.2 83.5 1,668 86.6 91.6 82.5 85.5 607 Middle 81.8 87.7 77.9 83.1 1,885 85.1 91.0 80.4 83.0 875 Fourth 84.7 89.7 80.7 82.9 2,292 91.2 92.2 85.6 87.9 963 Highest 88.2 91.9 83.2 88.9 2,338 89.7 93.7 85.1 89.4 911 Total 15-49 84.3 89.5 80.2 84.2 9,804 87.4 91.7 82.7 86.0 3,915 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners In the 2000 NDHS, 86 percent of women and 92 percent of men mentioned the condom as a method of HIV prevention. In the 2006-07 NDHS, 84 percent of women and 87 percent of men mentioned condom use. This indicates that there has been a decline in knowledge of this prevention method. For women, there is a positive association between knowledge of the use of condoms to prevent AIDS infection and level of education and wealth: better-educated and wealthier respondents were more likely to report condom use as a strategy to reduce the risk of AIDS than less educated and poorer respondents. There is substantial variation in knowledge of AIDS among women by region, ranging from 64 percent in Omaheke to 90 percent in Khomas and Ohangwena. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 195 There is no clear relationship between knowledge of the use of condoms and limiting sexual intercourse to one uninfected partner as ways to reduce the risk of AIDS and age, marital status, and residence. In general, men are more likely than women to mention these methods (83 percent compared with 80 percent). This is true in all age groups, and by marital status, residence and economic status. Women in Omaheke and Kunene are the least likely to know about these methods for reducing AIDS infection (60 and 64 percent, respectively), while women in Khomas and Ohangwena are the most likely to mention these methods (86 and 87 percent, respectively). This indicator has a strong positive association with level of education and, to a lesser extent, wealth status. Eighty-four percent of women mentioned abstaining from sexual intercourse as a prevention method compared with 86 percent of men. This is an improvement over the 2000 NDHS findings (35 percent for women and 41 percent for men). Similar to knowledge of the use of condoms and limiting the number of sexual partners, knowledge of abstinence as an effective strategy for reducing the risk of AIDS is associated with region, level of education, and economic status, but not with other background characteristics. For women, the proportion who mentioned this method ranges from 69 percent in Omaheke to 90 percent or higher in Oshana and Khomas. More than 90 percent of men in Kavango, Omusati, and Oshikoto are aware that abstaining from sexual intercourse is a way to prevent AIDS. This indicator shows a positive relationship with education and wealth for both sexes, the stronger relationship being with education. 14.2 COMPREHENSIVE KNOWLEDGE ABOUT HIV/AIDS In addition to knowing effective ways to avoid contracting HIV, it is useful to be able to identify incorrect beliefs about AIDS transmission. Common misconceptions about AIDS include the following: a) healthy looking person cannot have the AIDS virus, b) AIDS can be transmitted by mosquito bites, c) AIDS can be transmitted by supernatural means, and d) a person can become infected by sharing food with a person who has AIDS. Respondents were asked about these misconceptions and the findings are presented in Tables 14.3.1 and 14.3.2. Nine in ten women and eight in ten men are aware that HIV cannot be transmitted by supernatural means. A slightly higher proportion of women (81 percent) than men (72 percent) say that HIV cannot be transmitted by mosquito bites. Additionally, the vast majority of women and men know that people infected with HIV do not necessarily show signs of infection (nine in ten). Eighty- six percent of women and 80 percent of men know that a person cannot be infected by sharing food with someone who has HIV/AIDS. There are no significant differentials by age in women’s and men’s misconceptions about HIV/AIDS. As one would expect, women and men with higher levels of schooling, those in the higher wealth quintiles, and those living in urban areas are substantially more likely than other respondents to correctly reject individual misconceptions. There are regional variations depending on the particular misconception. Overall, misconceptions about HIV trans- mission are higher among women in Caprivi and Kunene, and among men in Ohangwena. Tables 14.3.1 and 14.3.2 show the percentage of women and men with comprehensive knowledge about AIDS, i.e., know two ways of preventing HIV transmission and reject two common misconceptions. The indicator is based on the two most common and relevant misconceptions in Namibia, that a person can become infected by sharing food with a person with AIDS and through mosquito bites. Table 14.3.1 shows that, overall, two in three women (67 percent) have comprehensive knowledge about AIDS. The level of comprehensive knowledge varies by age, marital status, type of residence, and education. Comprehensive knowledge of AIDS is lowest for women age 15-19 (62 percent) while the highest is among women age 25-29 (71 percent). Comprehensive knowledge of AIDS correlates positively with level of education and wealth status. For example, women with no education have the lowest level of comprehensive knowledge about AIDS (40 percent). In four of the thirteen regions of Namibia (Caprivi, Kavango, Kunene, and Omaheke) 50 percent or less of women have comprehensive knowledge about AIDS, lower than in the other regions. 196 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Namibia 2006-07 Percentage of respondents who say that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a compre- hensive knowledge about AIDS2 Number of women Age 15-24 85.7 83.4 86.4 87.6 76.9 64.9 4,101 15-19 84.2 83.3 86.7 86.8 76.3 62.2 2,246 20-24 87.5 83.5 85.9 88.4 77.6 68.2 1,855 25-29 89.9 83.0 87.4 88.4 80.6 70.9 1,623 30-39 88.2 79.0 86.4 84.7 79.1 69.3 2,462 40-49 87.7 74.3 85.3 80.8 77.8 66.3 1,618 Marital status Never married 88.6 84.9 88.8 88.7 80.9 69.5 5,676 Ever had sex 89.4 84.2 88.7 88.5 81.4 71.1 4,087 Never had sex 86.6 86.8 89.1 89.1 79.6 65.4 1,589 Married/living together 85.7 75.2 83.5 82.3 75.1 64.8 3,451 Divorced/separated/widowed 84.8 73.3 80.5 80.1 71.4 60.8 678 Residence Urban 90.1 85.8 86.8 89.2 80.6 69.5 4,772 Rural 84.7 75.9 86.0 82.7 76.0 65.1 5,032 Region Caprivi 73.7 75.5 76.2 83.1 57.7 50.2 474 Erongo 90.4 84.3 84.4 83.5 76.7 57.5 688 Hardap 92.1 80.0 83.9 88.8 80.1 64.2 315 Karas 83.2 75.8 82.5 82.6 71.2 61.9 318 Kavango 72.7 66.5 76.7 80.2 60.5 50.4 934 Khomas 92.8 88.7 88.1 92.2 84.1 76.2 2,218 Kunene 71.0 64.3 63.7 55.0 51.1 38.8 259 Ohangwena 93.3 80.9 89.4 86.7 84.7 75.5 1,043 Omaheke 79.8 75.3 83.0 78.9 71.8 47.9 373 Omusati 90.5 83.4 94.6 87.8 86.9 75.7 975 Oshana 92.6 86.3 95.8 91.1 90.1 78.9 819 Oshikoto 87.7 81.2 92.1 86.8 82.3 72.0 837 Otjozondjupa 84.9 73.3 80.6 80.3 72.6 62.4 550 Education No education 65.0 51.0 63.2 60.9 49.8 39.5 651 Incomplete primary 81.2 67.4 82.3 76.6 70.2 58.7 1,699 Complete primary 86.9 74.6 85.5 83.4 76.4 64.0 736 Incomplete secondary 89.9 85.6 89.4 89.4 82.0 70.8 4,751 Complete secondary 93.1 92.0 89.6 94.4 84.4 74.5 1,286 More than secondary 95.6 93.5 91.8 94.8 88.7 80.2 682 Wealth quintile Lowest 78.6 69.7 81.7 79.3 68.3 58.9 1,621 Second 86.1 75.5 86.5 81.8 77.8 68.0 1,668 Middle 86.0 78.3 86.0 84.3 77.2 64.9 1,885 Fourth 89.3 84.9 88.0 87.5 80.7 69.0 2,292 Highest 93.4 89.9 88.2 92.9 83.8 72.6 2,338 Total 15-49 87.3 80.7 86.4 85.9 78.2 67.2 9,804 1 Two most common local misconceptions: 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the risk of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. Table 14.3.2 shows that the overall level of comprehensive knowledge about AIDS among men is 63 percent, four percentage points lower than for women. As with women, the level of comprehensive knowledge varies by age, marital status, type of residence and education. Comprehensive knowledge is lowest among men age 15-19 (59 percent), rural men (59 percent), and men in Ohangwena, Oshana, and Omaheke (32, 45, and 46 percent, respectively). HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 197 Table 14.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Namibia 2006-07 Percentage of respondents who say that: Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a compre- hensive knowledge about AIDS2 Number of men Age 15-24 89.9 74.9 80.0 79.7 73.7 61.9 1,661 15-19 88.4 73.3 78.4 78.2 70.9 58.5 910 20-24 91.8 76.7 81.8 81.6 77.1 66.0 750 25-29 92.6 72.4 81.0 82.6 76.4 65.5 702 30-39 93.8 68.1 79.5 78.3 75.7 65.9 986 40-49 89.7 66.1 78.0 76.0 71.9 60.8 567 Marital status Never married 90.3 73.0 79.9 79.0 73.8 62.3 2,547 Ever had sex 92.4 73.9 81.8 80.7 76.6 65.0 2,014 Never had sex 82.0 69.9 72.6 72.7 63.3 52.0 533 Married/living together 93.7 69.7 79.9 80.0 76.1 65.6 1,205 Divorced/separated/widowed 91.2 60.1 76.1 80.0 71.4 64.2 163 Residence Urban 93.2 75.7 82.5 86.1 77.9 68.0 1,962 Rural 89.5 67.2 77.0 72.6 70.9 58.7 1,953 Region Caprivi 89.2 70.6 76.8 83.6 71.3 69.7 189 Erongo 95.0 76.9 83.9 86.2 81.5 70.3 362 Hardap 95.6 81.2 88.5 85.7 84.1 78.3 132 Karas 91.0 74.7 79.4 85.0 74.8 68.9 157 Kavango 91.5 77.6 88.9 88.9 82.2 74.6 331 Khomas 92.7 73.7 81.8 85.5 76.7 68.0 984 Kunene 86.5 58.7 82.6 72.4 74.2 62.4 92 Ohangwena 85.0 40.7 45.2 41.4 36.5 31.6 306 Omaheke 87.2 59.2 68.8 60.0 62.7 46.2 188 Omusati 96.1 86.6 89.6 84.8 86.1 78.2 320 Oshana 91.5 72.4 77.7 79.8 74.0 44.8 270 Oshikoto 97.1 72.5 89.0 86.4 86.7 63.9 322 Otjozondjupa 79.5 69.9 78.7 69.7 67.3 57.1 262 Education No education/preschool 82.0 44.7 64.3 58.1 56.4 42.4 360 Incomplete primary 87.7 54.7 73.7 65.4 65.7 54.4 856 Complete primary 90.5 67.8 80.5 82.7 75.7 64.1 252 Incomplete secondary 93.4 78.4 81.8 84.7 77.3 67.1 1,604 Complete secondary 94.7 89.1 88.6 91.4 85.1 72.8 538 More than secondary 97.0 85.4 87.7 91.3 85.0 76.4 305 Wealth quintile Lowest 87.2 63.8 75.5 70.0 67.9 55.4 560 Second 90.3 68.4 76.0 72.9 70.2 59.4 607 Middle 90.2 66.0 78.3 73.8 72.6 60.2 875 Fourth 93.4 70.9 81.2 83.8 76.7 67.2 963 Highest 93.5 84.0 84.7 90.1 80.7 70.0 911 Total 15-49 91.3 71.5 79.7 79.3 74.4 63.4 3,915 1 Two most common local misconceptions 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the risk of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 14.3 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing the level of knowledge about the of transmission of HIV from mother to child and reducing the risk of transmission from mother to child through the use of antiretroviral drugs is critical to reducing mother-to-child transmission of HIV (MTCT). To assess MTCT knowledge, respondents were asked if the virus that causes AIDS can be transmitted from a mother to a child through breastfeeding and whether a mother with HIV can reduce the risk of transmission to the baby by taking certain drugs during pregnancy. These two questions were tabulated together to produce an indicator measuring the proportion who responded correctly to both questions. 198 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.4 shows the percentage of women and men who know that: a) HIV can be transmitted from mother to child by breastfeeding, b) the risk of mother-to-child transmission of HIV can be reduced by the mother taking special drugs during pregnancy, and c) the combination of the two types of knowledge. Women in all age categories have a better understanding of the risk of MTCT through breastfeeding (88 percent) than men (77 percent). This represents an increase in knowledge over the 2000 NDHS (71 percent for women and 63 percent for men). Table 14.4 Knowledge of prevention of mother to child transmission of HIV Percentage of women and men who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Namibia 2006-07 Percentage of women who know that: Percentage of men who know that: Background characteristic HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 87.3 76.5 71.7 4,101 74.9 61.2 53.8 1,661 15-19 84.9 71.6 65.7 2,246 72.2 56.0 49.3 910 20-24 90.2 82.5 79.0 1,855 78.2 67.4 59.2 750 25-29 90.7 85.0 81.0 1,623 80.4 73.0 66.0 702 30-39 88.0 83.1 78.5 2,462 80.3 74.1 66.7 986 40-49 86.6 80.5 75.0 1,618 74.3 70.3 61.1 567 Marital status Never married 88.4 81.3 76.4 5,676 76.5 67.4 59.9 2,547 Ever had sex 89.9 84.6 80.3 4,087 79.3 71.6 63.6 2,014 Never had sex 84.4 72.7 66.5 1,589 65.8 51.3 45.6 533 Married/living together 87.0 78.8 74.1 3,451 77.9 70.0 61.7 1,205 Divorced/separated/widowed 88.9 79.0 74.2 678 82.8 60.2 56.3 163 Currently pregnant Pregnant 87.4 77.3 73.9 527 na na na na Not pregnant or not sure 87.9 80.4 75.6 9,277 na na na na Residence Urban 88.5 82.7 77.7 4,772 81.1 72.9 64.4 1,962 Rural 87.3 77.9 73.4 5,032 73.3 62.8 56.1 1,953 Region Caprivi 82.4 69.0 61.9 474 82.2 61.1 53.8 189 Erongo 81.3 79.2 72.6 688 78.6 69.3 58.2 362 Hardap 84.6 70.8 65.7 315 87.3 72.8 67.0 132 Karas 88.4 75.3 71.2 318 69.5 53.4 47.9 157 Kavango 89.3 67.1 64.9 934 88.5 62.4 59.9 331 Khomas 89.9 85.5 80.0 2,218 80.4 73.9 65.0 984 Kunene 78.5 60.9 58.6 259 81.1 70.9 63.8 92 Ohangwena 89.3 86.3 80.6 1,043 56.9 53.7 51.4 306 Omaheke 73.0 63.0 56.3 373 65.1 54.2 45.6 188 Omusati 90.6 88.9 84.5 975 86.6 87.3 78.8 320 Oshana 91.4 90.3 85.7 819 60.4 65.4 54.4 270 Oshikoto 92.5 86.0 82.6 837 80.6 71.7 60.3 322 Otjozondjupa 86.9 71.0 67.9 550 77.2 60.8 57.6 262 Education No education 71.9 52.1 48.7 651 63.7 49.4 45.5 360 Incomplete primary 85.5 73.0 68.7 1,699 73.9 61.0 54.5 856 Complete primary 87.0 77.5 72.6 736 77.8 66.8 60.5 252 Incomplete secondary 90.1 83.2 78.6 4,751 80.3 69.4 61.8 1,604 Complete secondary 89.7 87.3 81.6 1,286 80.1 78.3 68.3 538 More than secondary 91.9 93.9 87.5 682 80.1 83.2 71.4 305 Wealth quintile Lowest 85.8 72.8 68.8 1,621 68.7 55.3 49.0 560 Second 87.0 80.1 75.1 1,668 75.3 67.6 61.3 607 Middle 86.8 77.0 72.5 1,885 77.7 64.3 57.7 875 Fourth 91.6 83.6 80.5 2,292 82.8 73.8 67.2 963 Highest 87.3 84.8 77.8 2,338 77.2 72.9 61.6 911 Total 15-49 87.9 80.3 75.5 9,804 77.2 67.9 60.3 3,915 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 199 For both women and men, knowledge that HIV can be transmitted through breastfeeding has a strong relationship with level of education and wealth quintile. Four in five women know that the risk of MTCT can be reduced by the mother taking special drugs during pregnancy, compared with three in five men. Interestingly, pregnant women are slightly less likely to know about prevention of mother-to-child transmission (PMTCT) than women who are not currently pregnant. Respondents in urban areas, those with higher education, and those from wealthier households are more likely to know about PMTCT than other respondents. Knowledge of PMTCT varies by region. For women, it is lowest in Omaheke (73 percent) and highest in Oshikoto (93 percent). Overall, 76 percent of women and 60 percent of men know HIV can be transmitted through breastfeeding and that the risk of MTCT can be reduced by the mother taking special drugs during pregnancy. Knowledge is lowest among young respondents and those who have never had sex. A larger proportion of women and men in urban areas know about MTCT and PMTCT than in rural areas. For women, knowledge of both methods of transmission is less than 60 percent in Omaheke and Kunene, and 85 percent or higher in Omusati and Oshana. Less than half of men in Omaheke and Karas have this knowledge, compared with 79 percent of men in Omusati. 14.4 ACCEPTING ATTITUDES TOWARDS PEOPLE LIVING WITH AIDS Widespread stigma and discrimination about HIV/AIDS in a population can adversely affect people’s willingness to be tested for HIV and adherence to antiretroviral therapy. Reduction of stigma and discrimination in a population is an important indicator of the success of programmes targeting HIV and AIDS prevention, management, and control. To assess the level of stigma, the 2006-07 NDHS asked respondents who had heard of AIDS: a) if they would be willing to care for a relative sick with AIDS in their own household, b) if they would be willing to buy fresh vegetables from a market vendor who had the AIDS virus, c) if they thought a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching, and d) if they would want to keep a family member’s HIV status secret. Tables 14.5.1 and 14.5.2 show the results for women and men, respectively. Table 14.5.1 shows accepting attitudes towards people living with HIV/AIDS among women age 15-49. Over 90 percent of respondents said that they were willing to care for a family member with the AIDS virus in their home. This figure is similar to that recorded in the 2000 NDHS (91 percent). Seventy-five percent of women said they would buy food from a shopkeeper who has the AIDS virus. This proportion varies by region, ranging from 47 percent in Kunene to 84 percent in Erongo. Eighty-seven percent of women said a female teacher with the AIDS virus who is not sick should be allowed to continue teaching. This figure is higher than the 2000 NDHS finding (67 percent). The proportion of women with this attitude ranges by region from 60 percent in Kunene to 96 percent in Ohangwena. Overall, 57 percent of women would not want to keep secret that a family member got infected with the AIDS virus. This attitude varies substantially across regions, ranging from 18 percent in Caprivi to 77 percent in Oshana. The proportion of women who expressed accepting attitudes on all four indicators was 39 percent. Better-educated women and those in wealthier households are more likely to be accepting of people with HIV/AIDS when all four indicators are taken into account. 200 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.5.1 Accepting attitudes towards people living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with AIDS, by background characteristics, Namibia 2006-07 Percentage of women who: Background characteristic Are willing to care for a family member with the AIDS virus in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Percentage expressing accepting attitudes on all four indicators Number of women who have heard of AIDS Age 15-24 92.3 73.8 87.4 56.7 38.7 4,036 15-19 92.4 70.9 86.1 58.1 38.2 2,208 20-24 92.2 77.2 88.9 54.9 39.3 1,829 25-29 92.9 79.2 88.8 54.6 39.3 1,612 30-39 92.2 76.2 87.8 55.0 37.7 2,436 40-49 92.9 73.1 85.1 61.7 42.8 1,604 Marital status Never married 92.8 76.3 90.0 59.2 41.8 5,614 Ever had sex 92.7 78.4 90.4 57.7 41.8 4,040 Never had sex 93.1 70.9 89.2 63.0 41.6 1,574 Married/living together 91.9 74.2 84.1 54.1 36.7 3,402 Divorced/separated/widowed 92.2 70.7 81.4 49.7 31.1 672 Residence Urban 92.3 79.3 89.9 55.8 40.5 4,718 Rural 92.6 71.3 84.9 57.6 38.1 4,970 Region Caprivi 97.4 72.9 82.5 18.4 10.1 464 Erongo 93.1 84.0 91.6 57.8 44.2 688 Hardap 81.8 68.3 79.8 61.6 30.4 313 Karas 91.7 64.9 81.4 61.8 36.8 316 Kavango 84.3 73.9 72.6 39.7 21.1 914 Khomas 93.7 79.7 91.3 55.0 39.6 2,187 Kunene 80.2 47.4 59.8 38.1 15.9 258 Ohangwena 96.6 80.3 95.7 66.1 51.7 1,034 Omaheke 77.7 67.2 76.4 51.0 26.2 363 Omusati 96.3 75.3 92.2 71.3 51.8 970 Oshana 97.9 78.2 94.9 77.0 58.8 812 Oshikoto 97.1 71.7 91.4 64.8 44.7 833 Otjozondjupa 88.5 69.2 81.0 44.2 29.2 535 Education No education 82.5 53.6 64.5 50.6 24.8 607 Incomplete primary 91.3 65.8 80.5 51.4 31.7 1,678 Complete primary 92.8 68.1 85.3 54.7 33.2 732 Incomplete secondary 93.8 77.9 89.8 58.9 41.8 4,706 Complete secondary 92.5 83.8 93.8 60.8 45.6 1,283 More than secondary 94.4 90.1 97.4 55.1 47.5 682 Wealth quintile Lowest 91.7 68.9 81.0 54.3 34.6 1,585 Second 94.0 73.2 86.5 58.8 39.5 1,649 Middle 91.6 72.4 84.9 53.3 35.4 1,864 Fourth 92.1 75.3 89.5 56.9 40.2 2,265 Highest 92.9 83.0 92.2 59.5 44.4 2,325 Total 15-49 92.5 75.2 87.3 56.7 39.2 9,688 Table 14.5.2 shows the same information for men. In general, men have a lower level of acceptance than women on all four indicators (36 percent and 39 percent, respectively). However, men are slightly more likely than women to be willing to care for a family member with the AIDS virus in their home (95 percent and 92 percent, respectively). As with women, this indicator is higher than in the 2000 NDHS (92 percent). HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 201 Table 14.5.2 Accepting attitudes towards people living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes towards people with HIV/AIDS, by background characteristics, Namibia 2006-07 Percentage of men who: Background characteristic Are willing to care for a family member with the AIDS virus in the respondent's home Would buy fresh vege- tables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Percentage expressing accepting attitudes on all four indicators Number of men who have heard of AIDS Age 15-24 95.5 72.4 80.5 55.4 37.1 1,641 15-19 94.6 71.4 79.1 53.7 35.4 896 20-24 96.5 73.5 82.2 57.6 39.1 745 25-29 94.1 74.6 86.2 53.6 35.1 694 30-39 95.2 72.4 85.1 54.6 35.5 983 40-49 92.5 69.1 83.9 57.7 35.5 562 Marital status Never married 95.3 73.1 83.2 55.8 37.2 2,518 Ever had sex 95.4 74.1 83.7 55.8 36.8 2,004 Never had sex 94.7 69.5 81.1 56.1 38.7 514 Married/living together 93.9 71.8 84.7 54.8 35.2 1,200 Divorced/separated/widowed 92.7 63.1 72.7 49.1 25.3 163 Residence Urban 96.6 75.7 88.2 57.1 40.6 1,955 Rural 92.9 68.8 78.1 53.3 31.5 1,926 Region Caprivi 96.9 78.3 81.6 31.3 20.9 184 Erongo 95.0 73.1 85.2 52.4 31.5 358 Hardap 95.5 81.1 72.2 73.1 43.1 132 Karas 95.3 73.7 84.7 54.8 35.4 155 Kavango 95.7 76.0 82.6 55.9 40.7 330 Khomas 97.1 73.9 89.8 56.5 40.9 984 Kunene 88.2 59.9 66.0 66.0 38.4 91 Ohangwena 88.8 78.3 88.9 38.5 16.3 298 Omaheke 86.0 33.4 51.3 59.5 11.8 188 Omusati 95.2 72.3 89.2 71.0 54.0 319 Oshana 94.1 79.4 83.0 42.8 30.8 270 Oshikoto 98.2 68.0 82.2 50.8 36.8 321 Otjozondjupa 93.0 74.2 78.3 73.5 48.2 251 Education No education/preschool 87.2 54.4 64.6 57.8 26.2 349 Incomplete primary 92.3 61.2 75.5 51.9 27.1 842 Complete primary 97.2 62.2 79.6 51.8 33.7 249 Incomplete secondary 96.2 77.9 85.9 56.0 38.6 1,599 Complete secondary 97.0 82.6 93.2 60.6 47.5 536 More than secondary 96.1 84.0 96.6 50.6 40.6 305 Wealth quintile Lowest 90.8 67.0 78.4 47.2 26.7 546 Second 94.6 68.8 80.6 54.3 34.6 599 Middle 94.4 67.9 77.5 56.9 32.3 868 Fourth 96.1 74.6 86.1 55.8 37.4 959 Highest 96.0 79.4 90.1 58.4 44.9 909 Total 15-49 94.7 72.3 83.2 55.2 36.1 3,881 Seventy-two percent of men said they would buy food from a shopkeeper who has the AIDS virus. This figure varies by region, from 33 percent in Omaheke to 81 percent in Hardap. Eighty-three percent of men said a female teacher with the AIDS virus who is not sick should be allowed to continue teaching; this is a substantially higher rate than in the 2000 NDHS (55 percent). Across regions, only half of men in Omaheke would allow a female teacher with the AIDS virus who is not sick to continue teaching, compared with 90 percent of men in Khomas. In the remaining regions the proportions range between 72 and 89 percent. Fifty-five percent of men would not want to keep secret that a family member got infected with the AIDS virus. Across regions, the proportion varies from 31 percent in Caprivi to 74 percent in Otjozondjupa. Similar to women, there is a positive correlation between level of education and wealth 202 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour and the likelihood of expressing accepting attitudes towards persons with HIV/AIDS on all four indicators. By region, accepting attitudes range from 12 percent in Omaheke to 54 percent in Omusati. 14.5 ATTITUDES TOWARDS NEGOTIATING SAFER SEX The high levels of HIV transmission through sexual intercourse makes negotiating safer sex indispensable, especially in marital unions where women’s status is compromised by societal expectations, thereby increasing their vulnerability to HIV transmission. Table 14.6 shows the percentage of women and men age 15-49 who believe that, if a husband has a sexually transmitted disease, his wife is justified in refusing to have sexual intercourse with him or asking that they use a condom. The percentage of respondents who agree with this statement is high for both women and men (86 percent and 89 percent, respectively). The proportion of respondents who say that a wife is justified in asking her husband who has a sexually transmitted disease to use a condom is also high (89 percent for women and 92 percent for men). Table 14.6 Attitudes towards negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that if a husband has a sexually transmitted disease his wife is justified in refusing to have sexual intercourse with him or asking that they use a condom, by background characteristics, Namibia 2006-07 Women Men Background characteristic Refusing to have sexual intercourse Refusing sexual intercourse or asking that they use a condom Number of women Refusing to have sexual intercourse Refusing sexual intercourse or asking that they use a condom Number of men Age 15-24 82.6 82.6 4,101 87.7 87.7 1,661 15-19 79.7 79.7 2,246 86.2 86.2 910 20-24 86.1 86.1 1,855 89.5 89.5 750 25-29 87.4 87.4 1,623 86.7 86.7 702 30-39 87.5 87.5 2,462 90.1 90.1 986 40-49 88.2 88.2 1,618 89.9 89.9 567 Marital status Never married 84.8 84.8 5,676 87.4 87.4 2,547 Ever had sex 86.9 86.9 4,087 88.7 88.7 2,014 Never had sex 79.3 79.3 1,589 82.5 82.5 533 Married/living together 86.5 86.5 3,451 90.8 90.8 1,205 Divorced/separated/widowed 86.9 86.9 678 88.7 88.7 163 Residence Urban 89.1 89.1 4,772 90.6 90.6 1,962 Rural 82.2 82.2 5,032 86.3 86.3 1,953 Region Caprivi 85.7 85.7 474 85.5 85.5 189 Erongo 85.6 85.6 688 83.2 83.2 362 Hardap 95.0 95.0 315 88.3 88.3 132 Karas 89.5 89.5 318 94.1 94.1 157 Kavango 70.3 70.3 934 92.7 92.7 331 Khomas 92.2 92.2 2,218 91.6 91.6 984 Kunene 90.5 90.5 259 92.3 92.3 92 Ohangwena 84.0 84.0 1,043 68.9 68.9 306 Omaheke 88.9 88.9 373 94.0 94.0 188 Omusati 85.9 85.9 975 92.7 92.7 320 Oshana 78.7 78.7 819 90.3 90.3 270 Oshikoto 84.3 84.3 837 87.4 87.4 322 Otjozondjupa 85.9 85.9 550 89.1 89.1 262 Education No education 75.4 75.4 651 82.1 82.1 360 Incomplete primary 80.9 80.9 1,699 84.3 84.3 856 Complete primary 82.4 82.4 736 85.5 85.5 252 Incomplete secondary 86.4 86.4 4,751 90.3 90.3 1,604 Complete secondary 91.3 91.3 1,286 94.4 94.4 538 More than secondary 93.4 93.4 682 90.2 90.2 305 Total 15-49 85.5 85.5 9,804 88.5 88.5 3,915 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 203 Older respondents and those living in urban areas are more likely than younger and rural respondents to agree that a wife is justified in refusing to have sexual intercourse with her husband who has a sexually transmitted disease or insisting that they use a condom. For instance, 89 percent of urban women agree with these statements compared with 82 percent of rural women. Women and men who have not had sex and those with limited education are less likely to accept these attitudes towards women negotiating safer sexual relations with their husbands. Regionally, women in Kavango and men in Ohangwena are the least likely to have positive attitudes towards women negotiating of safer sex with their husbands. 14.6 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH AND BELIEFS ABOUT ABSTINENCE AND FAITHFULNESS HIV prevention programmes focus their messages and efforts on promoting three specific behaviours: use of condoms, limiting the number of sexual partners or staying faithful to one uninfected sexual partner, and abstinence. This section measures respondents’ perceptions of women’s and men’s roles regarding these behaviours and perceptions about educating youth about the three behaviours. Condom use is one of the main strategies for combating the spread of HIV; however, educating youth about condoms is sometimes controversial, with some people saying it promotes early sexual experimentation. To gauge attitudes towards condom education, NDHS respondents were asked if they thought that children age 12-14 should be taught about using a condom to avoid AIDS. The results are shown in Table 14.7. Because the table focuses on adult opinions, results are tabulated for respondents age 18-49. There is a high degree of agreement that children age 12-14 years should be taught about the use of condoms to avoid AIDS (84 percent of women and 85 percent of men). There are no substantial differences by marital status. Urban women are more likely than rural women to agree on teaching children age 12-14 about condom use to avoid AIDS (86 percent and 82 percent, respectively). However, there is no difference between urban and rural men. By region, agreement on teaching children age 12-14 abut the use of condoms ranges among women from 72 percent in Kavango to 88 percent in Otjozondjupa. For men, the corresponding figures are 62 percent in Ohangwena and 95 percent in Omusati and Kavango. In general, the proportion of respondents who support teaching children age 12-14 about condoms increases with level of education and wealth quintile. For example, 73 percent of women with no education compared with 86 percent of women with secondary education agree on instructing children 12-14 years about condoms. The figures for men are 78 percent and 87 percent, respectively. At the highest education level, however, approval declines slightly for both women and men (82 percent and 78 percent, respectively). 204 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 years should be taught about using a condom to avoid AIDS, by background characteristics, Namibia 2006-07 Women Men Background characteristic Percentage who agree Number Percentage who agree Number Age 18-24 85.2 2,736 84.6 1,108 18-19 83.3 881 85.9 357 20-24 86.1 1,855 84.0 750 25-29 85.1 1,623 86.4 702 30-39 82.3 2,462 84.9 986 40-49 83.1 1,618 81.8 567 Marital status Never married 86.3 4,355 84.5 1,995 Married or living together 81.3 3,408 84.9 1,204 Divorced/separated/widowed 81.8 677 82.6 162 Residence Urban 86.0 4,218 84.1 1,769 Rural 81.9 4,222 85.1 1,593 Region Caprivi 81.7 412 88.6 170 Erongo 86.7 622 80.2 334 Hardap 86.3 271 89.6 117 Karas 79.0 288 83.9 139 Kavango 71.9 792 95.2 273 Khomas 87.1 1,984 83.6 896 Kunene 86.3 225 89.5 83 Ohangwena 85.9 821 62.1 213 Omaheke 84.3 317 83.3 169 Omusati 81.0 808 95.4 259 Oshana 85.1 697 77.1 221 Oshikoto 84.3 695 89.4 244 Otjozondjupa 88.1 505 87.0 244 Education No education 72.5 628 77.7 343 Incomplete primary 82.3 1,490 84.5 711 Complete primary 85.2 567 84.1 167 Incomplete secondary 85.8 3,821 87.2 1,311 Complete secondary 86.3 1,251 86.8 524 More than secondary 82.0 682 77.9 305 Wealth quintile Lowest 77.8 1,336 82.5 449 Second 81.6 1,390 83.9 467 Middle 84.3 1,619 85.3 771 Fourth 87.6 2,071 87.1 872 Highest 85.5 2,022 82.7 803 Total 18-49 83.9 8,439 84.6 3,362 Findings in Figure 14.2 indicate that 73-80 percent of women and men age 15-49 believe that young women and men should wait until they are married to have sexual intercourse. Between 80 and 86 percent of women and men believe that married men should only have sex with their wives and that married women should only have sex with their husbands. At the same time, it is interesting to note that only 28 percent of women and 32 percent of men think that most married men they know actually have sex only with their wives. About half of the respondents think that most married women they know are faithful to their husbands. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 205 14.7 HIGHER-RISK SEX Information on sexual behaviour is important in designing and monitoring intervention programmes to control the spread of the HIV. The 2006-07 NDHS included questions on respondents’ sexual partners during their lifetime and over the 12 months preceding the survey. For male respondents, a question was asked on whether they paid for sex during the 12 months preceding the interview. These questions are personal and sensitive, and it is recognized that some respondents may have been reluctant to provide sincere information on recent sexual behaviour. 14.7.1 Multiple Partners and Condom Use The 2006-07 NDHS also assessed condom use among women and men with multiple partners or higher-risk sex in the 12 months preceding the survey. While truly effective protection requires condom use at every sexual encounter, the sexual encounters addressed in Tables 14.8.1 and 14.8.2 are those considered to pose the greatest risk of HIV transmission. Respondents who had more than one sexual partner or had sexual intercourse with a non-marital, non-cohabiting partner (higher-risk sexual intercourse) were also asked whether they used a condom at the last such encounter. Respondents were also asked to identify the number of sexual partners they have had in their lifetime; the mean number of lifetime sexual partners is presented in Tables 14.8.1 and 14.8.2. Table 14.8.1 shows that only 3 percent of women reported having two or more partners in the past 12 months; however, 49 percent of women had higher-risk sexual intercourse over the same period. The likelihood of having higher-risk sexual intercourse decreases with age: 84 percent for women age 15-19, 71 percent for women 20-24, and 22 percent for women 40-49. Across marital categories, women who have never married show the highest proportion (95 percent) having higher- risk sexual intercourse in the past year, followed by divorced/separated/widowed women (76 percent). 80 76 82 28 84 50 73 78 80 32 86 50 0 20 40 60 80 100 Percent Women Men Figure 14.2 Perceptions and Beliefs about Abstinence and Faithfulness Young men should wait until they are married to have sexual intercourse Young women should wait until they are married to have sexual intercourse Married men should only have sex with their wives Married women should only have sex with their husbands Most married men they know only have sex with their wives Most married women they know only have sex with their husbands NDHS 2006-07 206 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women Among women age 15-49 who had sexual intercourse in the past 12 months, the percentage who had intercourse with more than one partner and the percentage who had higher-risk sexual intercourse in the past 12 months; and among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and among those having higher-risk intercourse in the past 12 months, the percentage reporting that a condom was used at last higher-risk intercourse; and the mean number of sexual partners during her lifetime for women who ever had sexual intercourse, by background characteristics, Namibia 2006-07 Among women who had 2+ partners in the past 12 months: Among women who had higher- risk intercourse in the past 12 months: Among women who had sexual intercourse in the past 12 months: Among women who ever had sexual intercourse Background characteristic Percentage who had 2+ partners in past 12 months Percentage who had higher-risk intercourse in past 12 months Number of women Percentage who reported using a condom during last sexual intercourse Percentage who reported using a condom consistently with the last sexual partner Number of women Percentage who reported using a condom at last higher- risk intercourse Percentage who reported using a condom consistently with the last higher-risk partner Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 4.2 75.5 2,163 73.7 54.4 91 64.2 51.6 1,634 2.0 2,575 15-19 3.1 84.1 793 76.8 76.8 25 67.1 55.8 667 1.7 954 20-24 4.9 70.5 1,370 72.5 46.2 67 62.3 48.7 967 2.1 1,621 25-29 3.1 51.6 1,282 62.3 47.4 39 62.4 51.3 663 2.5 1,518 30-39 1.0 33.3 1,923 54.7 34.4 20 56.4 47.9 640 2.5 2,340 40-49 1.1 22.1 1,119 34.2 30.4 12 61.9 53.2 248 2.8 1,544 Marital status Never married 3.8 95.1 2,971 76.6 58.8 113 63.6 51.9 2,830 2.3 3,985 Married or living together 0.9 4.0 3,217 28.8 12.5 29 43.8 33.8 127 2.4 3,337 Divorced/separated/ widowed 7.0 76.3 299 57.1 41.7 21 53.9 47.5 228 2.9 656 Residence Urban 3.3 50.6 3,315 71.5 51.2 109 68.8 57.0 1,679 2.6 3,950 Rural 1.7 47.4 3,172 53.8 42.9 54 54.7 44.1 1,507 2.2 4,027 Region Caprivi 0.4 42.6 343 * * 1 51.3 36.0 147 2.2 430 Erongo 1.3 42.5 505 * * 7 68.9 59.1 214 2.6 566 Hardap 2.1 39.6 217 * * 4 46.7 41.5 86 2.3 260 Karas 2.5 42.8 218 * * 5 57.9 48.8 94 2.4 269 Kavango 0.8 30.7 654 * * 5 46.2 31.6 201 1.8 854 Khomas 4.5 52.8 1,521 (80.6) (50.7) 68 73.4 60.0 804 2.8 1,812 Kunene 5.1 45.0 210 * * 11 56.3 52.4 94 3.9 233 Ohangwena 0.3 53.8 574 * * 2 56.7 42.8 311 1.8 761 Omaheke 5.0 52.5 292 * * 15 60.9 48.3 153 4.0 327 Omusati 3.2 62.4 504 * * 16 54.3 48.8 316 1.7 704 Oshana 0.8 59.3 483 * * 4 65.2 54.0 286 2.0 613 Oshikoto 1.2 54.9 526 * * 6 65.6 55.5 290 2.2 659 Otjozondjupa 4.2 43.3 440 * * 18 56.3 46.7 191 2.8 489 Education No education 1.7 25.0 482 * * 8 34.8 26.2 121 2.9 609 Incomplete primary 1.8 34.9 1,194 * * 22 45.1 34.4 417 2.4 1,509 Complete primary 2.4 47.7 469 * * 11 50.7 45.9 224 2.5 588 Incomplete secondary 2.8 59.5 2,913 79.2 60.4 81 65.8 54.1 1,737 2.3 3,607 Complete secondary 3.5 55.2 918 * * 32 72.1 59.2 508 2.4 1,069 More than secondary 1.8 35.2 510 * * 9 69.9 58.0 179 2.4 595 Wealth quintile Lowest 1.2 44.7 1,021 * * 12 43.6 34.3 457 2.1 1,339 Second 1.7 49.4 985 * * 17 54.7 43.9 487 2.2 1,299 Middle 2.1 48.8 1,300 (59.9) (52.7) 27 59.2 47.4 637 2.4 1,567 Fourth 3.4 54.3 1,660 (77.3) (50.0) 56 69.3 57.5 903 2.6 1,955 Highest 3.3 46.1 1,521 (69.3) (55.4) 50 72.6 61.2 702 2.6 1,817 Total 15-49 2.5 49.0 6,487 65.7 48.5 163 62.1 50.9 3,186 2.4 7,977 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a non-marital, non-cohabiting partner Among women who had multiple sexual partners in the past 12 months, 66 percent reported using a condom during the last sexual intercourse, and 49 percent reported using a condom con- sistently, that is every time they had sex. Women age 15-19 reported the most frequent use of condoms during last sexual intercourse (77 percent), followed by women age 20-24 (73 percent). Among women age 15-19 who had two or more sexual partners in the past 12 months, 77 percent used condoms consistently with the last sexual partner. Older women are less consistent in using condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 207 Urban women are more likely to use condoms and more likely to use them consistently than rural women. By region, the number of women who had multiple sexual partners in the past 12 months is too small for meaningful analysis. Overall, 62 percent of women who had higher-risk sex in the past 12 months reported using a condom at last higher-risk sex, while 51 percent reported using a condom consistently. Women on average have two partners in their lifetime. While there are variations by age, marital status, urban-rural residence, education and wealth quintile, the most notable differences are found by region—less than two partners among women in Kavango, Ohangwena, and Omusati, and four partners among women in Kunene and Omaheke. Table 14.8.2 shows the same indicators for men age 15-49. Overall, 16 percent of men said that they had two or more partners in the past 12 months. Men age 20–24 years are the most likely to have two or more sexual partners in the past 12 months (25 percent), followed by men 15–24 (22 percent). Never-married men (21 percent) and divorced, separated, or widowed men (26 percent) are more likely to have two or more partners in the past 12 months than married men (8 percent). Three in five men (60 percent) had higher-risk sexual intercourse in the past 12 months. Men age 15-19 (98 percent) had the highest proportion engaging in higher-risk intercourse in the past 12 months followed by men age 20-24 (85 percent). Almost all men who are never married and those who are divorced, separated, or widowed engaged in higher-risk intercourse in the past 12 months (95 percent and 90 percent, respectively). Three in four men who had two or more sexual partners in the past 12 months reported using a condom during the last sexual intercourse, and 58 percent used a condom consistently. Condoms are most often used by young men: 84 percent for men age 15-19 and 81 percent for men age 20-24. The use of condoms is higher among urban men than rural men (79 percent compared with 69 percent). Condom use during higher-risk sexual intercourse varies by regions, from 64 percent in Kavango to 90 percent in Oshana. The mean number of lifetime sexual partners reported by men is seven. This figure varies significantly across subgroups. As expected, the number is larger for older men (three for men 15-19 compared with nine for men 40-49). While the urban-rural difference is small, there are notable differences by region, from four sexual partners in Oshana to nine in Karas and Omaheke. 208 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men Among men age 15-49 who had sexual intercourse in the past 12 months, the percentage who had intercourse with more than one partner and the percentage who had higher-risk sexual intercourse in the past 12 months; and among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and among those having higher-risk intercourse in the past 12 months, the percentage reporting that a condom was used at last higher-risk intercourse; and the mean number of sexual partners during his lifetime for men who ever had sexual intercourse, by background characteristics, Namibia 2006-07 Among men who had 2+ partners in the past 12 months: Among men who had higher-risk intercourse in the past 12 months: Among men who had sexual intercourse in the past 12 months: Among men who ever had sexual intercourse Background characteristic Percentage who had 2+ partners in past 12 months Percentage who had higher-risk intercourse in past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Percentage who reported using a condom consistently with the last sexual partner Number of men Percentage who reported using a condom at last higher- risk intercourse Percentage who reported using a condom consistently with the last higher- risk partner Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 21.7 90.1 848 82.2 61.4 184 81.1 67.6 764 4.6 1,139 15-19 16.8 98.0 341 84.0 55.3 57 81.3 68.1 334 3.2 467 20-24 25.0 84.8 507 81.3 64.2 127 81.0 67.2 430 5.6 672 25-29 18.2 67.8 564 72.0 64.1 102 76.1 65.2 382 6.4 650 30-39 13.2 46.1 837 74.3 57.7 111 76.4 65.7 386 8.8 908 40-49 8.8 21.6 462 45.7 27.3 41 74.8 60.2 100 9.0 505 Marital status Never married 21.3 94.5 1,453 83.3 68.4 310 79.3 68.1 1,373 6.0 1,936 Married or living together 8.3 12.6 1,129 41.2 24.1 94 78.5 55.0 142 7.9 1,113 Divorced/separated/ widowed 26.4 90.3 129 85.2 55.5 34 68.0 56.4 116 10.4 153 Residence Urban 17.0 56.7 1,460 78.9 62.4 249 83.4 70.3 827 7.8 1,668 Rural 15.1 64.3 1,250 68.6 52.1 189 73.4 61.9 804 5.8 1,535 Region Caprivi 17.5 57.2 155 (59.4) (43.0) 27 67.9 56.3 89 5.5 166 Erongo 22.8 53.9 292 81.6 77.0 66 84.9 80.0 157 8.6 314 Hardap 9.8 42.4 87 * * 9 75.9 65.7 37 5.8 104 Karas 15.6 61.7 111 (84.4) (70.2) 17 79.0 71.5 68 9.4 130 Kavango 12.6 57.3 268 (52.9) (30.5) 34 64.2 41.8 153 7.1 280 Khomas 16.0 56.8 701 79.1 50.7 112 82.0 64.6 398 7.9 851 Kunene 16.1 49.1 77 * * 12 73.2 66.5 38 6.0 77 Ohangwena 14.5 59.5 112 * * 16 68.6 49.9 66 4.9 200 Omaheke 23.8 66.5 150 (81.9) (78.5) 36 80.9 76.4 99 9.2 166 Omusati 15.5 79.7 172 * * 27 77.0 65.7 137 4.5 249 Oshana 11.6 69.2 169 (80.7) (77.5) 19 89.7 84.2 117 4.0 198 Oshikoto 21.4 72.1 219 68.6 46.3 47 78.9 63.2 158 6.5 247 Otjozondjupa 7.7 56.6 200 * * 15 79.9 76.1 113 6.2 221 Education No education 12.6 46.8 248 (49.5) (38.4) 31 60.4 54.0 116 5.8 316 Incomplete primary 12.9 55.5 556 66.9 54.9 72 68.2 60.2 309 6.2 671 Complete primary 19.9 66.0 146 (79.8) (31.6) 29 82.4 49.6 97 6.1 176 Incomplete secondary 17.5 67.7 1,082 75.7 59.4 189 82.0 69.3 732 6.1 1,304 Complete secondary 15.0 60.4 421 90.4 73.4 63 83.5 71.5 254 9.2 463 More than secondary 20.7 48.0 258 (72.8) (64.5) 53 86.3 75.1 124 10.2 273 Wealth quintile Lowest 13.8 58.1 340 54.3 33.6 47 58.8 44.7 197 4.6 427 Second 17.6 69.3 367 72.3 51.6 65 75.7 61.1 254 5.1 462 Middle 17.6 63.8 593 72.1 63.7 104 76.1 67.4 378 6.6 744 Fourth 13.8 59.7 726 77.8 66.2 100 82.9 73.9 433 7.2 822 Highest 17.8 53.7 685 82.5 58.9 122 88.0 70.7 368 9.1 748 Total 15-49 16.1 60.2 2,711 74.4 57.9 438 78.4 66.1 1,631 6.9 3,202 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a non-marital, non-cohabiting partner HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 209 14.7.2 Transactional Sex Transactional sex involves the exchange of sex for money, favours, or gifts. Transactional sex is associated with high risk of contracting HIV and other sexually transmitted infections because of compromised power relations and the tendency to have multiple partners. Male respondents in the 2006-07 NDHS who had had sex in the past 12 months were asked whether they paid anyone for sexual intercourse. Men who paid for sex were asked about condom use during the last paid sexual encounter. Table 14.9 shows that just over 1 percent of men age 15-49 years reported paying for sexual intercourse in the past 12 months. Among those, 77 percent reported using a condom the last time they paid for sexual intercourse (data not shown). Table 14.9 Payment for sexual intercourse among men Percentage of men age 15-49 reporting payment for sexual intercourse in the past 12 months, by background characteriatics, Namibia 2006-07 Payment for sexual intercourse in the past 12 months Background characteristic Percentage who paid for sexual intercourse Number of men Age 15-24 0.8 1,661 15-19 0.5 910 20-24 1.1 750 25-29 2.7 702 30-39 1.9 986 40-49 0.6 567 Marital status Never married 1.4 2,547 Married or living together 0.9 1,205 Divorced/separated/widowed 4.2 163 Residence Urban 0.8 1,962 Rural 1.9 1,953 Region Caprivi 8.2 189 Erongo 0.8 362 Hardap 0.3 132 Karas 2.0 157 Kavango 1.6 331 Khomas 0.5 984 Kunene 3.5 92 Ohangwena 1.8 306 Omaheke 2.6 188 Omusati 1.5 320 Oshana 0.0 270 Oshikoto 0.5 322 Otjozondjupa 0.3 262 Education No education/preschool 3.1 360 Incomplete primary 1.2 856 Complete primary 2.2 252 Incomplete secondary 1.0 1,604 Complete secondary 1.9 538 More than secondary 0.0 305 Wealth quintile Lowest 2.1 560 Second 1.5 607 Middle 2.4 875 Fourth 0.7 963 Highest 0.5 911 Total 15-49 1.4 3,915 210 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Men age 25-29 are the most likely to have paid for sexual intercourse in the past 12 months (3 percent). Men in rural areas (2 percent) are twice as likely to have had transactional sex in the past 12 months as men in urban areas (1 percent) Across regions, no man in Oshana report having paid sex, compared with 8 percent of men in Caprivi. 14.8 COVERAGE OF HIV COUNSELLING AND TESTING Knowledge of HIV status helps HIV-negative individuals make specific decisions that will help reduce the risk of contracting HIV. For those who are HIV positive, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. To assess awareness and coverage of HIV testing services, NDHS respondents were asked a) whether they know where to get an HIV test, b) whether they were ever tested and received results, c) whether they were ever tested but did not receive results, d) whether they were never tested, and e) whether they were last tested in the past 12 months and received the results. According to the findings presented in Table 14.10.1, almost all women age 15-49 know where to get an HIV test (92 percent). Knowledge of HIV testing is not directly associated with having taken the test; 45 percent of women have never been tested, 51 percent were tested at some time and received the results of the last test, and 4 percent were tested at some time but did not receive the results. The proportion of women who have ever been tested for HIV does not vary much by age. Rural women, women who have never had sex, less educated women, and women from poorer households are less likely than other women to have been tested. For example, only 34 percent of women with no education have been tested and know the results, compared with 78 percent of women with more than secondary education. Almost one in three women (29 percent) were tested for HIV in the past 12 months and received the results. Differences by background characteristics are similar to other indicators, with young women, women in rural areas, women with less education, and women in poorer households less likely to know their HIV status in the past 12 months. Table 14.10.2 shows data for men age 15-49. Men are less likely than women to know where to get an HIV test (87 percent compared with 92 percent). As with the case of women, knowledge of a place to get an HIV test is lowest among young men, those who have never had sex, men with no education and in men in the lower wealth quintiles. There are large differences in knowledge of where to get an HIV test by region, from 73 percent in Ohangwena to 96 percent in Khomas. One-third of men (32 percent) have been tested for HIV at some time and received the results of the last test, and 2 percent did not receive the test results. Men age 15-19, men who live in rural areas, those who have never had sex, men without any formal education, and men in households in the two lowest wealth quintiles are substantially less likely than men in other groups to have ever been tested for HIV and receive test results. Men are less likely than women to have been tested in the past 12 months and received the test results (18 percent and 29 percent, respectively). Variations in recent testing (past 12 months) by background characteristic are similar to those of men who have ever been tested, except that men with complete primary education are the least likely to have received HIV testing results in the past 12 months (9 percent). HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 211 Table 14.10.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Namibia 2006-07 Percent distribution of women by testing status and whether they received the results of the last test Background characteristic Percentage who know where to get an HIV test Ever tested and received results Ever tested, did not receive results Never tested1 Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of women Age 15-24 90.2 36.8 3.1 60.1 100.0 39.9 23.2 4,101 15-19 86.4 17.5 1.8 80.7 100.0 19.3 12.8 2,246 20-24 94.7 60.2 4.7 35.1 100.0 64.9 35.8 1,855 25-29 93.9 68.5 3.8 27.7 100.0 72.3 40.0 1,623 30-39 93.0 64.4 4.8 30.8 100.0 69.2 32.9 2,462 40-49 90.7 48.4 4.5 47.1 100.0 52.9 24.2 1,618 Marital status Never married 92.0 44.1 2.9 53.1 100.0 46.9 25.4 5,676 Ever had sex 94.2 57.1 3.8 39.1 100.0 60.9 32.5 4,087 Never had sex 86.3 10.6 0.5 88.9 100.0 11.1 7.0 1,589 Married or living together 91.0 61.3 5.4 33.3 100.0 66.7 33.8 3,451 Divorced/separated/ widowed 90.9 55.0 4.6 40.4 100.0 59.6 28.9 678 Residence Urban 94.5 59.6 3.3 37.2 100.0 62.8 33.1 4,772 Rural 88.8 42.7 4.4 52.9 100.0 47.1 24.3 5,032 Region Caprivi 89.0 35.8 4.2 60.1 100.0 39.9 17.2 474 Erongo 97.1 61.6 4.5 33.9 100.0 66.1 36.4 688 Hardap 90.1 46.6 4.7 48.7 100.0 51.3 20.3 315 Karas 96.8 55.3 7.6 37.1 100.0 62.9 24.7 318 Kavango 82.4 45.0 4.9 50.0 100.0 50.0 26.0 934 Khomas 94.8 63.4 2.8 33.8 100.0 66.2 34.6 2,218 Kunene 80.5 42.9 3.7 53.4 100.0 46.6 25.3 259 Ohangwena 90.4 41.1 3.6 55.3 100.0 44.7 23.7 1,043 Omaheke 86.8 45.2 6.6 48.2 100.0 51.8 24.5 373 Omusati 93.4 44.3 3.0 52.7 100.0 47.3 25.9 975 Oshana 92.1 51.7 4.1 44.2 100.0 55.8 32.0 819 Oshikoto 94.0 47.5 2.9 49.6 100.0 50.4 28.6 837 Otjozondjupa 90.5 51.7 4.6 43.6 100.0 56.4 28.7 550 Education No education 67.0 34.4 5.2 60.4 100.0 39.6 18.9 651 Incomplete primary 85.9 43.0 5.5 51.4 100.0 48.6 22.7 1,699 Complete primary 89.6 47.8 3.4 48.7 100.0 51.3 26.1 736 Incomplete secondary 94.4 47.8 3.3 48.9 100.0 51.1 27.1 4,751 Complete secondary 98.7 68.4 3.9 27.8 100.0 72.2 37.8 1,286 More than secondary 98.0 78.3 3.3 18.4 100.0 81.6 47.9 682 Wealth quintile Lowest 83.8 38.5 4.7 56.8 100.0 43.2 21.4 1,621 Second 88.6 42.3 4.1 53.6 100.0 46.4 24.9 1,668 Middle 90.3 47.2 4.6 48.2 100.0 51.8 27.9 1,885 Fourth 95.2 57.6 2.8 39.6 100.0 60.4 31.1 2,292 Highest 96.7 62.0 3.7 34.3 100.0 65.7 34.1 2,338 Total 15-49 91.6 50.9 3.9 45.2 100.0 54.8 28.6 9,804 1 Includes “don't know/missing” 212 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.10.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Namibia 2006-07 Percent distribution of men testing status and by whether they received the results of the last test Background characteristic Percentage who know where to get an HIV test Ever tested and received results Ever tested, did not receive results Never tested1 Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of men Age 15-24 82.9 17.0 1.2 81.8 100.0 18.2 10.5 1,661 15-19 77.1 7.5 1.1 91.3 100.0 8.7 5.7 910 20-24 90.0 28.4 1.3 70.3 100.0 29.7 16.3 750 25-29 89.5 40.4 2.4 57.2 100.0 42.8 23.7 702 30-39 92.1 42.6 3.9 53.4 100.0 46.6 21.5 986 40-49 88.3 47.2 2.7 50.0 100.0 50.0 24.1 567 Marital status Never married 85.6 24.7 1.6 73.6 100.0 26.4 14.8 2,547 Ever had sex 89.0 29.7 2.0 68.3 100.0 31.7 17.5 2,014 Never had sex 72.5 5.8 0.3 93.9 100.0 6.1 4.3 533 Married or living together 90.8 46.2 3.5 50.4 100.0 49.6 22.8 1,205 Divorced/separated/ widowed 86.5 41.1 4.6 54.3 100.0 45.7 22.8 163 Residence Urban 94.8 42.5 3.4 54.1 100.0 45.9 23.1 1,962 Rural 79.6 21.5 1.2 77.3 100.0 22.7 12.0 1,953 Region Caprivi 79.1 19.5 0.0 80.5 100.0 19.5 9.5 189 Erongo 94.8 47.1 4.1 48.8 100.0 51.2 27.5 362 Hardap 90.0 29.1 4.7 66.2 100.0 33.8 15.0 132 Karas 95.1 40.8 3.5 55.8 100.0 44.2 23.1 157 Kavango 81.0 17.1 2.8 80.1 100.0 19.9 7.8 331 Khomas 96.0 44.0 3.4 52.6 100.0 47.4 23.0 984 Kunene 75.8 27.8 2.7 69.5 100.0 30.5 14.6 92 Ohangwena 72.7 19.6 0.4 80.0 100.0 20.0 12.6 306 Omaheke 81.3 28.2 1.7 70.1 100.0 29.9 16.4 188 Omusati 89.0 22.6 0.7 76.7 100.0 23.3 13.1 320 Oshana 90.9 32.6 1.3 66.2 100.0 33.8 20.2 270 Oshikoto 82.1 23.8 1.0 75.2 100.0 24.8 16.3 322 Otjozondjupa 76.8 29.9 2.3 67.8 100.0 32.2 11.4 262 Education No education 65.8 16.2 1.8 82.0 100.0 18.0 10.3 360 Incomplete primary 75.3 23.8 2.1 74.1 100.0 25.9 12.7 856 Complete primary 85.0 21.6 1.8 76.6 100.0 23.4 9.2 252 Incomplete secondary 92.8 28.6 1.6 69.7 100.0 30.3 16.6 1,604 Complete secondary 97.9 52.9 2.0 45.1 100.0 54.9 27.1 538 More than secondary 99.8 63.5 8.2 28.4 100.0 71.6 35.3 305 Wealth quintile Lowest 73.6 13.1 0.7 86.2 100.0 13.8 8.2 560 Second 77.8 16.2 1.7 82.2 100.0 17.8 9.6 607 Middle 84.9 28.8 1.3 69.9 100.0 30.1 14.3 875 Fourth 93.3 38.7 2.9 58.3 100.0 41.7 21.6 963 Highest 97.7 50.2 4.1 45.7 100.0 54.3 27.5 911 Total 15-49 87.2 32.0 2.3 65.7 100.0 34.3 17.6 3,915 1 Includes 'don't know/missing' 14.8.1 HIV Testing and Counselling for Pregnant Women One of the tragic consequences of HIV infection in women is the transmission of the virus to their children. This can occur during pregnancy, at the time of delivery, or through breastfeeding. Worldwide, the effects of mother-to-child transmission (MTCT) of HIV are staggering, with more than two million children currently infected and almost 2,000 new infant infections occurring every day. The Namibian Government seeks to strengthen health systems and communities to deliver HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 213 prevention of MTCT (PMTCT) services to women through support for a wide variety of complementary interventions. These interventions include improvement of antenatal care services, voluntary HIV counselling and testing (VCT) for pregnant women and their spouses, administration of antiretroviral drug prophylaxis for HIV-positive pregnant women, and support for safer infant feeding practices. PMTCT programmes promoted by the Ministry of Health and Social Services also provide psychosocial, clinical, and nutritional support to women and men who are identified as HIV- positive in the course of PMTCT programmes. By the end of 2006, all 34 hospitals, state and faith-based organizations, about 178 health facilities were providing PMTCT services, and about 859 health workers were trained in the provision of such services. About 68,800 pregnant women had been seen at PMTCT sites as of March 2006. About 88 percent of pretest counselled women took the HIV test, and the HIV prevalence rate among tested women was recorded as 17 percent (MoHSS, 2004). Table 14.11 shows that among women who gave birth in the two years preceding the survey, 73 percent received HIV counselling during antenatal care for their most recent birth, and practically all of these women received the results of the test. The majority of women who were tested (62 percent) voluntarily accepted an offer for the HIV test and received the test results. The proportion of women who received the test and test results increases with age through age 29, then declines among women age 30 and older. Better educated women are more likely than less educated women to have been tested for HIV. Urban women are more likely than rural women to have been counselled, tested, and received the results (66 percent of and 59 percent, respectively). Table 14.11 Pregnant women counselled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received HIV counselling during antenatal care for their most recent birth, and percentage who accepted an offer of HIV testing by whether they received their test results, according to background characteristics, Namibia 2006-07 Percentage who were offered and accepted an HIV test during antenatal care and who: Background characteristic Percentage who received HIV counselling during antenatal care1 Received results Did not receive results Percentage who were counselled, were offered and accepted an HIV test, and who received results2 Number of women who gave birth in the past two years3 Age 15-24 72.5 75.0 3.7 62.6 818 15-19 66.7 70.7 4.4 56.1 234 20-24 74.8 76.7 3.5 65.2 584 25-29 75.4 75.6 2.6 66.0 490 30-39 74.1 69.2 5.8 59.8 630 40-49 63.9 60.4 3.4 50.6 116 Residence Urban 74.9 80.3 2.8 66.3 824 Rural 72.0 67.3 4.9 58.9 1,230 Region Caprivi 73.6 52.1 10.6 44.8 110 Erongo 74.8 81.2 1.7 64.1 111 Hardap 74.2 80.4 1.6 69.6 62 Karas 78.1 72.6 6.6 61.2 57 Kavango 61.0 58.1 5.9 47.7 291 Khomas 76.8 86.2 4.1 70.0 365 Kunene 53.3 49.4 3.3 45.2 73 Ohangwena 81.7 74.4 3.7 67.5 235 Omaheke 50.7 54.1 3.4 37.4 106 Omusati 80.7 80.8 1.0 71.7 193 Oshana 85.5 86.4 1.5 79.5 136 Oshikoto 76.9 75.8 2.9 69.1 172 Otjozondjupa 71.3 66.7 6.8 57.2 144 Continued… 214 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.11—Continued Percentage who were offered and accepted an HIV test during antenatal care and who: Background characteristic Percentage who received HIV counselling during antenatal care1 Received results Did not receive results Percentage who were counselled, were offered and accepted an HIV test, and who received results2 Number of women who gave birth in the past two years3 Education No education 42.1 41.0 4.6 31.4 223 Incomplete primary 66.7 64.9 5.4 53.3 407 Complete primary 81.5 70.5 5.7 63.4 170 Incomplete secondary 80.8 79.6 2.7 70.3 921 Complete secondary 75.5 86.4 3.8 69.5 244 More than secondary 80.3 79.5 8.4 66.5 91 Total 15-49 73.2 72.5 4.1 61.9 2,054 1 In this context, "counselled" means that someone talked with the respondent about all three of the following topics: 1) babies getting the AIDS virus from their mother, 2) preventing the virus, and 3) getting tested for the virus 2 Only women who were offered the test are included here; women who were either required or asked for the test are excluded from the numerator of this measure 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years 14.8.2 Male Circumcision Recent research in sub-Saharan Africa found that safe male circumcision can reduce a man’s chances of becoming infected with HIV. Three randomized controlled trials were conducted in which men with a foreskin were randomly assigned to either receive circumcision or not, and then followed over time to see if one group had a higher rate of acquiring HIV. The risk reduction for circumcised men was about 60 percent, i.e., six of ten infections could have been prevented by circumcising men (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). The World Health Organization (WHO) estimates that in countries of southern and eastern Africa with the highest HIV prevalence, male circumcision rates are generally under 20 percent (WHO, 2006). A Social Marketing Association (SMA) survey in 2004 of the National Defence Forces found that 26 percent of the interviewed soldiers were circumcised (this estimate is not necessarily representative of the Namibian male population). Table 14.12 shows that 21 percent of men age 15-49 have been circumcised. Among men who reported being circumcised, 84 percent were circumcised as a child (below 13 years old). Older men, men who live in urban areas, and those with higher education are more likely than other men to have been circumcised. The practice of circumcising men is most often found in Omahake and Kunene, where more than half of men are circumcised. In three other regions, Otjozondjupa, Kavango, and Khomas, male circumcision rates are also high (42 percent, 30 percent, and 27 percent, respectively). Seven in ten men who were circumcised in childhood had the operation performed by a health professional and one in four was performed by a traditional healer (data not shown). HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 215 Table 14.12 Male circumcision Percentage of men age 15-49 who reported being circumcised and among circumcised men, percentage who were circumcised by specific ages and percentage who were circumcised by specific persons, by background characteristics, Namibia 2006-07 Person who performed circumcision Age at circumcision Background characteristic Percentage circum- cised Number of men Below 13 13-19 20+ Missing Tradi- tional healer Health profes- sional Don't know/ missing Number of circumcised men Age 15-24 19.0 1,661 92.1 7.5 0.4 0.0 6.0 1.9 0.0 315 15-19 16.6 910 93.9 6.1 0.0 0.0 4.7 1.3 0.0 151 20-24 21.9 750 90.4 8.9 0.7 0.0 7.1 2.5 0.0 164 25-29 21.7 702 85.2 11.5 2.6 0.7 2.8 10.6 1.4 152 30-39 23.2 986 76.7 9.2 14.1 0.0 3.4 19.6 0.4 228 40-49 22.2 567 76.2 4.6 19.0 0.2 2.1 21.4 0.2 126 Residence Urban 25.9 1,962 81.4 8.8 9.6 0.2 4.2 14.1 0.3 507 Rural 16.1 1,953 88.5 7.4 4.0 0.1 3.9 7.1 0.5 314 Region Caprivi 6.3 189 * * * * * * * 12 Erongo 18.7 362 71.2 16.3 12.5 0.0 4.5 24.4 0.0 68 Hardap 6.5 132 * * * * * * * 9 Karas 9.3 157 (63.2) (15.8) (20.9) (0.0) (2.5) (31.6) (2.6) 15 Kavango 30.5 331 71.1 21.7 7.1 0.0 15.9 12.9 0.0 101 Khomas 26.6 984 84.3 5.4 10.1 0.3 2.4 13.1 0.3 262 Kunene 52.2 92 92.2 4.0 3.8 0.0 3.9 3.9 0.0 48 Ohangwena 0.6 306 * * * * * * * 2 Omaheke 56.7 188 97.2 2.1 0.7 0.0 1.8 1.0 0.0 107 Omusati 7.9 320 * * * * * * * 25 Oshana 14.1 270 81.5 10.6 7.9 0.0 2.4 12.0 4.1 38 Oshikoto 8.3 322 (82.6) (3.2) (14.2) (0.0) (0.0) (17.4) (0.0) 27 Otjozondjupa 41.6 262 97.9 2.1 0.0 0.0 0.8 1.3 0.0 109 Education No education/preschool 26.1 360 86.0 10.9 2.7 0.3 10.3 3.4 0.3 94 Incomplete primary 14.7 856 79.4 10.0 10.5 0.0 4.9 15.0 0.7 126 Complete primary 15.5 252 (78.9) (4.4) (15.8) (0.9) (4.1) (16.0) (0.9) 39 Incomplete secondary 20.2 1,604 85.0 8.4 6.4 0.2 4.5 10.1 0.4 324 Complete secondary 24.4 538 84.7 9.2 6.0 0.0 1.2 13.8 0.3 131 More than secondary 35.2 305 86.3 3.8 9.9 0.0 0.0 13.7 0.0 107 Total 15-49 21.0 3,915 84.1 8.3 7.5 0.2 4.1 11.4 0.4 821 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 14.8.3 Self-Reporting of Sexually Transmitted Infections (STI) In Namibia, about 80,000 people were treated for new sexually transmitted infections (STIs) in the 2005-06 fiscal year. STIs remain a major challenge in the prevention of primary and secondary infections with HIV. Namibia has experienced a heavy STI burden that ranks 8th among all hospital consultations. Syndromic management was introduced in 1995 as an intervention for STI control. However, because of the lack of human resources and capacity, implementation has not gone as smoothly as anticipated, and the training and supervision of health workers providing STI services has been weak. There was a decline in urethral discharge syndrome cases during the period 1995 to 2001. The number of urethral discharge and genital ulcer disease cases remained stable over the period 2002- 2005. There has been a steady increase of reported cases of vaginal discharge and pelvic inflammatory disease (PID); however, these syndromes are less specific for the presence of STI. Vaginal discharge syndrome (VD) and PID remain the predominant syndromes (showing the highest number of cases) compared with the other five syndromes. 216 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour In the 2006-07 NDHS, respondents who had ever had sexual intercourse were asked if they had had a disease in the past 12 months that was contracted through sexual contact, or if they had ever experienced either of two symptoms associated with STIs (bad-smelling, abnormal discharge from the vagina/penis or a genital sore or ulcer). Table 14.13 shows the self-reported prevalence of STIs and STI symptoms for men and women. Table 14.13 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Namibia 2006-07 Women Men Percentage of women who reported having in the past 12 months: Percentage of men who reported having in the past 12 months: Background characteristic STI Bad - smelling/ abnormal genital discharge Genital sore/ ulcer STI/ genital discharge/ sore or ulcer Number of women who ever had sexual intercourse STI Bad- smelling/ abnormal genital discharge Genital sore/ ulcer STI/ genital discharge/ sore or ulcer Number of men who ever had sexual intercourse Age 15-24 2.6 5.2 3.1 7.5 2,619 1.0 1.1 1.7 2.8 1,160 15-19 2.2 5.7 3.3 7.7 972 0.9 1.2 1.9 2.9 471 20-24 2.9 4.9 2.9 7.4 1,647 1.1 1.0 1.5 2.7 689 25-29 3.3 5.8 3.0 8.0 1,558 2.7 1.8 1.4 4.0 686 30-39 3.6 5.1 2.7 7.7 2,431 1.8 1.8 1.9 3.7 978 40-49 2.9 4.0 3.0 6.3 1,606 2.5 2.1 2.3 4.7 559 Marital status Never married 2.8 4.6 2.7 6.5 4,085 1.6 1.3 1.6 3.2 2,014 Married or living together 3.2 5.5 2.9 7.9 3,451 2.1 1.7 2.2 3.9 1,205 Divorced/separated/widowed 4.2 5.6 4.7 10.2 678 2.9 4.8 1.6 5.5 163 Male circumcision Circumcised na na na na 0 2.8 2.7 1.7 5.0 768 Not circumcised na na na na 0 1.6 1.3 1.8 3.2 2,610 Residence Urban 3.1 6.2 3.1 8.6 4,100 1.9 1.4 1.3 3.3 1,779 Rural 3.1 3.9 2.8 6.2 4,114 1.7 1.8 2.4 3.9 1,604 Region Caprivi 0.1 2.3 0.2 2.3 440 3.0 3.1 5.5 6.5 179 Erongo 3.0 6.0 3.0 8.4 604 2.6 1.6 1.5 4.0 334 Hardap 3.3 6.2 1.3 8.8 267 1.5 2.6 0.3 3.5 111 Karas 3.2 4.9 0.2 5.9 278 2.8 1.8 2.2 3.1 131 Kavango 2.3 2.2 4.1 5.9 865 0.3 0.9 1.3 2.3 291 Khomas 3.1 7.7 3.0 10.1 1,892 2.0 1.2 0.7 2.7 898 Kunene 7.5 9.9 7.5 12.9 241 2.5 3.6 2.7 5.9 84 Ohangwena 3.4 3.7 3.2 6.0 776 2.0 1.9 1.3 3.3 200 Omaheke 4.5 9.2 3.7 12.0 335 1.0 1.6 2.5 4.1 174 Omusati 2.0 2.4 1.8 4.2 723 1.7 1.7 2.1 4.3 262 Oshana 2.4 2.1 2.1 4.4 625 0.4 1.0 0.3 1.8 220 Oshikoto 2.3 3.4 2.3 5.2 662 2.1 1.8 3.6 5.4 258 Otjozondjupa 6.8 7.1 5.8 11.2 506 2.3 1.4 3.0 4.3 239 Education No education 3.0 4.9 3.5 7.1 631 1.1 1.8 2.4 3.3 331 Incomplete primary 4.3 5.5 4.6 9.1 1,545 1.8 2.8 3.5 5.7 714 Complete primary 3.7 6.5 4.3 7.8 595 4.3 4.3 1.8 5.5 182 Incomplete secondary 3.1 4.8 2.5 7.2 3,694 1.8 1.3 1.5 3.2 1,364 Complete secondary 2.0 5.4 2.0 7.0 1,124 1.8 0.6 0.6 2.5 490 More than secondary 1.7 3.5 1.4 5.3 625 1.3 0.0 0.2 1.5 302 Total 15-49 3.1 5.0 2.9 7.4 8,214 1.8 1.6 1.8 3.6 3,382 na = Not applicable Three percent of women and 2 percent of men age 15-49 reported having an STI in the past 12 months, while 7 percent of women and 4 percent of men reported having STI as well as symptoms suggestive of STIs in the past 12 months. Among women, there are small variations in reported STIs and symptoms of STIs in the past 12 months by background characteristics, except by region. Across regions, the infection ranges from 2 percent in Caprivi to 13 percent in Kunene. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 217 Among men, the prevalence of reported STIs and symptoms of STIs is lower than that reported by women. There are small variations across subgroups of men. It is interesting to note that Caprivi has the highest prevalence of reported STIs or STI symptoms among men (7 percent) and the lowest prevalence among women (2 percent). Additionally, STIs and the symptoms of STIs are more likely to be reported by men who have been circumcised than by men who have not been circumcised (5 percent compared with 3 percent). Respondents who had an STI or symptoms of an STI, were asked if they sought advice or treatment from any source. The findings are presented in Figure 14.3. More than 60 percent of women and men with STIs/symptoms of STIs in the past 12 months sought advice or treatment from a clinic, hospital, private doctor, or other health professional. Only a small percentage sought medical advice or treatment from other sources. About one in four respondents did not seek any professional medical assistance. 14.8.4 Prevalence of Medical Injections Health care workers have a low but measurable risk of HIV infection resulting from acci- dental exposure to infected blood or body fluids. Conversely, situations may exist where the health care worker is a potential source of HIV infection to patients, whereby patients are exposed to the blood or body fluids of an infected health care worker. Based on international epidemiological studies, CDC guidelines state that the overall risk of nosocomial transmission of HIV after a needle stick from an HIV seropositive source is estimated at 0.1 to 0.3 percent. As a result, HIV attributable to occupational exposure is uncommon (CDC, 1999). Non-sterile injections can pose a risk of infection with HIV and other diseases. To measure the potential risk of transmission of HIV associated with medical injections, women and men who were interviewed in the 2006-07 NDHS were asked if they had received an injection in the past 12 months and, if so, the number of injections. They were also asked whether, for the last injection, the needle and syringe were taken from a new, unopened package. 62 3 25 61 1 25 Clinic/hospital/ private doctor/ other health prof Advice or medicine from shop/pharmacy/ other sourc No advice or treatment 0 20 40 60 80 Percent Women Men Figure 14.3 Women and Men Seeking Treatment for STIs NDHS 2006-07 professional Advice or medicine from shop/pharmacy/ other source 218 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.14 shows that 31 percent of women and 18 percent of men received at least one medical injection in the past 12 months. On average, women received four injections and men received three. Urban women were more likely than rural women to receive medical injections in the past 12 months (34 percent compared with 28 percent), but medical injections for urban men were considerably higher than those for rural men (22 percent compared with 13 percent). Table 14.14 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Namibia 2006-07 Women Men Background characteristic Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the past 12 months Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of men For last injection, syringe and needle taken from a new, unopened package Number of men receiving medical injections in the past 12 months Age 15-24 32.9 2.9 4,101 96.6 1,349 14.0 2.5 1,661 91.7 233 15-19 32.1 2.5 2,246 96.8 721 14.7 2.7 910 92.2 133 20-24 33.9 3.3 1,855 96.4 628 13.3 2.3 750 91.2 100 25-29 30.6 3.7 1,623 97.9 497 16.0 3.4 702 98.6 112 30-39 30.1 4.1 2,462 97.2 742 20.7 2.7 986 96.1 204 40-49 27.0 4.6 1,618 97.0 437 23.8 2.9 567 97.8 135 Residence Urban 33.5 3.8 4,772 97.7 1,599 22.4 2.7 1,962 95.5 439 Rural 28.3 3.2 5,032 96.3 1,426 12.5 3.0 1,953 95.1 245 Region Caprivi 41.2 3.2 474 98.8 196 20.0 4.5 189 (100.0) 38 Erongo 40.6 4.5 688 97.6 279 21.6 2.5 362 97.4 78 Hardap 34.7 3.6 315 98.7 109 18.6 2.3 132 (93.5) 25 Karas 23.0 4.0 318 100.0 73 17.6 2.4 157 (95.8) 28 Kavango 26.4 4.0 934 93.9 247 10.8 3.1 331 (91.5) 36 Khomas 33.8 3.6 2,218 98.8 750 25.9 2.4 984 93.9 254 Kunene 40.3 4.1 259 93.4 105 19.2 2.5 92 (100.0) 18 Ohangwena 28.6 2.4 1,043 95.6 299 5.0 2.6 306 * 15 Omaheke 32.2 4.2 373 97.2 120 20.1 2.9 188 (100.0) 38 Omusati 23.8 3.0 975 94.5 232 5.7 3.5 320 * 18 Oshana 22.0 3.0 819 95.4 180 8.8 1.7 270 (94.2) 24 Oshikoto 28.6 3.1 837 99.6 239 19.2 4.3 322 97.1 62 Otjozondjupa 35.6 4.4 550 94.8 195 19.4 2.8 262 97.0 51 Education No education 20.0 4.0 651 92.8 130 7.0 1.4 360 (94.6) 25 Incomplete primary 27.6 3.1 1,699 94.3 469 14.6 2.6 856 95.4 125 Complete primary 29.2 2.7 736 98.2 215 19.6 2.2 252 (100.0) 49 Incomplete secondary 32.4 3.6 4,751 97.6 1,540 17.6 3.1 1,604 92.4 282 Complete secondary 32.4 3.9 1,286 98.4 417 21.7 2.7 538 98.9 116 More than secondary 37.2 3.9 682 97.3 254 28.4 3.0 305 97.6 87 Wealth quintile Lowest 28.1 3.3 1,621 96.3 456 9.6 4.1 560 94.8 54 Second 26.4 3.2 1,668 94.3 440 10.3 2.6 607 97.6 62 Middle 28.8 3.3 1,885 96.4 543 13.6 2.5 875 94.2 119 Fourth 33.6 3.5 2,292 97.8 771 19.5 2.8 963 92.2 188 Highest 34.9 4.1 2,338 98.6 816 28.6 2.7 911 97.7 261 Total 15-49 30.9 3.6 9,804 97.0 3,025 17.5 2.8 3,915 95.4 684 Note : Medical injections are those given by a doctor, nurse, pharmacist, dentist or other health worker. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 219 Almost all women and men who received a medical injection in the past 12 months said that for the last injection, the syringe and needle were taken from a new, unopened package (97 percent of women and 95 percent of men). For women, there were no substantial variations in this indicator. However, for men the proportion who reported safe injection practices ranged from 75 percent in Ohangwena to 100 percent in Caprivi, Kunene, Omaheke, and Omusati. Figure 14.4 shows the percent distribution of women and men who received a medical injection in the past 12 months by type of facility where the injection was received. The majority of injections were received in public sector facilities (77 percent for women and 70 percent for men), while 15 percent of women and 30 percent of men received the injection in a private medical facility. Women are more likely to report that the injection was received in a health centre (42 percent), while men are more likely to report that the last injection was received in a government hospital (54 percent). Figure 14.5 shows, for women and men who received medical injections in the past 12 months, the percentage whose last injection was given with a syringe and needle taken from a new, unopened package, by type of facility where the last injection was received. Overall, most public and private sector facilities practice safe injections (at least 90 percent). The lowest level of safe injections was reported by women attending other private medical facilities (49 percent). Figure 14.4 Type of Facility Where Last Medical Injection Was Received 81 33 42 5 1 15 14 1 0 4 70 54 15 0 1 29 26 1 1 2 PUBLIC SECTOR Government hospital Government health centre PHC mobile Other public PRIVATE MEDICAL Private hospital/clinic/doctor Dental clinic/office Pharmacy OTHER 0 20 40 60 80 100 Percent Women Men NDHS 2006-07 220 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 14.9 HIV KNOWLEDGE AND SEXUAL BEHAVIOUR AMONG YOUTH 14.9.1 Comprehensive HIV/AIDS Knowledge and Source of Condoms among Youth Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. In Namibia, the most common local misconceptions are that AIDS can be transmitted by mosquito bites and that a person can become infected by sharing food with a person who has AIDS. Table 14.15 addresses HIV/AIDS-related comprehensive knowledge of HIV/AIDS among persons age 15-24 years, and knowledge of a condom source. Condom use among young adults plays an important role in the prevention of HIV and other sexually transmitted infections, as well as unwanted pregnancies. Knowledge of a source for condoms is a proxy for assessing the ability of young adults to obtain and use condoms. Young respondents were asked the same set of questions on facts and beliefs about HIV transmission as other respondents. Information on the level of knowledge of the major ways to avoid HIV and the level of rejection of major misconceptions about HIV are shown in Tables 14.2, 14.3.1, and 14.3.2. Young women have a slightly higher level of comprehensive knowledge of AIDS than young men (65 percent compared with 62 percent). Knowledge increases with age; for example, comprehensive knowledge of AIDS among women and men age 15-17 is lowest (61 percent for women and 55 percent for men) compared with 68 and 66 for those in the 20-24 age group. Comprehensive knowledge of AIDS is highest among women and men who have ever had sexual intercourse (68 and 66 percent, respectively) and lowest among ever-married women (53 percent) and men who have never had sex (53 percent). While for young women there is no difference in comprehensive knowledge of AIDS between urban and rural areas (both 65 percent), urban men have a much higher level of comprehensive knowledge than their rural counterparts (68 percent and 58 percent, respectively). Figure 14.5 Percentage of Men and Women Whose Last Injection Was Given with a Syringe and Needle Taken From a New, Unopened Package, by Type of Facility Where Last Injection Was Received PUBLIC SECTOR Government hospital Government health centre Other public PRIVATE MEDICAL Private hospital/clinic/doctor Dental clinic/office Pharmacy Office or home of nurse/health worker Other private medical Other place at home 0 20 40 60 80 100 Percent Women Men NDHS 2006-07 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 221 Less than 50 percent of women in Caprivi, Kunene, and Omaheke have comprehensive knowledge of AIDS. Similarly, less than 50 percent of young men in Ohangwena, Omaheke, and Oshana have comprehensive knowledge of AIDS transmission and prevention. The level of comprehensive knowledge increases with level of education. While 33 percent of women with no education have comprehensive knowledge of AIDS, the corresponding percentage for women with secondary or higher education is 74 percent. For women and men, the differences by wealth quintiles are not significant. Table 14.15 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Namibia 2006-07 Women age 15-24 Men age 15-24 Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a source for condoms2 Number of women Percentage with comprehensive knowledge of AIDS1 Percentage who know a source for condoms 2 Number of men Age 15-19 62.2 86.2 2,246 58.5 88.1 910 15-17 61.2 83.4 1,365 55.1 85.0 553 18-19 63.6 90.4 881 63.7 93.0 357 20-24 68.2 93.1 1,855 66.0 95.0 750 20-22 68.8 93.0 1,160 67.9 94.1 473 23-24 67.2 93.2 696 62.7 96.6 277 Marital status Never married 66.9 89.9 3,531 61.7 91.0 1,561 Ever had sex 68.0 94.5 2,051 65.7 96.7 1,060 Never had sex 65.2 83.6 1,480 53.3 79.1 500 Ever married 52.8 85.5 570 64.3 94.4 100 Residence Urban 65.4 94.5 1,840 67.5 97.4 716 Rural 64.5 85.1 2,261 57.6 86.5 945 Region Caprivi 49.0 94.9 214 70.6 96.1 63 Erongo 56.5 97.1 239 63.5 97.4 103 Hardap 61.6 96.4 129 79.2 97.0 50 Karas 61.4 97.0 103 66.0 96.8 56 Kavango 53.8 81.6 450 77.6 94.2 162 Khomas 70.6 93.8 839 67.9 96.7 352 Kunene 35.1 89.7 92 59.1 92.4 35 Ohangwena 72.4 82.2 526 34.5 68.0 188 Omaheke 45.8 97.3 151 43.5 95.6 76 Omusati 71.6 85.2 444 77.3 90.9 173 Oshana 74.8 83.9 357 41.4 88.6 140 Oshikoto 73.8 90.7 374 64.5 92.5 173 Otjozondjupa 55.1 93.0 183 60.5 93.8 89 Education No education 33.2 64.3 121 39.6 73.8 85 Incomplete primary 49.2 72.2 498 45.2 79.0 331 Complete primary 59.9 82.8 335 63.3 90.7 141 Incomplete secondary 68.5 92.9 2,510 67.3 95.8 858 Complete secondary 71.0 96.4 495 72.2 98.5 194 More than secondary 74.3 97.3 142 (72.1) (97.6) 51 Wealth quintile Lowest 61.3 78.9 743 54.8 82.3 279 Second 68.1 85.5 741 59.1 85.5 322 Middle 60.0 88.0 799 58.2 89.5 377 Fourth 65.2 95.1 900 68.9 98.1 324 Highest 69.3 96.3 918 67.4 99.0 359 Total 64.9 89.3 4,101 61.9 91.2 1,661 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 2 Friends, family members, and home are not considered a source for condoms. 222 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 14.9.2 Age at First Sex Since HIV transmission in Namibia occurs predominantly through heterosexual intercourse between an infected and a non-infected person, age at first intercourse marks the time at which most individuals first risk exposure to the AIDS virus. Table 14.16 shows that 7 percent of young women and 18 percent of young men age 15-24 had sexual intercourse before age 15. Almost half of women and 59 percent of men age 18-24 had their first sexual experience by age 18. In general, young people in rural areas have sex at an earlier age than those in urban areas. Table 14.16 Age at first sexual intercourse among youth Percentage of young women and young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Namibia 2006-07 Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Background characteristic Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 7.4 2,246 na na 19.2 910 na na 15-17 8.0 1,365 na na 19.6 553 na na 18-19 6.5 881 49.8 881 18.6 357 61.1 357 20-24 6.5 1,855 43.8 1,855 16.6 750 58.4 750 20-22 6.5 1,160 44.4 1,160 16.1 473 57.2 473 23-24 6.6 696 42.8 696 17.5 277 60.5 277 Marital status Never married 5.3 3,530 41.0 2,211 18.5 1,561 58.6 1,009 Ever married 17.7 571 65.8 525 11.3 100 66.0 98 Knows source for condoms1 Yes 7.0 3,662 46.0 2,524 18.7 1,515 60.5 1,045 No 7.3 438 42.5 212 11.1 146 39.1 62 Residence Urban 5.4 1,840 41.6 1,285 18.8 716 58.0 523 Rural 8.3 2,261 49.4 1,451 17.5 945 60.4 585 Region Caprivi 17.8 214 70.8 151 35.1 63 68.6 45 Erongo 2.7 239 38.4 172 18.9 103 46.6 75 Hardap 6.7 129 37.2 86 9.5 50 41.8 34 Karas 0.5 103 34.4 74 12.1 56 51.5 38 Kavango 18.9 450 68.0 308 29.0 162 76.3 104 Khomas 4.3 839 40.8 606 17.9 352 59.7 264 Kunene 12.5 92 59.4 57 13.2 35 (63.8) 26 Ohangwena 4.6 526 36.7 305 16.8 188 48.2 95 Omaheke 13.0 151 57.6 95 19.7 76 69.5 57 Omusati 1.5 444 33.3 277 13.5 173 66.4 113 Oshana 3.6 357 32.9 234 12.7 140 47.3 92 Oshikoto 5.9 374 46.5 233 18.7 173 57.8 94 Otjozondjupa 8.9 183 62.4 138 12.7 89 63.4 72 Education No education 25.7 121 66.4 99 20.3 85 59.4 68 Incomplete primary 15.8 498 63.6 289 16.5 331 54.8 186 Complete primary 12.0 335 66.9 165 16.0 141 69.8 56 Incomplete secondary 5.4 2,510 46.5 1,581 17.9 858 60.3 565 Complete secondary 0.5 495 28.8 461 17.0 194 53.1 181 More than secondary 0.6 142 17.1 142 35.9 51 73.6 51 Wealth quintile Lowest 11.1 743 58.6 458 20.6 279 60.1 168 Second 7.4 741 45.1 464 20.0 322 63.8 182 Middle 11.2 799 50.7 534 15.6 377 59.8 274 Fourth 3.5 900 44.0 679 13.1 324 58.0 233 Highest 3.3 918 34.0 602 21.3 359 56.1 251 Total 15-24 7.0 4,101 45.7 2,736 18.0 1,661 59.3 1,108 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not available 1 Friends, family members, and home are not considered a source for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 223 Across regions, young people in Kavango and Caprivi are the most likely to have had sexual debut by age 15. For example, 18 percent of women age 15-24 in Caprivi had sex before age 15, and 71 percent of women age 18-24 had sex before age 18. For men, Caprivi has the highest percentage of young men who had sexual intercourse before the age of 15 years (35 percent). On the other hand, women in Karas and men in Hardap are the least likely to have sex by age 15 (less than 1 percent and 10 percent, respectively). The age at first sex increases with level of education, especially among women. Whereas more than one in four women age 15-24 with no education have had sex by age 15, less than 1 percent of women who completed secondary education have had sex by the same age. Figure 14.6 shows trends in age at first sex across two surveys: the 2000 NDHS and the 2006- 07 NDHS. The proportion of women age 15-19 who had sex by exact age 15 has declined slightly from 10 percent in 2000 to 7 percent in 2006-07. For men, the corresponding decline is sharper, from 31 percent to 19 percent. For women age 18-19, the proportion who had sex by age 18 declined from 59 percent in 2000 to 50 percent in 2006-07. The proportion for men is 74 and 61 percent, respectively. 14.9.3 Condom Use at First Sex Consistent condom use is advocated by HIV control programmes to reduce the risk of sexual transmission of HIV among sexually active young adults. Young adults who use condoms at first sex are more likely to sustain condom use later in life. Condom use at first sex serves as an indicator of reduced risk of exposure at the beginning of sexual activity. Table 14.17 shows that 60 percent of women and 48 percent of men used condoms at their first sexual intercourse. Women are consistently more likely than men to report condom use; 64 percent of women age 15-19 used a condom at first sexual intercourse compared with 53 percent of men the same age. For those age 20-24, the percentage is 58 percent for women and 44 percent for men. 10 31 59 74 7 19 50 61 0 20 40 60 80 Percent 2000 NDHS 2006-07 NDHS Figure 14.6 Trends in Age at First Sexual Intercourse Namibia 2000 and 2006-07 Percentage of women age 15-19 who had last sexual intercourse before exact age 15 Percentage of men age 15-19 who had last sexual intercourse before exact age 15 Percentage of women age 18-19 who had last sexual intercourse before exact age 18 Percentage of men age 18-19 who had last sexual intercourse before exact age 18 224 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour When comparing urban and rural youth, urban women are much more likely than rural women to report condom use at first sexual intercourse (67 percent compared with 54 percent). Urban men are also more likely to have used a condom at first sexual intercourse compared with rural men (52 percent and 44 percent, respectively). Use of condoms at first sex by women is lowest in Kavango (37 percent) and highest in Khomas (73 percent) and. For men, the percentages are 20 percent in Kavango and 74 percent in Karas. Among young people, there is a positive relationship between level of education and wealth status and use of a condom at first sexual intercourse. Table 14.17 Condom use at first sexual intercourse among youth Among young women and young men age 15-24 who have ever had sexual intercourse, percentage who used a condom the first time they had sexual intercourse, by background characteristics, Namibia 2006-07 Women age 15-24 Men age 15-24 Background characteristic Percentage who used a condom at first sexual intercourse Number of women who have ever had sexual intercourse Percentage who used a condom at first sexual intercourse Number of men who have ever had sexual intercourse Age 15-19 63.9 972 53.0 471 15-17 63.7 398 50.7 220 18-19 64.0 574 55.1 252 20-24 57.8 1,647 44.1 689 20-22 61.9 991 49.1 423 23-24 51.4 657 36.1 266 Marital status Never married 65.9 2,050 47.6 1,060 Ever married 39.0 569 49.6 100 Knows source for condom1 Yes 62.3 2,423 48.3 1,120 No 31.9 196 (32.3) 41 Residence Urban 66.7 1,217 52.2 539 Rural 54.2 1,403 43.9 622 Region Caprivi 52.2 180 30.9 55 Erongo 73.9 161 44.5 77 Hardap 62.1 83 63.3 29 Karas 58.4 67 74.3 34 Kavango 36.7 382 19.8 124 Khomas 72.5 542 54.8 269 Kunene 58.0 74 (47.6) 28 Ohangwena 59.4 270 46.0 89 Omaheke 68.5 112 55.7 63 Omusati 54.5 222 42.9 120 Oshana 64.2 180 67.7 92 Oshikoto 67.7 205 44.7 112 Otjozondjupa 57.2 142 49.4 70 Education No education/preschool 23.0 108 27.6 68 Incomplete primary 35.5 352 42.9 206 Complete primary 45.7 196 43.0 71 Incomplete secondary 65.6 1,503 49.5 620 Complete secondary 73.5 365 60.9 148 More than secondary 83.3 96 40.7 48 Wealth quintile Lowest 42.2 497 25.8 171 Second 53.9 425 46.8 211 Middle 55.6 537 47.5 279 Fourth 67.9 639 53.3 237 Highest 76.8 523 57.9 262 Total 60.0 2,619 47.7 1,160 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Friends, family members, and home are not considered a source for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 225 14.9.4 Abstinence and Premarital Sex Premarital sex and the interval between sexual initiation and marriage are among the factors contributing to the spread of HIV infection. Table 14.18 shows, for never-married women and men age 15-24, i) the percentage who have never had sex, ii) the percentage who had sex in the past 12 months, and iii) the percentage who used a condom at last sexual intercourse, among those who had sexual intercourse in the past 12 months. Table 14.18 Premarital sexual intercourse and condom use among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at last sexual intercourse, by background characteristics, Namibia 2006-07 Never-married women age 15-24 Never-married men age 15-24 Background characteristic Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married women Percentage who used condom at last sexual intercourse Number of women Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married men Percentage who used condom at last sexual intercourse Number of men Age 15-19 60.0 31.7 2,122 67.4 674 48.4 37.2 907 81.1 337 15-17 73.3 21.6 1,319 71.6 285 60.5 26.8 551 79.0 148 18-19 38.2 48.4 803 64.4 389 29.6 53.4 356 82.7 190 20-24 14.7 68.2 1,408 61.0 961 9.4 64.1 654 80.1 419 20-22 18.3 66.5 919 62.7 612 11.6 61.6 437 82.4 269 23-24 8.0 71.5 489 58.1 350 5.1 69.1 217 75.9 150 Knows source for condom1 Yes 39.0 48.9 3,175 65.2 1,553 27.8 52.0 1,421 81.8 738 No 68.2 23.0 356 34.9 82 74.9 13.2 140 * 19 Residence Urban 39.1 49.6 1,594 70.0 791 27.0 53.0 659 87.3 349 Rural 44.3 43.6 1,936 57.7 844 35.8 45.1 902 74.6 407 Region Caprivi 21.7 65.2 155 50.3 101 14.1 70.1 58 75.1 41 Erongo 39.9 53.7 193 74.9 104 29.5 51.9 89 (82.3) 46 Hardap 44.1 47.6 105 54.7 50 47.6 38.7 44 (71.7) 17 Karas 41.4 45.8 89 61.1 41 42.1 41.9 53 (87.5) 22 Kavango 24.3 58.8 279 48.4 164 25.6 68.0 150 68.0 102 Khomas 39.7 46.3 750 73.4 347 25.5 49.8 327 89.4 163 Kunene 30.0 58.4 60 67.9 35 25.1 (71.0) 27 (75.8) 20 Ohangwena 49.6 38.2 516 57.1 197 53.6 20.2 185 (63.8) 37 Omaheke 29.6 60.1 130 63.7 78 19.9 68.3 65 81.2 45 Omusati 51.2 36.2 434 57.0 157 31.1 41.7 173 83.1 72 Oshana 51.4 39.9 342 66.8 136 34.6 42.7 140 87.7 60 Oshikoto 48.8 41.7 348 74.1 145 36.6 49.6 167 77.0 83 Otjozondjupa 31.4 61.3 130 65.3 79 22.9 59.8 82 87.1 49 Education No education 21.7 66.6 57 34.0 38 23.0 52.1 73 (37.7) 38 Incomplete primary 39.9 43.3 364 44.7 157 40.5 39.6 310 64.6 123 Complete primary 48.4 41.2 287 44.3 118 52.1 31.0 135 (83.1) 42 Incomplete secondary 44.7 44.3 2,252 65.9 999 29.2 51.0 816 86.3 416 Complete secondary 30.0 57.8 434 77.8 251 26.2 58.4 178 88.3 104 More than secondary 33.9 52.5 135 72.1 71 6.7 (68.9) 50 (87.6) 34 Wealth quintile Lowest 42.1 44.3 585 47.7 259 40.6 42.7 265 58.9 113 Second 47.8 39.9 662 58.1 264 35.8 43.5 312 77.7 136 Middle 40.3 49.8 649 60.3 323 27.8 50.3 353 79.4 178 Fourth 33.4 55.3 782 70.0 432 29.1 47.7 297 83.6 141 Highest 46.3 41.7 852 74.8 355 29.0 56.4 334 94.2 189 Total 15-24 41.9 46.3 3,530 63.7 1,635 32.1 48.5 1,561 80.5 757 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Friends, family members, and home are not considered a source for condoms. 226 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Never-married young women age 15-19 show a relatively high level of abstinence: 60 percent have never had sexual intercourse compared with 15 percent of women age 20-24. For men, the percentage is 48 percent and 9 percent, respectively. Two in three (68 percent) never-married women age 20-24 had sexual intercourse in the past 12 months compared with 32 percent of women age 15-19. There are small differences by urban-rural residence. Across regions, while more than half of women in Ohangwena, Omusati, and Oshana have never had sexual intercourse, the corresponding percentage in Caprivi is 22 percent and in Kavango it is 24 percent. Less educated women are more likely than women with higher education to report a recent sexual experience. The relationship between wealth status and premarital sexual experience among women is unclear. For never-married young men, the highest percentage who have never had sexual intercourse by region is in Ohangwena (54 percent), while the lowest is in Caprivi (14 percent). There is no clear relationship between level of education and wealth status and premarital sexual experience among men. A large proportion of never-married women and men reported using a condom at last sexual intercourse in the past 12 months (64 percent of women and 81 percent of men). While there are no differentials by age, it is notable that never-married youth are more likely to use condoms if they know a source for condoms (other than friends and family) and if they have a higher level of education and live in a household in the higher wealth quintiles. 14.9.5 Higher-Risk Sex and Condom Use among Young Adults Tables 14.19.1 and 14.19.2 show the proportion of young adults who engaged in higher-risk sex in the past 12 months, and the proportion who used a condom at last higher-risk sex among young men and women age 15-24 who had sexual intercourse in the past 12 months. Younger women are more likely to engage in higher-risk sexual intercourse than older women (84 percent for women 15-24 compared with 71 percent for women 20-24). Women age 15-19 are also more likely than women age 20-24 to report using a condom at last higher-risk sexual intercourse (67 percent and 62 percent, respectively). Urban women are more likely to have higher-risk sexual intercourse than rural women (79 percent and 72 percent, respectively) and more likely to use a condom at last higher-risk sexual intercourse (71 percent compared with 58 percent, respectively). Approximately half of women with no formal education said they had higher-risk sexual intercourse in the past 12 months compared with 9 in 10 women with more than secondary education. Condom use at last higher-risk sexual intercourse was reported by 36 percent of women with no education compared with 77 percent of women with more than secondary education. Nine in ten men age 15-24 had higher-risk sex in the past 12 months and 81 percent reported using a condom at last higher-risk sex (Table 14.19.2). Higher-risk sex is much higher among men age 15-19 than men age 20-24 (98 percent compared with 85 percent). The rate is also much higher among men who have never been married (97 percent). Among young men who had sex with a non- marital, non-cohabiting partner, 91 percent knew where to obtain condoms, compared with 77 percent of young women. Condom use at last higher-risk sex was reported by 66 percent of men with incomplete primary education compared with 89 percent of men who completed secondary education. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 227 Table 14.19.1 Higher-risk sexual intercourse and condom use among youth: Women Among young women age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse in the past 12 months, and among those having higher-risk intercourse in the past 12 months, the percentage reporting that a condom was used at last higher-risk intercourse, by background characteristics, Namibia 2006-07 Among women age 15-24 who had sexual intercourse in the past 12 months: Among women age 15-24 who had higher-risk sexual intercourse in the past 12 months: Background characteristic Percentage who had higher-risk intercourse in the past 12 months1 Number of women Percentage who reported using a condom at last higher-risk intercourse1 Number of women Age 15-19 84.1 793 67.1 667 15-17 86.2 330 71.2 284 18-19 82.6 464 64.0 383 20-24 70.5 1,370 62.2 965 20-22 72.8 832 63.8 606 23-24 66.8 538 59.5 360 Marital status Never married 95.0 1,635 64.7 1,553 Ever married 15.0 529 53.8 80 Knows source for condoms2 Yes 77.4 2,006 65.6 1,553 No 50.6 158 37.0 80 Residence Urban 79.4 1,020 70.7 810 Rural 71.9 1,143 57.8 822 Region Caprivi 64.2 156 52.0 100 Erongo 73.4 145 74.3 107 Hardap 63.8 72 55.4 46 Karas 80.2 53 62.9 43 Kavango 53.3 320 47.6 170 Khomas 83.3 432 74.1 360 Kunene 71.2 64 68.2 46 Ohangwena 81.8 206 58.6 169 Omaheke 77.9 98 65.7 76 Omusati 89.5 166 57.8 149 Oshana 88.2 149 66.5 131 Oshikoto 85.5 171 74.3 146 Otjozondjupa 68.7 131 60.9 90 Education No education 50.4 92 35.8 46 Incomplete primary 56.6 283 45.3 160 Complete primary 68.3 161 45.0 110 Incomplete secondary 79.4 1,242 67.0 986 Complete secondary 85.0 308 75.3 261 More than secondary 87.9 77 76.7 68 Wealth quintile Lowest 63.3 402 48.4 255 Second 76.9 338 59.4 260 Middle 69.8 461 59.4 322 Fourth 81.1 543 71.4 441 Highest 84.8 419 74.4 355 Total 15-24 75.5 2,163 64.2 1,633 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered a source for condoms. 228 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 14.19.2 Higher-risk sexual intercourse and condom use among youth: Men Among young men age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse in the past 12 months, and among those having higher-risk intercourse in the past 12 months, the percentage reporting that a condom was used at last higher-risk intercourse, by background characteristics, Namibia 2006-07 Among men age 15-24 who had sexual intercourse in the past 12 months: Among men age 15-24 who had higher-risk sexual intercourse in the past 12 months: Background characteristic Percentage who had higher-risk intercourse in the past 12 months1 Number of men Percentage who reported using a condom at last higher-risk intercourse1 Number of men Age 15-19 98.0 341 81.3 334 15-17 97.2 150 79.6 145 18-19 98.7 192 82.6 189 20-24 84.8 507 81.0 430 20-22 87.3 305 82.0 267 23-24 80.9 201 79.2 163 Marital status Never married 96.5 757 80.7 730 Ever married 36.6 91 (89.2) 33 Knows source for condoms2 Yes 90.5 825 82.2 747 No 75.0 23 * 17 Residence Urban 86.7 405 87.8 351 Rural 93.2 443 75.4 413 Region Caprivi 94.1 46 76.4 43 Erongo 91.1 59 84.9 54 Hardap 60.7 23 * 14 Karas 91.3 25 (87.5) 22 Kavango 92.4 113 69.1 105 Khomas 85.9 188 89.8 162 Kunene 78.9 25 (76.4) 20 Ohangwena 77.8 40 (59.3) 31 Omaheke 90.2 54 85.5 49 Omusati 98.5 72 82.9 71 Oshana 96.7 60 87.3 58 Oshikoto 96.4 89 77.7 85 Otjozondjupa 92.4 54 85.7 50 Education No education 86.2 45 (42.8) 39 Incomplete primary 86.3 142 65.8 123 Complete primary 94.0 48 82.5 45 Incomplete secondary 91.3 458 86.7 418 Complete secondary 91.1 119 88.7 108 More than secondary 85.7 36 (86.1) 31 Wealth quintile Lowest 91.6 125 60.1 115 Second 93.1 144 77.9 134 Middle 90.4 199 79.4 180 Fourth 82.8 168 84.3 139 Highest 92.7 212 94.7 196 Total 15-24 90.1 848 81.1 764 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered a source for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 229 Figure 14.7 presents data on the practice of abstinence, being faithful, and condom use (ABC) behaviours among youth age 15-24 from the 2000 NDHS and 2006-07 NDHS. Overall, in the 2006- 07 NDHS, 36 percent of young women and 30 percent of young men have never had sex. These figures are higher than those reported in the 2000 NDHS (32 percent and 21 percent, respectively). The percentage of women who had sexual intercourse with one partner and used a condom at last sexual intercourse increased from 21 percent in 2000 to 27 percent in 2006-07. For men, the increase was small, from 29 percent to 31 percent over the same period. The proportion of young women and men who had sexual intercourse with more than one partner and did not use a condom remained at the same level (less than 1 percent for women and 2 percent for men). However, the percentage of men who had more than one sexual partner and used a condom at last sexual intercourse has decreased from 13 percent in 2000 to 9 percent in 2006-07. There has been is a notable increase in the percentage of women age 20-24 who had sexual intercourse with only one partner and used a condom at last sex, from 24 percent in 2000 to 35 percent in 2006-07. 14.9.6 Cross-generational Sexual Partners Research from around the world shows a steady and significant increase in the rates of HIV infection among women, particularly women in Africa, Asia, Latin America, and the Caribbean. A substantial proportion of HIV/AIDS cases occur among young women age 15-29, indicating that many of these women were infected with HIV as adolescents. Anatomical, biological, and other factors contribute to young women’s heightened vulnerability to HIV/AIDS. The variable, gender— while routinely and automatically acknowledged as important—goes beyond clinical and treatment issues, and even beyond anatomical, male-female differences. Twenty years into the HIV/AIDS epidemic, gender and the role it plays remains unclear (Rivers and Aggleton, 1999). Figure 14.7 Abstinence, Being Faithful, and Condom Use (ABC) among Young Women and Men 15- 19 20- 24 15- 24 15- 19 20- 24 15- 24 15- 19 20- 24 15- 24 15- 19 20- 24 15- 24 0 20 40 60 80 100 Percent Never had sex No partners in last year One partner, used condom at last sex One partner, no condom use at last sex Multiple partners, used condom at last sex Multiple partners, no condom use at last sex Note: Number of partners refers to the 12 months preceding the survey. NDHS 2006-07 2000 2006-072006-07 2000 WOMEN MEN Age 230 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour This section examines the prevalence of sexual intercourse between partners with large age differences. Women age 15-19 who had higher- risk sexual intercourse in the past 12 months were asked the age of all their partners. In the event they did not know a partner’s exact age, they were asked if the partner was older or younger than they were, and if older, whether the partner was 10 or more years older. The results are shown in Table 14.20. Overall, 4 percent of young women said that they had had sexual intercourse with a man 10 or more years older. The likelihood of a woman having higher-risk sexual intercourse with an older man increases with age (3 percent for woman age 15-17 compared with 6 percent for women age 18- 19). Sexual intercourse between women age 15-19 and men 10 or more years older decreases with increasing education. Women age 15-19 with no formal education or with less than primary education have the greatest likelihood of having sexual intercourse with a man 10 or more years older (8 percent and 9 percent, respectively). The corresponding proportion for women who have completed secondary education is 3 percent. 14.9.7 Drunkenness during Sex among Young Adults Engaging in sexual intercourse under the influence of alcohol can impair judgment, compro- mise power relations, and contribute to risky sexual behaviour. Respondents who had sex in the past 12 months were asked (for each partner) if they or their partner drank alcohol the last time they had sex with that partner, and whether they or their partner was drunk. Table 14.21 shows the proportion of women and men age 15–24 who had sexual intercourse while being drunk or had sexual intercourse with a partner who was drunk in the past 12 months. Less than 1 percent of women and 5 percent of men reported being drunk while having sexual intercourse in the past 12 months. These figures increase to 4 percent for young women and 5 percent for young men when sexual intercourse in the past 12 months with a partner who was drunk is added. For women and men, the likelihood of having sexual intercourse when drunk or with a partner who was drunk increases with age. The highest proportion is 6 percent for women and 10 percent for men age 23-24. Table 14.20 Age-mixing in sexual relationships among women age 15-19 Percentage of women age 15-19 who had higher-risk sexual intercourse in the past 12 months with a man who was 10 or more years older than they, by background characteristics, Namibia 2006-07 Background characteristic Percentage of women who had higher-risk sexual intercourse with a man 10+ years older1 Number of women who had higher-risk sexual intercourse in the past 12 months1 Age 15-17 2.7 284 18-19 5.5 383 Marital status Never married 4.2 651 Ever married * 16 Knows source for condoms2 Yes 3.7 625 No (12.6) 42 Residence Urban 5.3 295 Rural 3.5 373 Region Caprivi 1.9 52 Erongo (8.4) 41 Hardap (18.4) 17 Karas * 12 Kavango 0.6 104 Khomas 3.3 120 Kunene (9.6) 26 Ohangwena 5.0 69 Omaheke (3.4) 35 Omusati (2.5) 48 Oshana 3.7 44 Oshikoto 4.8 62 Otjozondjupa (7.4) 36 Education No education (7.6) 20 Incomplete primary 7.9 83 Complete primary 3.1 61 Incomplete secondary 3.8 432 Complete secondary 3.3 61 More than secondary * 9 Wealth quintile Lowest 3.6 135 Second 4.9 123 Middle 4.1 134 Fourth 6.8 154 Highest 1.4 120 Total 15-19 4.3 667 Total 15-24 4.3 667 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered a source for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour │ 231 While there is no variation by residence for women, men in urban areas are two times more likely than men in rural areas to have been under the influence of alcohol during sexual intercourse or have a partner who was under the influence (7 percent and 4 percent, respectively). For women, knowledge of a condom source does not influence the likelihood of sexual intercourse while drunk. However, for men, the percentage is 6 percent among those who know a source for condoms compared with 1 percent among men who do not know a source. Regionally, women’s reported prevalence of sexual intercourse while drunk is highest in Otjozondjupa (2 percent), while for men it is highest in Erongo (13 percent). Table 14.21 Drunkenness during sexual intercourse among youth Among all young women and young men age 15-24, the percentage who had sexual intercourse in the past 12 months while being drunk and percentage who had sexual intercourse in the past 12 months when drunk or with a partner who was drunk, by background characteristics, Namibia 2006-07 Women age 15-24 Men age 15-24 Background characteristic Percentage who had sexual intercourse in the past 12 months when drunk Percentage who had sexual intercourse in the past 12 months when drunk or with a partner who was drunk Number of women Percentage who had sexual intercourse in the past 12 months when drunk Percentage who had sexual intercourse in the past 12 months when drunk or with a partner who was drunk Number of men Age 15-19 0.4 2.2 2,246 2.0 2.8 910 15-17 0.3 1.1 1,365 1.5 1.9 553 18-19 0.6 4.0 881 2.7 4.1 357 20-24 1.2 5.4 1,855 7.7 8.3 750 20-22 1.0 4.7 1,160 6.9 7.5 473 23-24 1.6 6.4 696 9.0 9.6 277 Marital status Never married 0.6 3.0 3,530 4.0 4.8 1,561 Ever married 1.8 7.4 571 12.4 12.6 100 Knows source for condoms2 Yes 0.8 3.7 3,662 5.0 5.7 1,515 No 0.3 3.2 438 0.0 0.6 146 Residence Urban 0.8 3.7 1,840 6.5 7.2 716 Rural 0.8 3.6 2,261 3.1 3.8 945 Region Caprivi 0.0 2.5 214 7.1 7.1 63 Erongo 1.2 4.1 239 11.7 13.3 103 Hardap 1.3 3.7 129 3.8 7.0 50 Karas 0.5 0.5 103 7.7 7.7 56 Kavango 0.6 6.2 450 7.0 9.3 162 Khomas 0.7 3.2 839 6.4 7.3 352 Kunene 2.5 7.3 92 6.6 6.6 35 Ohangwena 0.3 1.9 526 0.0 0.0 188 Omaheke 0.8 6.1 151 4.3 6.5 76 Omusati 1.2 2.3 444 2.0 2.0 173 Oshana 0.6 3.0 357 2.0 2.0 140 Oshikoto 0.7 3.8 374 2.5 2.5 173 Otjozondjupa 1.9 7.4 183 3.2 3.2 89 Education No education 2.2 9.8 121 1.7 2.1 85 Incomplete primary 1.0 5.3 498 2.5 3.3 331 Complete primary 0.8 3.2 335 1.1 1.1 141 Incomplete secondary 0.8 3.1 2,510 6.7 7.7 858 Complete secondary 0.2 4.3 495 3.2 3.2 194 More than secondary 0.7 1.9 142 (1.2) (1.2) 51 Wealth quintile Lowest 0.4 3.5 743 2.7 3.4 279 Second 0.8 3.7 741 2.6 3.2 322 Middle 1.1 4.3 799 4.7 5.0 377 Fourth 1.7 5.1 900 2.7 4.0 324 Highest 0.0 1.8 918 9.1 10.0 359 Total 15-24 0.8 3.7 4,101 4.5 5.3 1,661 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Friends, family members, and home are not considered a source for condoms. 232 │ HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 14.9.8 Voluntary HIV Counselling and Testing among Young Adults Table 14.22 shows that 31 percent of sexually active women age 15-24 and 13 percent of sexu- ally active men age 15-24 have been tested for HIV and received the test results in the past 12 months. Women in all subgroups are much more likely than men to have taken the test and received the results. For example, 36 per- cent of women age 20-24 were tested for HIV and received the re- sults in the past 12 months, com- pared with 15 percent of men in the same age group. Respondents who have ever been married, those who know where to get condoms, and those who live in urban areas are more likely than other respondents to know their HIV status. For both young women and young men, there is a positive correlation be- tween level of education and wealth status and the likelihood of young people knowing their HIV status. Regionally, young women in Oshikoto and Oshana reported the highest coverage for HIV test- ing (38 and 41 percent, respec- tively), while for men the highest coverage is in Oshana and Khomas (23 and 24 percent, respectively). Table 14.22 Recent HIV tests among youth Among young women and young men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who had an HIV test in the past 12 months and received the results of the test, by background characteristics, Namibia 2006-07 Women age 15-24 Men age 15-24 Background characteristic Percentage who have been tested for HIV and received results in the past 12 months Number of women Percentage who have been tested for HIV and received results in the past 12 months Number of men Age 15-19 23.3 843 9.0 366 15-17 17.8 345 5.3 160 18-19 27.0 499 11.9 206 20-24 35.9 1,470 15.4 569 20-22 35.8 887 15.0 341 23-24 36.0 583 16.1 228 Marital status Never married 30.7 1,742 12.5 831 Ever married 33.2 571 16.1 104 Knows source for condoms1 Yes 31.5 2,141 13.1 911 No 28.7 172 5.8 24 Residence Urban 33.3 1,089 17.0 456 Rural 29.5 1,224 9.0 479 Region Caprivi 16.3 161 9.8 50 Erongo 34.7 155 10.3 73 Hardap 27.9 77 6.2 26 Karas 36.0 54 17.7 29 Kavango 28.4 347 3.2 128 Khomas 31.3 460 24.3 214 Kunene 26.2 71 4.7 27 Ohangwena 30.4 216 8.1 40 Omaheke 37.2 107 12.1 59 Omusati 31.0 176 9.4 76 Oshana 41.3 159 22.7 63 Oshikoto 37.7 185 9.1 93 Otjozondjupa 31.6 145 6.8 57 Education No education 25.9 104 3.4 47 Incomplete primary 26.3 310 6.1 153 Complete primary 29.5 172 1.2 50 Incomplete secondary 30.2 1,319 12.3 524 Complete secondary 40.3 329 29.7 125 More than secondary 42.5 80 20.7 36 Wealth quintile Lowest 26.0 428 4.8 135 Second 28.7 365 7.7 154 Middle 31.4 495 11.3 218 Fourth 33.7 589 15.0 181 Highest 35.1 436 20.4 248 Total 15-24 31.3 2,313 12.9 935 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Friends, family members, and home are not considered a source for condoms: Women’s Empowerment and Demographic and Health Outcomes | 233 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 The 2006-07 NDHS Women’s Questionnaire collected data on women’s empowerment to examine the relationship between women’s status and health outcomes for women and children. This chapter covers a range of topics including type of earnings, women’s control over their own cash earnings and those of their husband/partner, and women’s participation in household decision-making. The respondents were asked about their attitude towards wife beating, and the circumstances under which they think a woman is justified in refusing to have sexual intercourse with her husband/partner. The data are used to define three indicators of women’s empowerment, namely women’s participation in decision-making, the degree of acceptance of wife beating, and the degree of acceptance of a wife refusing to have sexual intercourse with her husband/partner. The effects of women’s empowerment on maternal and child health and contraceptive decision-making are also examined. 15.1 EMPLOYMENT AND FORM OF EARNINGS In the 2006-07 NDHS, respondents were asked a number of questions about their employ- ment status at the time of the survey and the continuity of their employment in the 12 months prior to the survey. The measurement of women’s employment is difficult because some of the activities that women do, especially work on family farms, in family businesses, or in the informal sector, are often not perceived by women themselves as employment and hence are not reported as such. To avoid underestimating women’s employment, women were asked several questions to ascertain their employment status. First, women were asked, “Aside from your own housework, are you currently working?” Women who answered “no” to this question were then asked, “As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business, or work on the family farm or in the family business. Are you currently doing any of these things or any other work?” Women who answered “no” to this question were asked, “Have you done any work in the past 12 months?” Women are considered currently employed if they answered “yes” to either of the first two questions. Women who answered “yes” to the third question are not currently employed but have worked in the past 12 months. All employed women were asked their occupation; whether they were paid in cash, in kind, or not at all; and for whom they worked. Like education, employment also be a source of empowerment for both women and men. It may be particularly empowering for women if it puts them in control of income. Table 15.1 shows the percent distribution of women and men age 15-49 by employment status and form of payment, according to age. More than half of women (53 percent) and 69 percent of men are currently employed. Seven in ten women receive cash payments, 3 percent are paid in cash and kind, and one in four are not paid for their work. Employment generally increases with age. The proportion of women and men who are employed is lowest among those age 15-19, and increases with age. The low employment rate at younger ages is expected because many young people are still in school. Women’s employment peaks at 69 percent among those age 30-34 while men’s employment is highest among those age 35-39 (87 percent). 234 | Women’s Empowerment and Demographic and Health Outcomes Table 15.1 Employment and cash earnings: All women and men Percentage of all women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of women and men employed in the past 12 months by type of earnings, according to age, Namibia 2006-07 All respondents Percent distribution of respondents employed in the past 12 months, by type of earnings Age Percentage employed Number Cash only Cash and in-kind In-kind only Not paid Missing Total Number WOMEN 15-19 25.6 2,246 33.5 1.4 2.9 60.3 1.9 100.0 575 20-24 48.1 1,855 68.5 3.0 2.3 25.7 0.5 100.0 892 25-29 62.7 1,623 75.3 3.0 1.9 19.4 0.3 100.0 1,018 30-34 68.8 1,417 74.4 2.2 1.8 21.1 0.5 100.0 975 35-39 67.0 1,045 75.3 2.9 1.1 20.7 0.1 100.0 700 40-44 68.2 928 73.9 3.0 0.6 22.1 0.5 100.0 633 45-49 63.4 689 68.3 4.7 2.0 25.0 0.0 100.0 437 Total 53.4 9,804 68.6 2.8 1.8 26.3 0.5 100.0 5,231 MEN 15-19 34.4 910 35.1 6.0 7.3 51.2 0.4 100.0 314 20-24 66.3 750 71.4 4.5 1.4 22.2 0.6 100.0 498 25-29 79.3 702 81.3 6.8 1.4 10.5 0.0 100.0 556 30-34 84.4 586 85.6 2.6 0.6 10.6 0.5 100.0 494 35-39 87.3 400 82.1 4.5 0.8 12.6 0.0 100.0 349 40-44 84.7 331 82.9 3.5 0.5 13.1 0.0 100.0 281 45-49 85.5 235 74.2 5.2 3.8 16.6 0.2 100.0 201 Total 68.8 3,915 74.6 4.8 1.9 18.4 0.3 100.0 2,693 Married and employed women who earn cash for their work were asked the relative magnitude of their earnings compared with to their husband/partner’s earnings. In addition, they were asked who the main decision-maker is with regard to the use of their earnings. This information may provide some insight into women’s empowerment in the family and the extent of their control over decision-making in the household. It is expected that employment and earnings are more likely to empower women if they control their own earnings and perceive their earnings as significant relative to those of their husband/partner. Table 15.2 shows that six in ten married women (61 percent) and 90 percent of married men are currently employed. Employment among married women increases with age, ranging from 30 percent among women age 15-19 to 66-67 percent among women in their thirties and early forties. For men, employment is 84 percent for men age 20-24 and thereafter stays at around 90 percent. Women’s Empowerment and Demographic and Health Outcomes | 235 Table 15.2 Employment and cash earnings: Currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Namibia 2006-07 Currently married respondents Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Age Percentage employed Number Cash only Cash and in-kind In-kind only Not paid Missing Total Number WOMEN 15-19 29.7 118 (40.9) (1.0) (0.0) (48.5) (9.6) 100.0 35 20-24 44.2 398 61.2 4.3 2.6 31.9 0.0 100.0 176 25-29 59.8 625 74.7 2.1 1.7 21.3 0.3 100.0 374 30-34 67.3 751 72.6 3.3 1.6 22.6 0.0 100.0 505 35-39 66.7 612 76.1 2.8 1.4 19.5 0.2 100.0 408 40-44 66.3 522 72.2 3.0 0.4 24.4 0.0 100.0 346 45-49 62.3 424 66.8 3.9 2.0 27.2 0.0 100.0 264 Total 61.1 3,451 71.4 3.0 1.5 23.8 0.3 100.0 2,108 MEN 15-19 * 3 * * * * * 100.0 3 20-24 83.7 76 79.9 0.8 0.3 19.0 0.0 100.0 63 25-29 91.9 199 83.0 3.7 1.2 12.1 0.0 100.0 183 30-34 90.4 260 86.9 3.3 0.3 9.4 0.0 100.0 235 35-39 90.8 248 83.1 3.2 1.0 12.8 0.0 100.0 225 40-44 89.8 242 84.9 3.0 0.2 11.9 0.0 100.0 217 45-49 89.8 178 75.6 3.6 4.5 16.3 0.0 100.0 160 Total 90.1 1,205 82.9 3.2 1.2 12.8 0.0 100.0 1,086 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS AND THE RELATIVE MAGNITUDE OF WOMEN’S EARNINGS Table 15.3 presents information on the degree to which currently married women with cash earnings in the past 12 months have control over their earnings and their perception of the magnitude of their earnings relative to those of their husband/partner. Four in ten married women say that they are the main decision-maker on how their earnings are used and half say that the decision is made jointly with their husband/partner. Only 10 percent of women reported that their husband alone decides how their earnings are used. Respondents’ degree of control over the use of their earnings varies by background characteristics. Women age 15-19 are somewhat less likely to make independent decisions on their earnings than older women. Women with five or more children and those with no children are more likely to have control over their earnings than other women. On the other hand, women with 1-4 children are more likely to make joint decisions with their husband on how their cash earnings are spent. Rural women are somewhat more likely than urban women to have their husbands take the lead role in making decisions about their cash earnings (13 percent and 9 percent, respectively). Urban women are somewhat more likely than rural women to report that they make decisions about how their money is spent jointly with their husband/partner (51 percent compared with 46 percent). The percentage of women who make independent decisions on their earnings varies across regions, ranging from to 21 percent in Karas to 58 percent in Oshana. However, women in Karas are the most likely to decide jointly with their husband/partner how to spend the money they earn (66 percent). Husband’s dominance in control over the wife’s earnings is seen particularly in Kavango, where 23 percent of women say that the decision on how their income is spent is made mainly by their husband. 236 | Women’s Empowerment and Demographic and Health Outcomes Table 15.3 Control over women's cash earnings and relative magnitude of women's earnings: Women Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife's cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Namibia 2006-07 Person who decides how wife's cash earnings are used: Wife’s cash earnings compared with husband's cash earnings: Background characteristic Mainly wife Wife and husband jointly Mainly husband Other Missing Total More Less About the same Husband/ partner has no earnings Don't know/ Missing Total Number of women Age 15-19 * * * * * 100.0 * * * * * 100.0 15 20-24 46.4 39.9 12.6 1.1 0.0 100.0 11.6 73.2 10.8 2.9 1.4 100.0 115 25-29 44.6 43.2 11.0 0.6 0.5 100.0 16.9 66.2 9.0 5.2 2.7 100.0 287 30-34 36.4 54.2 8.6 0.0 0.8 100.0 18.4 64.7 11.3 3.0 2.5 100.0 383 35-39 33.1 54.2 10.5 0.0 2.2 100.0 13.8 61.7 16.8 4.2 3.6 100.0 322 40-44 41.0 50.4 7.5 0.0 1.1 100.0 15.1 67.0 12.5 2.3 3.1 100.0 260 45-49 43.1 46.6 10.2 0.0 0.0 100.0 14.9 66.8 11.9 3.3 3.1 100.0 187 Number of living children 0 47.1 39.4 9.6 2.7 1.3 100.0 24.0 59.5 9.9 4.5 2.1 100.0 134 1-2 37.5 52.1 9.8 0.1 0.5 100.0 16.3 66.6 11.8 3.0 2.3 100.0 725 3-4 37.5 51.7 9.9 0.1 0.8 100.0 13.4 66.5 13.8 3.7 2.6 100.0 527 5+ 47.0 40.0 10.4 0.0 2.6 100.0 13.5 65.8 10.2 4.4 6.1 100.0 183 Residence Urban 38.9 51.2 8.6 0.4 0.9 100.0 15.6 66.6 12.1 3.2 2.5 100.0 1,079 Rural 40.5 45.8 12.8 0.1 0.9 100.0 15.7 64.2 12.3 4.3 3.5 100.0 490 Region Caprivi 30.9 53.5 14.6 0.0 1.0 100.0 12.5 65.3 13.7 5.4 3.1 100.0 47 Erongo 39.8 50.2 9.3 0.0 0.7 100.0 10.4 69.0 15.0 3.7 1.9 100.0 248 Hardap 28.1 59.2 10.9 0.0 1.8 100.0 20.1 71.0 3.4 2.9 2.5 100.0 59 Karas 20.9 66.0 13.1 0.0 0.0 100.0 13.3 75.2 8.1 2.0 1.4 100.0 84 Kavango 42.7 29.9 22.5 1.6 3.3 100.0 20.8 49.1 19.0 5.0 6.1 100.0 92 Khomas 38.1 56.7 5.0 0.0 0.3 100.0 16.0 64.6 14.2 3.0 2.2 100.0 496 Kunene 35.7 47.6 14.8 1.9 0.0 100.0 16.1 61.4 16.7 3.0 2.9 100.0 48 Ohangwena 54.3 37.6 8.1 0.0 0.0 100.0 15.6 66.9 9.5 5.6 2.4 100.0 63 Omaheke 43.4 36.0 17.8 0.0 2.9 100.0 21.8 59.1 8.1 2.6 8.4 100.0 66 Omusati 28.8 61.6 6.2 0.0 3.5 100.0 14.2 58.8 15.7 6.0 5.3 100.0 65 Oshana 57.8 28.7 11.8 1.7 0.0 100.0 19.1 63.4 7.5 6.5 3.6 100.0 98 Oshikoto 40.3 50.0 8.4 0.0 1.3 100.0 16.1 70.7 8.7 2.1 2.3 100.0 88 Otjozondjupa 45.6 39.1 13.7 0.6 1.0 100.0 16.2 75.9 4.9 1.8 1.2 100.0 114 Education No education/preschool 48.6 33.4 14.8 1.7 1.5 100.0 10.1 57.9 18.2 7.4 6.4 100.0 85 Incomplete primary 47.7 39.9 10.9 0.0 1.5 100.0 12.0 68.9 9.7 6.6 2.7 100.0 222 Complete primary 50.4 40.3 8.2 0.0 1.1 100.0 11.6 76.3 7.5 2.2 2.4 100.0 96 Incomplete secondary 40.2 47.2 11.4 0.5 0.8 100.0 13.8 68.9 11.3 2.5 3.5 100.0 553 Complete secondary 29.2 62.1 8.4 0.2 0.1 100.0 17.7 67.2 10.0 3.5 1.7 100.0 325 More than secondary 36.6 54.9 7.0 0.0 1.4 100.0 22.7 55.1 17.7 2.5 2.1 100.0 288 Wealth quintile Lowest 53.8 23.9 17.9 2.5 1.9 100.0 6.2 61.1 23.0 4.4 5.3 100.0 60 Second 53.4 35.4 10.1 0.3 0.9 100.0 15.7 64.9 7.9 10.0 1.6 100.0 121 Middle 43.1 40.4 14.4 0.7 1.5 100.0 11.3 66.5 13.3 4.8 4.2 100.0 249 Fourth 42.8 47.2 8.8 0.1 1.0 100.0 18.4 65.7 9.7 2.3 3.9 100.0 475 Highest 31.7 59.4 8.2 0.1 0.5 100.0 16.2 66.3 13.2 2.7 1.6 100.0 664 Total 39.4 49.5 9.9 0.3 0.9 100.0 15.7 65.9 12.1 3.5 2.8 100.0 1,569 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Women’s Empowerment and Demographic and Health Outcomes | 237 It is interesting to note that better-educated women and women who live in households in the higher wealth quintiles are more likely to say that decisions on the use of their earnings are shared with their husbands. For example, 55 percent of women with more than secondary education decide jointly with their husband or partner how their earnings are used, compared with 33 percent for women with no education. Table 15.3 also shows women’s perception of the magnitude of their earnings relative to those of their husband/partner by background characteristics. Sixty-six percent of women report that their cash earnings are less than their husband’s, 16 percent say that their earnings are more than their husband’s, and 12 percent say that their earnings match their husband’s. In addition, 4 percent of women say that their husband has no cash earnings. Women with no children are more likely than those with children to be better paid than their husband/partner. Twenty percent or more of women in Hardap, Kavango, and Omaheke earn more than husband/partners. Better educated women are more likely than women with less education to have a higher income than their husband/partner. For example, 23 percent of women with more than secondary education earn more than their partner/husband compared with only 10 percent of those with no education. 15.3 CONTROL OVER HUSBAND’S EARNINGS Table 15.4 shows, for currently married women and men, who decides how the man’s cash earnings are spent, by background characteristics. Overall, 57 percent of women say that decisions are made jointly with their husband, 26 percent say their the husband is the main decision-maker, and 16 percent say they are the main decision-maker on how their husband’s income is spent. There is no clear pattern on the distribution of women according to who makes decisions on their husband’s earnings. In both rural and urban areas the spending of men’s earnings is mostly a joint decision (57 and 59 percent, respectively). Women in Omusati and Hardap are the most likely to have joint control over their husband’s income (78 percent and 73 percent, respectively), while women in Oshana are the least likely to have a say in the use of their husband’s earnings (41 percent). Shared decision-making regarding the husband’s earnings reported by women in Hardap (73 percent) is generally confirmed by the reports of men (78 percent). overall, men show the same general patterns as those reported by women. 238 | Women’s Empowerment and Demographic and Health Outcomes Table 15.4 Control over men's cash earnings Percent distribution of currently married women 15-49 whose husbands receive cash earnings and currently married men age 15-49 who receive cash earnings, by person who decides how men's cash earnings are used, according to background characteristics, Namibia 2006-07 Women Men Background characteristic Mainly wife Husband and wife jointly Mainly husband Other Missing Total Number of women Mainly wife Husband and wife jointly Mainly husband Missing Total Number of men Age 15-19 * * * * * 100.0 15 * * * * 100.0 1 20-24 15.8 53.6 30.0 0.6 0.0 100.0 111 4.6 60.7 29.9 4.8 100.0 51 25-29 16.6 55.9 27.5 0.0 0.0 100.0 272 8.2 49.2 39.2 3.4 100.0 159 30-34 15.7 63.3 20.5 0.0 0.5 100.0 370 7.4 53.9 34.9 3.7 100.0 212 35-39 14.4 54.1 30.2 0.8 0.5 100.0 307 7.1 57.4 34.2 1.3 100.0 194 40-44 15.1 55.5 28.5 0.0 0.8 100.0 253 7.0 58.4 32.6 2.0 100.0 191 45-49 18.1 57.2 24.7 0.0 0.0 100.0 181 3.0 55.4 41.1 0.5 100.0 127 Number of living children 0 15.9 49.6 31.9 1.7 0.9 100.0 128 5.6 45.4 36.7 12.3 100.0 79 1-2 15.4 59.3 25.1 0.0 0.2 100.0 701 8.2 56.8 33.2 1.8 100.0 357 3-4 15.6 58.7 25.1 0.5 0.1 100.0 507 6.2 57.5 35.3 1.0 100.0 274 5+ 16.9 51.3 30.6 0.0 1.3 100.0 173 5.1 53.5 39.6 1.8 100.0 224 Residence Urban 16.1 56.8 26.2 0.4 0.5 100.0 1,044 5.9 57.8 33.4 2.9 100.0 648 Rural 14.8 58.6 26.6 0.0 0.0 100.0 465 8.2 49.6 40.8 1.4 100.0 287 Region Caprivi 10.0 65.9 24.1 0.0 0.0 100.0 44 5.0 52.3 42.7 0.0 100.0 56 Erongo 9.8 59.2 29.5 1.0 0.4 100.0 239 5.3 54.5 39.6 0.6 100.0 157 Hardap 12.5 73.1 12.5 0.0 1.9 100.0 57 9.1 78.2 6.7 5.9 100.0 39 Karas 15.3 66.6 18.1 0.0 0.0 100.0 82 7.1 67.7 25.2 0.0 100.0 47 Kavango 21.5 42.7 34.2 1.7 0.0 100.0 87 6.4 37.9 37.6 18.1 100.0 62 Khomas 16.5 60.7 22.8 0.0 0.0 100.0 481 7.4 61.5 30.2 0.9 100.0 315 Kunene 21.0 46.6 32.4 0.0 0.0 100.0 46 (13.5) (26.0) (60.5) (0.0) 100.0 20 Ohangwena 11.4 69.2 19.4 0.0 0.0 100.0 57 * * * * 100.0 21 Omaheke 24.0 43.6 32.4 0.0 0.0 100.0 64 7.3 27.5 65.2 0.0 100.0 36 Omusati 6.6 77.5 15.0 0.0 0.9 100.0 61 * * * * 100.0 17 Oshana 23.1 35.2 41.1 0.0 0.6 100.0 90 (8.0) (37.7) (47.4) (6.8) 100.0 37 Oshikoto 13.9 60.6 24.1 0.0 1.3 100.0 86 (6.4) (64.7) (26.6) (2.2) 100.0 45 Otjozondjupa 19.9 42.7 35.8 0.6 1.0 100.0 112 2.3 58.8 37.9 1.0 100.0 83 Education No education/preschool 23.3 35.0 36.6 5.0 0.0 100.0 79 7.5 38.8 52.3 1.4 100.0 95 Incomplete primary 15.9 53.2 30.3 0.0 0.5 100.0 207 4.5 47.0 45.1 3.4 100.0 196 Complete primary 18.4 48.0 32.4 0.0 1.2 100.0 91 (8.9) (45.0) (46.1) (0.0) 100.0 39 Incomplete secondary 18.3 57.1 24.4 0.0 0.2 100.0 539 6.2 56.0 34.7 3.1 100.0 321 Complete secondary 11.9 64.7 23.1 0.2 0.0 100.0 314 8.5 64.2 26.1 1.3 100.0 140 More than secondary 11.6 62.0 25.6 0.0 0.8 100.0 280 7.6 69.8 20.4 2.2 100.0 144 Wealth quintile Lowest 14.6 54.0 28.8 2.6 0.0 100.0 56 (13.4) (37.7) (45.0) (3.9) 100.0 47 Second 18.8 56.4 24.7 0.0 0.0 100.0 108 5.3 52.6 39.1 3.0 100.0 77 Middle 20.5 49.7 29.3 0.0 0.5 100.0 236 6.5 41.5 47.6 4.5 100.0 197 Fourth 16.4 56.1 26.5 0.5 0.5 100.0 464 5.7 58.3 34.4 1.7 100.0 274 Highest 12.9 61.5 25.1 0.1 0.3 100.0 646 6.9 63.8 27.8 1.5 100.0 340 Total 15.7 57.4 26.3 0.3 0.4 100.0 1,509 6.6 55.3 35.7 2.4 100.0 935 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Table 15.5 shows, for currently married women who earned cash in the past 12 months, the person who decides how their cash earnings are used, and for all currently married women whose husbands earned cash in the past 12 months, the person who decides how their husband’s cash earnings are used, according to the relative magnitude of the earnings of the women and their husband/. Data in the table show that whether the woman earns more or less than her husband, about half of married couples decide jointly how to spend the cash income. The joint decision is more likely (six in ten couples) if the wife’s income is the same as the husband’s. Husbands are the main decision- maker for their income if the wife is not employed or did not work in the past 12 months (42 and 41 percent, respectively). Women’s Empowerment and Demographic and Health Outcomes | 239 Table 15.5 Women's perceptions of who controls earnings and the relative size of earnings Percent distributions of currently married women age 15-49 with cash earnings in the past 12 months by person who decides how the wife’s cash earnings are used and percent distribution of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband's cash earnings are used, according to the relation between wife’s and husband's cash earnings, Namibia 2006-07 Person who decides how the wife's cash earnings are used: Person who decides how husband's cash earnings are used: Women's earnings relative to husband's earnings Mainly wife Wife and husband jointly Mainly husband Other Missing Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing Total Number of women More than husband/partner 39.5 51.5 8.6 0.4 0.0 100.0 246 20.7 57.4 21.6 0.3 0.0 100.0 245 Less than husband/partner 41.3 48.3 10.2 0.2 0.0 100.0 1,033 15.0 56.4 28.3 0.1 0.2 100.0 1,030 Same as husband partner 24.8 63.4 11.7 0.0 0.0 100.0 190 11.7 66.1 22.2 0.0 0.0 100.0 190 Husband/ partner has no cash earnings/did not work 55.7 34.1 9.3 0.9 0.0 100.0 55 na na na na na na na Woman has no cash earnings na na na na na na na 10.0 46.3 41.9 0.6 1.2 100.0 477 Woman did not work in past 12 months na na na na na na na 14.3 42.9 40.7 0.8 1.3 100.0 1,258 Don't know/missing 38.2 24.7 2.0 2.5 32.6 100.0 44 20.7 41.5 23.4 5.6 8.8 100.0 44 Total1 39.4 49.5 9.9 0.3 0.9 100.0 1,569 14.3 50.1 34.2 0.5 0.8 100.0 3,245 na = Not applicable 1 Excludes cases where a woman or her husband/partner has no earnings and includes cases where a woman does not know whether she earned more or less than her husband/partner 15.4 WOMEN’S PARTICIPATION IN DECISION-MAKING In addition to educational attainment, employment status, and control over earnings, the 2006-07 NDHS collected information on some direct measures of women’s autonomy and status. Specifically, questions were asked on women’s participation in household decision-making, their acceptance of wife beating, and their opinions about the conditions under which a wife is justified in refusing to have sexual relations with her husband. Such information provides insight into women’s control over their environment and their attitudes towards gender roles, both of which are relevant to understanding women’s demographic and health behaviour. The first measure, women’s level of participation in household decision-making requires little explanations because the ability to make decisions about one’s own life has obvious importance to women’s empowerment. The other two measures derive from the notion that gender equity is essential to women’s empowerment. Responses that support the view that the beating of wives by husbands is justified reflect a low perception of women’s status. These responses indicate acceptance of norms that give men the right to use force against women, which is a violation of women’s human rights. Similarly, beliefs about whether and when a woman can refuse to have sex with her husband reflect issues of gender equity regarding sexual rights and bodily integrity. In addition to providing an important measure of women’s empowerment, information on women’s attitudes towards sexual rights is useful for improving and monitoring reproductive health programmes that depend on women’s willingness and ability to control their own sexual lives. To assess women’s decision-making autonomy, information was sought on women’s partici- pation in four different types of household decisions: respondent’s own health care, making major household purchases, making household purchases for daily needs, and visiting respondent’s family or relatives. Having a final say in the decision-making processes is the highest degree of autonomy. Women are considered to participate in a decision if they alone or jointly with their husband/partner have the final say in that decision. Table 15.6 shows the percent distribution of currently married women according to the person in the household who usually makes decisions concerning four specific matters. 240 | Women’s Empowerment and Demographic and Health Outcomes The data show that for the respondent’s own health care, women are the main decision- makers: 45 percent of married women reported that they mainly make decisions about their own health care. For large household purchases, more than half (52 percent) of women say that the decision is made together with their husband/partner; 23 percent of women say that they make major household decisions, and 24 percent say that the decision is made mainly by their husband/partner. Decisions to the woman’s visit family or relatives are most likely to be made by wives and husbands jointly (54 percent). Table 15.6 Women's participation in decision-making Percent distribution of currently married women age 15-49 by person who usually makes decisions on four specific issues, Namibia 2006-07 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 44.8 39.2 15.2 0.1 0.2 0.4 100.0 3,451 Major household purchases 22.8 52.2 23.8 0.3 0.4 0.5 100.0 3,451 Purchases of daily household needs 40.6 40.5 17.8 0.2 0.3 0.5 100.0 3,451 Visits to her family or relatives 24.7 53.6 20.4 0.2 0.6 0.4 100.0 3,451 Table 15.7 shows the participation of women in decision-making according to men. Except for decisions on the purchase of daily household needs, 59 to 79 percent of all the other issues are decided jointly. The table shows that men feel strongly about involving women in deciding the number of children the family should have (79 percent). Table 15.7 Women's participation in decision-making according to men Percent distribution of currently married men 15-49 by person they think should have a say in making decisions about five specific issues, Namibia 2006-07 Decision Wife Wife and husband equally Husband Don't know/ depends Missing Total Number of men Major household purchases 10.7 60.1 28.6 0.6 0.0 100.0 1,205 Purchases of daily household needs 48.8 36.2 12.9 2.0 0.1 100.0 1,205 Visits to wife's family or relatives 15.3 63.5 19.1 1.7 0.4 100.0 1,205 What to do with the money wife earns 25.7 59.2 13.1 1.8 0.1 100.0 1,205 How many children to have 3.6 78.8 14.8 2.7 0.0 100.0 1,205 Table 15.8.1 shows the percentage of currently married women age 15-49 years who usually make specific decisions either by themselves or jointly with their husband, by background characteristics. The four decisions included in the table are: own health care; making major household purchases; making purchases for daily household needs, and visits to woman’s family or relatives. The results indicate that the majority of currently married women participate in making decisions about their own health care (84 percent), major household purchases (75 percent), daily purchases (81 percent), and decisions regarding visits to her family or relatives (78 percent). Overall, 64 percent of currently married women participate in all four specified decisions and only 9 percent say that they do not participate in any of the decisions. The degree of independence in making household decisions increases with age. For example, 41 percent of women age 15-19 participate in all four decisions compared with 69 percent of women age 40-44. Women who earn cash, urban women, the most educated women, and women in the wealthiest households are more likely to have a final say in all the specified decisions. For example, whereas 73 percent of urban women participate in all four decisions, the corresponding proportion of rural women is 55 percent. Across regions, women in Erongo, Karas, and Khomas (80-82 percent) are the most likely to participate in all four decisions, while women in Kavango are the least likely to participate (36 percent). Women’s Empowerment and Demographic and Health Outcomes | 241 Table 15.8.1 Women's participation in decision-making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Namibia 2006-07 Decision Background characteristic Own health care Making major household purchases Making purchases for daily household needs Visits to her family or relatives Percentage who participate in all four decisions Percentage who participate in none of the specified decisions Number of women Age 15-19 65.6 64.2 65.5 64.2 40.5 16.8 118 20-24 79.2 68.5 74.1 67.5 55.1 12.6 398 25-29 84.2 73.1 79.4 77.2 60.9 8.3 625 30-34 87.9 80.3 84.2 81.9 68.6 6.6 751 35-39 81.6 72.6 80.0 77.5 64.7 11.8 612 40-44 87.5 77.4 85.7 83.0 69.3 5.8 522 45-49 85.8 78.7 85.4 83.0 70.1 7.7 424 Employment (past 12 months) Not employed 76.9 65.3 72.7 70.0 54.7 15.1 1,342 Employed for cash 91.3 85.7 89.7 87.5 76.9 4.0 1,569 Employed not for cash 80.6 68.4 77.5 72.4 51.4 7.6 534 Missing * * * * * * 6 Number of living children 0 81.5 76.0 81.6 79.4 62.3 7.3 269 1-2 86.5 77.1 81.8 78.4 66.2 8.1 1,450 3-4 82.5 75.2 81.9 78.6 63.9 9.3 1,061 5+ 82.0 70.2 78.4 77.1 61.7 10.5 670 Residence Urban 89.2 82.5 86.7 85.5 73.4 5.7 1,731 Rural 78.8 67.5 75.5 71.1 55.2 12.1 1,719 Region Caprivi 73.7 84.6 88.1 69.0 52.0 7.5 200 Erongo 92.6 86.7 89.6 90.4 79.2 3.0 327 Hardap 88.2 88.0 87.1 84.9 76.8 7.5 131 Karas 89.2 86.0 88.6 85.3 81.9 8.7 139 Kavango 73.7 54.8 62.0 51.0 35.9 16.7 477 Khomas 94.5 86.6 90.7 92.3 80.3 2.1 749 Kunene 68.0 59.6 64.1 63.2 50.4 21.4 141 Ohangwena 81.8 69.4 83.6 80.2 62.3 8.4 218 Omaheke 72.6 69.1 74.4 68.7 56.4 17.7 150 Omusati 88.0 71.3 82.6 87.6 66.8 5.3 195 Oshana 90.1 75.3 86.2 85.5 68.1 4.0 197 Oshikoto 86.3 73.7 83.0 82.6 64.0 6.2 246 Otjozondjupa 73.2 66.0 70.8 69.3 55.5 20.1 278 Education No education/preschool 65.1 55.9 63.2 57.9 40.1 21.2 408 Incomplete primary 80.6 69.2 76.7 73.5 56.8 11.2 805 Complete primary 81.9 72.8 77.9 73.4 58.3 10.0 242 Incomplete secondary 87.2 78.6 85.1 82.0 68.4 6.7 1,226 Complete secondary 93.3 85.6 89.0 89.9 79.6 3.6 435 More than secondary 93.1 87.5 91.5 89.5 81.6 2.6 334 Wealth quintile Lowest 73.3 59.8 65.9 62.5 43.4 15.3 590 Second 78.3 67.7 77.4 71.6 54.4 12.4 502 Middle 80.5 72.8 80.7 74.4 59.4 9.6 698 Fourth 88.2 78.4 83.7 82.6 69.7 7.1 798 Highest 93.6 88.5 91.8 92.2 83.4 3.5 863 Total 84.0 75.1 81.2 78.3 64.3 8.9 3,451 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. To assess women’s overall decision-making autonomy, the decisions in which women participate (alone or jointly with their husband/partner) have been summed to form a single measure of empowerment. Figure 15.1 shows the number of decisions in which women participate. 242 | Women’s Empowerment and Demographic and Health Outcomes In the survey, male respondents were asked whether they think a wife should have the greater say alone or equal say with her husband in making decisions on various issues. These issues are the same as those presented to female respondents: making major household purchases, making purchases for daily household needs, visiting the wife’s family or relatives, deciding what to do with the money the wife earns, and deciding how many children to have. Eighty-five percent of married men said that a wife should have a say in decisions about purchases for daily household needs and in the use of the money she has earned; 82 percent of married men say that a wife should have a say alone or jointly with her husband in the decision on how many children the couple will have (Table 15.8.2). Seven in ten currently married men say that a wife should have a say in making decisions about household purchases and 79 percent say that the wife should have a say in visits to her family or relatives. Less than half of currently married men think that a wife should participate alone or jointly in all five of the specified decisions, and only 1 percent think that wives should not be involved in any of the decisions. According to men, a wife’s participation in decision-making increases with age, education, and wealth quintile. For example, 65 percent of men age 20-24 think that a wife should be involved in making decisions on major household purchases, compared with 74 percent of men age 45-49. Better educated men are more likely to say that a wife should be involved in decision-making compared with less educated men: 69 percent for men with more than secondary education compared with 36 percent for men with no education. Men in urban areas are more likely than those in rural areas to say that a wife should be involved in major decision-making. The differences in regional support among men on participation of women in the five decisions ranges from 15 percent in Caprivi to 72 percent in Karas. Men in Kunene are the most likely to think that a wife should not take part in decision-making (10 percent). NDHS 2006-07 Figure 15.1 Number of Decisions in Which Women Participate 3 decisions 13% 4 decisions 64% 2 decisions 8% 1 decision 5% 0 decisions 9% Women’s Empowerment and Demographic and Health Outcomes | 243 Table 15.8.2 Men's attitude towards wives' participation in decision-making Percentage of currently married men age 15-49 who think a wife, either alone or jointly with her husband should have a say on five specific decisions, by background characteristics, Namibia 2006-07 Decision Background characteristic Making major household purchases Making purchases for daily household needs Visits to her family or relatives What to do with the money the wife earns How many children to have Percentage who participate in all five decisions Percentage who participate in none of the specified decisions Number of men Age 15-19 * * * * * * * 3 20-24 64.6 80.6 67.7 85.8 79.5 41.4 1.1 76 25-29 66.5 84.8 75.1 80.1 78.3 44.9 0.6 199 30-34 71.9 81.2 81.9 85.5 83.4 47.4 1.1 260 35-39 71.5 87.2 76.3 86.6 83.1 47.2 1.8 248 40-44 72.2 89.4 81.7 85.6 86.1 55.1 0.7 242 45-49 74.1 83.8 82.9 86.6 81.3 52.1 2.0 178 Employment (past 12 months) Not employed 67.1 85.2 79.7 81.7 80.1 47.1 1.9 119 Employed for cash 74.8 87.0 80.1 86.8 83.8 51.7 0.8 935 Employed not for cash 49.5 72.4 69.3 76.5 75.8 32.0 3.7 152 Number of living children 0 79.0 84.5 76.2 89.0 89.2 57.9 2.9 110 1-2 68.5 85.3 77.4 86.1 83.9 48.2 1.1 446 3-4 68.4 84.2 79.0 83.9 78.9 44.7 1.1 351 5+ 74.3 85.5 81.3 83.1 81.9 51.1 1.2 298 Residence Urban 78.2 87.2 84.4 88.9 84.1 55.1 0.8 714 Rural 60.0 81.7 70.5 79.3 80.1 39.6 1.9 491 Region Caprivi 60.9 90.4 32.4 58.8 57.4 15.1 0.0 82 Erongo 70.0 87.1 75.0 82.7 78.0 35.6 0.9 163 Hardap 88.0 90.9 92.7 99.1 94.9 69.3 0.0 45 Karas 76.5 93.3 85.0 85.7 86.0 71.8 2.0 48 Kavango 52.7 73.0 77.8 82.3 85.5 31.6 2.6 125 Khomas 81.5 87.3 89.8 91.6 83.9 62.0 0.9 332 Kunene 52.8 77.6 62.6 76.2 67.3 39.1 10.4 43 Ohangwena (73.3) (78.7) (89.0) (74.1) (84.4) (65.9) (1.8) 38 Omaheke 48.8 69.8 65.3 67.5 78.6 22.6 2.1 53 Omusati 55.3 91.1 86.1 90.0 86.5 44.4 0.0 47 Oshana 78.3 91.0 87.2 98.5 88.0 63.2 0.0 53 Oshikoto 83.0 78.7 76.2 89.8 90.9 53.7 0.0 73 Otjozondjupa 70.1 89.8 81.8 89.1 90.7 57.0 0.4 104 Education No education/preschool 55.7 75.8 74.9 73.5 75.8 36.3 2.7 159 Incomplete primary 65.8 81.7 71.9 80.8 75.8 37.7 1.8 284 Complete primary 56.0 78.3 76.5 88.3 82.8 40.2 3.5 56 Incomplete secondary 73.4 86.7 74.8 84.4 81.8 47.2 0.8 381 Complete secondary 80.8 90.8 90.7 94.3 90.8 66.5 0.0 168 More than secondary 83.8 92.1 92.6 94.6 93.8 69.4 0.7 156 Wealth quintile Lowest 51.2 78.1 65.0 75.6 72.9 29.8 2.2 154 Second 58.9 84.4 69.2 74.5 76.5 36.2 1.4 134 Middle 66.4 78.6 72.0 79.5 79.6 39.7 2.0 246 Fourth 77.0 86.8 79.3 86.8 83.2 51.8 1.3 311 Highest 81.4 90.9 92.2 95.1 90.0 65.1 0.3 360 Total 15-49 70.8 85.0 78.7 85.0 82.4 48.8 1.3 1,205 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.5 ATTITUDES TOWARDS WIFE BEATING Violence against women has serious consequences for their mental and physical well-being, including their reproductive and sexual health. One of the most common forms of violence against women worldwide is abuse by a husband or partner (Heise et al., 1999). The 2006-07 NDHS gathered information on women’s attitudes toward wife beating, a proxy for women’s perception of their status. Women who believe that a husband is justified in hitting or beating his wife for any of the specified reasons may believe themselves to be low in status both 244 | Women’s Empowerment and Demographic and Health Outcomes absolutely and relative to men. Such a perception could act as a barrier to accessing health care for themselves and their children, affect their attitude toward contraceptive use, and impact their general well-being. Women were asked whether a husband is justified in beating his wife under a series of specific circumstances: wife burns the food, argues with husband, goes out without telling husband, neglects the children, refuses sexual relations with husband, and has sex with other men. Table 15.9.1 summarizes women’s attitudes toward wife beating in these six specific circumstances. Table 15.9.1 Attitudes towards wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Namibia 2006-07 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason Number of women Age 15-19 13.5 14.9 19.7 28.2 10.1 37.6 2,246 20-24 12.9 15.8 19.8 27.9 12.1 38.7 1,855 25-29 11.5 16.3 17.7 24.4 11.7 33.5 1,623 30-34 11.0 15.8 17.2 23.6 13.1 32.1 1,417 35-39 11.1 15.0 19.2 23.4 12.9 32.3 1,045 40-44 11.9 14.9 19.2 26.3 13.7 34.7 928 45-49 14.6 15.4 19.5 25.1 12.3 33.1 689 Employment (past 12 months) Not employed 13.7 17.9 21.0 29.6 14.2 39.5 4,568 Employed for cash 8.0 9.4 12.0 18.3 7.0 25.2 3,738 Employed not for cash 19.1 23.5 30.0 34.0 17.8 47.3 1,467 Missing * * * * * * 32 Marital status Never married 12.0 13.3 17.5 25.6 10.0 34.6 5,673 Married or living together 12.2 17.7 20.0 25.3 14.2 34.7 3,451 Divorced/separated/widowed 16.6 22.5 25.5 32.4 17.7 42.3 678 Missing * * * * * * 3 Number of living children 0 11.3 12.1 16.7 24.0 8.9 33.3 3,419 1-2 12.0 16.3 18.7 25.8 12.4 35.4 3,620 3-4 11.9 16.2 20.2 26.0 13.3 33.9 1,789 5+ 18.4 23.0 24.8 33.2 18.8 43.7 976 Residence Urban 6.3 9.6 10.6 15.8 6.8 22.4 4,772 Rural 18.1 21.1 26.7 35.6 17.0 47.4 5,032 Region Caprivi 38.2 54.6 60.3 63.0 38.4 81.3 474 Erongo 4.9 7.6 8.6 13.4 6.4 22.8 688 Hardap 8.6 13.7 13.3 23.1 6.2 28.8 315 Karas 2.3 3.4 5.3 11.2 4.0 13.8 318 Kavango 18.7 30.7 35.3 40.4 26.0 54.8 934 Khomas 2.7 4.8 4.6 8.8 3.1 13.4 2,218 Kunene 10.7 24.4 27.1 35.7 14.7 43.0 259 Ohangwena 21.1 21.2 26.8 40.0 19.0 56.2 1,043 Omaheke 7.2 12.1 16.8 25.2 6.7 33.4 373 Omusati 17.4 17.4 26.6 33.5 16.6 44.5 975 Oshana 12.9 9.1 15.7 25.0 5.9 34.0 819 Oshikoto 14.1 10.3 13.3 23.5 7.6 29.7 837 Otjozondjupa 11.0 18.2 19.4 25.3 12.8 32.5 550 Education No education/preschool 19.8 29.2 30.5 35.9 25.0 50.0 651 Incomplete primary 22.8 25.1 27.9 35.8 20.4 48.2 1,699 Complete primary 16.4 18.9 24.3 32.8 14.7 42.6 736 Incomplete secondary 10.9 13.9 18.2 26.0 10.4 35.5 4,751 Complete secondary 3.5 6.3 7.7 13.8 4.1 18.2 1,286 More than secondary 1.7 3.5 5.6 6.7 2.1 10.5 682 Wealth quintile Lowest 23.7 30.8 34.6 43.3 25.4 58.2 1,621 Second 18.7 20.4 27.0 35.5 16.9 47.9 1,668 Middle 15.1 18.1 24.1 32.1 13.5 42.6 1,885 Fourth 8.0 10.1 12.6 19.7 6.8 26.5 2,292 Highest 2.1 4.5 4.3 8.3 3.1 12.7 2,338 Total 12.4 15.5 18.9 25.9 12.0 35.2 9,804 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Women’s Empowerment and Demographic and Health Outcomes | 245 Table 15.9.1 indicates that 35 percent of women agree with at least one of the five specified reasons for a husband to beat his wife. One in four women say that wife beating is justified if a wife neglects the children, 19 percent say it is justified if the wife goes out without informing the husband, 16 percent say it is justified if she argues with the husband, and 12 percent each say it is justified if the wife burns the food or refuses to have sex with the husband. The percentage of women who agree with at least one reason for beating a wife does not vary by the woman’s age. Women who are employed but receive no cash earnings are much more likely than women who are paid in cash to agree with at least one reason for wife beating (47 percent and 25 percent, respectively). Formerly married women are more likely to agree on a reason for wife beating (42 percent) than never-married women or married women (35 percent each). The number of children a woman has influences her perception on wife beating; 44 percent of women with five or more children agree on at least one reason justifying wife beating, compared with 33-35 percent among women with fewer children. There are regional variations in attitudes towards wife beating, ranging from 13-14 percent in Karas and Khomas to 81 percent of women in Caprivi. In other regions, the proportion of women who agree on a reason justifying wife beating ranges between 23 percent in Erongo and 56 percent in Ohangwena. There is a negative relationship between agreement with at least one reason for wife beating and level of education and wealth status. Fifty percent of women with no education said that husbands are justified in beating their wives for at least one of the specified reasons compared with 11 percent of women with more than secondary education. Similarly, 58 percent of women in the lowest wealth quintile agree with at least one reason justifying wife beating compared with 13 percent of women in the highest quintile. Men were also asked about their opinions on the justification of wife beating under certain circumstances. Nationally, 41 percent of men agree that wives can be beaten for at least one of the specified reasons. Among the various reasons for justifying wife beating, the largest difference between men and women is when a wife goes out without telling the husband (19 percent for women and 27 percent for men). As shown in Table 15.9.2, younger men are more likely than older men to say that a husband is justified in hitting or beating his wife for at least one of the specified reasons (49 percent for men age 20-24 compared with 28 percent for men age 45-49). Men who are employed but receive no cash earnings (51 percent) are more likely than other men to agree with at least one reason justifying wife beating. Formerly married men are more likely to agree on at least one reason for wife beating (47 percent) than never-married men (45 percent) or married men (32 percent). The number of children a man has influences his perception on wife beating. Men with no children are the most likely to agree with at least one reason (44 percent) compared with men who have children (39 percent or less). Men in rural areas are much more likely than men in urban areas to agree with a reason justifying wife beating (51 percent compared with 31 percent). Men in Omusati, Ohangwena, and Oshikoto regions are the most likely to say that a husband is justified in hitting or beating his wife for at least one of the specified reasons (63-67 percent), compared with only 12 percent in Karas region. There is an inverse relationship between a man’s level of education and wealth quintile and his perception of wife beating. For example, 63 percent of men in the lowest wealth quintile say that a husband is justified in hitting or beating his wife for at least one of the specified reasons compared with 23 percent of men in the highest wealth quintile. 246 | Women’s Empowerment and Demographic and Health Outcomes Table 15.9.2 Attitudes towards wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Namibia 2006-07 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason Number of men Age 15-19 14.0 21.2 27.8 30.0 9.1 44.2 910 20-24 9.8 21.8 29.9 31.3 9.5 48.5 750 25-29 9.5 19.0 27.4 27.8 7.3 39.3 702 30-34 9.5 17.8 24.7 24.9 8.2 35.7 586 35-39 6.7 16.4 25.6 25.1 4.7 36.9 400 40-44 7.7 15.2 28.2 25.6 8.2 39.5 331 45-49 9.2 14.9 22.3 21.3 7.4 28.0 235 Employment (past 12 months) Not employed 13.7 21.2 29.0 27.6 11.1 45.6 1,220 Employed for cash 7.2 15.8 23.4 24.9 6.3 35.4 2,138 Employed not for cash 13.5 26.8 37.8 39.4 8.2 51.2 548 Missing * * * * * * 8 Marital status Never married 11.2 20.7 29.1 30.0 9.3 44.5 2,545 Married or living together 8.2 14.7 22.5 21.6 5.3 32.1 1,205 Divorced/separated/widowed 7.9 24.2 30.2 37.4 10.2 47.2 163 Missing * * * * * * 1 Number of living children 0 11.0 20.3 27.5 29.3 9.1 43.8 2,096 1-2 10.5 19.6 26.9 27.0 7.4 38.8 967 3-4 6.4 15.8 25.1 23.4 6.0 34.7 481 5+ 9.4 14.6 28.2 25.9 7.1 36.6 370 Residence Urban 5.5 13.0 19.3 21.0 4.1 30.9 1,962 Rural 14.9 25.1 35.0 34.4 12.2 50.7 1,953 Region Caprivi 25.6 36.1 33.4 34.7 12.8 58.1 189 Erongo 9.9 17.4 29.4 24.7 5.1 41.1 362 Hardap 2.4 10.0 7.2 12.4 3.1 17.5 132 Karas 1.7 3.2 5.2 7.8 1.0 11.8 157 Kavango 2.6 7.6 32.3 28.9 3.3 42.3 331 Khomas 4.7 13.1 16.9 20.5 4.9 28.0 984 Kunene 8.7 24.4 30.1 37.6 6.4 41.5 92 Ohangwena 35.5 30.2 40.3 33.6 27.1 65.2 306 Omaheke 5.2 9.5 15.4 22.3 2.7 31.5 188 Omusati 11.7 33.3 55.4 58.4 18.9 66.5 320 Oshana 3.2 30.6 31.3 15.4 8.2 44.3 270 Oshikoto 22.2 31.7 45.3 50.9 8.8 63.3 322 Otjozondjupa 3.0 6.5 5.6 12.3 1.8 18.1 262 Education No education/preschool 18.4 23.8 34.5 34.3 9.5 49.8 360 Incomplete primary 15.5 26.8 38.8 37.1 11.2 52.9 856 Complete primary 14.7 23.3 30.6 37.1 9.5 48.0 252 Incomplete secondary 7.9 18.3 25.0 25.9 8.2 39.6 1,604 Complete secondary 4.7 10.4 17.0 20.0 3.4 29.2 538 More than secondary 3.2 7.0 11.6 8.5 4.5 16.6 305 Wealth quintile Lowest 21.1 33.6 45.5 44.7 17.3 63.3 560 Second 18.0 27.6 37.0 37.0 12.8 54.1 607 Middle 8.7 19.3 29.8 29.2 8.0 43.9 875 Fourth 5.1 13.1 20.4 22.3 4.4 33.0 963 Highest 4.9 10.2 13.9 15.4 3.3 23.2 911 Total 15-49 10.1 19.0 27.1 27.7 8.1 40.8 3,915 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 15.6 ATTITUDES TOWARDS REFUSING SEX WITH HUSBAND The extent of control women have over when and with whom they have sexual intercourse has implications for health outcomes, such as transmission of HIV and other sexually transmitted infections (STIs). To measure beliefs about sexual empowerment of women, the 2006-07 NDHS included questions on whether the respondent thinks that a wife is justified in refusing to have sexual Women’s Empowerment and Demographic and Health Outcomes | 247 intercourse with her husband under three circumstances: when she knows her husband has a sexually transmitted infection; when she knows her husband has sexual intercourse with other women; and when she is tired or not in the mood. These three circumstances for which women’s opinions are sought have been chosen because they are effective in combing the issue of women’s rights with the consequences for women’s health. Tables 15.10.1 and 15.10.2 show the responses of all women and all men, respectively. Table 15.10.1 Attitudes towards refusing sexual intercourse with husband: Women Percentage of all women age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Namibia 2006-07 Wife is justified in refusing intercourse with her husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of women Age 15-19 79.7 78.7 79.2 66.7 10.1 2,246 20-24 86.1 85.4 86.2 74.8 5.5 1,855 25-29 87.4 85.3 84.9 74.4 5.1 1,623 30-34 88.2 87.5 88.6 78.8 4.5 1,417 35-39 86.5 84.6 85.9 74.1 5.1 1,045 40-44 89.0 87.0 89.5 79.2 4.8 928 45-49 87.0 87.7 83.9 75.0 5.2 689 Employment (past 12 months) Not employed 82.6 80.5 81.5 69.5 8.5 4,568 Employed for cash 89.7 88.9 89.4 79.2 3.1 3,738 Employed not for cash 83.8 84.7 83.7 73.0 6.9 1,467 Missing 89.7 93.6 86.6 86.6 6.4 32 Marital status Never married 84.8 83.7 84.6 72.7 6.3 5,673 Married or living together 86.5 85.2 84.9 75.2 6.3 3,451 Divorced/separated/widowed 86.9 85.6 87.0 76.0 4.9 678 Missing 100.0 100.0 100.0 100.0 0.0 3 Number of living children 0 83.8 82.3 82.0 70.9 7.7 3,419 1-2 86.5 85.7 86.6 75.6 5.3 3,620 3-4 86.7 86.7 87.2 76.0 5.1 1,789 5+ 86.0 82.7 84.2 73.2 6.6 976 Residence Urban 89.1 87.7 87.8 78.4 4.2 4,772 Rural 82.2 81.2 82.1 69.5 8.1 5,032 Region Caprivi 85.7 74.4 82.0 65.4 7.4 474 Erongo 85.6 87.2 86.3 76.0 5.1 688 Hardap 95.0 91.7 92.9 87.5 2.1 315 Karas 89.5 88.2 86.9 79.6 4.5 318 Kavango 70.3 69.6 71.1 57.5 19.0 934 Khomas 92.2 90.3 89.9 81.9 2.2 2,218 Kunene 90.5 86.8 89.4 80.8 4.4 259 Ohangwena 84.0 79.7 82.5 69.5 7.6 1,043 Omaheke 88.9 83.1 87.7 73.8 4.6 373 Omusati 85.9 83.0 84.5 71.9 5.4 975 Oshana 78.7 86.1 81.8 67.6 6.4 819 Oshikoto 84.3 88.0 86.1 75.0 5.3 837 Otjozondjupa 85.9 87.4 86.2 77.7 6.3 550 Education No education/preschool 75.4 70.0 72.1 57.9 15.0 651 Incomplete primary 80.9 80.5 81.3 68.8 9.7 1,699 Complete primary 82.4 79.1 80.1 67.7 8.3 736 Incomplete secondary 86.4 85.4 85.9 75.0 5.3 4,751 Complete secondary 91.3 91.0 92.6 83.2 2.2 1,286 More than secondary 93.4 94.2 89.1 81.8 0.8 682 Wealth quintile Lowest 78.1 75.8 76.5 63.3 12.0 1,621 Second 81.9 80.4 82.0 69.0 8.0 1,668 Middle 84.2 83.4 84.7 71.9 6.6 1,885 Fourth 88.3 87.3 87.9 77.8 4.2 2,292 Highest 91.6 91.1 89.8 82.2 2.6 2,338 Total 85.5 84.4 84.9 73.8 6.2 9,804 248 | Women’s Empowerment and Demographic and Health Outcomes There is a high level of agreement between women and men on the three reasons that justify a woman refusing to have sexual relations with her husband (84 percent or higher). The most accepted reason among women and men is if the wife knows her husband has a sexually transmitted infection (86 and 89 percent, respectively). The percentage of women and men who agree that a woman can refuse to have sexual intercourse with her husband for all three specified reasons is 74 percent each. There are no substantial differences in women’s perceptions on refusing sexual intercourse by age, employment status, marital status, and number of children. Table 15.10.1 indicates that women in urban areas are more likely than those in rural areas to say that a woman is justified in refusing to have sex with her husband for all of the specified reasons (78 compared with 70 percent, respectively). There are large regional differences in the percentage of women who say that a woman is justified in refusing to have sex with her husband for all of the reasons, ranging from 58 percent in Kavango to between 80 and 88 percent in Hardap, Karas, Kunene, and Khomas. On the other hand, the percentage of women who agree with none of the reasons for a wife refusing sexual intercourse with her husband is lowest in Hardap and Khomas (2 percent) and highest in Kavango (19 percent). Table 15.10.2 shows that, as with women, there are no differences in men’s attitudes towards a woman’s right to refuse to have sexual intercourse with her husband by age, employment status, marital status, and number of children. Urban men are more likely than rural men to say that a woman is justified in refusing to have sex with her husband for all of the reasons (77 compared with 72 percent, respectively). There are also large regional differences in men’s perceptions of a woman’s right to refuse to have sex with her husband, ranging from 54 percent in the Ohangwena to 88 percent in Omusati. The percentage of men who agree with none of the reasons to justify a wife refusing to have intercourse with her husband is lowest in Caprivi (1 percent) and highest in Ohangwena (15 percent). There is an inverse relationship between a man’s level of education and wealth quintile and the specified reasons justifying a wife’s refusal to have of sexual intercourse with her husband. For example, 7 percent of men with the least education say that a wife is justified in refusing to have sex with her husband compared with 2 percent of men with more than secondary education. Similarly, 9 percent of men in the lowest wealth quintile say that a wife is justified in refusing to have sex with her husband compared with 3 percent of men in the highest wealth quintile. Women’s Empowerment and Demographic and Health Outcomes | 249 Table 15.10.2 Attitudes towards refusing sexual intercourse with husband: Men Percentage of all men age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Namibia 2006-07 Wife is justified in refusing intercourse with her husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of men Age 15-19 86.2 82.1 83.3 73.0 6.0 910 20-24 89.5 85.2 87.2 75.4 3.8 750 25-29 86.7 83.1 86.3 70.0 3.2 702 30-34 91.3 86.0 89.2 76.5 2.2 586 35-39 88.5 87.3 90.0 77.1 3.6 400 40-44 90.4 87.3 89.6 76.4 3.0 331 45-49 89.1 83.4 89.5 76.9 5.1 235 Employment (past 12 months) Not employed 86.5 82.6 84.7 72.6 5.9 1,220 Employed for cash 89.3 85.2 87.6 74.3 3.0 2,138 Employed not for cash 89.7 85.9 90.1 78.8 3.5 548 Missing * * * * * 8 Marital status Never married 87.4 84.1 86.6 73.6 4.1 2,545 Married or living together 90.8 85.3 88.0 76.1 3.6 1,205 Divorced/separated/widowed 88.7 84.4 86.3 74.0 4.3 163 Missing * * * * * 1 Number of living children 0 87.4 83.8 85.5 73.2 4.2 2,096 1-2 90.4 86.1 88.9 76.0 2.7 967 3-4 89.8 83.6 88.2 74.6 4.6 481 5+ 87.8 85.8 89.8 76.7 4.7 370 Residence Urban 90.6 87.4 88.2 77.2 2.6 1,962 Rural 86.3 81.6 85.9 71.5 5.3 1,953 Region Caprivi 85.5 72.5 88.7 58.7 1.3 189 Erongo 83.2 85.5 89.6 70.5 2.5 362 Hardap 88.3 90.2 91.5 83.0 5.3 132 Karas 94.1 88.9 91.9 83.2 2.2 157 Kavango 92.7 82.6 87.9 77.3 4.1 331 Khomas 91.6 88.0 85.2 77.6 3.2 984 Kunene 92.3 84.6 86.3 73.1 1.7 92 Ohangwena 68.9 72.6 72.9 54.3 14.6 306 Omaheke 94.0 88.5 90.6 80.9 1.5 188 Omusati 92.7 95.0 92.5 87.6 2.4 320 Oshana 90.3 76.1 84.4 69.7 3.9 270 Oshikoto 87.4 89.5 90.3 78.2 2.9 322 Otjozondjupa 89.1 76.2 89.2 69.0 4.2 262 Education No education/preschool 82.1 76.6 81.9 64.1 6.7 360 Incomplete primary 84.3 80.6 82.2 68.3 6.8 856 Complete primary 85.5 84.7 84.9 72.0 4.0 252 Incomplete secondary 90.3 85.5 88.8 76.7 3.1 1,604 Complete secondary 94.4 91.4 90.7 82.3 1.2 538 More than secondary 90.2 87.3 93.1 79.3 1.8 305 Wealth quintile Lowest 81.3 76.9 79.2 64.3 8.6 560 Second 87.8 82.8 86.8 73.3 5.0 607 Middle 88.8 84.0 89.0 74.1 2.8 875 Fourth 89.1 86.5 89.0 76.3 2.8 963 Highest 92.3 88.8 88.1 79.5 2.7 911 Total 15-49 88.5 84.5 87.1 74.4 3.9 3,915 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Table 15.11 shows men’s attitudes about a husband's rights when a wife refuses to have sexual intercourse with him. The most acceptable action taken is for the husband to reprimand the wife (24 percent). Other courses of action are to have sex with another woman (16 percent), refuse financial support (16 percent), and force the wife to have sex (5 percent). Very few men agree with all of the specified reasons, and 64 percent agree with none of the reasons. 250 | Women’s Empowerment and Demographic and Health Outcomes Disagreement with all of the specified reasons justifying the husband’s sexual rights is expressed most strongly by men in Omusati (30 percent) and least strongly by men in Karas (90 percent). Table 15.11 Men's attitudes towards a husband's rights when his wife refuses to have sexual intercourse Percentage of men age 15-49 who think that a husband has the right to certain behaviours when a wife refuses to have sex with him when he wants her to, by background characteristics, Namibia 2006-07 When a woman refuses to have sex with her husband, he has the right to: Background characteristic Get angry and reprimand her Refuse her financial support Use force to have sex Have sex with another woman Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of men Age 15-19 22.5 19.1 6.7 16.2 1.3 60.7 910 20-24 27.6 20.4 5.3 18.3 2.0 59.4 750 25-29 27.2 15.5 4.7 15.9 1.1 61.1 702 30-34 23.9 13.8 4.6 16.0 1.6 65.9 586 35-39 24.1 9.5 4.1 11.3 1.2 67.5 400 40-44 18.8 13.3 4.6 13.8 1.4 71.6 331 45-49 17.0 11.0 6.1 10.2 2.9 75.3 235 Employment (past 12 months) Not employed 24.0 20.8 8.2 20.1 2.6 58.5 1,220 Employed for cash 22.5 12.5 4.3 12.7 1.0 67.3 2,138 Employed not for cash 30.6 18.8 2.7 16.1 1.2 61.4 548 Missing * * * * * * 8 Marital status Never married 25.7 18.5 5.9 18.0 1.6 59.9 2,545 Married or living together 20.7 10.3 4.2 9.5 1.5 72.1 1,205 Divorced/separated/widowed 23.0 18.7 4.0 20.7 0.5 64.0 163 Missing * * * * * * 1 Number of living children 0 24.9 18.6 5.8 17.4 1.5 60.6 2,096 1-2 26.5 13.0 4.4 14.3 1.3 63.8 967 3-4 19.6 11.2 3.8 11.1 1.3 72.5 481 5+ 18.8 14.8 6.7 13.3 2.4 71.0 370 Residence Urban 19.4 10.3 3.9 11.3 0.6 69.2 1,962 Rural 28.7 21.6 6.6 19.6 2.5 58.3 1,953 Region Caprivi 35.6 17.0 5.9 12.6 2.2 56.4 189 Erongo 31.1 12.3 4.1 12.9 1.6 60.1 362 Hardap 9.0 7.9 1.7 8.4 0.2 82.2 132 Karas 6.1 3.9 2.0 4.3 0.3 89.8 157 Kavango 7.6 5.4 4.1 8.5 0.7 83.7 331 Khomas 18.6 11.7 5.2 12.1 0.4 67.3 984 Kunene 16.7 8.3 3.2 12.9 0.9 74.8 92 Ohangwena 29.1 25.4 25.3 19.1 9.1 50.4 306 Omaheke 17.5 10.4 1.7 13.9 0.6 70.5 188 Omusati 52.5 51.4 5.5 53.5 3.2 30.1 320 Oshana 29.1 25.3 1.3 25.6 0.7 53.3 270 Oshikoto 39.5 14.4 1.7 6.7 0.3 50.8 322 Otjozondjupa 7.7 5.2 0.2 4.7 0.0 86.4 262 Education No education/preschool 29.1 16.7 8.4 17.2 2.4 58.7 360 Incomplete primary 30.8 19.9 8.9 19.2 3.6 56.4 856 Complete primary 29.6 19.9 5.1 14.3 1.4 58.8 252 Incomplete secondary 23.1 16.7 4.8 14.5 0.8 64.7 1,604 Complete secondary 17.4 11.9 0.9 13.6 0.5 70.8 538 More than secondary 11.4 4.0 1.6 12.5 0.6 77.7 305 Wealth quintile Lowest 34.5 25.2 9.7 20.6 3.6 52.5 560 Second 33.7 23.6 8.7 22.0 2.7 51.5 607 Middle 25.1 17.5 4.1 17.0 1.2 63.9 875 Fourth 18.8 11.2 3.6 10.8 1.2 69.9 963 Highest 15.7 8.5 3.2 11.5 0.1 72.4 911 Total 15-49 24.0 15.9 5.3 15.5 1.5 63.8 3,915 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Women’s Empowerment and Demographic and Health Outcomes | 251 15.7 WOMEN’S EMPOWERMENT INDICATORS The three sets of empowerment indicators, namely women’s participation in household decisions, their attitude toward wife beating, and their attitude towards a wife’s right to refuse sexual intercourse with her husband/partner, can be summarized in three indices. The first index shows the number of decisions in which women participate alone or jointly with their husband/partner (see Table 15.8.1 for the list of decisions). This index has values ranging from 0 to 4 and is positively related to women’s empowerment. It reflects the degree of decision-making control that women are able to exercise in areas that affect their lives and environments. Table 15.12 shows that there is a negative relationship between agreement on reasons for wife beating and the number of decisions a woman participates in. For example, 57 percent of women who did not participate in household decision-making disagree with all the reasons for wife beating compared with 70 percent for the most empowered women. The same relationship is seen for a woman refusing to have sexual intercourse with her husband (59 percent and 79 percent, respectively). Table 15.12 Indicators of women's empowerment Percentage of women age 15-49 who participate in all decision-making, percentage who disagree with all reasons for justifying wife-beating, and percentage who agree with all reasons for refusing sexual intercourse with husband, by value on each of the indicators of women's empowerment, Namibia 2006-07 Currently married women Empowerment indicator Percentage who participate in all decision- making Number of women Percentage who disagree with all the reasons justifying wife beating Percentage who agree with all the reasons for refusing sexual intercourse with husband Number of women Number of decisions in which women participate1 0 na na 57.1 58.6 307 1-2 na na 44.2 66.2 471 3-4 na na 70.0 78.6 2,672 Number of reasons for which wife- beating is justified2 0 72.6 2,253 na 76.6 6,354 1-2 50.1 659 na 71.2 2,020 3-4 49.0 365 na 65.9 1,073 5 42.8 173 na 62.2 357 Number of reasons given for refusing to have sexual intercourse with husband 3 0 46.8 219 58.0 na 609 1-2 56.4 638 57.8 na 1,959 3 67.7 2,594 67.3 na 7,237 na = Not applicable 1 Restricted to currently married women. See Table 15.8.1 for the list of decisions. 2 See Table 15.9.1 for the list of reasons 3 See Table 15.10.1 for the list of reasons The second index, which has values ranging from 0 to 5, is the total number of reasons for which the respondent feels that a husband is justified in beating his wife (see Table 15.9.1 for the list of reasons). A lower score on this indicator is interpreted as reflecting a greater sense of entitlement and self-esteem, and higher status for women. Most of the women interviewed (73 percent) who participate in all decision-making do not agree with any reason for which wife beating is justified compared with those who agree with all five reasons (43 percent). A large proportion of women who do not justify wife beating (78 percent) also agree with all reasons for refusing sexual intercourse with husband while those who justify all reasons for wife beating score low on reasons for refusal to having sex with husband. The third index, which has values ranging from 0 to 3, is the number of circumstances in which the respondent feels that a woman is justified in refusing sexual intercourse with her husband/ 252 | Women’s Empowerment and Demographic and Health Outcomes partner (see Table 15.10.1 for the list of circumstances). This indicator reflects perceptions of sexual roles and women’s rights over their bodies and relates positively to women’s sense of self and empowerment. Among women who participate in all decision-making, 68 percent feel that a woman is justified in refusing sexual intercourse with her husband, compared with 47 percent of women who give no reason for refusing sexual intercourse. Table 15.12 shows how these three indicators relate to each other. In general, the pattern indicates that women who participate in household decisions are also more likely to have gender- egalitarian beliefs. 15.8 CURRENT USE OF CONTRACEPTION BY WOMEN’S EMPOWERMENT STATUS A woman’s ability to control her fertility and the contraceptive method she chooses are likely to be affected by her status, self-image, and sense of empowerment. A woman who feels that she is unable to control other aspects of her life may be less likely to feel she can make decisions regarding fertility. She may also feel the need to choose contraceptive methods that are easier to conceal from her husband/partner or which do not depend on his cooperation. Table 15.13 shows the relationship of each of the three indicators of women’s empowerment with current use of contraceptive methods by currently married women age 15-49 in Namibia. It is evident from the data that there is a positive relationship between women’s status and use of contraceptives. Contraceptive use is highest among women who participate most (3-4) in household decisions. This pattern is consistent for both any method and modern methods. For example, current use of modern contraceptive methods increases from 38 percent among women who believe there is no justifiable reason for a wife to refuse sexual intercourse with a husband to 55 percent among women with three reasons for refusing to have sexual intercourse with a husband. Table 15.13 Current use of contraception by women's status Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women's status, Namibia 2006-07 Modern methods Empowerment indicator Any method Any modern method Female sterili- zation Male sterili- zation Temporary modern female methods1 Male condom Any traditional method Not currently using Total Number of women Number of decisions in which women participate2 0 43.2 41.1 7.1 0.4 23.5 10.2 2.1 56.8 100.0 307 1-2 44.2 42.1 4.6 0.1 26.8 10.6 2.2 55.8 100.0 471 3-4 58.3 56.9 11.7 0.5 34.1 10.6 1.5 41.7 100.0 2,672 Number of reasons for which wife beating is justified3 0 59.3 57.6 12.6 0.6 31.9 12.5 1.7 40.7 100.0 2,253 1-2 51.7 50.8 7.8 0.2 34.9 7.9 1.0 48.3 100.0 659 3-4 42.5 41.3 4.4 0.0 31.2 5.7 1.2 57.5 100.0 365 5 38.8 34.9 2.5 0.0 26.9 5.5 3.9 61.2 100.0 173 Number of reasons given for refusing to have sexual intercourse with husband 4 0 40.6 38.4 4.5 0.0 30.2 3.6 2.2 59.4 100.0 219 1-2 55.7 53.9 9.5 0.2 31.0 13.2 1.8 44.3 100.0 638 3 56.1 54.6 11.0 0.5 32.6 10.5 1.5 43.9 100.0 2,594 Total 55.1 53.4 10.3 0.4 32.2 10.6 1.6 44.9 100.0 3,451 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly and lactational amenorrhoea method 2 See Table 15.8.1 for the list of decisions 3 See Table 15.9.1 for the list of reasons 4 See Table 15.10.1 for the list of reasons Women’s Empowerment and Demographic and Health Outcomes | 253 15.9 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS Women’s fertility preferences are commonly lower than those of their partners. As a woman becomes more empowered to negotiate fertility decision-making, she has more control over contraceptive use and consequently, her chances of becoming pregnant and giving birth. Table 15.14 shows how women’s ideal family size and their unmet need for family planning vary by the three indicators of women’s empowerment. Table 15.14 Women's empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women age 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women's empowerment, Namibia 2006-07 All women Percentage of currently married women with an unmet need for family planning2 Empowerment indicator Mean ideal number of children1 Number of women For spacing For limiting Total Number of women Number of decisions in which women participate3 0 4.1 301 4.6 4.7 9.2 307 1-2 4.3 460 7.3 4.0 11.3 471 3-4 3.6 2,643 3.1 2.5 5.6 2,672 Number of reasons for which wife beating is justified 4 0 2.9 6,298 3.5 2.6 6.1 2,253 1-2 3.2 1,992 3.6 3.3 6.9 659 3-4 3.6 1,065 6.0 3.4 9.4 365 5 3.9 352 5.0 4.1 9.2 173 Number of reasons given for refusing to have sexual intercourse with husband5 0 3.1 597 4.5 4.7 9.2 219 1-2 3.2 1,933 6.0 2.2 8.2 638 3 3.0 7,176 3.2 2.9 6.2 2,594 Total 3.1 9,706 3.8 2.9 6.7 3,451 1 Mean excludes respondents who gave non-numeric responses. 2 See table 7.3.1 for the definition of unmet need for family planning 3 Restricted to currently married women. See Table 15.8.1 for the list of decisions. 4 See Table 15.9.1 for the list of reasons 5 See Table 15.10.1 for the list of reasons The less empowered the woman is, the larger is her family size because she has less opportunity to decide on the number of the children she wants. The data also indicate that family size decreases with the increasing number of decisions in which a woman has a final say. For example, the mean ideal number of children for women who participate in none of the decisions is 4.1 children compared with 3.6 children for women who participate in 3-4 decisions. Table 15.14 also indicates that, in general, more empowered women are more likely to meet their family planning needs. 15.10 WOMEN’S STATUS AND REPRODUCTIVE HEALTH CARE Table 15.15 examines whether women’s use of antenatal, delivery, and postnatal care services from health workers varies by their level of empowerment as measured by the three indicators of empowerment. In societies where health care is widespread, women’s empowerment may not affect their access to reproductive health services; in other societies, however, increased empowerment of women is likely to increase their ability to seek out and use health services to better meet their own reproductive health goals, including the goal of safe motherhood. 254 | Women’s Empowerment and Demographic and Health Outcomes The data indicate that there is a positive relationship between empowerment and use of health services. Women who are more empowered are more likely to receive outreach care and assistance from a health professional. For instance, 85 percent of women who do not take part in any form of decision-making received antenatal care from a health professional, compared with 95 percent of women who participate in 3-4 decisions. Similarly, the number of reasons for which women feel that a wife is justified in refusing to have sexual intercourse with her husband has a strong positive relationship with all three indicators. For example, the proportion of women who received delivery assistance from health personnel increased from 66 percent among women who accept all the reasons justifying wife beating to 87 percent among those who say that none of the reasons are justifiable. Table 15.15 Reproductive health care and women's empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance and postnatal care from health personnel for the most recent birth, by indicators of women's empowerment, Namibia 2006-07 Empowerment indicator Received antenatal care from health personnel Received delivery assistance from health personnel Received postnatal care from health personnel within the first two days after delivery1 Number of women with a child born in the past five years Number of decisions in which women participate 2 0 84.8 63.9 51.6 205 1-2 91.8 69.3 49.2 295 3-4 94.5 83.9 63.1 1,448 Number of reasons for which wife beating is justified 3 0 95.2 86.9 66.8 2,407 1-2 95.1 81.2 56.1 814 3-4 92.5 71.2 50.0 486 5 91.0 66.3 51.3 192 Number of reasons given for refusing to have sexual intercourse with husband 4 0 85.5 67.1 45.2 225 1-2 93.6 80.9 57.0 777 3 95.6 84.4 64.3 2,896 Total 94.6 82.7 61.7 3,898 Note: “Health personnel” includes doctor, nurse, midwife, or auxiliary nurse or auxiliary midwife. 1 Includes deliveries in a health facility and not in a health facility 2 Restricted to currently married women. See Table 14.5.1 for the list of decisions. 3 See Table 14.6.1 for the list of reasons 4 See Table 14.7.1 for the list of reasons Orphans and Vulnerable Children | 255 ORPHANS AND VULNERABLE CHILDREN 16 The HIV epidemic in Namibia has taken a toll on the children whose social and economic well-being has been compromised because of the serious illness or death of a parent or other adult in the household. This chapter looks at the situation of orphaned and vulnerable children (OVCs) in Namibia including the extent to which children who are orphaned and vulnerable are disadvantaged in comparison to other children. The chapter also presents information on support provided to households in which there are orphaned or vulnerable children. By definition, the 2006-07 NDHS, which is a household survey, does not collect information on children in institutions or children who are living on the street. The exclusion of these children is not likely to have a significant effect on the values of these indicators. However, given their lack of representation, the 2006-07 NDHS results should be considered a minimum estimate of the problem of OVCs in Namibia. The Ministry of Gender Equality and Child Welfare (MGECW) defines an orphan as a child below age 18 with one or both parents deceased. The MGECW also has a specific definition for vulnerable children, however the definition was not yet available when the NDHS data were collected. The 2006-07 NDHS defined a vulnerable child as a child below age 18 who has a chronically ill parent or who lives in a household where an adult has been chronically ill or has died in the 12 months preceding the survey. Chronically ill is defined as an adult who cannot take part in basic household chores for at least three of the last 12 months. 16.1 ORPHANS AND VULNERABLE CHILDREN 16.1.1 Children’s Living Arrangements and Orphanhood Information was collected in the household questionnaire on the living arrangements and survival status of all children under age 18 resident in the households included in the 2006-07 NDHS sample. These data are presented in Table 16.1. Household heads were asked about the survival status of the biological parents of each child residing in the household. Biological parents were emphasized to avoid measuring the survival status of foster parents. If the household head was not sure of the status of one of the parents the survival status was left as missing. Only one-quarter of the children in Namibia live with both parents. Children in the wealthiest households were most likely to be living with both parents (40 percent), while less than 20 percent of children in Ohangwena, Omusati, Oshana, and Oshikoto live with both parents. Erongo has the highest proportion of children living with both parents (45 percent). Research from 10 countries in the region suggests that orphans’ well-being often depends on their relatedness to the household head. The more distant the relationship between the child and the household head, the worse the outcomes are for the children (UNICEF, 2006). In Namibia, 36 percent of children under age 18 do not live with either biological parent. In rural areas, the proportion of children living away from their biological parents is 44 percent, while in urban areas the proportion is 23 percent. Interestingly, 24 percent of children live with neither parent despite both parents being alive. Children in rural areas are twice as likely as children in urban areas to not be living with either parent. A total of 13 percent of children were paternal orphans, regardless of their mother’s status and 7 percent of children were maternal orphans, regardless of father’s status. Among those children, 3 percent were double orphans, implying they had lost both parents. 256 | Orphans and Vulnerable Children Table 16.1 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by children's living arrangements and survival status of parents, the percentage of children not living with a biological parent, according to background characteristics, Namibia 2006-07 Living with mother but not father Living with father but not mother Not living with either parent Percent- age not living with a biological parent Information missing on father/ mother Total Living with both parents Only father alive Only mother alive Both dead Number of children Background characteristic Father alive Father dead Mother alive Mother dead Both alive Age 0-4 32.6 40.4 2.0 1.9 0.2 19.0 1.0 0.8 0.2 2.0 100.0 23.0 5,461 <2 36.7 49.8 1.1 0.9 0.1 8.3 0.3 0.2 0.0 2.7 100.0 11.4 2,236 2-4 29.7 33.8 2.6 2.5 0.3 26.4 1.5 1.2 0.3 1.6 100.0 31.0 3,224 5-9 27.5 25.5 5.4 4.6 0.7 26.9 2.8 3.7 1.4 1.7 100.0 36.4 5,278 10-14 20.7 20.5 7.8 5.8 0.9 25.2 5.8 7.3 4.5 1.5 100.0 44.2 5,420 15-17 19.2 17.8 9.2 4.7 1.9 24.0 7.0 7.5 5.4 3.3 100.0 47.2 2,774 Sex Male 25.9 27.8 5.6 4.4 0.9 22.7 3.8 4.5 2.5 1.9 100.0 35.4 9,475 Female 25.7 26.6 5.7 4.0 0.7 24.6 3.7 4.3 2.6 2.0 100.0 37.3 9,457 Residence Urban 34.9 29.9 4.6 6.1 1.4 14.1 2.3 2.4 2.0 2.3 100.0 23.1 6,604 Rural 21.0 25.8 6.2 3.1 0.5 28.8 4.6 5.5 2.8 1.8 100.0 43.5 12,329 Region Caprivi 29.6 20.7 12.9 3.4 1.8 14.4 5.4 5.8 4.9 1.2 100.0 31.6 1,044 Erongo 44.8 23.3 3.8 6.4 0.7 13.9 1.5 2.3 1.5 1.9 100.0 21.1 893 Hardap 34.5 29.6 6.5 2.2 1.0 17.0 2.5 2.0 1.5 3.1 100.0 26.1 545 Karas 32.1 32.2 4.9 4.0 0.4 17.8 2.3 2.3 1.5 2.4 100.0 26.4 558 Kavango 34.5 25.9 7.2 4.5 1.1 15.2 3.0 3.8 3.0 1.7 100.0 26.7 2,404 Khomas 36.8 32.1 3.0 7.4 1.3 11.5 2.2 1.6 1.5 2.6 100.0 19.4 2,676 Kunene 26.5 27.7 3.7 1.7 0.2 28.7 2.7 2.7 0.4 5.6 100.0 40.1 655 Ohangwena 12.2 27.2 5.3 3.1 0.3 34.0 5.2 6.9 3.2 2.5 100.0 51.9 2,621 Omaheke 26.0 24.9 2.8 3.8 0.4 32.7 3.4 3.1 1.0 1.9 100.0 42.0 892 Omusati 13.7 24.0 6.2 3.2 0.4 35.2 4.9 7.5 3.3 1.5 100.0 52.4 2,236 Oshana 17.5 28.4 8.3 2.9 0.8 25.8 4.8 6.2 3.9 1.5 100.0 42.1 1,490 Oshikoto 18.0 29.2 5.5 3.3 0.8 30.0 4.8 5.0 2.5 0.9 100.0 43.3 1,936 Otjozondjupa 36.3 27.2 2.8 4.9 0.6 22.5 2.7 1.7 0.6 0.9 100.0 28.3 984 Wealth quintile Lowest 23.5 26.8 7.4 2.2 0.6 24.8 4.6 5.5 2.8 1.8 100.0 39.5 4,499 Second 17.8 27.5 6.9 3.1 0.7 27.9 4.8 5.6 3.3 2.4 100.0 44.0 4,341 Middle 23.9 26.0 5.6 4.0 0.7 27.7 3.9 4.6 2.2 1.5 100.0 39.9 3,749 Fourth 28.1 29.8 4.5 4.6 0.8 21.3 3.2 3.5 2.3 1.9 100.0 32.2 3,218 Highest 40.2 26.2 2.7 8.2 1.4 13.9 1.7 2.0 1.6 2.2 100.0 21.3 3,126 Total <15 27.0 28.8 5.0 4.1 0.6 23.6 3.2 3.9 2.0 1.7 100.0 34.5 16,160 Total <18 25.8 27.2 5.6 4.2 0.8 23.7 3.8 4.4 2.5 2.0 100.0 36.4 18,933 Note: Table is based on de jure household members, i.e., usual members. Total includes one child with information missing on sex. The 2000 NDHS collected information on orphanhood only for children under age 15. Table 16.1 shows orphanhood and living arrangements for children under age 15 for comparison with the 2000 survey data. The number of double orphans under age 15 increased from 1 percent in 2000 to 2 percent in 2006-07. The proportion of children under 15 who had lost one or both parents increased from 15 percent to 17 percent between 2000 and 2006-07. 16.1.2 Orphaned and Vulnerable Children The MGECW recognizes that children whose parents are ill for an extended period or who live in households where other adults suffer from chronic illness can experience substantial hardship, as serious illness may limit the resources available to feed, clothe, and educate a family’s youngest members. The 2006-07 NDHS included questions to determine if any adults in the household (including the child’s parents) had been chronically ill during the 12 months preceding the survey. Members of the household were considered to be chronically ill if they had been very sick, i.e., too sick to work or do normal activities for a period of at least three months during the past year. Questions were also included for children whose parents were not living in the same household at the time of the survey to determine if the parent(s) had been chronically ill in the past 12 months. In addition, the household head was asked if any adult (age 18-59) in the household died in the past year and whether that adult was sick for three of the 12 months preceding the death. A child in any of these situations is classified as vulnerable. Orphans and Vulnerable Children | 257 Table 16.2 shows the proportion of children considered to be orphaned or vulnerable. At the time of the 2006-07 NDHS, 28 percent of children were orphaned or vulnerable. Seventeen percent of children were orphaned and 14 percent were vulnerable. The number of orphans and the number of vulnerable children do not sum to the number of OVCs because some children fall in both categories. Among the children classified as vulnerable, the majority live in a household where an adult had been very sick for at least three of the past 12 months. Table 16.2 Orphans and vulnerable children (OVC) Percentage of de jure children under age 18 years who are orphans or made vulnerable due to illness of an adult member of the household, by background characteristics, Namibia 2006-07 Percentage of children who: Percentage of children who have a very sick parent OR live in a household where an adult has been very sick OR died in the past 12 months (vulnerable children) Live in a household where at least 1 adult who died in the past 12 months and had been very sick for at least 3 months before he/she died2 Live in a household where at least 1 adult who has been very sick for at least 3 months in the past 12 months2 Have a very sick parent for at least 3 months in the past 12 months1 Percentage of children who are orphans and/or vulnerable (orphans) Percentage of children with one or both parents dead (orphans) Number of children Background characteristic Age 0-4 4.2 4.9 10.0 3.8 13.9 17.0 5,461 <2 1.6 4.3 10.4 3.5 13.8 14.8 2,236 2-4 6.0 5.4 9.8 4.0 14.0 18.6 3,224 5-9 14.1 5.8 9.8 3.5 13.7 24.9 5,278 10-14 26.7 6.6 10.8 3.6 15.2 36.7 5,420 15-17 31.2 6.9 10.8 3.6 15.3 40.1 2,774 Sex Male 17.5 6.2 10.4 3.7 14.5 28.6 9,475 Female 17.2 5.7 10.2 3.6 14.4 27.8 9,457 Residence Urban 12.9 4.9 8.2 2.0 10.8 21.3 6,604 Rural 19.8 6.5 11.4 4.5 16.4 31.9 12,329 Region Caprivi 31.1 10.8 13.8 5.1 19.5 41.9 1,044 Erongo 9.7 4.8 9.1 1.4 10.2 18.6 893 Hardap 14.1 5.5 9.9 4.5 14.8 26.1 545 Karas 11.6 5.2 8.4 2.1 10.3 21.0 558 Kavango 18.1 7.2 13.9 4.5 17.8 31.4 2,404 Khomas 9.8 4.8 6.5 1.4 8.5 16.9 2,676 Kunene 9.8 4.5 7.1 2.5 10.2 19.2 655 Ohangwena 21.3 5.7 10.4 5.0 16.2 33.4 2,621 Omaheke 10.8 3.4 4.8 3.8 9.0 18.5 892 Omusati 22.7 6.4 11.6 3.0 16.1 34.3 2,236 Oshana 24.3 6.6 12.8 4.3 17.9 36.7 1,490 Oshikoto 18.7 6.4 12.2 5.0 17.7 32.0 1,936 Otjozondjupa 8.9 3.6 6.9 2.9 10.3 17.8 984 Wealth quintile Lowest 21.2 6.9 13.1 4.9 17.8 34.0 4,499 Second 21.4 7.0 12.7 5.2 18.6 34.7 4,341 Middle 17.1 6.8 10.9 3.4 15.1 29.0 3,749 Fourth 14.6 4.8 6.6 2.4 10.3 22.6 3,218 Highest 9.5 3.3 5.9 1.1 7.1 15.8 3,126 Total <15 15.0 5.8 10.2 3.6 14.3 26.2 16,160 Total <18 17.4 6.0 10.3 3.6 14.4 28.2 18,933 Note: Table is based only on children who usually live in the household. Very sick means person was too sick to work or do normal activities. Total includes one child with information missing on sex 1 Whether or not sick parent lives in same household as child 2 Persons age 18-59 The proportion of children considered OVCs increases with age from 15 percent among children age two to 40 percent among those age 15-17. There are smaller proportions of OVCs in urban areas than in rural areas (21 and 32 percent, respectively). The proportion of OVCs is highest in the poorest wealth quintile (34 percent) and lowest for those in the wealthiest quintile (16 percent), suggesting that children in the poorer households are more likely to have a chronically ill adult present or to have experienced the death of an adult in the household. Table 16.2 and Figure 16.1 show the proportion of OVCs by region in Namibia. Caprivi region has the highest proportion of OVCs (42 percent), while in Erongo, Khomas, Kunene, Omaheke, and Otjozondjupa less than 20 percent of children are OVCs. 258 | Orphans and Vulnerable Children Figure 16.1 OVC Population, Namibia 2006-07 16.2 SOCIAL AND ECONOMIC SITUATION OF ORPHANED AND VULNERABLE CHILDREN As the HIV epidemic matures, it is important to monitor the OVC situation to ensure that the needs of these children are met. Information collected in the 2006-07 NDHS household questionnaire can be used to examine several important aspects of the social and economic situation of orphaned and vulnerable children. The questionnaire includes information on school attendance, possession of items considered basic for meeting a child’s material needs, residence with siblings, and nutritional status. These results provide a means for assessing the impact on children’s welfare of the chronic illness and/or death of parents or other adult members of the household (UNICEF, 2005). Orphans and Vulnerable Children | 259 16.2.1 School Attendance Orphaned and vulnerable children are at greater risk of dropping out of school. This can happen for many reasons, such as the inability to pay school fees, the need to help with household work, or the need to stay home to care for a sick parent or younger siblings. Table 16.3 presents data on school attendance rates for children age 10-14. The first few columns of the table compare the situation of children who have lost both parents and the situation of children whose parents are both alive and the child is living with at least one parent. The rest of the columns compare school attendance for the entire population of OVCs with school attendance of children who are neither orphaned nor vulnerable. School attendance ratios are presented of the proportion of orphans to non- orphans living with at least one parent and OVCs to non-OVCs. The results in Table 16.3 indicate that double orphans do not fare worse in school attendance than children living with at least one biological parent. This is also true for OVCs versus non-OVCs: OVCs age 10-14 were just as likely to be attending school as non-OVCs. Data at the regional level should be used with caution because of the small number of OVCs in several regions. For example, the attendance figures in Kunene are an exception to the general pattern because the proportion of OVCs attending school is higher than the proportion of non-OVCs attending school (67 percent compared with 51 percent). Table 16.3 School attendance by survivorship of parents and by OVC status For de jure children 10-14 years of age, the percentage attending school by survivorship of parents and OVC status and the ratios of the percentages attending for parental survival and OVC status, by background characteristics, Namibia 2006-07 Percentage of children attending school by survivorship of parents Percentage of children attending school by OVC status Background characteristic Both parents dead Number Both parents alive; child living with at least one parent Ratio2 OVC Non-OVC Number Ratio1 Percentage attending school Number Percentage attending school Number Sex Male 93.4 134 92.8 1,317 1.01 93.3 976 91.7 1,709 1.02 Female 93.9 112 95.3 1,231 0.99 96.0 1,010 94.6 1,724 1.01 Residence Urban 95.9 68 96.2 1,174 1.00 94.8 497 95.8 1,323 0.99 Rural 92.8 179 92.1 1,374 1.01 94.5 1,490 91.5 2,110 1.03 Region Caprivi (98.6) 26 96.1 107 1.03 96.8 155 95.6 131 1.01 Erongo * 2 94.8 156 * (95.4) 56 95.2 170 1.00 Hardap * 4 94.1 92 * 97.8 53 91.9 109 1.07 Karas * 5 98.3 98 * 97.2 46 97.4 118 1.00 Kavango (90.9) 38 90.7 388 1.00 90.6 279 89.2 445 1.02 Khomas * 24 98.1 518 * 99.5 144 98.2 546 1.01 Kunene * 1 57.4 78 * 67.0 42 51.6 109 1.30 Ohangwena (84.5) 46 95.9 246 0.88 93.8 340 94.0 458 1.00 Omaheke * 4 80.2 75 * 80.9 49 81.0 124 1.00 Omusati (96.4) 37 99.6 242 0.97 97.9 322 98.5 446 0.99 Oshana (100.0) 33 99.2 186 1.01 98.6 216 98.1 266 1.01 Oshikoto * 21 95.0 229 * 95.2 233 96.5 344 0.99 Otjozondjupa * 4 88.3 134 * 91.0 53 87.1 168 1.04 Wealth quintile Lowest 90.0 64 89.5 536 1.01 92.1 563 89.1 765 1.03 Second 95.9 74 92.4 491 1.04 94.2 552 92.4 720 1.02 Middle 90.6 41 93.0 414 0.97 95.8 430 90.8 604 1.05 Fourth 93.9 38 96.9 504 0.97 95.5 258 96.0 644 1.00 Highest 100.0 28 97.6 604 1.02 99.3 184 97.9 700 1.01 Total 93.6 246 94.0 2,548 1.00 94.6 1,987 93.2 3,434 1.02 Note: Table is based on children who usually live in the household. Total includes one child with information missing on sex. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent 2 Ratio of the percentage for OVC to the percentage for non-OVC 260 | Orphans and Vulnerable Children 16.2.2 Basic Material Needs The 2006-07 NDHS collected information on whether children age 5-17 in the household had basic material needs; i.e., a pair of shoes, two sets of clothes, and a blanket. Table 16.4 shows the results of these questions for all children and for OVCs. Only 50 percent of children age 5-17 in Namibia had all of the specified items. Ownership of the basic material needs for children does not vary by the child’s age or sex. Urban children are more likely to have the material needs met than rural children (73 percent and 37 percent, respectively). As expected, there is a clear association between household wealth status and whether children in the household had the three items. Across regions, children in Ohangwena and Kavango were the least likely to have the three materials (12 percent and 18 percent, respectively). On the other hand, 85 percent of children in Khomas have these materials. Table 16.4 Possession of basic material needs by orphans and vulnerable children Among de jure children age 5-17 years, the percentage possessing three minimum basic material needs, the percentage of OVCs and non-OVCs who possess all three basic material needs, and the ratio of the percentage for OVCs to the percentage for non- OVCs, by background characteristics, Namibia 2006-07 Percentage possessing all three basic needs, by OVC status Among children age 5-17, percentage possessing: OVC Non-OVC Background characteristic Percentage possessing all three basic needs Number Percentage possessing all three basic needs Number Ratio2 Shoes Two sets of clothes Blanket All three basic needs1 Number of children Age 5-9 63.2 70.4 55.3 48.4 5,278 37.3 1,313 52.1 3,965 0.72 10-14 63.8 69.7 57.5 49.3 5,420 40.7 1,987 54.3 3,434 0.75 15-17 67.3 71.9 63.3 54.2 2,774 45.8 1,112 59.7 1,662 0.77 Sex Male 63.6 70.1 58.1 50.2 6,741 41.3 2,223 54.5 4,517 0.76 Female 65.0 70.8 57.6 49.8 6,731 40.7 2,188 54.1 4,543 0.75 Age of household head <25 72.1 76.7 64.8 58.0 396 48.9 147 63.3 249 0.77 25-49 69.4 75.7 63.7 56.6 6,609 46.9 1,809 60.2 4,800 0.78 50+ 58.6 64.7 51.4 42.7 6,467 36.2 2,456 46.7 4,011 0.77 Child's status Orphan 60.9 68.0 54.6 44.5 2,442 44.5 2,442 na na na Vulnerable 55.1 64.2 47.3 37.5 1,353 37.5 1,353 na na na Orphan and vulnerable 50.7 60.8 44.0 34.9 617 34.9 617 na na na Not orphan or vulnerable 67.5 72.7 61.3 54.3 9,060 na na 54.3 9,060 na Residence Urban 81.4 87.8 77.4 73.2 4,776 62.3 1,178 76.7 3,599 0.81 Rural 55.0 60.9 47.1 37.2 8,696 33.2 3,235 39.6 5,462 0.84 Region Caprivi 63.0 66.3 65.6 52.1 730 47.7 355 56.2 374 0.85 Erongo 83.0 88.0 79.5 75.6 626 61.6 133 79.4 493 0.78 Hardap 80.9 91.6 81.5 74.1 388 68.2 115 76.6 273 0.89 Karas 81.7 89.0 80.3 73.9 402 73.6 96 74.1 305 0.99 Kavango 32.1 53.1 25.8 17.9 1,740 18.1 628 17.8 1,112 1.02 Khomas 90.9 93.0 87.9 85.0 1,912 77.2 387 87.0 1,525 0.89 Kunene 35.5 41.4 41.1 28.7 409 26.3 98 29.5 312 0.89 Ohangwena 36.6 37.3 19.0 12.3 1,923 11.9 720 12.5 1,203 0.95 Omaheke 74.2 85.2 74.3 66.5 525 65.0 128 67.0 397 0.97 Omusati 74.7 74.8 72.5 61.6 1,701 55.7 647 65.3 1,053 0.85 Oshana 73.4 80.9 60.3 51.3 1,129 44.8 471 55.9 659 0.80 Oshikoto 67.0 72.6 54.1 42.8 1,401 30.3 519 50.2 881 0.60 Otjozondjupa 80.6 85.7 77.5 72.4 587 62.7 116 74.8 471 0.84 Wealth quintile Lowest 36.4 44.9 32.2 20.9 3,234 20.2 1,268 21.4 1,966 0.95 Second 54.2 62.5 43.7 33.6 3,089 32.3 1,207 34.4 1,882 0.94 Middle 68.2 75.3 60.4 50.8 2,538 44.7 896 54.1 1,642 0.83 Fourth 82.6 86.9 75.9 70.8 2,283 62.8 617 73.8 1,666 0.85 Highest 94.4 95.0 91.7 90.7 2,329 88.2 424 91.2 1,905 0.97 Total 64.3 70.4 57.9 50.0 13,473 41.0 4,412 54.3 9,060 0.75 Note: Table is based on children who usually live in the household. Total includes one child with information missing on sex na = Not applicable 1 Shoes, two sets of clothing, a blanket 2 Ratio of the percentage for OVCs to the percentage for non-OVCs Orphans and Vulnerable Children | 261 OVCs are less likely to have the three items than non-OVCs: 41 percent of OVCs had all three items compared with 54 percent of non-OVCs. This differential was most pronounced in Oshikoto, where 30 percent of OVCs had the items compared with 50 percent of non-OVCs. The gap in material needs between OVCs and non-OVCs was least pronounced in Kavango, Karas, Omaheke, and Ohangwena. The table differentiates between children who are orphaned and children who are vulnerable. Children who are orphaned could have been orphaned for up to 17 years while children who are vulnerable tend to be in a crisis period in their life, because a parent or adult in the household is chronically ill or an adult has recently died. Table 16.4 shows that 54 percent of children who are not orphans or vulnerable have these items, compared with 45 percent of orphans and 38 percent of vulnerable children. Only 35 percent of children who were classified as both orphaned and vulnerable had all three items. 16.2.3 Orphans Living with Siblings A common coping strategy of families when a head of household has died is to separate the children to distribute the burden of caring for the children. This often leads to additional trauma for the children. Sibling connections are particularly important after the death of a parent; continuing sibling bonds can help children maintain a sense of cohesion within a family. Table 16.5 presents information about orphans who are not living with their siblings. Questions about living arrangements were only asked for siblings younger than age 18 because older siblings are likely to leave the home to get married or to move for work or for school. Table 16.5 shows that 55 percent of children who are orphaned do not live with all of their siblings under the age of 18. As expected, older children are more likely than younger children to live apart from their siblings. Male children and maternal orphans are also more likely to live apart from their siblings. The proportion of orphans not living with siblings varies by urban-rural residence: 46 percent in urban areas compared with 57 percent in rural areas. There are variations by region, suggesting that there may be cultural differences affecting whether children are separated from their siblings after the death of a parent. 16.2.4 Nutritional Status Research on the nutritional status of orphans has produced conflicting results and is limited by the small number of young children who are orphans. However, adding in the vulnerable children provides adequate numbers of children under age five for comparison. It should be noted that the data on underweight status reflect a child’s overall growth progression during his/her lifetime. Also, children’s status as orphaned or vulnerable may be recent and may not yet be reflected in the child’s nutritional status. Table 16.5 Orphans not living with siblings Among orphans under age 18 who have one or more siblings under age 18 years, the percentage who do not live with all their siblings under age 18, by background characteristics, Namibia 2006-07 Background characteristic Percentage of orphans not living with all siblings Number of orphans with one or more siblings Age 0-4 44.5 76 5-9 54.8 320 10-14 53.8 653 15-17 57.6 422 Sex Male 57.6 748 Female 51.6 724 Orphanhood status Maternal orphan 58.3 387 Paternal orphan 52.9 909 Both parents dead 55.5 175 Residence Urban 46.4 340 Rural 57.1 1,132 Region Caprivi 40.6 121 Erongo (27.9) 28 Hardap (39.9) 23 Karas (40.8) 30 Kavango 43.3 185 Khomas (61.4) 82 Kunene (66.1) 36 Ohangwena 55.5 226 Omaheke 62.9 57 Omusati 63.4 229 Oshana 56.1 219 Oshikoto 65.6 191 Otjozondjupa 36.5 44 Wealth quintile Lowest 58.7 432 Second 52.8 451 Middle 52.8 311 Fourth 51.6 174 Highest 56.1 104 Total 54.6 1,472 Note: Table is based on children who usually live in the household. Figures in parentheses are based on 25-49 unweighted cases. 262 | Orphans and Vulnerable Children Table 16.6 considers the effect of orphanhood on the nutritional status of children under age five. The results show that overall, 22 percent of children in Namibia are underweight. OVCs are more likely to be underweight than non-OVCs (27 percent and 21 percent, respectively). Interestingly, the differential between OVCs and non-OVCs is most pronounced in the wealthiest households where the percentage of children who are underweight is 17 percent for OVCs compared with 8 percent for non-OVCs. Table 16.6 Underweight orphans and vulnerable children Among de jure children under age five who slept in the household the night before the survey, percentage who are underweight, and percentage underweight by OVC status, according to background characteristics, Namibia 2006-07 Children under five Percentage of children under five who are underweight1 OVCs Non-OVCs Background characteristic Number of children Percentage underweight1 Number of OVCs Percentage underweight1 Number of non-OVCs Ratio2 Age <1 year 8.8 938 11.0 142 8.4 797 1.31 1-2 years 26.6 1,983 29.7 317 26.0 1,666 1.15 3-4 years 22.8 1,876 30.5 358 21.0 1,518 1.46 Sex Male 22.0 2,403 27.5 422 20.9 1,982 1.32 Female 21.2 2,394 26.1 394 20.2 1,999 1.29 Residence Urban 15.1 1,530 17.7 187 14.7 1,343 1.20 Rural 24.7 3,267 29.6 629 23.5 2,637 1.26 Region Caprivi 19.0 272 10.7 68 21.7 204 0.49 Erongo 9.8 220 * 24 10.2 196 0.62 Hardap 22.8 134 (26.3) 24 22.0 110 1.19 Karas 21.5 131 (16.4) 19 22.3 113 0.74 Kavango 22.8 595 27.7 111 21.6 484 1.28 Khomas 14.9 628 (29.8) 57 13.4 571 2.22 Kunene 20.2 205 (20.3) 23 20.2 182 1.01 Ohangwena 27.5 625 30.7 143 26.5 482 1.16 Omaheke 16.8 320 (24.3) 25 16.1 295 1.51 Omusati 25.3 500 27.5 113 24.6 387 1.12 Oshana 27.4 330 37.6 72 24.6 258 1.53 Oshikoto 25.9 487 31.6 85 24.7 402 1.28 Otjozondjupa 18.8 348 25.9 52 17.6 296 1.47 Wealth quintile Lowest 27.3 1,142 31.6 232 26.3 910 1.20 Second 27.8 1,121 32.7 272 26.2 849 1.25 Middle 21.2 1,058 19.4 167 21.5 892 0.91 Fourth 16.0 800 17.1 88 15.8 711 1.08 Highest 9.1 676 16.5 57 8.4 618 1.96 Total 21.6 4,797 26.8 816 20.5 3,981 1.31 Note: Table is based on children who usually live in the household and who also slept in household the night preceding the interview. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Two or more standard deviations below mean of the WHO Child Growth Standards for weight-for-age 2 Ratio of the percentage for OVCs to the percentage for non OVCs 16.2.5 Sex before Age 15 Teenage orphans and vulnerable children may be at a greater higher risk of early sexual debut because they may lack adult guidance to help them to protect themselves. The 2006-07 NDHS collected information on sexual activity for all respondents age 15-49. Information on OVC status was collected for all children in the household under the age of 18. The availability of these data allow for analysis of sexual behaviour of OVCs age 15-17, to see whether they are at increased risk of HIV or sexually transmitted infections. Orphans and Vulnerable Children | 263 Table 16.7 shows that young women who are OVCs are more likely to have sex before age 15 than non-OVCs (10 percent compared with 7 percent). There were no significant differences among young men by OVC status. Table 16.7 Sexual intercourse before age 15 among orphans and vulnerable children Percentage of de jure children age 15-17 who had sexual intercourse before exact age 15, by OVC status, and ratio of the percentage for OVCs to the percentage for non-OVCs, by sex, Namibia 2006-07 Women Men OVC status Percentage who had sexual intercourse before exact age 15 Number of women Percentage who had sexual intercourse before exact age 15 Number of men OVC 10.1 474 20.6 199 Non-OVC 7.1 784 19.5 322 Total 8.2 1,259 19.9 522 Ratio 1.41 na 1.06 na Note: Table is based on children who usually live in the household and who also slept in household the night preceding the interview na = Not applicable 1 Ratio of the percentage for OVCs to the percentage for non-OVCs 16.3 CARE AND SUPPORT FOR OVCS Families are the best hope for the care of orphaned and vulnerable children, but they require support from outside sources. Families need a combination of economic, material, and psychosocial support. Areas of interventions that can help families include: improvement of household economic capacity; provision of psychosocial support to affected children and their caregivers; strengthening and supporting childcare capacities; support of succession planning; prolonging the lives of parents; and strengthening young people’s life skills. A partnership of governmental and community agencies, including faith-based organizations, will be needed to provide this support (UNICEF, 2005). The 2006-07 NDHS collected data for measuring several indicators of the extent to which families and communities are recognizing and addressing the need to care for young children who are orphaned and/or vulnerable. 16.3.1 Succession Planning If developed properly, succession planning can ensure that children receive appropriate care and support in the event of the death of a parent or primary caregiver. In the 2006-07 NDHS, respondents who were primary caregivers for children under the age of 18 were asked, ‘Have you made arrangements for someone to care for [your children] in the event that you fall sick or are unable to care for them?’ This question is used as a proxy measure for succession planning. Table 16.8 shows that 58 percent of women and men are primary caregivers for children under age 18. Women are more likely than men to care for children (63 percent and 45 percent, respectively). The burden of caring for children is higher among less educated and poorer respondents. 264 | Orphans and Vulnerable Children Table 16.8 Succession planning Percentage of de facto women and men age 15-49 who are primary caregivers for children under age 18, and among the primary caregivers, the percentage who have made arrangements for someone else to care for the children in the event of their own inability to do so because of illness or death, by background characteristics, Namibia 2006-07 Background characteristic Percentage of women and men who are primary caregivers Number of women and men Percentage of caregivers who have made succession arrangements Number of primary caregivers Age 15-19 9.0 3,156 42.9 284 20-29 57.3 4,930 47.6 2,826 30-39 87.1 3,448 50.7 3,003 40-49 82.9 2,185 49.0 1,811 Sex Male 45.3 3,915 52.3 1,774 Female 62.7 9,804 48.0 6,149 Education No education/preschool 75.7 1,010 33.4 765 Incomplete primary 68.0 2,555 38.8 1,737 Complete primary 59.4 988 43.8 587 Incomplete secondary 51.1 6,355 49.4 3,245 Complete secondary 55.2 1,823 64.2 1,007 More than secondary 59.0 987 75.7 582 Residence Urban 58.1 6,735 59.5 3,916 Rural 57.4 6,984 38.7 4,008 Region Caprivi 64.6 663 24.0 429 Erongo 61.8 1,050 65.0 650 Hardap 62.3 447 46.9 279 Karas 62.8 475 69.1 298 Kavango 62.7 1,264 36.6 792 Khomas 56.2 3,202 63.0 1,799 Kunene 67.1 351 40.8 236 Ohangwena 51.9 1,349 26.7 700 Omaheke 64.3 562 56.9 361 Omusati 50.4 1,294 37.2 652 Oshana 52.6 1,090 36.4 573 Oshikoto 53.3 1,159 54.0 617 Otjozondjupa 66.2 811 59.5 537 Wealth quintile Lowest 60.6 2,181 28.3 1,322 Second 55.1 2,275 35.5 1,253 Middle 60.5 2,760 44.9 1,670 Fourth 61.6 3,254 57.3 2,006 Highest 51.5 3,249 69.3 1,673 Total 57.8 13,719 48.9 7,923 Note: Table is based on women and men who slept in household the night before the survey Less than half (49 percent) of caregivers have made succession plans for the children they look after. As expected, women and men age 15-19 are the least likely to have made these plans. The proportion of caregivers age 20 and older who have made plans for their children’s care does not vary much (48-51 percent). Succession planning is more likely to be done by men than by women (52 and 48 percent, respectively). The likelihood of caregivers making succession plans increases with level of education: 33 percent among those with no education compared with 76 percent among those with more than secondary education. Caregivers in wealthier households are twice as likely to have a succession plan for their children as those in poorer households. Caregivers in Caprivi and Ohangwena are the least likely to have succession plans, while those in Karas and Erongo are the most likely to have succession plans. Orphans and Vulnerable Children | 265 16.3.2 Widows Dispossessed of Property A common occurrence among widows in Namibia is the dispossession of property by her husband’s relatives. Dispossession of property worsens the situation of people who care for children and the children themselves. It is impor- tant, therefore, to ensure that inheritance laws include enforcement mechanisms to protect the rights of women and children to inherit property after the death of the husband or father (UNICEF, 2005). The 2006-07 NDHS asked women who had been widowed whether they received any of their late husband’s assets or valuables. Table 16.9 presents information on widows disposed of property. It shows the proportion of women who were or are widows (ever-widowed) and the prevalence of dispossession. Only 3 percent of women reported having ever been widowed. Among those women, 40 percent said that they did not receive any of their husband’s assets. The number of widowed women who were dispossessed of their husband’s assets is too small to be analyzed by background character- istics. Widows in poorest households are twice as likely to be dispossessed as those in wealthier households. 16.3.3 External Support for Households with OVCs When households are no longer able to cope with the needs of a sick household member or with the number of children in need of support, it is important for the community to step in as a safety net. The impact of the HIV epidemic has forced some households to rely on outside assistance. Communities are providing that assistance in a number of ways. The 1006-07 NDHS collected information from household respondents on the extent to which free external care and support services are reaching very sick adults (age 18-59) and orphans and vulnerable children. Table 16.9 Widows dispossessed of property Percentage of de facto women age 15-49 who are, or have ever been, widowed, and the percentage of these women who have been dispossessed of their late husband’s property, by background characteristics, Namibia 2006-07 Among ever- widowed women: Background characteristic Percentage of ever- widowed women Number of women Percentage who were dispossessed of property1 Number of women Age 15-19 0.1 2,246 * 1 20-29 0.7 3,478 53.9 24 30-39 4.1 2,462 31.2 100 40-49 11.8 1,618 42.5 191 Marital status Married 1.9 3,451 55.9 64 Widowed 100.0 252 35.9 252 Age of youngest child No children 0.3 3,326 * 9 < 18 years 4.5 6,253 41.3 283 18+ years 11.1 225 (32.6) 25 Residence Urban 2.1 4,772 33.9 100 Rural 4.3 5,032 42.8 216 Region Caprivi 9.6 474 33.1 45 Erongo 2.9 688 * 20 Hardap 2.5 315 * 8 Karas 2.2 318 * 7 Kavango 7.1 934 65.9 66 Khomas 1.0 2,218 * 22 Kunene 2.3 259 * 6 Ohangwena 3.7 1,043 (33.6) 38 Omaheke 2.5 373 * 9 Omusati 3.2 975 (21.3) 31 Oshana 3.5 819 (33.0) 29 Oshikoto 3.4 837 (34.1) 28 Otjozondjupa 1.2 550 * 7 Education No education/preschool 6.9 651 60.8 45 Incomplete primary 6.8 1,699 42.8 116 Complete primary 3.7 736 (25.7) 27 Incomplete secondary 2.2 4,751 34.4 103 Complete secondary 1.2 1,286 * 15 More than secondary 1.4 682 * 10 Wealth quintile Lowest 6.2 1,621 52.9 100 Second 4.2 1,668 31.2 69 Middle 3.4 1,885 46.8 65 Fourth 2.1 2,292 27.7 48 Highest 1.4 2,338 (23.9) 33 Total 3.2 9,804 40.0 316 Note: Table is based on women who slept in the household the night before the survey Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Respondent received none of her late husband's assets 266 | Orphans and Vulnerable Children Table 16.10 shows, for adults age 18-59 who were chronically ill or died after a chronic illness in the year preceding the survey, the percentage who received certain types of free external support during the past year or the past 30 days, or the 30 days prior to the person’s death. Among adults age 18-59 who were either very sick or died in the past 12 months, 10 percent received free medical support at least once a month during the illness, 5 percent received emotional support in the past 30 days, and 4 percent received social/material support in the past 30 days. Sixteen percent of these adults received at least one occurrence of medical, emotional, or social/material support in the past 30 days; less than 1 percent received all three types of support. The proportion of adults who received external support during a serious and lengthy illness does not vary much by background characteristics. Moreover, the number of adults who were either very sick or died in the past 12 months is too small for analysis at the regional level. Adults in rural areas are more likely than those in urban areas to have received support (17 percent and 14 percent, respectively). Sick adults in the wealthiest households are about half as likely to receive free support as those in other households. Table 16.10 External support for very sick persons Percentage of women and men age 18-59 who have been either very sick or who died within the past 12 months after being very sick, whose households received certain free basic external support to care for them within the past year, by background characteristics, Namibia 2006-07 Percentage of very sick persons whose households received: Background characteristic Medical support at least once a month during illness Emotional support in the past 30 days Social/ material support in the past 30 days Al least one type of support in the past 30 days All three types of support in the past 30 days None of the three types of support Number of persons Age 18-29 9.8 6.3 4.7 16.5 0.2 83.5 277 30-39 11.7 5.2 5.0 17.4 0.5 82.6 292 40-49 10.8 4.6 3.4 16.0 0.0 84.0 308 50-59 6.6 3.4 4.6 12.5 0.0 87.5 228 Sex Male 9.4 5.3 3.0 14.9 0.0 85.1 494 Female 10.3 4.7 5.5 16.5 0.3 83.5 611 Residence Urban 10.8 2.8 3.0 13.6 0.3 86.4 385 Rural 9.4 6.1 5.2 16.9 0.1 83.1 720 Region Caprivi 6.1 5.7 4.6 10.7 0.0 89.3 91 Erongo 7.5 3.3 1.9 10.6 0.0 89.4 75 Hardap 16.1 5.7 4.5 20.8 0.0 79.2 37 Karas (9.5) (12.3) (12.9) (17.6) (4.7) 82.4 32 Kavango 13.9 4.6 1.7 17.3 0.0 82.7 148 Khomas 10.8 2.2 4.9 13.8 0.3 86.2 151 Kunene 7.2 1.2 0.0 8.4 0.0 91.6 28 Ohangwena 4.8 8.5 1.8 13.3 0.0 86.7 138 Omaheke (28.5) (0.0) (4.7) (28.5) (0.0) (71.5) 29 Omusati 7.6 6.0 5.8 17.5 0.0 82.5 127 Oshana 11.4 4.3 8.2 20.2 0.0 79.8 103 Oshikoto 7.1 6.8 8.0 18.0 0.0 82.0 97 Otjozondjupa 15.0 0.0 0.0 15.0 0.0 85.0 48 Wealth quintile Lowest 8.6 6.6 4.0 15.2 0.0 84.8 296 Second 7.7 5.0 5.1 15.6 0.0 84.4 251 Middle 16.1 4.6 6.9 22.5 0.2 77.5 250 Fourth 10.3 3.1 2.7 13.1 0.5 86.9 189 Highest 4.0 4.2 1.7 7.6 0.5 92.4 119 Total 9.9 4.9 4.4 15.8 0.2 84.2 1,105 Note: Table is based on women and men who usually live in the household and who were very sick (unable to work or do normal activities) in the past 12 months or who died in the past 12 months and were very sick at least 3 of the 12 months before death. Support refers to the past 30 days for living persons and in the 30 days preceding death for deceased persons. Figures in parentheses are based on 25-49 unweighted cases. 1 Support such as companionship, counselling from a trained counsellor or spiritual support for which there was no payment 2 Support such as help with household work, training for a caregiver, legal services, clothing, food or financial support for which there was no payment Orphans and Vulnerable Children | 267 Table 16.11 shows the percentage of orphaned and vulnerable children who live in households that received free external support. Only 17 percent of OVCs live in households that received external support. The majority of that support came in the form of social/material support, which was received by 11 percent of OVCs. School-related assistance was received by 4 percent of OVCs and 2 percent of OVCs received emotional support and 2 percent received medical support. Table 16.11 External support for orphans and vulnerable children Percentage of orphans and vulnerable children under age 18 whose households received certain free basic external support in the past 12 months to care for the child, by background characteristics, Namibia 2006-07 Percentage of orphans and vulnerable children whose households received: Background characteristic Medical support in the past 12 months1 Emotional support in the past 3 months2 Social/ material support in the past 3 months3 School- related assistance in the past 12 months4 Al least one type of support5 All of the types of support5 None of the types of support Number of OVC children Age 0-4 1.8 1.8 5.1 na 7.7 0.0 92.3 930 5-9 1.8 1.8 10.3 3.2 14.6 0.1 85.4 1,313 10-14 2.6 2.2 14.5 5.3 20.2 0.2 79.8 1,987 15-17 2.1 2.5 12.2 6.4 19.4 0.1 80.6 1,112 Sex Male 2.0 1.8 11.5 4.0 16.6 0.1 83.4 2,710 Female 2.4 2.4 11.1 4.2 16.3 0.2 83.7 2,631 Child's status Orphan 2.9 2.6 17.6 4.7 23.2 0.2 76.8 2,612 Vulnerable 1.1 1.5 2.9 2.3 6.5 0.1 93.5 2,053 Orphan and vulnerable 2.7 1.9 12.9 6.9 20.9 0.0 79.1 677 Residence Urban 3.3 2.3 5.8 4.9 11.8 0.3 88.2 1,406 Rural 1.8 2.0 13.3 3.8 18.1 0.1 81.9 3,937 Region Caprivi 4.0 2.5 12.6 6.4 19.4 0.0 80.6 437 Erongo 4.2 2.6 1.5 0.9 9.3 0.0 90.7 166 Hardap 3.4 3.6 4.0 5.5 9.8 1.7 90.2 142 Karas 8.1 4.7 7.2 6.2 11.2 3.7 88.8 117 Kavango 1.9 0.8 2.2 4.3 7.5 0.0 92.5 754 Khomas 1.7 2.4 5.6 4.0 9.5 0.0 90.5 453 Kunene 0.8 0.4 0.5 0.8 2.1 0.0 97.9 126 Ohangwena 0.9 1.1 16.0 2.2 19.6 0.0 80.4 875 Omaheke 1.7 0.0 0.5 6.0 7.8 0.0 92.2 165 Omusati 0.5 3.5 16.4 4.6 22.0 0.0 78.0 766 Oshana 2.7 3.3 18.6 5.3 24.2 0.0 75.8 547 Oshikoto 3.3 2.3 19.1 2.7 23.6 0.0 76.4 620 Otjozondjupa 2.4 0.0 2.9 7.2 11.2 0.0 88.8 175 Wealth quintile Lowest 1.2 1.6 11.4 3.2 15.7 0.0 84.3 1,529 Second 2.6 2.3 13.6 3.6 18.7 0.1 81.3 1,507 Middle 2.4 2.0 13.3 5.9 19.7 0.2 80.3 1,087 Fourth 2.0 2.2 8.3 3.9 13.0 0.2 87.0 727 Highest 3.5 2.9 4.5 4.6 9.9 0.4 90.1 493 Total 2.2 2.1 11.4 4.1 16.5 0.1 83.5 5,343 Note: Table is based on de jure household members, i.e., usual household members. Total includes one child with missing information on sex. na = Not applicable 1 Medical care, supplies or medicine 2 Companionship, counselling from a trained counsellor, or spiritual support for which there was no payment 3 Help with household work, training for a caregiver, legal services, clothing, food, or financial support for which there was no payment 4 Allowance, free admission, books, or supplies for which there is no payment. Percentage calculated for ages 5-17 years 5 Four types of support for those age 5-17, three types of support (i.e., excluding school support) received by those age 0-4 268 | Orphans and Vulnerable Children Older children are more likely than younger children to receive external support. There were no variations in the likelihood of receiving support by sex of the OVC. Children classified in the 2006-07 NDHS as vulnerable were often in a tougher situation than children who were orphaned. This is because during the one-year period, they lived in a household where a parent or an adult household member was very sick or had recently died, whereas orphans may have lost their parents up to 17 years ago. Despite this distinction, only 7 percent of vulnerable children received at least one type of support, compared with 23 percent of orphans. Among children who were both orphaned and vulnerable, 21 percent received free external support. Support was more available to urban OVCs than rural OVCs. the OVCs in Oshana, Oshikoto, Omusati, Ohangwena, and Caprivi were the most likely to receive support (20 percent or higher), while only 2 percent of OVCs in Kunene received support. Access to Health Care | 269 ACCESS TO HEALTH CARE 17 Access to health care facilities, in terms of distance, time, and costs, can be a useful indicator of the quality of life of the population. Where health care services are available and within reach, people make use of the services for the benefit of themselves and their family. As in the 2000 NDHS, questions on the accessibility of health care services in the 2006-07 NDHS focused on the government health facilities, although there are a number of facilities operated by the private sector and non- governmental organizations. In the 2006-07 NDHS, household respondents were asked “What is the name of the nearest government health facility that provides health services to this community?” The interviewer recorded the name of the facility mentioned. Respondents who were able to name a facility were further asked the mode of transport used if he/she were to go to the facility and how long it would take to go from the house to the facility using the identified mode of transport. If the facility named was not a hospital, the respondent was also asked to name the nearest government hospital; and then the same questions were asked about the mode of transport and time required to reach the nearest government hospital. Unlike the 2000 NDHS, questions on the cost of health care services were not asked in the 2006-07 NDHS. Furthermore, the 2006-07 NDHS did not record the actual distance from the household to the nearest public health facility—which was measured in the 2000 NDHS using GPS units—making it impossible to compare the results of the two surveys. 17.1 PROXIMITY TO GOVERNMENT HEALTH FACILITIES Table 17.1 shows the distribution of households by the nearest government health facility. A clinic is the nearest public health facility for seven in ten households in Namibia. This is to be expected because there are more clinics in the country than any other type of facility. For two in ten households, a hospital is the nearest government health facility, and 7 percent of households are nearest to a health centre. Table 17.1 Nearest government health facility Percent distribution of households by the nearest government health facility, according to residence and region, Namibia 2006-07 Residence/ region Hospital Health centre Clinic Outreach point Don’t know/ missing Total Number of households Residence Urban 27.5 4.9 61.4 0.2 5.9 100.0 4,260 Rural 15.5 9.3 74.3 0.3 0.5 100.0 4,940 Region Caprivi 7.4 14.9 77.3 0.0 0.4 100.0 514 Erongo 23.0 11.8 61.5 0.0 3.7 100.0 837 Hardap 10.1 4.6 83.8 0.2 1.3 100.0 328 Karas 32.9 3.2 62.7 0.1 1.0 100.0 382 Kavango 14.7 5.3 79.1 0.1 0.7 100.0 750 Khomas 20.5 3.2 65.6 0.4 10.3 100.0 1,950 Kunene 34.8 1.7 63.1 0.0 0.3 100.0 305 Ohangwena 7.2 3.6 87.0 0.9 1.3 100.0 829 Omaheke 6.5 12.6 80.3 0.3 0.3 100.0 426 Omusati 28.0 9.1 62.6 0.2 0.1 100.0 855 Oshana 30.0 12.0 56.8 0.6 0.6 100.0 663 Oshikoto 22.7 14.7 61.6 0.0 1.0 100.0 745 Otjozondjupa 38.6 1.4 58.8 0.0 1.2 100.0 615 Total 21.1 7.3 68.3 0.3 3.0 100.0 9,200 270 | Access to Health Care Rural households are more likely to be located nearest to a clinic than urban households (74 percent and 61 percent, respectively) as well as a health centre (9 percent and 4 percent, respectively). On the other hand, urban households are more likely than rural households to be nearest to a government hospital (28 percent and 16 percent, respectively). The proximity of households to government health facilities varies across regions. Eighty percent or more of households in Hardap, Ohangwena, and Omaheke have a clinic as the nearest government health facility compared with less than 60 percent of households in Oshana and Otjozondjupa. On the other hand, some households are nearest to a hospital. For example, while 59 percent of households in Otjozondjupa have a clinic as the nearest government health facility, 39 percent of households have a hospital as the closest facility. Very few households mentioned outreach points as the nearest government health facility. 17.2 TYPE OF TRANSPORT TO GOVERNMENT HEALTH FACILITIES Households were asked what means of transport they would use if they were to go to the government facilities they named. Table 17.2 shows that 63 percent of households would walk to the nearest government health facility. This proportion is lower than that reported in the 2000 NDHS (67 percent). On the other hand, the proportion of households that use car/motorcycle or public transport to travel to the nearest government health facility (17 percent and 18 percent, respectively) has increased slightly from the levels reported in the 2000 NDHS (15 percent and 11 percent, respectively). Overall, only 2 percent of households use animal/animal cart to go to the nearest health facility. This proportion has not changed since 2000. There are variations in the type of transport used to get to the nearest health facility by urban- rural residence. Urban households are more likely to use a car or motorcycle than rural households (21 percent and 14 percent, respectively), while rural households are more likely to use public transport than urban households (21 percent and 15 percent, respectively). Regional variations in mode of transport to health facilities are substantial. About three in ten households in Hardap, Karas, Khomas, Kunene, Omaheke, and Otjozondjupa use car or motorcycle. Animal/animal cart is an important means of transport to health facilities in Kunene (15 percent of households), while 93 percent of households in Kavango walk to the nearest health facility. Table 17.2 Means of transport to government health facility Percent distribution of households by means of transport to nearest government health facility, according to residence and region, Namibia 2006-07 Residence/ region Car/ motorcycle Bus/ taxi Animal/ animal cart Walking Total Number of households Residence Urban 20.7 14.6 0.3 64.3 100.0 4,001 Rural 13.7 21.4 3.1 61.7 100.0 4,790 Region Caprivi 2.7 8.2 1.8 87.3 100.0 506 Erongo 23.7 11.4 2.5 62.5 100.0 794 Hardap 29.2 7.7 3.7 59.3 100.0 325 Karas 32.3 23.1 2.6 41.9 100.0 377 Kavango 0.9 5.0 0.9 93.1 100.0 747 Khomas 28.9 21.6 0.8 48.7 100.0 1,751 Kunene 28.1 12.5 14.6 44.8 100.0 303 Ohangwena 4.0 11.1 0.8 84.0 100.0 800 Omaheke 35.2 30.8 3.2 30.8 100.0 423 Omusati 5.5 22.6 0.5 71.5 100.0 842 Oshana 2.9 23.8 1.2 72.1 100.0 655 Oshikoto 7.4 33.5 0.9 58.1 100.0 657 Otjozondjupa 28.7 20.8 1.6 48.9 100.0 611 Total 16.9 18.3 1.9 62.9 100.0 8,790 Note: Table excludes “other” and missing responses on means of transport. Access to Health Care | 271 17.3 TYPE OF TRANSPORT TO GOVERNMENT HOSPITALS Table 17.3 shows the means of transport households would use to reach the nearest government hospital. The distribution of households by transport to the nearest hospital is quite different from that for transport to the nearest health facility. Because of the greater overall distance to hospitals, fewer households (17 percent) reported they would walk to the nearest government hospital; the majority would use public transport (63 percent). Rural households rely particularly on public transport to go to hospitals (71 percent) while most urban households either take public transport (51 percent) or walk (30 percent). There are regional variations in the use of public transport to travel to government hospitals; the range is from 22 percent in Kunene to 91 percent in Oshana. Table 17.3 Means of transport to government hospital Percent distribution of households whose nearest government health facility is a not hospital by means of transport to hospital, according to residence and region, Namibia 2006-07 Residence/ region Car/ motorcycle Bus/ taxi Animal/ animal cart Walking Other/ missing Total Number of households Residence Urban 18.1 50.5 0.2 30.0 1.1 100.0 2,768 Rural 19.8 71.1 0.9 7.3 1.0 100.0 4,008 Region Caprivi 7.9 76.6 0.0 14.4 1.1 100.0 473 Erongo 20.5 62.3 0.4 15.2 1.6 100.0 595 Hardap 35.3 27.9 0.4 35.4 0.8 100.0 287 Karas 39.9 39.5 1.3 17.5 1.8 100.0 247 Kavango 4.2 52.3 0.2 42.6 0.7 100.0 627 Khomas 26.9 59.8 0.1 12.1 1.1 100.0 1,332 Kunene 56.0 21.5 2.8 18.1 1.6 100.0 196 Ohangwena 11.3 75.3 1.0 10.9 1.5 100.0 734 Omaheke 31.8 53.7 0.7 12.5 1.3 100.0 396 Omusati 19.7 71.8 0.3 7.5 0.7 100.0 595 Oshana 3.5 91.4 1.2 3.5 0.4 100.0 448 Oshikoto 5.8 77.9 1.5 14.5 0.3 100.0 480 Otjozondjupa 19.4 53.1 0.2 26.5 0.7 100.0 368 Total 19.1 62.7 0.6 16.6 1.0 100.0 6,776 Note: Table excludes households in which the respondent did not know the name of the nearest government hospital. 17.4 TIME TO GOVERNMENT HEALTH FACILITIES Household respondents were asked how long it takes to get to the nearest government health facility and hospital. Data on the time required to reach government health services is presented in Table 17.4. Looking at the total column, one in five households is within 15 minutes of a government health facility and three in five are within one hour of a facility. Reflecting the dispersed population of Namibia, 9 percent of households are more than 3 hours from the nearest government health facility. Overall, the mean time to the nearest facility is 74 minutes. Urban households take much less time than rural households to reach the nearest government health facility (25 minutes and 114 minutes, respectively). As expected, hospitals are less accessible than other government health facilities. The mean time to reach a government hospital is 99 minutes. Just over one in four households is less that 30 minutes from the nearest government hospital; 14 percent of households are three or more hours from the nearest hospital. Because government health facilities tend to be concentrated in cities and towns, urban households are closer to hospitals than rural households and travel times vary substantially. The mean time to the nearest government hospital is 37 minutes for urban households, compared with 150 minutes for rural households. When asked what type of transport they would use to go to the nearest government health facility, more than 60 percent of households reported that they would walk. The percentages are 272 | Access to Health Care similar for urban and rural households (60 percent). One in six households would use a car or motorcycle, and 18 percent would use public transport to go to the nearest government health facility. When households were asked what transport they would use to go to the nearest government hospital, the responses differed substantially from those for transport to the nearest government health facility. About 20 percent of households would walk to the nearest hospital (31 percent of urban households and 10 percent of rural households). Rural households are much more likely than urban households to use public transport (64 percent compared with 38 percent). Another 20 percent of rural households and 22 percent of urban households would use a car or motorcycle to go the nearest government hospital. Table 17.4 Time to reach government health facility and means of transport Percent distribution of households by time to reach nearest government health facility and nearest government hospital and mean time to reach facilities, and percent distribution by type of transport to nearest government health facility and nearest government hospital, Namibia 2006 Time and type of transport Nearest government health facility Nearest government hospital Urban Rural Total Urban Rural Total Time to facility < 15 minutes 37.1 9.2 22.1 26.0 2.6 13.5 15-29 minutes 26.7 8.1 16.7 26.1 4.8 14.6 30-59 minutes 22.9 19.9 21.2 24.5 16.3 20.1 1-2 hours 7.1 44.5 27.2 13.4 48.2 32.1 3-4 hours 0.2 11.7 6.4 1.2 17.9 10.1 4 + hours 0.2 4.3 2.4 0.8 6.5 3.9 Don’t know/time missing 0.7 2.4 1.6 0.6 0.3 0.4 Don’t know/facility missing 5.1 0.1 2.4 7.5 3.4 5.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Mean time to facility 24.6 114.4 73.5 37.3 149.6 98.9 Number of households 4,016 4,816 8,832 3,918 4,756 8,674 Transport to facility Car/motorcycle 19.5 13.3 16.2 22.4 20.3 21.3 Bus/taxi 13.7 20.7 17.5 37.8 64.4 52.1 Animal/ animal cart 0.3 3.0 1.8 0.2 1.1 0.7 Walking 60.4 59.9 60.1 31.1 9.9 19.7 Other 0.4 0.5 0.5 0.2 0.3 0.3 Don’t know/facility missing 5.1 0.1 2.4 7.5 3.4 5.3 Missing 0.6 2.4 1.6 0.7 0.6 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 4,260 4,940 9,200 4,260 4,940 9,200 References | 273 REFERENCES Auvert, B. D. Taljaard, E. Lagarde, J. Sobngwi-Tambekou, R. Sitta, and A. Puren. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. Presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil. Bailey, R.C., S. Moses, C.B. Parker, K. Agot, I. Maclean, et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 369: 643–656. Centers for Disease Control and Prevention (CDC). 1998. Guideline for infection control in health care personnel. Atlanta, Georgia, USA: CDC. Central Bureau of Statistics (CBS) [Namibia] 2003. 2001 Population and Housing Census. Windhoek, Namibia: National Planning Commission, Central Bureau of Statistics. G8 Countries Annual Summit meeting. 2005. Chair’s Summary. Gleneagles, Scotland: G8 Countries. Gaomab, M. 2007. Business Namibia: Economic Outlook 2007. Windhoek, Namibia: A.D.S Publications. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 369: 657–666. Gwatkin, D.R., S. Rutstein, K. Johnson, R.P. Pande, and A. Wagstaff. 2000. Socio-economic differences in health, nutrition, and population. HNP/Poverty Thematic Group. Washington, D.C.: World Bank. Heise L, Ellsberg M, Gottemoeller M. 1999. Ending violence against women. Baltimore, MD: Johns Hopkins University Press. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006. Special Summit of African Union on HIV and AIDS, Tuberculosis, and Malaria (ATM). Abuja, Nigeria: UNAIDS. Millennium Declaration: Report of the Secretary-General. New York: United Nations General Assembly. Ministry of Finance (MOF) [Namibia]. 2007. Medium Term Expenditure Framework 2006/07. Windhoek, Namibia: Ministry of Finance. Ministry of Health and Social Services (MoHSS). 2003. Namibia Demographic and Health Survey 2000. Windhoek, Namibia: MoHSS. Ministry of Health and Social Services (MoHSS) and ORC Macro. 1993. Namibia Demographic and Health Survey 1992. Windhoek, Namibia and Calverton, Maryland, USA: MoHSS and Macro International Inc. Ministry of Health and Social Services (MoHSS) [Namibia]. 2007. Annual Report 2005/06. Windhoek, Namibia: MOHSS. 274 | References Ministry of Health and Social Services (MoHSS) [Namibia]. 2004. The National Strategic Plan on HIV/AIDS; Third Medium Term Plan (MTP III), 2004–2009. Windhoek, Namibia: MoHSS. Ministry of Health and Social Services (MoHSS) [Namibia]. 2004. The National Strategic Plan on TB; Medium Term Plan (TB-MTP I), 2004-2009. Windhoek, Namibia: MoHSS. Ministry of Health and Social Services (MoHSS) [Namibia]. 2007. Report of the 2006 National HIV Sentinel Survey. Windhoek, Namibia: MoHSS Ministry of Health and Social Services (MoHSS) [Namibia]. 2005d. TB report 2005 (unpublished). Ministry of Health and Social Services(MoHSS) [Namibia]. 2005a. National Malaria Policy. Windhoek, Namibia: MoHSS. Ministry of Health and Social Services (MoHSS) [Namibia]. 2005b. Malaria Epidemic Preparedness and Response Guidelines. Windhoek, Namibia: MoHSS. Ministry of Health and Social Services (MoHSS) [Namibia]. 2005c. National Roll Back Malaria Five Year Strategic Plan 2003-2005. Windhoek, Namibia: MoHSS. Ministry of Health and Social Services (MoHSS) [Namibia]. 2007. Annual Report 2005/06. Windhoek, Namibia: MoHSS. Ministry of Labour and Social Welfare (MLSW) [Namibia]. 2004. Namibia Labour Force Survey 2004. Windhoek, Namibia: Ministry of Labour and Social Welfare. Namibia Research Facilitation Services (NRFS). 2006. HIV/AIDS Knowledge, Attitudes, Practice, and Behaviors (KAPB) Study in Namibia. Windhoek, Namibia: RFS. National Planning Commission (NPC) [Namibia]._______. Second National Development Plan (NDP2). Vol. 1. Macroeconomic, Sectoral, and Cross-Sectoral Policies. Windhoek, Namibia: NPC. National Planning Commission (NPC) [Namibia], and Central Bureau of Statistics (CBS) [Namibia]. 2003. 2001 Population and Housing Census. Windhoek, Namibia: CBS. Nawa Life Trust/Johns Hopkins University. 2007. NAMIBIA HIV/AIDS Community Survey Report, Rundu, Walvis Bay, Keetmanshoop and Oshakati. Pan-American Health Organization (PAHO)/World Health Organization (WHO). 2003. Guiding principles for complementary feeding of the breastfed child. Washington, D.C./Geneva, Switzerland: PAHO/WHO. Rivers, K. and P. Aggleton. 1999. Adolescent sexuality, gender and the HIV epidemic. HIV and Development Programme. New York: UNDP. UNICEF. 2005. Guide to Monitoring and Evaluation of the National Response For Children Orphaned and Made Vulnerable by HIV/AIDS. New York: UNICEF. UNICEF, UNAIDS, and USAID. 2006. Africa’s Orphaned and Vulnerable Generations: Children Affected by AIDS. New York: UNICEF United Nations General Assembly. 2001. Declaration of Commitment on HIV/AIDS. New York, New York: United Nations. References | 275 United Nations General Assembly. 2002. Building a world fit for children: The United Nations General Assembly Special Session on Children, 8-10 May, 2002. New York: United Nations. United Nations Children’s Fund (UNICEF). 2006. Child protection information sheets. New York: UNICEF. United Nations General Assembly. 2001. Road map towards the implementation of the United Nations WHO, UNICEF and JMP. 2004. Guide for Water Supply, Sanitation and Hygiene Related Household Survey. WHO, UNICEF and Joint Monitoring Programme for Water Supply and Sanitation. World Health Organization (WHO) and UNICEF. 1998. Complementary feeding of young children in developing countries: A review of current scientific knowledge. Geneva, Switzerland: WHO. World Health Organization (WHO). 2005a. Guiding principles for feeding nonbreastfed children 6 to 24 months of age. Geneva, Switzerland: WHO. World Health Organization (WHO). 2006. Multicentre Growth Reference Study Group. Geneva, Switzerland: WHO. World Health Organization (WHO) Bulletin. 2006. Volume 84: Number 7, July 2006, 505-588. Geneva, Switzerland: WHO. WHO. Handbook for the documentation of interpersonal violence prevention programmes. 2004. Geneva: World Health Organization. World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation. 2004. Meeting on the MDG drinking water and sanitation target: A mid-term assessment of progress. New York: World Health Organization and United Nations Children’s Fund. World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation. 2005. Water for life: making it happen. Geneva: World Health Organization and United Nations Children’s Fund. Appendix A | 277 SAMPLE DESIGN AND IMPLEMENTATION APPENDIX A A.1 SAMPLE DESIGN The primary objective of the 200-07 Namibia Demographic and Health Survey (NDHS) is to provide estimates with acceptable precision for important population characteristics such as fertility, contraceptive prevalence, selected health indicators, and infant mortality rates for Namibia as a whole, urban and rural areas separately, and each of the 13 regions. Sample frame In 2001, the Central Bureau of Statistics (CBS) carried out a Housing and Population Census. Administratively, Namibia is divided into 13 regions. In turn, each region is subdivided into constituencies (107 in total). For the census taking, each administrative unit was sub-divided into enumeration areas (EAs), which is totally classified as urban or rural. A total of more than 4,000 EAs were demarcated for the census operation. Each EA comprised of about 100 households. For each EA, a sketch map was drawn. The sketch shows the EA boundaries, location of buildings, and other landmarks. After the census, smaller EAs were merged with adjoining EAs and larger ones are split to form primary sampling units (PSUs) which are more or less uniform size. The list of PSUs is used as a sampling frame. Hence, a PSU can be an EA, part of an EA, or more than one EA. The total number of PSUs in the frame is about 3,750. Sample A representative probability sample of 10,000 households was selected for the 2006-07 NDHS. The sample was selected in two stages with PSUs as the first stage and households as the second stage sampling units. A total of 500 PSUs were selected with probability proportional to size, the size being the number of households enumerated in the 2001 Population Census. The selection of the PSUs was a systematic, one-stage operation carried out independently for each of the 13 regions. In the second stage, a complete listing of households and mapping exercise was carried out for each PSU in November 2006 to January 2007. This exercise was carried out by field staff recruited for the 2006-07 Namibia Inter-Censal Demographic Survey (NIDS) and the NDHS. The NIDS was conducted by the CBS. The list of households obtained was used as the frame for the second stage random selection of households. The listing excluded homeless people and people living in institutional households (army barracks, hospitals, police camps, boarding schools, etc.). In each PSU, 40 households were selected systematically and out of this sample 20 each were selected systematically for the NDHS and the NIDS, such that the two samples are independent. Although the two surveys were fielded at approximately the same time, in general the NIDS teams were ahead of the NDHS teams, allowing successful interviews with households selected for both surveys. In clusters where the number of households was less than 40, some households were selected for both surveys and were visited by both NDHS and NIDS teams. In PSUs where the number of households was between 20 and 39, some households were visited by the NDHS and NIDS teams at different times. In PSUs with fewer than 20 households, all households were visited by both teams at different times. 278 | Appendix A All women age 15-49 and all men age 15-49 who were either permanent residents of the households in the 2006-07 NDHS sample or visitors present in the household on the night before the survey were eligible to be interviewed. Sample Size Table A.1 shows the distribution of the selected EAs in each region. Table A.1 Sample allocation by region Percent distribution of women and men age 15-49 by background characteristics, Namibia 2006-07 Number of clusters Region Urban Rural Total Caprivi 13 20 33 Erongo 28 14 42 Hardap 15 17 32 Karas 17 16 33 Kavango 14 29 43 Khomas 43 12 55 Kunene 11 17 28 Ohangwena 5 34 39 Omaheke 10 18 28 Omusati 6 34 40 Oshana 20 25 45 Oshikoto 11 29 40 Otjozondjupa 19 23 42 Total 212 288 500 A. 2 SA M PL E IM PL EM EN TA TI O N Ta bl e A. 2 S am pl e im pl em en ta tio n: W om en Pe rc en t di st rib ut io n of h ou se ho ld s an d el ig ib le w om en b y re su lts o f th e ho us eh ol d an d in di vi du al i nt er vi ew s, a nd h ou se ho ld , el ig ib le w om en a nd o ve ra ll re sp on se r at es , ac co rd in g to u rb an -r ur al re sid en ce a nd re gi on , N am ib ia 2 00 6- 07 Re sid en ce Re gi on Re su lt U rb an Ru ra l C ap riv i Er on go H ar da p Ka ra s Ka va ng o Kh om as Ku ne ne O ha ng w en a O m ah ek e O m us at i O sh an a O sh ik ot o O tjo zo nd ju pa To ta l Se le ct ed h ou se ho ld s C om pl et ed (C ) 91 .6 92 .8 93 .6 91 .2 90 .5 88 .8 93 .7 91 .1 88 .4 95 .0 92 .8 96 .2 92 .0 96 .0 89 .3 92 .3 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt a t h om e (H P) 1. 7 0. 9 1. 5 1. 8 1. 1 0. 8 0. 5 2. 1 1. 8 1. 2 1. 3 0. 6 1. 7 0. 6 0. 8 1. 2 Po st po ne d (P ) 0. 1 0. 0 0. 2 0. 2 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 1 Re fu se d (R ) 0. 5 0. 1 0. 0 0. 4 0. 0 0. 2 0. 1 0. 5 0. 2 0. 1 0. 2 0. 4 0. 5 0. 3 0. 7 0. 3 D w el lin g no t f ou nd (D N F) 0. 7 0. 5 0. 9 0. 0 0. 9 0. 3 0. 7 1. 5 0. 7 0. 1 0. 9 0. 1 0. 6 0. 0 0. 4 0. 6 H ou se ho ld a bs en t ( H A) 3. 2 2. 8 1. 8 2. 9 4. 1 7. 1 1. 6 2. 5 5. 4 2. 1 3. 4 1. 9 1. 7 1. 4 4. 5 2. 9 D w el lin g va ca nt /a dd re ss n ot a dw el lin g (D V) 1. 7 2. 3 1. 8 3. 5 2. 0 2. 6 2. 6 1. 5 3. 4 0. 6 1. 4 0. 6 2. 5 1. 3 3. 1 2. 0 D w el lin g de st ro ye d (D D ) 0. 3 0. 3 0. 2 0. 1 0. 5 0. 3 0. 6 0. 3 0. 2 0. 3 0. 0 0. 0 0. 9 0. 5 0. 5 0. 3 O th er (O ) 0. 2 0. 3 0. 0 0. 0 0. 9 0. 0 0. 2 0. 6 0. 0 0. 6 0. 0 0. 1 0. 2 0. 0 0. 6 0. 3 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed h ou se ho ld s 4, 25 0 5, 72 0 65 7 84 0 64 0 66 0 85 3 1, 10 0 55 9 77 9 55 9 79 9 88 5 79 9 84 0 9, 97 0 H ou se ho ld re sp on se ra te (H RR ) 96 .8 98 .5 97 .3 97 .5 97 .8 98 .7 98 .6 95 .7 97 .1 98 .5 97 .6 98 .8 97 .1 99 .1 97 .8 97 .8 El ig ib le w om en C om pl et ed (E W C ) 92 .9 96 .2 96 .5 95 .2 90 .8 95 .2 92 .9 92 .4 93 .3 96 .0 95 .0 97 .7 94 .1 96 .2 95 .4 94 .7 N ot a t h om e (E W N H ) 4. 4 1. 7 1. 5 2. 6 5. 4 1. 7 4. 9 5. 1 3. 7 2. 3 2. 9 1. 2 3. 1 1. 3 2. 3 3. 0 Po st po ne d (E W P) 0. 2 0. 0 0. 0 0. 0 0. 2 0. 2 0. 0 0. 5 0. 2 0. 0 0. 2 0. 0 0. 2 0. 2 0. 0 0. 1 Re fu se d (E W R) 0. 9 0. 2 0. 4 1. 6 0. 8 1. 4 0. 3 0. 5 0. 6 0. 4 0. 4 0. 2 0. 7 0. 4 0. 3 0. 6 Pa rtl y co m pl et ed (E W PC ) 0. 5 0. 4 0. 3 0. 0 0. 7 0. 6 0. 3 0. 7 0. 9 0. 3 0. 0 0. 1 0. 2 1. 3 0. 0 0. 4 In ca pa ci ta te d (E W I) 0. 5 0. 9 0. 1 0. 5 1. 0 0. 6 1. 1 0. 5 0. 6 0. 8 1. 2 0. 5 1. 2 0. 6 0. 5 0. 7 O th er (E W O ) 0. 6 0. 4 1. 2 0. 2 1. 2 0. 4 0. 6 0. 4 0. 6 0. 2 0. 4 0. 2 0. 5 0. 0 1. 5 0. 5 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f w om en 4, 74 2 5, 61 0 68 0 64 2 60 6 51 8 1, 07 2 1, 07 8 46 4 1, 03 7 51 6 97 6 1, 08 2 93 7 74 4 10 ,3 52 El ig ib le w om en re sp on se ra te (E W RR ) 92 .9 96 .2 96 .5 95 .2 90 .8 95 .2 92 .9 92 .4 93 .3 96 .0 95 .0 97 .7 94 .1 96 .2 95 .4 94 .7 O ve ra ll re sp on se ra te (O RR ) 90 .0 94 .8 93 .9 92 .7 88 .8 93 .9 91 .6 88 .4 90 .6 94 .6 92 .6 96 .6 91 .4 95 .3 93 .3 92 .6 1 U sin g th e nu m be r o f h ou se ho ld s fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H RR ) i s ca lc ul at ed a s: 10 0 * C __ __ __ __ __ __ __ __ __ __ __ _ C + H P + P + R + D N F 2 U sin g th e nu m be r o f e lig ib le w om en fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e el ig ib le w om an re sp on se ra te (E W RR ) i s ca lc ul at ed a s: 10 0 * EW C __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ EW C + E W N H + E W P + E W R + E W PC + E W I + E W O 3 T he o ve ra ll re sp on se ra te (O RR ) i s ca lc ul at ed a s: O RR = H RR * E W RR /1 00 Appendix A | 279 Ta bl e A. 3 S am pl e im pl em en ta tio n: M en Pe rc en t di st rib ut io n of h ou se ho ld s an d el ig ib le m en b y re su lts o f th e ho us eh ol d an d in di vi du al in te rv ie w s, a nd h ou se ho ld , el ig ib le m en a nd o ve ra ll re sp on se r at es , ac co rd in g to u rb an -r ur al r es id en ce a nd re gi on N am ib ia 2 00 6- 07 Re sid en ce Re gi on Re su lt U rb an Ru ra l C ap riv i Er on go H ar da p Ka ra s Ka va ng o Kh om as Ku ne ne O ha ng w en a O m ah ek e O m us at i O sh an a O sh ik ot o O tjo zo nd ju pa To ta l Se le ct ed h ou se ho ld s C om pl et ed (C ) 91 .6 92 .3 93 .0 92 .9 90 .9 88 .5 94 .1 90 .4 88 .2 94 .3 91 .0 95 .7 93 .4 95 .2 87 .1 92 .0 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt a t h om e (H P) 1. 8 1. 0 2. 4 1. 4 0. 9 0. 9 0. 7 2. 5 1. 8 1. 3 1. 4 0. 3 1. 8 0. 8 1. 2 1. 4 Po st po ne d (P ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 Re fu se d (R ) 0. 4 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 4 0. 4 0. 3 0. 4 0. 5 0. 5 0. 3 0. 5 0. 2 D w el lin g no t f ou nd (D N F) 0. 7 0. 5 0. 3 0. 0 0. 9 0. 3 1. 2 1. 5 1. 1 0. 3 1. 1 0. 0 0. 7 0. 0 0. 2 0. 6 H ou se ho ld a bs en t ( H A) 3. 1 3. 0 1. 2 1. 9 3. 8 7. 3 1. 2 2. 2 5. 0 2. 8 4. 7 2. 8 1. 4 1. 8 6. 0 3. 1 D w el lin g va ca nt /a dd re ss n ot a dw el lin g (D V) 1. 7 2. 4 2. 7 3. 6 2. 5 2. 7 2. 1 1. 6 3. 2 0. 5 1. 4 0. 5 1. 6 1. 8 3. 8 2. 1 D w el lin g de st ro ye d (D D ) 0. 3 0. 4 0. 3 0. 2 0. 6 0. 3 0. 5 0. 5 0. 4 0. 3 0. 0 0. 0 0. 7 0. 3 0. 2 0. 3 O th er (O ) 0. 2 0. 2 0. 0 0. 0 0. 3 0. 0 0. 2 0. 9 0. 0 0. 3 0. 0 0. 3 0. 0 0. 0 0. 7 0. 2 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed h ou se ho ld s 2, 12 5 2, 85 6 32 8 42 0 32 0 33 0 42 5 55 0 28 0 38 9 27 9 39 9 44 2 39 9 42 0 4, 98 1 H ou se ho ld re sp on se ra te (H RR ) 96 .9 98 .2 97 .1 98 .5 98 .0 98 .6 98 .0 95 .4 96 .5 98 .1 96 .9 99 .2 96 .9 99 .0 97 .6 97 .7 El ig ib le m en C om pl et ed (E M C ) 83 .9 91 .5 87 .4 90 .5 78 .6 91 .4 89 .2 83 .9 86 .2 83 .3 90 .7 89 .3 90 .0 94 .5 89 .6 88 .1 N ot a t h om e (E M N H ) 11 .3 5. 0 9. 0 4. 6 13 .9 4. 5 7. 8 11 .4 9. 6 11 .5 4. 5 5. 8 8. 2 3. 7 6. 6 7. 8 Po st po ne d (E M P) 0. 4 0. 1 0. 0 0. 5 0. 3 0. 0 0. 0 0. 9 0. 0 0. 3 0. 0 0. 0 0. 0 0. 0 0. 3 0. 2 Re fu se d (E M R) 2. 4 0. 6 0. 4 2. 8 2. 0 1. 7 0. 5 2. 1 1. 6 1. 0 2. 4 0. 9 0. 5 0. 5 1. 6 1. 4 Pa rtl y co m pl et ed (E M PC ) 0. 4 0. 2 0. 4 0. 5 0. 3 0. 3 0. 0 0. 2 1. 1 0. 6 0. 0 0. 6 0. 0 0. 5 0. 0 0. 3 In ca pa ci ta te d (E M I) 0. 7 1. 9 2. 5 0. 8 2. 7 1. 7 0. 5 0. 7 0. 5 2. 6 2. 0 1. 8 1. 0 0. 5 1. 6 1. 4 O th er (E M O ) 1. 0 0. 6 0. 4 0. 3 2. 0 0. 3 2. 0 0. 9 1. 1 0. 6 0. 4 1. 5 0. 3 0. 3 0. 3 0. 8 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f m en 1, 99 5 2, 45 1 27 7 38 8 29 4 29 2 40 9 57 8 18 8 31 2 24 6 32 7 38 9 38 2 36 4 4, 44 6 El ig ib le m en re sp on se ra te (E M RR ) 83 .9 91 .5 87 .4 90 .5 78 .6 91 .4 89 .2 83 .9 86 .2 83 .3 90 .7 89 .3 90 .0 94 .5 89 .6 88 .1 O ve ra ll re sp on se ra te (O RR ) 81 .2 89 .9 84 .9 89 .1 77 .0 90 .2 87 .5 80 .0 83 .1 81 .8 87 .9 88 .6 87 .2 93 .5 87 .4 86 .0 1 U sin g th e nu m be r o f h ou se ho ld s fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H RR ) i s ca lc ul at ed a s: 10 0 * C __ __ __ __ __ __ __ __ __ __ __ C + H P + P + R + D N F 2 U sin g th e nu m be r o f e lig ib le m en fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e el ig ib le m an re sp on se ra te (E M RR ) i s ca lc ul at ed a s: 10 0 * EM C __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ EM C + E M N H + E M P + E M R + E M PC + E M I + E M O 3 Th e ov er al l r es po ns e ra te (O RR ) i s ca lc ul at ed a s: O RR = H RR * E M RR /1 00 280 | Appendix A Appendix B | 281 ESTIMATES OF SAMPLING ERRORS Appendix B The estimates from a sample survey are affected by two types of errors: (1) non-sampling errors, and (2) sampling errors. Non-sampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2006-07 Namibia Demographic and Health Survey (NDHS) to minimize this type of error, non-sampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2006-07 NDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2006-07 NDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2006-07 NDHS is the ISSA Sampling Error Module. This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = =− ⎥⎥⎦ ⎤ ⎢⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ − − == H h h h m i hi h h m z z m m x frvarrSE h 1 2 1 2 1 2 2 1)()( in which hihihi rxyz −= , and hhh rxyz −= where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, 282 | Appendix B yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2006-07 NDHS, there were 500 non-empty clusters. Hence, 500 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − = ∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 500 clusters, r(i) is the estimate computed from the reduced sample of 499 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, ISSA computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. ISSA also computes the relative error and confidence limits for the estimates. Sampling errors for the 2006-07 DHS are calculated for selected variables considered to be of primary interest for woman’s survey and for man’s surveys, respectively. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the eleven regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.17 present the value of the statistic (R), its standard error (SE), the number of unweighted (N-UNWE) and weighted (N-WEIG) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to child-bearing. The confidence interval (e.g., as calculated for children ever born to women age 40-49) can be interpreted as follows: the overall average from the national sample is 4.390 and its standard error is 0.078. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 4.39 ± 2 × 0.078. There is a high probability (95 percent) that the true average number of children ever born to all women age 40 to 49 is between 4.234 and 4.546. Sampling errors are analyzed for two separate groups of estimates: (1) means and proportions, and (2) complex demographic rates. At the national level, mostly relative standard error values (SE/R) for the means and proportions are below 10 percent, however the highest relative standard error values are for indicators with very low values (i.e., less than 2 percent). So in general, the relative standard errors for most estimates for the country as a whole are small, except for indicators with very small values, i.e., for estimates which are rare in the population. For example, the relative standard error for Appendix B | 283 the total fertility rate (TFR 0-3 years) is small (2.6 percent) since births are a fairly common event. However, for the mortality rates which are rarer events, the average relative standard error value is higher; for example, the relative standard error for the 0-4 year estimate of infant mortality is 7.1. The relative standard error varies across sub-populations. For example, for the variable children ever born to women age 40-49, the relative standard errors as a percent of the estimated mean for the whole country, for the urban areas and for the rural areas are 1.8 percent, 3.1 percent and 2.0 percent, respectively. For the total sample, the value of the design effect (DEFT), averaged over all selected variables, is 1.291 which means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.291 over that in an equivalent simple random sample. 284 | Appendix B Table B.1 List of selected variables for sampling errors, Namibia 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Variable Estimate Base population ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion All women 15-49 Literate Proportion All women 15-49 No education Proportion All women 15-49 Secondary education or higher Proportion All women 15-49 Net attendance ratio for primary school Ratio Children 7-12 years Never married Proportion All women 15-49 Currently in union Proportion All women 15-49 Married before age 20 Proportion Women age 20-49 Had sexual intercourse before age 18 Proportion Women age 20-49 Currently pregnant Mean All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women age 40-49 Mean Women 40-49 Knows any contraceptive method Proportion All women 15-49 Ever using contraceptive method Proportion All women 15-49 Currently using any contraceptive method Proportion All women 15-49 Currently using pill Proportion All women 15-49 Currently