Nepal - Multiple Indicator Cluster Survey - 2014

Publication date: 2014

Monitoring the situation of children and women Nepal Multiple Indicator Cluster Survey Final Report 2014 United Nations Children’s Fund Government of Nepal National Planning Commission Secretariat Central Bureau of Statistics Monitoring the situation of children and women Nepal Multiple Indicator Cluster Survey Final Report 2014 United Nations Children’s Fund Government of Nepal National Planning Commission Secretariat Central Bureau of Statistics © Central Bureau of Statistics and UNICEF Nepal December 2015 All UNICEF materials are protected by copyright, including text, photographs, images and videotapes. Permission is required to reproduce any part of this publication. Permission will be freely granted to educational or non-profit organizations. Please contact: Government of Nepal Central Bureau of Statistics Thapathali Kathmandu, Nepal Tel: 977 1 4245947, 4229406 Website: www.cbs.gov.np United Nations Children’s Fund (UNICEF) United Nations House Pulchowk, Lalitpur Tel: 977 1 5523200 PO Box 1187 Kathmandu, Nepal Website: http://www. unicef.org/nepal The Nepal Multiple Indicator Cluster Survey (MICS) was carried out in 2014 by the Central Bureau of Statistics (CBS) as part of the global MICS programme. Technical and financial support was provided by the United Nations Children’s Fund (UNICEF). The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Suggested citation: Central Bureau of Statistics, 2015. Nepal Multiple Indicator Cluster Survey 2014, Final Report. Kathmandu, Nepal: Central Bureau of Statistics and UNICEF Nepal. Cover Photo: ©UNICEF Nepal/2015/CSKarki NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 III Summary Table of Survey Implementation and Survey Population Multiple Indicator Cluster Survey, Nepal, 2014 Survey implementation Sample frame -­‐ Updated National Population and Housing Census, 2011 September–October, 2013 Questionnaires Household Women (aged 15–49) Children under five Water quality testing Interviewer training January–February, 2014 Fieldwork February–June, 2014 Survey sample Households -­‐ Sampled -­‐ Occupied -­‐ Interviewed -­‐ Response rate (percent) 13,000 12,598 12,405 98.5 Children under five -­‐ Eligible -­‐ Mothers/caretakers interviewed -­‐ Response rate (percent) 5,663 5,349 94.5 Women -­‐ Eligible for interviews -­‐ Interviewed -­‐ Response rate (percent) 14,936 14,162 94.8 Water quality testing for households -­‐ Selected for testing -­‐ Occupied -­‐ Tested -­‐ Response rate (percent) 1,560 1,511 1,492 98.7 Household population Average household size 4.6 Percentage of population living in -­‐ Urban areas -­‐ Rural areas 17.2 82.8 Percentage of population under: -­‐ Age 5 -­‐ Age 18 10.1 40.2 Percentage of women aged 15–49 years with at least one live birth in the last 2 years 14.5 Housing characteristics Household or personal assets Percentage of households with -­‐ Electricity -­‐ Finished floor -­‐ Finished roofing -­‐ Finished walls 84.9 34.9 85.3 41.2 Percentage of households that own -­‐ A television -­‐ A refrigerator -­‐ Agricultural land -­‐ Farm animals/livestock 51.5 13.6 75.5 68.8 Mean number of persons per room used for sleeping 2.4 Percentage of households where at least a member has or owns a -­‐ Mobile phone -­‐ Car or truck 91.2 1.9 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014IV 1See Appendix E for a detailed description of MICS indicators CHILD MORTALITY Early childhood mortality* MICS Indicator Indicator Description Value 1.1 Neonatal mortality rate Probability of dying within the first month of life 23 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 33 1.3 Post-neonatal mortality rate Difference between infant and neonatal mortality rates 11 1.4 Child mortality rate Probability of dying between the first and the fifth birthdays 5 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 38 * Rates refer to the five-year period preceding the survey NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight-for-age of the WHO standard 30.1 8.6 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height-for-age of the WHO standard 37.4 15.8 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight-for-height of the WHO standard 11.3 3.2 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight-for-height of the WHO standard 2.1 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 97.3 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 48.7 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 56.9 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 74.9 2.9 Continued breastfeeding at 1 year Percentage of children aged 12–15 months who received breast milk during the previous day 93.6 2.10 Continued breastfeeding at 2 years Percentage of children aged 20–23 months who received breast milk during the previous day 86.7 2.11 Median duration of breastfeeding The age in months when 50 percent of children aged 0–35 months did not receive breast milk during the previous day 36 2.12 Age-appropriate breastfeeding Percentage of children aged 0–23 months appropriately fed during the previous day 79.3 2.13 Introduction of solid, semi- solid or soft foods Percentage of infants aged 6–8 months who received solid, semi-solid or soft foods during the previous day 73.5 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children aged 6–23 months who received at least 2 milk feedings during the previous day 59.5 2.15 Minimum meal frequency Percentage of children aged 6–23 months who received solid, semi-solid and soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the previous day 74.4 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Nepal, 2014 Summary Table of Findings1 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 V Breastfeeding and infant feeding: continued MICS Indicator Indicator Description Value 2.16 Minimum dietary diversity Percentage of children aged 6–23 months who received foods from 4 or more food groups during the previous day 37.0 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children aged 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 32.3 22.8 2.18 Bottle feeding Percentage of children aged 0–23 months who were fed with a bottle during the previous day 11.5 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodide/iodate 81.5 Low birth weight 2.20 Low-birth-weight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 24.2 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 60.0 CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children aged 12–23 months who received BCG vaccine by their first birthday 87.5 3.2 Polio immunization coverage Percentage of children aged 12–23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 85.2 3.3 Diphtheria, pertussis and tetanus (DPT) immunization coverage Percentage of children aged 12–23 months who received the third dose of DPT vaccine (DPT3) by their first birthday 83.1 3.4 MDG 4.3 Measles immunization coverage Percentage of children aged 12–23 months who received measles vaccine by their first birthday 84.5 3.5 Hepatitis B immunization coverage Percentage of children aged 12–23 months who received the third dose of Hepatitis B vaccine (HepB3) by their first birthday 83.1 3.6 Haemophilus influenzae type B (Hib) immunization coverage Percentage of children aged 12–23 months who received the third dose of Hib vaccine (Hib3) by their first birthday 83.1 3.8 Full immunization coverage Percentage of children aged 12–23 months who received all vaccinations recommended in the national immunization schedule by their first birthday (measles by second birthday) 67.1 Tetanus toxoid 3.9 Neonatal tetanus protection Percentage of women aged 15–49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 77.3 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 12.0 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 47.2 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 18.2 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre-packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 45.9 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014VI Acute respiratory infection (ARI) symptoms MICS Indicator Indicator Description Value - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 6.7 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 50.1 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 74.9 Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 74.7 Malaria/fever - Children with fever Percentage of children under age 5 with fever in the last 2 weeks 20.1 3.20 Care-seeking for fever Percentage of children under age 5 with fever in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 46.4 WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 93.3 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 13.6 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 60.1 4.4 Safe disposal of child’s faeces Percentage of children aged 0–2 years whose last stools were disposed of safely 48.0 4.5 Place for handwashing Percentage of households with a specific place for handwashing where water and soap or other cleansing agent are present 72.5 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 94.9 4.C1 E.coli concentration in household drinking water Percentage of household members with E.coli risk level in household water ≥ 1 cfu/100ml 82.2 4.C2 E.coli concentration in source water Percentage of households with E.coli risk level in source water ≥ 1 cfu/100ml 71.1 REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate for women aged 15–49 years 2.3 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women aged 15–19 years 71 5.2 Early childbearing Percentage of women aged 20–24 years who had at least one live birth before age 18 16.0 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women aged 15–49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 49.7 5.4 MDG 5.6 Unmet need Percentage of women aged 15–49 years who are currently married or in union who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 25.2 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 VII Maternal and newborn health MICS Indicator Indicator Description Value 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women aged 15–49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 68.3 59.5 5.6 Content of antenatal care Percentage of women aged 15–49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 61.2 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women aged 15–49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 55.6 5.8 Institutional deliveries Percentage of women aged 15–49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 55.2 5.9 Caesarean section Percentage of women aged 15–49 years whose most recent live birth in the last 2 years was delivered by caesarean section 8.6 Postnatal health checks 5.10 Post-partum stay in health facility Percentage of women aged 15–49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 76.0 5.11 Postnatal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a postnatal care visit within 2 days after delivery 57.6 5.12 Postnatal health check for the mother Percentage of women aged 15–49 years who received a health check while in facility or at home following delivery, or a post- natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 57.9 CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children aged 36–59 months who are attending an early childhood education programme 50.7 6.2 Support for learning Percentage of children aged 36–59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 67.2 6.3 Father’s support for learning Percentage of children aged 36–59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 10.1 6.4 Mother’s support for learning Percentage of children aged 36–59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 30.4 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 4.8 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 59.2 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 20.6 6.8 Early child development index Percentage of children aged 36–59 months who are developmentally on track in at least three of the following four domains: literacy–numeracy, physical, social–emotional, and learning 64.4 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014VIII LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young women Percentage of young women aged 15–24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 84.0 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 74.2 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 57.3 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary-school age currently attending primary or secondary school 85.9 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary-school age currently attending secondary school or higher 66.1 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 0.99 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.02 CHILD PROTECTION Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 58.1 Child labour 8.2 Child labour Percentage of children aged 5–17 years who are involved in child labour 37.4 Child discipline 8.3 Violent discipline Percentage of children aged 1–14 years who experienced psychological aggression or physical punishment during the last one month 81.7 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of women aged 15–49 years who were first married or in union before age 15 15.5 8.5 Marriage before age 18 Percentage of women aged 20–49 years who were first married or in union before age 18 48.5 8.6 Young women aged 15–19 years currently married or in union Percentage of women aged 15–19 years who are married or in union 24.5 8.7 Polygyny Percentage of women aged 15–49 years who are in a polygynous union 4.1 8.8a 8.8b Spousal age difference Percentage of young women who are married or in union and whose spouse is 10 or more years older (a) among women aged 15–19 years (b) among women aged 20–24 years 6.3 7.5 Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of women aged 15–49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food 42.9 62.3 1.00 1.00 76.3 41.6 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 IX Children’s living arrangements MICS Indicator Indicator Description Value 8.13 Children’s living arrangements Percentage of children aged 0–17 years living with neither biological parent 4.8 8.14 Prevalence of children with one or both parents dead Percentage of children aged 0–17 years with one or both biological parents dead 4.3 8.15 Children with at least one parent living abroad Percentage of children 0–17 years with at least one biological parent living abroad 18.2 HIV/AIDS AND SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of women aged 15–49 years who have heard of AIDS 78.4 9.1 MDG 6.3 Knowledge about HIV prevention among young women Percentage of young women aged 15–24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 26.4 9.2 Knowledge of mother-to- child transmission of HIV Percentage of women aged 15–49 years who correctly identify all three means of mother-to-child transmission of HIV 38.4 9.3 Accepting attitudes towards people living with HIV Percentage of women aged 15–49 years expressing accepting attitudes on all four questions toward people living with HIV 48.6 HIV testing 9.4 Women who know where to be tested for HIV Percentage of women aged 15–49 years who state knowledge of a place to be tested for HIV 57.9 9.5 Women who have been tested for HIV and know the results Percentage of women aged 15–49 years who have been tested for HIV in the last 12 months and who know their results 2.7 9.7 HIV counselling during antenatal care Percentage of women aged 15–49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 14.1 9.8 HIV testing during antenatal care Percentage of women aged 15–49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 13.7 ACCESS TO MASS MEDIA AND ICT Access to mass media MICS Indicator Indicator Description Value 10.1 Exposure to mass media Percentage of women aged 15–49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 11.1 Use of information/communication technology 10.2 Use of computers Percentage of young women aged 15–24 years who used a computer during the last 12 months 21.7 10.3 Use of internet Percentage of young women aged 15–24 years who used the internet during the last 12 months 19.6 36.4 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014X SUBJECTIVE WELL-BEING MICS Indicator Indicator Description Value 11.1 Life satisfaction Percentage of young women aged 15–24 years who are very or somewhat satisfied with their life, overall 80.8 11.2 Happiness Percentage of young women aged 15–24 years who are very or somewhat happy 82.3 11.3 Perception of a better life Percentage of young women aged 15–24 years whose life improved during the last one year, and who expect that their life will be better after one year 57.0 TOBACCO AND ALCOHOL USE Tobacco use MICS Indicator Indicator Description Value 12.1 Tobacco use Percentage of women aged 15–49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month 9.2 12.2 Smoking before age 15 Percentage of women aged 15–49 years who smoked a whole cigarette before age 15 3.9 Alcohol use 12.3 Use of alcohol Percentage of women aged 15–49 years who had at least one alcoholic drink at any time during the last one month 9.5 12.4 Use of alcohol before age 15 Percentage of women aged 15–49 years who had at least one alcoholic drink before age 15 6.8 XI XII XIII XIV XV NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XVI TABLE OF CONTENTS Summary Table of Survey Implementation and Survey Population Summary Table of Findings Preface Acknowledgements Foreword Table of Contents List of Tables List of Figures List of Abbreviations Map of Nepal Showing Nepal MICS Sample Domains and Corresponding Districts Executive Summary III IV XI XIII XV XVI XVIII XXII XXIII XXIV XXV I. Introduction Background Survey Objectives II. Sample and Survey Methodology Sample Design Questionnaires Training and Fieldwork Data Processing III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Characteristics of Households Characteristics of Female and Male Respondents 15–49 Years of Age and Children Under Five Housing Characteristics, Asset Ownership, and Wealth Quintiles IV. Child Mortality V. Nutrition Low Birth Weight Nutritional Status Breastfeeding and Infant and Young Child Feeding Salt Iodization Micronutrient Intake Children’s Vitamin A Supplementation VI. Child Health Vaccinations Japanese Encephalitis Neonatal Tetanus Protection Care of Illness Diarrhoea Acute Respiratory Infection Solid Fuel Use Malaria/Fever VII. Water and Sanitation Use of Improved Water Sources Use of Improved Sanitation Handwashing Water Quality 1 1 2 3 3 4 5 5 6 6 8 11 14 19 24 24 26 31 42 46 47 49 49 51 55 56 58 68 73 76 82 83 92 101 109 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XVII VIII. Reproductive Health Fertility Contraception Unmet Need Antenatal Care Assistance at Delivery Place of Delivery Postnatal Health Checks Newborn Care Practices Experience of Discrimination during Menstruation (Chhaupadi) Spousal Separation IX. Early Childhood Development Early Childhood Care and Education Quality of Care Developmental Status of Children Perception on Minimum Years of Schooling X. Literacy and Education Literacy among Young Women School Readiness Primary and Secondary School Participation Participation in Non-Formal Education XI. Child Protection Birth Registration Child Labour Child Discipline Early Marriage and Polygyny Attitudes toward Domestic Violence Children’s Living Arrangements XII. HIV and AIDS Knowledge about HIV Transmission and Misconceptions about HIV/AIDS Accepting Attitudes toward People Living with HIV/AIDS Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care HIV Indicators for Young Women XIII. Access to Mass Media and Use of Information/Communication Technology Access to Mass Media Use of Information/Communication Technology XIV. Subjective Well-being XV. Tobacco and Alcohol Use Tobacco Use Alcohol Use Appendices Appendix A. Sample Design Appendix B. List of Personnel Involved in the Survey Appendix C. Estimates of Sampling Errors Appendix D. Data Quality Tables Appendix E. MICS5 Indicators: Numerators and Denominators Appendix F. MICS Questionnaires 113 113 118 122 124 131 134 136 148 151 151 153 153 155 161 163 165 165 166 167 176 178 178 181 186 190 196 199 203 203 208 210 213 216 216 218 220 226 226 230 233 238 242 281 299 310 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XVIII Results of household, women’s, and under-5 interviews Household age distribution by sex Household composition Women’s background characteristics Under-5s background characteristics Housing characteristics Household assets Wealth quintiles Early childhood mortality rates Early childhood mortality rates by socioeconomic characteristics Early childhood mortality rates by demographic characteristics Low birth weight infants Nutritional status of children Initial breastfeeding Breastfeeding Duration of breastfeeding Age-appropriate breastfeeding Introduction of solid, semi-solid, or soft foods Infant and young child feeding practices Bottle feeding Iodized salt consumption Type of salt used in households Micronutrient intake among mothers Children’s vitamin A supplementation Vaccinations in the first years of life Vaccinations against Japanese encephalitis Vaccinations by background characteristics Neonatal tetanus protection Reported disease episodes Care-seeking during diarrhoea Feeding practices during diarrhoea Oral rehydration solution and zinc Oral rehydration therapy with continued feeding and other treatments Source of ORS and zinc Care-seeking for acute respiratory infection (ARI) and treatment of symptoms with antibiotics Knowledge of the two danger signs of pneumonia Solid fuel use Solid fuel use by place of cooking Care-seeking during fever Treatment of children with fever Diagnostics and antimalarial treatment of children Use of improved water sources Household water treatment Time to source of drinking water Person collecting water Types of sanitation facilities Use and sharing of sanitation facilities Table HH.1: Table HH.2: Table HH.3: Table HH.4: Table HH.5: Table HH.6: Table HH.7: Table HH.8: Table CM.1: Table CM.2: Table CM.3: Table NU.1: Table NU.2: Table NU.3: Table NU.4: Table NU.5: Table NU.6: Table NU.7: Table NU.8: Table NU.9: Table NU.10: Table NU.11: Table NU.12: Table NU.13: Table CH.1: Table CH.1JE: Table CH.2: Table CH.3: Table CH.4: Table CH.5: Table CH.6: Table CH.7: Table CH.8: Table CH.9: Table CH.10: Table CH.11: Table CH.12: Table CH.13: Table CH.14: Table CH.15: Table CH.16: Table WS.1: Table WS.2: Table WS.3: Table WS.4: Table WS.5: Table WS.6: LIST OF TABLES 7 8 10 11 13 15 17 18 20 21 22 25 28 33 35 37 38 39 40 42 43 45 47 48 50 52 53 56 57 59 60 62 64 66 69 71 74 75 77 78 81 84 87 90 91 93 95 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XIX Drinking water and sanitation ladders Disposal of child’s faeces Water and soap at place for handwashing Availability of soap or other cleansing agent Distance between latrine and place for handwashing Critical times for handwashing Description of E. coli risk categories Household drinking water quality Source drinking water quality Fertility rates Adolescent birth rate and total fertility rate Early childbearing Trends in early childbearing Use of contraception Unmet need for contraception Antenatal care coverage Number of antenatal care visits and timing of first visit Content of antenatal care Assistance during delivery and Caesarean section Place of delivery Postpartum stay in health facility Postnatal health checks for newborns Postnatal care visits for newborns within one week of birth Postnatal health checks for mothers Postnatal care visits for mothers within one week of birth Postnatal health checks for mothers and newborns Newborn care practices in non-institutional deliveries First-time bathing of newborns Discrimination practices during menstruation period Spousal separation Early childhood education Support for learning Learning materials Inadequate care Early child development index Perception on minimum years of education for child Literacy (young women) School readiness Primary school entry Primary school attendance and out-of-school children Secondary school attendance and out-of-school children Education gender parity Out-of-school gender parity Participation in non-formal education Birth registration Children’s involvement in economic activities Children’s involvement in household chores Child labour Child discipline Attitudes toward physical punishment Early marriage and polygyny (women) Trends in early marriage (women) Table WS.7: Table WS.8: Table WS.9: Table WS.10: Table WS.11: Table WS.12: Table WQ.A: Table WQ.1: Table WQ.2: Table RH.1: Table RH.2: Table RH.3: Table RH.4: Table RH.5: Table RH.6: Table RH.7: Table RH.8: Table RH.9: Table RH.10: Table RH.11: Table RH.12: Table RH.13: Table RH.14: Table RH.15: Table RH.16: Table RH.17: Table RH.18: Table RH.19: Table RH.20: Table RH.21: Table CD.1: Table CD.2: Table CD.3: Table CD.4: Table CD.5: Table CD.6: Table ED.1: Table ED.2: Table ED.3: Table ED.4: Table ED.5: Table ED.6: Table ED.7: Table ED.8: Table CP.1: Table CP.2: Table CP.3: Table CP.4: Table CP.5: Table CP.6: Table CP.7: Table CP.8: 97 99 102 104 107 108 110 111 112 114 115 116 117 119 123 125 128 130 132 135 137 139 141 143 145 147 148 149 150 152 154 156 159 160 162 164 166 167 169 170 172 174 175 177 179 182 184 185 187 189 191 192 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XX Table CP.9: Table CP.10: Table CP.11: Table CP.12: Table CP.13: Table CP.14: Table HA.1: Table HA.2: Table HA.3: Table HA.4: Table HA.5: Table HA.6: Table MT.1: Table MT.2: Table SW.1: Table SW.2: Table SW.3: Table TA.1: Table TA.2: Table TA.3: Spousal age difference Attitudes toward domestic violence Attitudes towards abusive behaviour by mothers-in-law Children’s living arrangements and orphanhood Children with parents living abroad Children living away from their biological mother Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women) Knowledge of mother-to-child HIV transmission (women) Accepting attitudes toward people living with HIV (women) Knowledge of a place for HIV testing (women) HIV counselling and testing during antenatal care Key HIV and AIDS indicators (young women) Exposure to mass media (women) Use of computers and internet (women) Domains of life satisfaction (women) Overall life satisfaction and happiness (women) Perception of a better life (women) Current and ever use of tobacco (women) Age at first use of cigarettes and frequency of use (women) Use of alcohol (women) 194 197 198 200 201 202 204 207 209 211 212 214 217 219 221 224 225 227 229 231 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XXI APPENDICES: Table SD.1: Table SE.1: Table SE.2: Table SE.3: Table SE.4: Table SE.5: Table SE.6: Table SE.7: Table SE.8: Table SE.9: Table SE.10: Table SE.11: Table SE.12: Table SE.13: Table SE.14: Table SE.15: Table SE.16: Table SE.17: Table SE.18: Table SE.19: Table DQ.1: Table DQ.2: Table DQ.3: Table DQ.4: Table DQ.5: Table DQ.6: Table DQ.7: Table DQ.8: Table DQ.9: Table DQ.10: Table DQ.11: Table DQ.12: Table DQ.13: Table DQ.14: Table DQ.15: Table DQ.16: Table DQ.17: Table DQ.18: Table DQ.19: Table DQ.20: Table DQ.21: Table DQ.22: Table DQ.23: Table DQ.24: Allocation of sample clusters (primary sampling units) to sampling strata Indicators selected for sampling error calculations Sampling errors: Total sample Sampling errors: Urban Sampling errors: Rural Sampling errors: Eastern Mountains Sampling errors: Eastern Hills Sampling errors: Eastern Terai Sampling errors: Central Mountains Sampling errors: Central Hills Sampling errors: Central Terai Sampling errors: Western Mountains Sampling errors: Western Hills Sampling errors: Western Terai Sampling errors: Mid-Western Mountains Sampling errors: Mid-Western Hills Sampling errors: Mid-Western Terai Sampling errors: Far Western Mountains Sampling errors: Far Western Hills Sampling errors: Far Western Terai Age distribution of household population Age distribution of eligible and interviewed women Age distribution of children in household and under-5 questionnaires Birth date reporting: Household population Birth date and age reporting: Women Birth date and age reporting: Under-5s Birth date reporting: Children, adolescents and young people Birth date reporting: First and last births Completeness of reporting Completeness of information for anthropometric indicators: Underweight Completeness of information for anthropometric indicators: Stunting Completeness of information for anthropometric indicators: Wasting Heaping in anthropometric measurements Observation of birth certificates Observation of vaccination cards Observation of women’s health cards Observation of places for handwashing Respondents to under-5 questionnaire Selection of children aged 1–17 years for the child labour and child discipline modules School attendance by single age Sex ratio at birth among children ever born and living Births by calendar years Reporting of age at death in days Reporting of age at death in months 235 243 245 247 249 251 253 255 257 259 261 263 265 267 269 271 273 275 277 279 283 284 284 285 286 286 287 287 288 288 289 289 289 290 291 292 293 293 294 295 296 296 297 298 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XXII Age and sex distribution of household population Early child mortality rates Under-5 mortality rates by area Trend in under-5 mortality rates Underweight, stunted, wasted and overweight children under five (moderate and severe) Initiation of breastfeeding Infant feeding patterns by age Use of iodized salt Vaccinations by age of 12 months for children aged 12–23 months and 24–35 months Children under five with diarrhoea who received ORS Children under five with diarrhoea receiving ORT and continued feeding Percentage of household members by source of drinking water Percentage of household members by use and sharing of sanitation facilities Use of improved drinking water sources and improved sanitation facilities by household members Age-specific fertility rates by area Differentials in contraceptive use Person assisting at delivery Education indicators by sex Children under five whose births are registered Child disciplining methods, children aged 1–14 years Early marriage among women Women with comprehensive knowledge of HIV transmission Accepting attitudes towards people living with HIV/AIDS Ever and current smokers Number of household population by single ages Weight and height/length measurements by digits reported for the decimal points Figure HH.1: Figure CM.1: Figure CM.2: Figure CM.3: Figure NU.1: Figure NU.2: Figure NU.3: Figure NU.4: Figure CH.1: Figure CH.2: Figure CH.3: Figure WS.1: Figure WS.2: Figure WS.3: Figure RH.1: Figure RH.2: Figure RH.3: Figure ED.1: Figure CP.1: Figure CP.2: Figure CP.3: Figure HA.1: Figure HA.2: Figure TA.1: APPENDIX: Figure DQ.1: Figure DQ.2: LIST OF FIGURES 9 20 21 23 30 34 36 44 51 63 65 86 96 98 114 121 134 176 180 188 193 206 210 228 281 282 NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XXIII ACT Artemisinin-based combination therapy AIDS acquired immune deficiency syndrome ANC antenatal care ARI acute respiratory infection ASFR age-specific fertility rate BCG Bacillis-Cereus-Geuerin (tuberculosis) CBR crude birth rate CPR contraceptive prevalence rate CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DK don’t know DPT diphteria pertussis tetanus EC Escherichia coli (E. coli) ECD early childhood development ECDI early child development index ENPHO Environment and Public Health Organization EPI Expanded Programme on Immunization GFR general fertility rate GPI gender parity index HIV human immunodeficiency virus ICT information/communication technology IDD iodine deficiency disorders I/NGO international (and national) non-governmental organization ITN insecticide-treated bednet IU International Unit IUD intrauterine device LAM lactational amenorrhea method MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MICS5 fifth global round of Multiple Indicator Cluster Survey programme MoHP Ministry of Health and Population NAR net attendance rate NDHS Nepal Demographic and Health Survey NVAP National Vitamin A Programme ORS oral rehydration salts ORT oral rehydration treatment PNC postnatal care ppm parts per million SPSS Statistical Package for Social Sciences TFR total fertility rate UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization LIST OF ABBREVIATIONS NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XXIV M ap o f N ep al S ho w in g N ep al M IC S Sa m pl e D om ai ns a nd C or re sp on di ng D is tr ic ts NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XXV Executive Summary The Nepal Multiple Indicator Cluster Survey (MICS 2014) was conducted by the Central Bureau of Statistics under the National Planning Commission from January to June 2014. Technical and financial support for the survey was provided by the United Nations Children’s Fund (UNICEF) Nepal. Nepal MICS 2014 provides valuable information and the latest evidence on the situation of children and women in Nepal before the country was hit by an earthquake of 7.8 magnitude on 25 April 2015. The survey presents data from an equity perspective by indicating disparities by sex, region, area, education, household wealth, and other characteristics. Nepal MICS 2014 is based on a sample of 12,405 households interviewed and provides a comprehensive picture of children and women in the 15 sub-regions of the country. Child Mortality The 2014 MICS provides various measures of childhood calculated from information collected through birth histories of women aged 15–49. According to survey results, in the most recent five-year period prior to the survey, the under-5 mortality rate in Nepal is 38 deaths per 1,000 live births, the infant mortality rate is 33 deaths per 1,000 live births, and the neonatal mortality rate is 23 deaths per 1,000 live births. There are substantial disparities in terms of urban–rural location, mother’s education and household wealth status as well as between regions. Infant and under-5 mortality rates in rural areas are both over 50 percent higher than in urban areas. Mortality rates decrease with an increase in the education level of the mother. Children in the poorest households are twice as likely to die before reaching one and five years of age compared to children living in the richest households. Nutritional Status and Breastfeeding Some 60 percent of newborns were weighed at birth. For all births, 24 percent of infants were estimated to weigh less than 2,500 grams. There was some regional variation, ranging from 20 percent in the Eastern Terai to 33 percent in the Mid-Western Mountains. One in three (30 percent) children under five in Nepal were moderately or severely underweight, with 9 percent classified as severely underweight. More than one-third (37 percent) were moderately or severely stunted, with 16 percent severely stunted, and 11 percent were moderately or severely wasted, with 3 percent severely wasted. Only 2 percent of children were moderately or severely overweight. Children in rural areas were more likely than those in urban areas to be underweight, stunted or wasted. Those children whose mother has secondary or higher education were the least likely to be underweight, stunted or wasted compared to children of mothers with no education. Older children were more likely than younger children to be underweight and/or stunted but less likely to be wasted. Almost all (97 percent) newborns in Nepal were breastfed at some point after birth. However, only 49 percent started breastfeeding at the recommended time (i.e., within one hour of birth). Some 57 percent of infants under six months of age were exclusively breastfed and 75 percent received breast milk as the predominant source of nourishment during the day prior to the survey. Boys were more likely than girls to be exclusively breastfed. A cultural dimension partially explains this difference, as boys are usually introduced to semi-solid food at six months as compared to girls at five months. Mother’s education level was negatively associated with exclusive breastfeeding. Some 94 percent of children aged 12–15 months and 87 percent of children aged 20–23 months were still being breastfed. Approximately 79 percent of all children aged 0–23 months were receiving age-appropriate breastfeeding. Overall, 74 percent of infants aged 6–8 months had received solid, semi-solid or soft foods at least once during the previous day. Boys were more likely than girls to receive solid, semi-solid or soft foods. NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XXVI Of children aged 6–23 months, 74 percent had adequate meal frequency and 37 percent had adequate dietary diversity. Overall, 32 percent received a minimum acceptable diet. Some 12 percent of children aged 0–23 months in Nepal were fed using a bottle with a nipple. Urban children were much more likely than rural children to be bottle fed, and bottle feeding was positively correlated with mother’s education level and household wealth status. Adequately iodized salt, defined as containing 15 or more parts per million (15+ ppm), is used in 82 percent of households, with considerably higher consumption in urban areas (96 percent) and among the richest households (98 percent) than in rural areas (78 percent) and among the poorest households (64 percent). Use of iodized salt was lowest in the Far Western Hills (54 percent) and highest in the Central Hills (92 percent). Child Health and Care of Illness Four in every five mothers who gave birth in the two years prior to the survey were adequately protected against neonatal tetanus (77 percent). Regionally, the highest percentage was in the Eastern Terai (86 percent) and the lowest was in the Far Western Hills (60 percent). The likelihood of protection against neonatal tetanus increased with a woman’s level of education and household wealth status. Only 67 percent of women with no education were protected compared to 90 percent with higher than secondary education. Further, only 61 percent of women living in the poorest households were protected compared to 88 percent of women living in the richest households. Twelve percent of children under five had experienced diarrhoea during the two weeks preceding the survey. Of children with diarrhoea, 47 percent were taken to a qualified health care provider for advice or treatment. Mother’s education level was positively associated with seeking care: 43 percent of women with no education sought care from a health facility or health provider compared to 58 percent of women with higher education. Some 18 percent were treated with oral rehydration salts (ORS) and zinc as recommended. Children aged 0–11 months (11 percent) were the least likely to receive ORS and zinc. Overall, 46 percent of children received oral rehydration therapy (ORT) and continued feeding during the episode of diarrhoea. Older children (48–59 months), urban children and children whose mother had higher education were much more likely than their counterparts to receive ORT and continued feeding. Seven percent of children under five showed symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, of whom 50 percent were taken to a qualified health provider. Although appropriate medical care was sought for only 25 percent of children with ARI symptoms, antibiotic treatment was given to 75 percent of these children. Children in poorer households were less likely than others to be taken to a qualified provider for treatment of ARI, and to be given antibiotics. Additionally, only 46 percent of mothers or caretakers recognized at least one of two danger signs of pneumonia (fast and/or difficulty in breathing). Women living in households in the poorest wealth quintile were least likely to recognize the danger signs of pneumonia. Overall, three-quarters (75 percent) of all households in Nepal used solid fuels for cooking, with the primary source of fuel being wood (65 percent). Use of solid fuels was low in urban areas (24 percent), while only 1 percent of households in Kathmandu Valley used solid fuels for cooking. Differentials with respect to household wealth and the education level of the household head were also important. In households where the head had no education, 89 percent of household members used solid fuels for cooking. Almost all households in the poorest wealth quintile used solid fuels for cooking. Twenty percent of under-5s had an episode of fever in the two weeks preceding the survey. Of these, 46 percent were taken to a qualified provider for advice or treatment. However, no advice or treatment was sought in 29 percent of cases. Younger children (0–11 months) were more likely than their counterparts to receive care from a qualified provider (55 percent). Mother’s education level and household wealth status were both positively correlated with seeking care from a qualified provider. Less than 1 percent of children with fever were treated with Artemisinin-based combination therapy (ACT) and an additional 1 percent received an antimalarial other than ACT. NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XXVII Water and Sanitation Drinking water was used from an improved drinking water source almost universally (93 percent of the population). Among those who did not have access to an improved drinking water source, only 14 percent used an appropriate water treatment method. About 67 percent of users of improved drinking water sources had a water source directly on their premises. In addition, 22 percent used an improved drinking water source with a round trip of less than 30 minutes. In total, 7 percent of household members took more than 30 minutes to collect water. Rural households were more likely than urban households to spend more than 30 minutes collecting water. Some 30 percent of households in the Mid-Western Hills took 30 minutes or more to collect water. Water was usually collected by adult women (84 percent) in the household. The education level of the household head and the household’s wealth status were both positively associated with having a water source on the premises. Approximately 72 percent of the population of Nepal is living in households using improved sanitation facilities. However, only 60 percent are using improved sanitation facilities that are not shared. Some 26 percent still practiced open defecation. Urban areas were much more likely than rural areas to use improved sanitation facilities (94 percent cf. 67 percent), and the use of improved sanitation facilities is strongly correlated with the education level of the household head. Strikingly, the poorest households were less likely than households in the second and middle wealth quintiles to practice open defecation, possibly as a result of recent targeted interventions that provide the poorest with sanitation facilities. Overall, 56 percent of the household population used an improved drinking water source as well as an improved sanitation facility. Child faeces were disposed of in a safe manner for 48 percent of children under the age of two years. This was twice as common in urban areas as rural areas (81 percent cf. 43 percent), and there were significant regional differences (24 percent in the Far Western Terai cf. 78 percent in the Eastern Hills). In households where a place for handwashing was observed, 73 percent had water and soap or another cleansing agent present at that place. The proportion of households with water and soap or cleansing agent available at the handwashing place varied by region, being highest in the Eastern Terai (81 percent) and the lowest in the Mid-Western and Far Western Mountains (41 percent each). It was lower in rural areas than urban areas (69 percent cf. 85 percent). It was positively associated with the education level of the household head and household wealth status. A water quality testing questionnaire was included in the Nepal MICS for the first time, aiming to collect data on the quality of water actually consumed throughout Nepal through the use of a test for microbiological parameters such as E. coli and total coliform. Overall, more than four-fifths (82 percent) of household members were at the risk of E. coli concentration ≥ 1 cfu/100 ml in their household water. People living in the richest households were less likely than those living in the poorest households to have E. coli in their drinking water (64 percent cf. 91 percent). Likewise, the quality of drinking water at source was also measured. In total, almost three-quarters (71 percent) of the household population were at risk of E. coli due to its concentration in their source of drinking water. The poorest households were more likely than the richest households to have E. coli in their source of drinking water (88 percent cf. 58 percent). Eight out of 10 households (84 percent) with unimproved sources of drinking water had E. coli, whereas it dropped to 70 percent for those households that had an improved source of drinking water. Unimproved sources were much more likely than improved sources to fall into the very high risk category. NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XXVIII Reproductive Health The total fertility rate in Nepal is 2.3, meaning that a Nepali women, by the end of her reproductive years, will have given birth to an average of 2.3 children. The adolescent birth rate is 71 births per 1,000 women aged 15–19 years. Early childbearing is relatively common, with about one in six (16 percent) women aged 20–24 years having had a live birth before the age of 18. About 50 percent of women aged 15–49 years and currently married or in a marital union were using some form of contraception, with 47 percent using a modern method and 3 percent using a traditional method. However, contraceptive prevalence was relatively low among women aged 15–19 years (19 percent). Interestingly, women’s education level was negatively associated with contraceptive use. Some 25 percent of women had an unmet need for contraception, with 10 percent requiring it for spacing and 15 percent requiring it for limiting. Notably, unmet need was higher among younger women than older women, ranging from 48 percent for women aged 15–19 years to 11 percent for women aged 45–49 years. Education level was positively associated with unmet need, with only 19 percent of women with no education expressing an unmet need compared to 32 percent of women with higher education. About 68 percent of women aged 15–49 years with a live birth in the two years preceding the survey received antenatal care from skilled health personnel at least once, and 60 percent had the recommended four antenatal care visits by any provider. Some 61 percent had received all elements of the antenatal checkup (blood pressure checked, urine sample taken and blood sample taken). Urban women were much more likely than rural women to receive all recommended antenatal care practices. Education level and household wealth status were both strongly associated with the likelihood of a woman receiving appropriate antenatal care. Around 55 percent of women aged 15–49 years with a live birth in the two years preceding the survey delivered at a health facility and 56 percent were attended by a skilled health provider. Importantly, women who had received at least four antenatal care visits were much more likely to deliver in a health facility (73 percent) than those who had 1–3 visits (38 percent) or no visits (10 percent). Urban women were much more likely than rural women to be attended by a skilled provider (90 percent cf. 51 percent). Furthermore, 95 percent of women who gave birth in a health facility were attended by a skilled provider, while only 7 percent of women who gave birth at home were attended by a skilled provider—a 14-fold difference. Women with higher levels of education and those living in the richest households were much more likely than their counterparts to deliver in a health facility and to be assisted by a skilled provider at delivery. Some 9 percent of women were delivered by Caesarean section. Around 76 percent of women who gave birth in a health facility stayed 12 hours or more in the facility after delivery. Urban women were more likely than rural women to stay for 12 hours or more (86 percent cf. 74 percent). Postnatal checkups were given to 58 percent of newborns and 58 percent of mothers within two days after delivery. Newborns delivered in a health facility were much more likely than those delivered at home to receive a postnatal health check (91 percent cf. 17 percent). An increase in the mother’s education level and the household wealth status increased the likelihood of a postnatal health check for both newborns and mothers. Early Childhood Development Half of all children (51 percent) aged 36–59 months were attending early childhood education programmes. Four-year-olds were more likely than three-year-olds to be attending (65 percent cf. 37 percent). Children in urban areas were much more likely than those in rural areas to attend (78 percent cf. 47 percent). In addition, two-thirds of children (67 percent) also lived in households where NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XXIX adults had engaged with them in four or more activities that promote learning and school readiness during the three days prior to the survey. Father’s involvement in such activities was somewhat limited, with only 10 percent of children having a father who had engaged with them in four or more activities compared to 30 percent of children whose mother had done so. In Nepal, only 5 percent of children aged 0–59 months lived in a household where at least three children’s books were present, and less than 1 percent lived in a household with 10 or more children’s books. Urban children were much more likely than rural children to live in a household with at least three children’s books (15 percent cf. 3 percent), with 31 percent of children in Kathmandu valley living in a household with at least three children’s books. The presence of children’s books was positively correlated with mother’s education and household wealth levels. Some 59 percent of under-5s had access to two or more types of playthings. One in five (21 percent) children under five was left with inadequate care during the week preceding the survey (either left alone or in the care of another child under the age of 10). Rural children were more likely than urban children to have inadequate care (21 percent cf. 15 percent). Mother’s education level and household wealth status were both negatively associated with a child being left with inadequate care. Overall, 64 percent of children aged 36–59 months were developmentally on track according to the early child development index (ECDI). The score is based on the percentage of children who are developmentally on track in at least three of the following four domains: literacy–numeracy, physical, social–emotional and learning. Urban children, children who are attending early childhood education, and children of better educated mothers and from wealthier households have slightly higher development index scores. Literacy and Education Some 84 percent of women aged 15–24 years were literate. As expected, literacy was strongly associated with education level: just 5 percent of young women with no education were literate. However, only 62 percent of young women with primary education were considered literate, suggesting major shortcomings in the quality of primary education in the country since such a significant proportion of young women were still unable to read a short simple statement. Almost three-quarters (74 percent) of children in first grade of primary school had attended preschool during the previous school year. The net intake rate in primary education, i.e., the percentage of children of school-entry age who enter the first grade of primary school, was low at 42 percent. Household wealth status was not correlated with net intake rate; notably, the proportion of children in this age group who were living in households in the poorest wealth quintile and were attending first grade was nine percentage points higher than that of their counterparts living in the richest households (52 percent cf. 43 percent). The primary school adjusted net attendance ratio was 76 percent. Younger children had lower primary school net attendance ratios than older children, and were more likely to be in preschool or out of school. Some 62 percent of children of secondary-school age were currently attending secondary school or higher, 27 percent were still attending primary school, and 11 percent were out of school. Older children were more likely than younger counterparts to be out of school, with some 22 percent of children who started the school year at age 16 out of school. Mother’s education and household wealth status were both positively correlated with secondary school attendance ratios. The gender parity index (GPI) for both primary and secondary school was 1.00, indicating virtually no difference in the attendance of girls and boys at primary and secondary school. The primary GPI was NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XXX higher for rural children than urban children, and the secondary GPI was lower for rural children than urban children. Child Protection Although a high proportion of mothers or caretakers of children under five (86 percent) know how to register a birth in Nepal, registration is still not widely practiced, with only 58 percent of births registered. The difference between knowledge and practice persists across all background dimensions. In total, 37 percent of children aged 5–17 years were involved in child labour, with 30 percent working under hazardous condition. Children from rural areas were much more likely than children from urban areas to be involved in child labour (41 percent cf. 16 percent). Children attending school were less likely than children not attending school to be involved in child labour (36 percent cf. 47 percent). Mother’s education and household wealth status were negatively correlated with child labour. The majority (81 percent) of children aged 1–14 years in Nepal had been subjected to at least one form of psychological or physical punishment by household members in the month prior to the survey. Around 14 percent had experienced severe physical punishment (hitting child on the head, ears or face or hitting child hard and repeatedly). Interestingly, this does not match well with only 35 percent of respondents believing that physical punishment is a necessary part of child-rearing. Almost one in six (16 percent) women aged 15–49 years was first married before the age of 15, and nearly half (49 percent) of women aged 20–49 years were married before the age of 18. Of women aged 15–19 years, 25 percent were already married. Early marriage is widely practiced in Nepal and is prevalent across all background dimensions; however, trends based on other data sources suggest that it has declined in recent years. Among currently married women aged 15–49 years, 4 percent were in a polygynous marriage. Spousal age difference is generally not large in Nepal and marriage to a much older husband is not very common. Some 6 percent of women aged 15–19 years and 8 percent of women aged 20–24 years were married to a spouse who is 10 or more years older. Interestingly, marriage to an older spouse was more common for women with better education and living in richer households. Overall, 43 percent of women felt that a husband was justified in hitting or beating his wife in at least one of five situations (wife neglects the children, wife goes out without telling husband, wife argues with husband, wife refuses to have sex with husband, wife burns the food). Such agreement was more likely in rural areas than urban areas (46 percent cf. 29 percent). Younger women tended to show lower agreement than older women. Agreement was highest among women with no education and those living in households in the poorest wealth quintile. Around 5 percent of children aged 0–17 years were living with neither of their biological parents, and 4 percent reported that one or both of their biological parents had passed away. About 18 percent of children had at least one biological parent living abroad. HIV/AIDS and Orphanhood More than three in four (78 percent) women aged 15–49 years in Nepal had heard of AIDS, but only one in four (26 percent) had comprehensive knowledge, meaning they can correctly identify two ways of preventing HIV infection (know that a healthy looking person can have HIV, and reject the two most common misconceptions about HIV transmission). Only two in five (38 percent) women correctly identified all three means of mother-to-child transmission of HIV. Overall, 49 percent of women NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014 XXXI expressed an accepting attitude towards people living with HIV. On all HIV/AIDS-related indicators, urban women were more likely than rural women to have knowledge and accepting attitudes. Education level and household wealth status were both positively correlated with knowledge and accepting attitudes. Around 58 percent of women aged 15–49 years knew of a place where they can be tested for HIV. Knowledge about a place to get tested had a strong positive correlation with both education level and household wealth status. Of women who had received antenatal care during their last pregnancy, 14 percent reported that they had received counselling on HIV during antenatal care, while 9 percent received HIV counselling, were offered an HIV test, were tested, and received the result. Again, education level and household wealth status were strongly associated with the likelihood of being tested and receiving the result. Finally, as over half of new adult HIV infections are among people aged 15–24 years, changing their behaviour is especially important to reduce new infections. Results for this age group are generally better than for the population aged 15–49 years as a whole. Some 36 percent of young women had comprehensive knowledge, 45 percent knew all three means of HIV transmission from mother to child, and 68 percent knew of a place to get tested for HIV. Access to Mass Media and ICT Of all women aged 15–49 years in Nepal, one-fifth (19 percent) read a newspaper or magazine at least once a week, 41 percent listened to the radio, and 57 percent watched television. In total, 11 percent were exposed to all three types of media on a weekly basis. For young women aged 15–24 years, 22 percent had used a computer and 20 percent had used the internet during the 12 months prior to the survey. Access to mass media and information/communication technology was more prevalent among younger women, women who live in urban areas, those with better education and those living in richer households. Subjective Well-being In the Nepal MICS 2014, a set of questions related to subjective well-being were asked to women aged 15–24 years to understand how satisfied this group of young people is in different areas of their lives. Life satisfaction is a measure of an individual’s level of well-being. Life satisfaction is measured in categories ‘very satisfied’, ‘somewhat satisfied‘, ‘neither satisfied nor unsatisfied’, ‘somewhat unsatisfied’ and ‘very unsatisfied’. They were also measured for happiness and for the question on happiness, the same scale was used, ranging from ‘very happy’ to ‘very unhappy’, in the same fashion. For three domains, satisfaction with school, job and income, the denominators are confined to those who are currently attending school, have a job, and have an income. Of the different domains, young women were the most satisfied with their family life (85 percent), their friendships (82 percent), the way they look (81 percent), and their health (78 percent). The proportions were lower for living environment (75 percent) and treatment by others (70 percent). Some 89 percent of young women were satisfied with school, 79 percent were satisfied with their job, and 77 percent were satisfied with their income. More educated women tended to have higher levels of satisfaction than women with little or no education, and women living in households in richer wealth quintiles tended to have higher levels of satisfaction than those living in households in poorer wealth quintiles. Overall, 81 percent of young women expressed satisfaction with their life. In addition, 82 percent of young women said they were very or somewhat happy. NEPAL MULTIPLE INDIC ATOR CLUSTER SURVEY 2014XXXII Respondents were also asked whether they thought their life had improved during the year preceding the survey, and whether they thought their life would be better in one year subsequent to the survey. Three in five (60 percent) young women thought their life had improved and four in five (82 percent) expected their life to get better; some 57 percent thought both. Tobacco and Alcohol Use In Nepal, 9 percent of women aged 15–49 years reported that they had smoked cigarettes or used other tobacco products on one or more days during the month preceding the survey. Cigarettes were the most commonly used tobacco product. Tobacco use was higher among older, less educated and poorer women. Some 4 percent of women had smoked a whole cigarette before the age of 15 years. Some 10 percent of women aged 15–49 years had at least one drink of alcohol on one or more days during the month preceding the survey, and 7 percent reported that they had first drunk alcohol before the age of 15. There was great regional variation, ranging from 1 percent of women in the Far Western Hills to 51 percent of women in the Eastern Mountains. Women with no education and those from the poorest household population were about three times more likely than women with higher education and those from the richest household population to have drunk alcohol during the previous month. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 1 Introduction C H A P T E R1 Background This report is based on the Nepal Multiple Indicator Cluster Survey (MICS), conducted in 2014 by the Central Bureau of Statistics, Government of Nepal, with technical support from UNICEF. The survey provides statistically sound and internationally comparable data essential for developing evidence- based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and sub-national levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 20142 The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” This survey has also generated information on indicators that are comparable with the ecological sub- regions defined in previous national surveys (e.g. the Nepal Demographic and Health Surveys). The results will contribute to monitoring progress made over the past decade on children’s and women’s issues. They will also help in identifying the regional and geographic disparities that exist within the country. The Nepal MICS results will be critically important for final MDG reporting in 2015, and are expected to form part of the baseline data for the post-2015 era. The Nepal MICS is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women’s and Children’s Health. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The Nepal MICS 2014 has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Nepal; • To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention; • To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action; • To collect disaggregated data for the identification of disparities, to allow for evidence-based policy-making aimed at social inclusion of the most vulnerable; • To contribute to the generation of baseline data for the post-2015 agenda; • To validate data from other sources and the results of focused interventions. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 3 Sample and Survey Methodology C H A P T E R2 Sample Design The sample for the Nepal MICS was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for the following 15 sub-regions: • Eastern Mountains • Central Terai • Mid-Western Hills • Eastern Hills • Western Mountains • Mid-Western Terai • Eastern Terai • Western Hills • Far Western Mountains • Central Mountains • Western Terai • Far Western Hills • Central Hills • Mid-Western Mountains • Far Western Terai The urban and rural areas within each sub-region were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas were selected systematically with probability proportional to size. After a household listing was carried out within the selected enumeration areas, a systematic sample of 25 households was drawn in each sample enumeration area. The total sample size consisted of 13,000 households in 520 sample enumeration areas. One of these enumeration areas was not visited because it was inaccessible due to high altitude and heavy snowfall during the field work period. The sample was stratified by region, urban and rural areas, and is not self- weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A, Sample Design. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 20144 Questionnaires Four sets of questionnaires were used in the survey: (1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; (2) a questionnaire for individual women administered in each household to all women aged 15–49 years; (3) an under-5 questionnaire, administered to mothers (or caretakers) for all children under five years of age living in the household; and (4) a water quality testing questionnaire to test for bacteria and measure E. coli content in household drinking water and water source in a sub- sample of the households. The Household Questionnaire included the following modules: • List of Household Members • Education • Child Labour • Child Discipline • Household Characteristics • Water and Sanitation • Handwashing • Salt Iodization The Questionnaire for Individual Women was administered to all women aged 15–49 years living in the households, and included the following modules: • Woman’s Background • Access to Mass Media and Use of Information/Communication Technology • Fertility/Birth History • Desire for Last Birth • Maternal and Newborn Health • Postnatal Health Checks • Illness Symptoms • Contraception • Unmet Need • Attitudes Toward Domestic Violence • Marriage/Union • HIV/AIDS • Tobacco and Alcohol Use • Life Satisfaction The Questionnaire for Children Under Five was administered to mothers (or caretakers) of children under five years of age1 living in the households. Normally, the questionnaire was administered to mothers of under-5s; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: • Age • Birth Registration • Early Childhood Development • Breastfeeding and Dietary Intake • Immunization • Care of Illness • Anthropometry 1 The terms ‘children under five’, ‘children aged 0–4 years’, and ‘children aged 0–59 months’ are used interchangeably in this report. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 5 The Questionnaire for Water Quality Testing was administered to a sub-sample of selected households for measuring E. coli content in the household drinking water and included only one module: • Water Quality The questionnaires are based on the MICS5 model questionnaire2. From the MICS5 model English version, the questionnaires were customized and translated into Nepali, Maithili and Bhojpuri. Pre-test training was conducted in Dhulikhel, Kavre District, from 25 October to 2 November 2013. Pre-test fieldwork was conducted in 25 households of both urban and rural locations in Sindhupalchowk District (Mountains), Tanahun District (Hills) and Dhanusa District (Terai) during November 2013. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Nepal MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for handwashing, and measured the weights and heights of children under five. Details and findings of these observations and measurements are provided in the respective sections of the report. In each cluster, water from three households and one source of drinking water were tested for E. coli. Testing was conducted by the team measurer. As a routine quality control measure, the supervisor regularly observed the measurer in the testing of blanks. In addition, professional laboratory technicians from an external agency were engaged for the purpose. They visited field teams during the survey and observed the measurers during testing, giving corrective support as needed. Training and Fieldwork Master training of trainers was held 12–20 January 2014. This was followed by three weeks of residential training for fieldworkers from 30 January to 19 February 2014 in Banepa, Kavre District. Training included lectures on interviewing techniques and the contents of the questionnaires, mock interviews between trainees to gain practice in asking questions, and demonstration on anthropometric measurement and water quality test. Towards the end of the training period, trainees spent four days in practice interviewing in villages near to Banepa. The data were collected by 15 teams; each comprised three female interviewers, one editor, one measurer and one supervisor. Fieldwork began in February 2014 and concluded in June 2014. Data Processing Data were entered using CSPro software, Version 5.0. Data were entered on 10 laptop computers by 10 data-entry operators, one questionnaire administrator, overseen by one data-entry supervisor with two secondary editors. For quality assurance purposes, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS programme and adapted to the Nepal questionnaire were used throughout. Data processing began simultaneously with data collection in March 2014 and was completed in July 2014. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, Version 21.0. Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. 2The model MICS5 questionnaires can be found at http://mics.unicef.org/tools NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 20146 Sample Coverage and the Characteristics of Households and Respondents C H A P T E R3 Sample Coverage Of the 13,000 households selected for the sample, 12,598 were found to be occupied. Of these, 12,405 were successfully interviewed for a household response rate of 98.5 percent. One cluster was dropped due to remote location and heavy snowfall. In the interviewed households, 14,936 women (aged 15–49 years) were identified. Of these, 14,162 were successfully interviewed, yielding a response rate of 94.8 percent for women within the interviewed households. There were 5,663 children under five listed in the household questionnaires. Questionnaires were completed for 5,349 of these children, which corresponds to a response rate of 94.5 percent for children under five within interviewed households. Overall response rates of 93.4 percent and 93.0 percent are calculated for the individual interviews of women and children under five, respectively (Table HH.1). The household response rates were similar across regions and areas, with a slightly lower rate in the Far Western Terai. The response rates for women and children under five show a similar pattern, with the exception of the Western Mountains, where the women’s overall response rate was 85.8 percent. Ta bl e HH .1 : R es ul ts o f h ou se ho ld , w om en ’s a nd u nd er -5 in te rv ie ws Nu m be r o f h ou se ho lds , w om en a nd ch ild re n un de r f ive b y i nt er vie w re su lts , a nd h ou se ho ld, w om en ’s an d un de r-5 s’ re sp on se ra te s, Ne pa l, 2 01 4 To ta l Ar ea Re gio n Ur ba n Ru ra l Ea ste rn M ou n- ta ins Ea ste rn Hi lls Ea ste rn Te ra i Ce nt ra l M ou n- ta ins Ce nt ra l Hi lls Ce nt ra l Te ra i W es te rn M ou n- ta ins W es te rn Hi lls W es te rn Te ra i M id- W es te rn M ou n- ta ins M id- W es te rn Hi lls M id- W es te rn Te ra i Fa r W es te rn M ou n- ta ins Fa r W es te rn Hi lls Fa r W es te rn Te ra i To ta l Ur ba n Ka th - m an du va lle y Ot he r ur ba n Ho us eh ol ds Sa m ple d 13 ,0 00 3, 15 0 80 0 2, 35 0 9, 85 0 80 0 80 0 1, 00 0 80 0 1, 60 0 1, 00 0 40 0 1, 00 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 Oc cu pie d 12 ,5 98 3, 05 8 76 9 2, 28 9 9, 54 0 77 8 78 1 98 1 77 8 1, 54 8 97 1 38 0 97 7 78 7 75 2 78 0 77 2 77 5 75 7 78 1 In te rv iew ed 12 ,4 05 2, 99 2 73 9 2, 25 3 9, 41 3 77 6 77 7 97 4 77 1 1, 50 3 95 6 37 4 97 3 78 2 74 3 77 8 75 9 75 9 73 6 74 4 Ho us eh old re sp on se ra te 98 .5 97 .8 96 .1 98 .4 98 .7 99 .7 99 .5 99 .3 99 .1 97 .1 98 .5 98 .4 99 .6 99 .4 98 .8 99 .7 98 .3 97 .9 97 .2 95 .3 W om en El igi ble 14 ,9 36 3, 66 8 88 8 2, 78 0 11 ,2 68 85 7 87 7 1, 16 0 74 8 1, 73 9 1, 22 0 29 6 1, 08 1 1, 10 8 85 3 92 5 99 8 98 7 98 0 1, 10 7 In te rv iew ed 14 ,1 62 3, 47 9 84 3 2, 63 6 10 ,6 83 84 0 85 5 1, 09 7 72 0 1, 65 5 1, 11 8 25 8 1, 00 0 1, 04 9 81 7 88 3 94 9 96 5 92 7 1, 02 9 W om en ’s re sp on se ra te 94 .8 94 .8 94 .9 94 .8 94 .8 98 .0 97 .5 94 .6 96 .3 95 .2 91 .6 87 .2 92 .5 94 .7 95 .8 95 .5 95 .1 97 .8 94 .6 93 .0 W om en ’s ov er all re sp on se ra te 93 .4 92 .8 91 .2 93 .3 93 .5 97 .8 97 .0 93 .9 95 .4 92 .4 90 .2 85 .8 92 .1 94 .1 94 .6 95 .2 93 .5 95 .8 92 .0 88 .6 Ch ild re n un de r f iv e El igi ble 5, 66 3 95 6 18 4 77 2 4, 70 7 33 6 29 3 41 5 24 1 44 0 56 1 82 38 7 41 6 54 9 43 1 31 6 43 4 46 9 29 3 M ot he rs / ca re ta ke rs int er vie we d 5, 34 9 90 7 17 6 73 1 4, 44 2 32 5 28 4 38 4 23 8 41 8 50 4 77 35 8 38 9 51 7 41 4 30 3 42 0 43 5 28 3 Un de r-5 s re sp on se ra te 94 .5 94 .9 95 .7 94 .7 94 .4 96 .7 96 .9 92 .5 98 .8 95 .0 89 .8 93 .9 92 .5 93 .5 94 .2 96 .1 95 .9 96 .8 92 .8 96 .6 Un de r-5 s o ve ra ll re sp on se ra te 93 .0 92 .8 91 .9 93 .2 93 .1 96 .5 96 .4 91 .9 97 .9 92 .2 88 .5 92 .4 92 .1 92 .9 93 .0 95 .8 94 .3 94 .8 90 .2 92 .0 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 7 Ta bl e HH .1 : R es ul ts o f h ou se ho ld , w om en ’s a nd u nd er -5 in te rv ie ws Nu m be r o f h ou se ho lds , w om en a nd ch ild re n un de r f ive b y i nt er vie w re su lts , a nd h ou se ho ld, w om en ’s an d un de r-5 s’ re sp on se ra te s, Ne pa l, 2 01 4 To ta l Ar ea Re gio n Ur ba n Ru ra l Ea ste rn M ou n- ta ins Ea ste rn Hi lls Ea ste rn Te ra i Ce nt ra l M ou n- ta ins Ce nt ra l Hi lls Ce nt ra l Te ra i W es te rn M ou n- ta ins W es te rn Hi lls W es te rn Te ra i M id- W es te rn M ou n- ta ins M id- W es te rn Hi lls M id- W es te rn Te ra i Fa r W es te rn M ou n- ta ins Fa r W es te rn Hi lls Fa r W es te rn Te ra i To ta l Ur ba n Ka th - m an du va lle y Ot he r ur ba n Ho us eh ol ds Sa m ple d 13 ,0 00 3, 15 0 80 0 2, 35 0 9, 85 0 80 0 80 0 1, 00 0 80 0 1, 60 0 1, 00 0 40 0 1, 00 0 80 0 80 0 80 0 80 0 80 0 80 0 80 0 Oc cu pie d 12 ,5 98 3, 05 8 76 9 2, 28 9 9, 54 0 77 8 78 1 98 1 77 8 1, 54 8 97 1 38 0 97 7 78 7 75 2 78 0 77 2 77 5 75 7 78 1 In te rv iew ed 12 ,4 05 2, 99 2 73 9 2, 25 3 9, 41 3 77 6 77 7 97 4 77 1 1, 50 3 95 6 37 4 97 3 78 2 74 3 77 8 75 9 75 9 73 6 74 4 Ho us eh old re sp on se ra te 98 .5 97 .8 96 .1 98 .4 98 .7 99 .7 99 .5 99 .3 99 .1 97 .1 98 .5 98 .4 99 .6 99 .4 98 .8 99 .7 98 .3 97 .9 97 .2 95 .3 W om en El igi ble 14 ,9 36 3, 66 8 88 8 2, 78 0 11 ,2 68 85 7 87 7 1, 16 0 74 8 1, 73 9 1, 22 0 29 6 1, 08 1 1, 10 8 85 3 92 5 99 8 98 7 98 0 1, 10 7 In te rv iew ed 14 ,1 62 3, 47 9 84 3 2, 63 6 10 ,6 83 84 0 85 5 1, 09 7 72 0 1, 65 5 1, 11 8 25 8 1, 00 0 1, 04 9 81 7 88 3 94 9 96 5 92 7 1, 02 9 W om en ’s re sp on se ra te 94 .8 94 .8 94 .9 94 .8 94 .8 98 .0 97 .5 94 .6 96 .3 95 .2 91 .6 87 .2 92 .5 94 .7 95 .8 95 .5 95 .1 97 .8 94 .6 93 .0 W om en ’s ov er all re sp on se ra te 93 .4 92 .8 91 .2 93 .3 93 .5 97 .8 97 .0 93 .9 95 .4 92 .4 90 .2 85 .8 92 .1 94 .1 94 .6 95 .2 93 .5 95 .8 92 .0 88 .6 Ch ild re n un de r f iv e El igi ble 5, 66 3 95 6 18 4 77 2 4, 70 7 33 6 29 3 41 5 24 1 44 0 56 1 82 38 7 41 6 54 9 43 1 31 6 43 4 46 9 29 3 M ot he rs / ca re ta ke rs int er vie we d 5, 34 9 90 7 17 6 73 1 4, 44 2 32 5 28 4 38 4 23 8 41 8 50 4 77 35 8 38 9 51 7 41 4 30 3 42 0 43 5 28 3 Un de r-5 s re sp on se ra te 94 .5 94 .9 95 .7 94 .7 94 .4 96 .7 96 .9 92 .5 98 .8 95 .0 89 .8 93 .9 92 .5 93 .5 94 .2 96 .1 95 .9 96 .8 92 .8 96 .6 Un de r-5 s o ve ra ll re sp on se ra te 93 .0 92 .8 91 .9 93 .2 93 .1 96 .5 96 .4 91 .9 97 .9 92 .2 88 .5 92 .4 92 .1 92 .9 93 .0 95 .8 94 .3 94 .8 90 .2 92 .0 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 20148 Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. This distribution is also used to produce the population pyramid in Figure HH.1. In the 12,405 households successfully interviewed for the survey, 56,539 household members were listed. Of these, 26,983 were males and 29,556 were females. Table HH.2 shows the age–sex structure of the household population. The proportions of child, working and old-age age groups (0–14 years, 15–64 years, and 65 years and over) in the household population of the sample were 34.0 percent, 60.1 percent and 5.9 percent, respectively. In the Nepal National Population and Housing Census 2011, these figures were 34.9 percent, 59.8 percent and 5.3 percent, respectively. More significantly, the proportion of children aged 0–4 years was 10.1 percent in this survey compared to 9.7 percent in the 2011 census. The surveyed population indicated a sex ratio of 90.0, lower than the 94.2 indicated in the 2011 census. However, the dependency ratio was 66.5 percent, consistent with the 67.1 percent found in the 2011 census. Similarly, the proportion of children aged 0–17 years was 40.2 percent in this survey, close to the 41.8 percent in the 2011 census. Complete reporting of birth year and month was 93.1 percent among the surveyed population, while 4.9 percent were able to report year only. Among women aged 15–49 years, it was 96.8 percent, and for children, it was 100 percent. Table HH.2: Household age distribution by sex Percentage and frequency distribution of household population by five-year age groups, dependency age groups, and by child (aged 0–17 years) and adult populations (aged 18 or more), by sex, Nepal, 2014 Total Males Females Number Percent Number Percent Number Percent Total 56,824 100.0 26,917 100.0 29,907 100.0 Age (years) 0–4 5,715 10.1 2,951 11.0 2,764 9.2 5–9 6,332 11.1 3,176 11.8 3,157 10.6 10–14 7,293 12.8 3,553 13.2 3,740 12.5 15–19 5,836 10.3 2,866 10.6 2,970 9.9 20–24 4,551 8.0 1,946 7.2 2,604 8.7 25–29 4,288 7.5 1,718 6.4 2,570 8.6 30–34 3,695 6.5 1,597 5.9 2,098 7.0 35–39 3,498 6.2 1,532 5.7 1,966 6.6 40–44 3,085 5.4 1,434 5.3 1,651 5.5 45–49 2,499 4.4 1,308 4.9 1,191 4.0 50–54 2,775 4.9 1,159 4.3 1,616 5.4 55–59 2,034 3.6 1,035 3.8 999 3.3 60–64 1,870 3.3 940 3.5 930 3.1 65–69 1,406 2.5 702 2.6 704 2.4 70–74 917 1.6 465 1.7 451 1.5 75–79 457 0.8 246 0.9 211 0.7 80–84 366 0.6 197 0.7 169 0.6 85+ 205 0.4 89 0.3 115 0.4 DK/ Missing 3 0.0 1 0.0 2 0.0 Dependency age groups 0–14 19,341 34.0 9,680 36.0 9,660 32.3 15–64 34,131 60.1 15,536 57.7 18,595 62.2 65+ 3,349 5.9 1,699 6.3 1,650 5.5 DK/ Missing 3 0.0 1 0.0 2 0.0 Child and adult populations Children aged 0–17 years 22,862 40.2 11,462 42.6 11,400 38.1 Adults aged 18+ years 33,958 59.8 15,454 57.4 18,505 61.9 DK/ Missing 3 0.0 1 0.0 2 0.0 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 9 Figure HH.1 shows age and sex distribution of the household population. Figure HH.1: Age and sex distribution of household population, Nepal, 2014 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents aged 15–49 years, and children under five. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provides background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.1 Table HH.3 provides basic background information on the households, including the sex of the household head, region, area, number of household members, and education of household head. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. 1See Appendix A: Sample Design, for more details on sample weights. Note: Four household members with missing age and/or sex are excluded Percent NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201410 The weighted and unweighted total numbers of households are equal, since sample weights were normalized. The table also shows the weighted mean household size estimated by the survey. The weighted and unweighted numbers indicate over-sampling in all five Mountain regions, the Far Western Hills and the Terai. Under-sampling was found in the Eastern Terai, Central Hills, Central Terai and Western Hills. Overall, the urban areas, except Kathmandu valley, are over-sampled and the rural areas are under-sampled. More than two-thirds (71 percent) of surveyed households were headed by a male; this was a decrease from the 74 percent found in the 2011 census. Only one in five households (20 percent) was located in urban areas, with 6 percent in Kathmandu valley and 14 percent in other urban areas. Around half (50 percent) of households had 2–4 members, and 46 percent had five or more members. However, a few (5 percent) had a single member. The average household size was 4.6 members, a reduction from the 4.9 found in the 2011 census. Some 42 percent of households were headed by a person with no education. The remaining households were headed by a person with primary education (20 percent), secondary education (20 percent) and higher education (19 percent). Table HH.3: Household composition Percentage and frequency distribution of households by selected characteristics, Nepal, 2014 Weighted percent Number of households Weighted Unweighted Total 100.0 12,405 12,405 Sex of household head Male 70.6 8,762 8,943 Female 29.4 3,643 3,462 Region Eastern Mountains 1.4 179 776 Eastern Hills 6.2 767 777 Eastern Terai 14.9 1,845 974 Central Mountains 2.4 299 771 Central Hills 17.6 2,182 1,503 Central Terai 15.5 1,924 956 Western Mountains 0.1 10 374 Western Hills 13.1 1,628 973 Western Terai 7.5 924 782 Mid-Western Mountains 1.3 156 743 Mid-Western Hills 6.2 763 778 Mid-Western Terai 5.4 672 759 Far Western Mountains 1.5 185 759 Far Western Hills 2.8 346 736 Far Western Terai 4.2 524 744 Area Urban 20.0 2,476 2,992 Kathmandu valley 6.3 782 739 Other urban 13.7 1,694 2,253 Rural 80.0 9,929 9,413 Number of household members 1 4.6 575 651 2 12.2 1,518 1,533 3 16.6 2,058 2,002 4 20.9 2,598 2,493 5 17.7 2,192 2,228 6 12.4 1,538 1,528 7+ 15.5 1,924 1,970 Education of household head None 41.9 5,202 5,267 Primary 19.5 2,419 2,441 Secondary 19.7 2,446 2,422 Higher 18.7 2,314 2,249 DK/ Missing 0.2 24 26 Mean household size (persons) 4.6 12,405 12,405 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 11 Characteristics of Female Respondents 15–49 Years of Age and Children Under Five Tables HH.4 and HH.5 provide information on the background characteristics of female respondents aged 15–49 years and children under five. In both tables, the total number of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). The tables also show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4: Women’s background characteristics Percentage and frequency distribution of women aged 15–49 years by selected characteristics, Nepal, 2014 Weighted percent Number of women Weighted Unweighted Total 100.0 14,162 14,162 Region Eastern Mountains 1.3 186 840 Eastern Hill 5.7 807 855 Eastern Terai 14.6 2,071 1,097 Central Mountains 1.9 274 720 Central Hills 16.4 2,320 1,655 Central Terai 16.4 2,327 1,118 Western Mountains 0.1 8 258 Western Hills 11.7 1,659 1,000 Western Terai 8.7 1,236 1,049 Mid-Western Mountains 1.2 169 817 Mid-Western Hills 6.0 856 883 Mid-Western Terai 6.0 855 949 Far Western Mountains 1.6 225 965 Far Western Hills 3.1 433 927 Far Western Terai 5.2 735 1,029 Area Urban 19.7 2,792 3,479 Kathmandu valley 6.1 868 843 Other urban 13.6 1,924 2,636 Rural 80.3 11,370 10,683 Age (years) 15–19 19.2 2,721 2,781 20–24 17.0 2,402 2,475 25–29 17.0 2,414 2,322 30–34 14.1 2,003 1,922 35–39 13.4 1,901 1,871 40–44 11.2 1,582 1,598 45–49 8.0 1,139 1,193 Marital/union status Currently married/in union 76.5 10,830 10,688 Widowed 1.8 248 271 Divorced 0.1 19 15 Separated 0.2 28 36 Never married/in union 21.4 3,037 3,152 Motherhood and recent births Never gave birth 28.9 4,086 4,209 Ever gave birth 71.1 10,076 9,953 Gave birth in last two years 14.5 2,048 2,086 No birth in last two years 56.8 8,038 7,876 Education None 37.4 5,294 5,510 Primary 14.2 2,004 1,969 Secondary 27.0 3,830 3,779 Higher 21.4 3,032 2,903 DK/ Missing 0.0 1 1 Wealth index quintile Poorest 17.3 2,453 4,000 Second 19.2 2,720 2,873 Middle 19.4 2,752 2,141 Fourth 21.3 3,020 2,402 Richest 22.7 3,218 2,746 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201412 Table HH.4 provides background characteristics of female respondents aged 15–49 years. The table includes information on the distribution of women according to region, area, age, marital/union status, motherhood status, births in last two years, education2 and wealth index quintiles3,4. Like the household sample, there was over-sampling of female respondents in all Mountain and Far Western regions, and the Western Mountains had it to an extreme degree. On the other hand, there was under-sampling in the Eastern Terai, Central Hills, Central Terai and Western Hills. Women living in households in the poorest quintile were highly over-sampled while those living in households in the fourth and the richest quintiles were under-sampled. Women with no education were also over-sampled. Overall, 80 percent of female respondents were from rural areas compared to 20 percent from urban areas (6 percent in Kathmandu valley and 14 percent in other urban areas). The proportion of female respondents in the youngest age group (15–19 years) was 19 percent and it gradually decreased to 8 percent in the oldest age group (45–49 years). A large proportion of surveyed women (77 percent) were married or in a marital union, and slightly over one-fifth (21 percent) had never been married. Over two-thirds of women (71 percent) had given birth at least once in their lifetime, and 15 percent had given birth in the two years preceding the survey. Over one-third of female respondents (37 percent) had never been to school, while 14 percent had completed primary education, 27 percent had completed secondary education and 21 percent had completed higher education. The distribution of women by wealth index quintile shows the smallest proportion in households in the poorest quintile (17 percent) increasing gradually to the largest proportion in households in the richest quintile (23 percent). Background characteristics of children under five are presented in Table HH.5. These include the distribution of children by sex, region and area, age in months, respondent type, mother’s (or caretaker’s) education, and wealth. The proportion of boys (52 percent) was slightly higher than that of girls (48 percent). In total, 87 percent of children under five lived in rural areas and 13 percent lived in urban areas, of which 3 percent lived in Kathmandu valley. However, urban areas were over-sampled, except for Kathmandu valley. 2Throughout this report, unless otherwise stated, ‘education’ refers to highest educational level ever attended by the respondent when it is used as a back- ground variable. 3The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into five equal parts (quintiles) from lowest (poorest) to highest (richest). In the Nepal MICS, the following assets were used in these calculations: radio, television, non-mobile telephone, refrigerator, table and chair set, sofa, fan, desktop computer, improved cooking stove, wardrobe, wall clock, microwave oven, dhiki/janto, washing machine, car or truck, boat, mobile telephone, bicycle/rickshaw, motorbike/scooter, animal-drawn cart, laptop computer, ownership of dwelling, agricultural land, bank account and animals/livestock. The wealth index is assumed to capture the underlying long-term wealth through information on the household‘s assets, and is intended to produce a ranking of households by wealth from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular dataset they are based on. Further information on the construction of the wealth index can be found in: Filmer, D. and Pritchett, L., 2001. Estimating wealth effects without expendi- ture data - or tears: An application to educational enrolments in states of India. Demography 38(1): 115–132; Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Report No. 6. Calverton, Maryland: ORC Macro; and Rutstein, S.O., 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Paper No. 60. Calverton, Maryland: Macro International Inc. 4When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as ‘women in the richest household population’, which is used interchangeably with ‘women in the wealthiest survey population’ and similar. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 13 The proportion of children under five with an uneducated mother was 42 percent. In terms of wealth quintile, 15 percent of under-5s with an uneducated mother were living in households in the richest quintile, while between 20 percent and 22 percent were living in households in each of the other wealth quintiles. As evident from the unweighted numbers of children, over-sampling occurred in all Mountain regions, and the Far Western Hills and Far Western Terai. Under-sampling occurred in the Eastern Terai, Central Hills, Central Terai and Western Hills. Table HH.5: Under-5s background characteristics Percentage and frequency distribution of children under five by selected characteristics, Nepal, 2014 Weighted percent Number of children under five Weighted Unweighted Total 100.0 5,349 5,349 Sex Male 51.7 2,766 2,801 Female 48.3 2,583 2,548 Region Eastern Mountains 1.4 72 325 Eastern Hills 5.1 272 284 Eastern Terai 14.5 775 384 Central Mountains 1.8 95 238 Central Hills 11.6 620 418 Central Terai 21.1 1,131 504 Western Mountains 0.0 2 77 Western Hills 11.2 601 358 Western Terai 8.8 469 389 Mid-Western Mountains 2.0 108 517 Mid-Western Hills 7.6 409 414 Mid-Western Terai 5.4 291 303 Far Western Mountains 1.9 100 420 Far Western Hills 3.9 210 435 Far Western Terai 3.7 197 283 Area Urban 13.1 699 907 Kathmandu valley 3.4 181 176 Other urban 9.7 518 731 Rural 86.9 4,650 4,442 Age 0–5 months 8.5 455 452 6–11 months 9.8 523 527 12–23 months 18.8 1,008 1,029 24–35 months 20.2 1,079 1,062 36–47 months 21.3 1,137 1,123 48–59 months 21.5 1,147 1,156 Respondent to under-5 questionnaire Mother 98.7 5,279 5,271 Other primary caretaker 1.3 70 78 Mother’s education [a] None 42.3 2,265 2,396 Primary 17.2 921 908 Secondary 22.0 1,179 1,113 Higher 18.3 980 927 DK/ Missing 0.1 4 5 Wealth index quintile Poorest 22.1 1,183 1,994 Second 20.3 1,085 1,079 Middle 22.0 1,176 808 Fourth 20.3 1,086 809 Richest 15.3 819 659 [a] In this table and throughout the report, mother’s education refers to educational attainment of mothers as well as caretakers of children under five, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201414 Housing Characteristics, Asset Ownership, and Wealth Quintiles Tables HH.6, HH.7 and HH.8 provide further details on household characteristics. Table HH.6 presents characteristics of housing, disaggregated by area and region, distributed by whether the dwelling has electricity, the main materials of the flooring, roof and exterior walls, as well as the number of rooms used for sleeping. Some 85 percent of households had electricity (98 percent of urban households compared to 82 percent of rural households). Over 90 percent of households in the Central Hills, Central Mountains and Eastern Terai had access to electricity, while only 51 percent of households in the Mid-Western Hills and 69 percent in the Mid-Western Mountains had it. Some 64 percent of households had natural flooring; this was more common in rural areas (76 percent) than urban areas (17 percent). Finished flooring was found in 83 percent of urban households. The proportion of households with natural flooring was highest in the Far Western Hills (99 percent) and lowest in the Central Hills (34 percent). Most households had finished roofs (85 percent) with the highest proportion in the Central Hills (97 percent) and the lowest in the Mid-Western Mountains (24 percent). Exterior walls were rudimentary in 49 percent of households and finished in 41 percent. Rudimentary walls were most common in rural areas (58 percent) and finished walls were most common in urban areas (86 percent). Some 39 percent of households had two rooms for sleeping, while 31 percent had one and 29 percent had three or more. The average number of persons using each sleeping room was 2.4; it was higher in rural areas (2.5 persons) than urban areas (2.2 persons). The mean number ranged from 1.8 persons in the Western Mountains to 2.8 persons in the Far Western Hills. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 15 Ta bl e HH .6 : H ou si ng c ha ra ct er is tic s Pe rc en ta ge o f h ou se ho lds b y s ele cte d ho us ing ch ar ac te ris tic s, ac co rd ing to a re a of re sid en ce a nd re gio ns , N ep al, 2 01 4 To ta l Ar ea Re gio n Ur ba n Ka th - m an du va lle y Ot he r ur ba n Ru ra l Ea ste rn M ou n- ta ins Ea ste rn Hi lls Ea ste rn Te ra i Ce nt ra l M ou n- ta ins Ce nt ra l Hi lls Ce nt ra l Te ra i W es te rn M ou n- ta ins W es te rn Hi lls W es te rn Te ra i M id- W es te rn M ou n- ta ins M id- W es te rn Hi lls M id- W es te rn Te ra i Fa r W es te rn M ou n- ta ins Fa r W es te rn Hi lls Fa r W es te rn Te ra i El ec tri ci ty Ye s 84 .9 97 .7 99 .7 96 .8 81 .7 77 .7 83 .1 93 .0 92 .5 94 .4 81 .8 86 .5 88 .2 86 .8 69 .3 50 .9 79 .4 75 .6 70 .1 89 .8 No 15 .1 2. 3 0. 3 3. 2 18 .2 22 .3 16 .9 6. 9 7. 5 5. 6 18 .2 13 .5 11 .8 13 .2 30 .7 49 .1 20 .6 24 .4 29 .9 10 .2 M iss ing 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 Fl oo rin g Na tu ra l fl oo r 64 .1 17 .0 3. 1 23 .4 75 .8 85 .5 82 .4 61 .6 87 .9 33 .6 65 .0 37 .0 65 .8 49 .2 96 .8 92 .2 76 .2 95 .9 98 .7 69 .7 Ru dim en ta ry flo or 0. 8 0. 3 0. 5 0. 2 0. 9 8. 5 3. 0 1. 2 1. 0 0. 6 0. 5 52 .5 0. 2 0. 0 1. 7 0. 1 0. 0 0. 5 0. 0 0. 0 Fi nis he d flo or 34 .9 82 .5 95 .9 76 .4 23 .0 5. 1 14 .5 37 .1 9. 1 65 .5 34 .6 9. 8 33 .9 50 .8 1. 4 6. 5 23 .8 3. 3 1. 1 30 .3 Ot he r 0. 2 0. 2 0. 5 0. 1 0. 2 0. 4 0. 0 0. 1 1. 9 0. 3 0. 0 0. 4 0. 2 0. 0 0. 0 1. 2 0. 0 0. 3 0. 0 0. 0 DK / M iss ing 0. 0 0. 0 0. 0 0. 0 0. 0 0. 4 0. 2 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 Ro of Na tu ra l r oo fin g 13 .4 1. 9 0. 0 2. 7 16 .3 42 .8 33 .0 15 .1 2. 0 1. 5 9. 0 57 .8 9. 2 8. 2 64 .2 39 .4 21 .5 5. 8 8. 7 5. 5 Ru dim en ta ry ro of ing 0. 8 0. 2 0. 1 0. 3 0. 9 7. 4 0. 3 0. 1 2. 4 1. 3 1. 4 3. 1 0. 2 0. 1 5. 4 0. 1 0. 0 0. 1 0. 0 0. 4 Fi nis he d ro of ing 85 .3 97 .8 99 .9 96 .8 82 .2 46 .8 66 .5 84 .7 95 .5 97 .0 88 .8 25 .3 90 .7 91 .5 24 .2 59 .8 78 .4 90 .8 90 .9 93 .9 Ot he r 0. 5 0. 1 0. 0 0. 2 0. 5 3. 0 0. 1 0. 1 0. 1 0. 2 0. 8 13 .7 0. 0 0. 3 6. 2 0. 7 0. 2 3. 2 0. 5 0. 2 M iss ing /D K 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. 0 0. 0 0. 0 0. 0 0. 0 0. 0 Ex te rio r w al ls Na tu ra l w all s 8. 8 2. 7 0. 5 3. 7 10 .4 5. 1 4. 6 7. 2 4. 9 5. 2 3. 5 6. 8 21 .1 9. 0 4. 4 10 .1 25 .7 3. 1 1. 5 5. 9 Ru dim en ta ry w all s 48 .9 11 .3 1. 5 15 .8 58 .3 83 .0 73 .8 50 .9 85 .8 24 .6 53 .5 71 .1 42 .4 17 .5 94 .6 81 .3 28 .8 88 .0 96 .8 52 .7 Fi nis he d wa lls 41 .2 85 .5 97 .8 79 .8 30 .2 8. 5 17 .4 39 .6 8. 6 69 .8 43 .1 22 .1 36 .4 73 .5 0. 9 8. 4 43 .4 8. 6 1. 8 39 .6 Ot he r 0. 9 0. 5 0. 2 0. 7 1. 0 3. 5 4. 1 2. 2 0. 6 0. 4 0. 0 0. 0 0. 1 0. 0 0. 0 0. 2 2. 2 0. 3 0. 0 1. 7 DK / M iss ing 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 Ro om s us ed fo r s le ep in g 1 31 .4 38 .0 38 .5 37 .8 29 .7 47 .1 37 .9 32 .0 36 .1 33 .1 26 .5 43 .5 37 .4 22 .6 31 .0 35 .9 28 .3 19 .1 25 .7 24 .1 2 38 .7 32 .5 31 .2 33 .1 40 .2 35 .5 37 .0 41 .8 38 .8 34 .5 37 .3 31 .0 38 .8 36 .8 39 .5 40 .8 43 .9 42 .1 44 .9 41 .3 3 or m or e 29 .2 28 .5 28 .1 28 .6 29 .4 17 .1 24 .9 25 .6 25 .1 30 .4 35 .9 25 .4 23 .9 39 .7 29 .5 23 .3 27 .3 37 .5 29 .1 32 .4 DK / M iss ing 0. 7 1. 0 2. 2 0. 5 0. 7 0. 4 0. 3 0. 6 0. 0 2. 1 0. 2 0. 0 0. 0 0. 9 0. 0 0. 0 0. 5 1. 3 0. 3 2. 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 10 0. 0 10 0. 0 10 0. 0 10 0. 0 Nu m be r o f ho us eh ol ds 12 ,4 05 2, 47 6 78 2 1, 69 4 9, 92 9 17 9 76 7 1, 84 5 29 9 2, 18 2 1, 92 4 10 1, 62 8 92 4 15 6 76 3 67 2 18 5 34 6 52 4 M ea n nu m be r o f pe rs on s pe r r oo m us ed fo r s le ep in g 2. 4 2. 2 2. 1 2. 2 2. 5 2. 8 2. 3 2. 4 2. 1 2. 1 2. 5 1. 8 2. 2 2. 4 2. 8 2. 7 2. 6 2. 6 2. 8 2. 5 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201416 Table HH.7 shows distribution of households by ownership of assets and ownership of dwelling. Some 40 percent of households owned a radio and 52 percent owned a television. No urban–rural difference was observed in possession of a radio, while 80 percent of urban households owned a television compared to 44 percent of rural households. Ownership of a television was highest in the Central Hills (72 percent) and lowest in the Far Western Hills (7 percent). Some 14 percent of households possessed a refrigerator; this was five times more likely in urban areas (38 percent) than in rural areas (8 percent). The majority of households owned agricultural land (76 percent) and farm animals/livestock (69 percent). More households in rural areas owned these assets (83 percent and 80 percent, respectively) than in urban areas (48 percent and 25 percent, respectively). The highest proportion of households with agricultural land was in the Far Western Mountains (97 percent) and the lowest proportion was in the Central Terai (64 percent). In 91 percent of households at least one person owned a mobile phone (97 percent in urban areas and 90 percent in rural areas). The highest proportion was in the Central and Western Hills (94 percent) and the lowest proportion was in the Mid-Western Mountains (70 percent). In 57 percent of households at least one person had a bank account (79 percent in urban areas and 52 percent in rural areas). It was highest in the Central Hills (71 percent) and lowest in the Mid-Western Mountains (19 percent). Most households (87 percent) owned their dwelling. It was more common in rural areas (93 percent) than urban areas (59 percent), where 39 percent of households rented their accommodation. Ownership of the dwelling was the highest in Far Western Hills and Mountains (99 percent) and lowest in the Central Hills (66 percent). NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 17 Ta bl e HH .7 : H ou se ho ld a ss et s Pe rc en ta ge o f h ou se ho lds b y o wn er sh ip of a ss et s a nd o wn er sh ip of d we llin g, N ep al, 2 01 4 To ta l Ar ea Re gio n Ur ba n Ka th - m an du va lle y Ot he r ur ba n Ru ra l Ea ste rn M ou n- ta ins Ea ste rn Hi lls Ea ste rn Te ra i Ce nt ra l M ou n- ta ins Ce nt ra l Hi lls Ce nt ra l Te ra i W es te rn M ou n- ta ins W es te rn Hi lls W es te rn Te ra i M id- W es te rn M ou n- ta ins M id- W es te rn Hi lls M id- W es te rn Te ra i Fa r W es te rn M ou n- ta ins Fa r W es te rn Hi lls Fa r W es te rn Te ra i Ho us eh ol ds th at o wn a Ra dio 40 .4 41 .9 42 .0 41 .8 40 .0 54 .1 51 .4 31 .9 50 .9 42 .0 37 .5 38 .6 52 .5 29 .3 30 .6 37 .6 34 .9 60 .6 42 .1 34 .7 Te lev isi on 51 .5 80 .2 88 .7 76 .3 44 .3 22 .1 33 .6 63 .6 39 .7 72 .4 55 .9 51 .4 55 .8 57 .7 11 .2 15 .0 42 .2 8. 5 6. 7 46 .0 No n- m ob ile p ho ne 9. 0 25 .8 37 .9 20 .2 4. 8 4. 5 4. 8 8. 7 2. 8 24 .1 4. 9 13 .2 7. 1 7. 1 3. 4 1. 5 3. 9 5. 6 1. 8 6. 7 Re fri ge ra to r 13 .6 38 .3 47 .3 34 .2 7. 5 2. 2 1. 9 14 .4 2. 7 31 .0 10 .4 9. 4 13 .5 19 .2 1. 0 1. 8 8. 8 0. 0 0. 1 9. 9 Im pr ov ed st ov e 9. 0 2. 3 1. 9 2. 5 10 .7 8. 3 19 .7 6. 3 8. 9 5. 0 1. 6 75 .1 22 .1 1. 9 50 .2 17 .0 5. 8 3. 0 3. 8 3. 4 Ta ble 57 .7 83 .5 85 .8 82 .4 51 .3 42 .4 60 .5 75 .2 25 .6 69 .0 65 .8 65 .8 51 .9 55 .3 14 .5 24 .4 56 .7 21 .3 12 .6 67 .3 Ch air 57 .4 77 .0 77 .0 77 .0 52 .5 29 .6 46 .9 73 .9 35 .3 63 .7 76 .4 55 .7 46 .3 60 .0 17 .0 25 .8 53 .0 32 .6 21 .8 67 .2 Be d/ co t 92 .4 98 .4 99 .4 97 .9 90 .9 85 .2 94 .5 95 .7 95 .4 97 .4 95 .0 81 .8 93 .0 99 .2 69 .7 74 .5 92 .8 77 .0 54 .0 96 .7 So fa 15 .9 40 .2 55 .8 33 .0 9. 9 1. 9 4. 3 17 .4 3. 9 37 .6 11 .0 6. 4 15 .4 17 .6 2. 6 3. 1 9. 4 0. 7 0. 9 12 .4 W ar dr ob e 45 .4 74 .4 86 .3 68 .9 38 .1 27 .6 34 .5 48 .0 45 .7 73 .5 40 .2 51 .6 48 .9 48 .8 20 .7 14 .3 36 .9 12 .5 3. 7 45 .2 Co m pu te r ( de sk to p) 8. 6 25 .2 42 .2 17 .3 4. 5 1. 3 2. 8 8. 0 3. 3 24 .9 4. 0 5. 9 5. 6 8. 5 1. 3 2. 1 4. 9 1. 2 0. 6 8. 3 W all cl oc k 45 .7 71 .9 82 .1 67 .2 39 .1 33 .9 41 .0 53 .9 25 .9 64 .2 40 .3 42 .5 44 .2 48 .5 8. 5 15 .6 48 .3 43 .5 18 .3 51 .3 El ec tri c f an 40 .6 69 .2 55 .3 75 .6 33 .5 2. 7 7. 2 65 .8 1. 8 39 .6 60 .7 0. 0 24 .1 70 .1 .5 8. 0 45 .2 0. 3 0. 7 61 .2 Dh iki / ja nt o 31 .6 11 .8 3. 5 15 .6 36 .6 67 .7 53 .3 25 .1 34 .0 12 .2 24 .9 9. 3 52 .4 23 .2 29 .9 51 .3 31 .7 49 .3 46 .0 21 .1 M icr ow av e ov en 1. 8 6. 5 16 .4 1. 9 0. 6 0. 1 0. 1 0. 5 0. 0 7. 9 0. 4 3. 2 1. 1 0. 6 0. 0 0. 1 0. 4 0. 0 0. 3 0. 7 W as hin g m ac hin e 1. 5 6. 0 13 .2 2. 7 0. 4 0. 1 0. 0 1. 1 0. 2 5. 9 0. 3 2. 1 0. 9 0. 8 0. 0 0. 1 0. 3 0. 0 0. 0 0. 8 Ho us eh ol ds th at o wn Ag ric ult ur al lan d 75 .5 47 .6 44 .5 49 .1 82 .5 92 .7 91 .9 65 .3 95 .7 67 .0 63 .7 71 .1 77 .9 77 .1 88 .5 94 .0 83 .3 96 .9 94 .7 78 .1 Fa rm a nim als / liv es to ck 68 .8 25 .1 7. 3 33 .4 79 .6 92 .2 88 .7 69 .6 87 .8 41 .3 61 .9 63 .3 72 .0 65 .3 84 .5 88 .0 78 .4 96 .5 94 .4 81 .7 Ho us eh ol ds w he re a t l ea st o ne m em be r o wn s or h as a W at ch 75 .0 86 .0 90 .9 83 .8 72 .2 77 .0 83 .4 72 .8 76 .1 85 .1 72 .0 83 .6 80 .7 68 .1 60 .5 67 .2 63 .6 75 .7 68 .4 66 .2 M ob ile p ho ne 91 .2 96 .8 98 .3 96 .1 89 .8 83 .3 92 .4 92 .3 86 .4 94 .0 91 .6 87 .9 94 .0 92 .4 70 .1 85 .3 90 .3 79 .2 83 .3 93 .2 Bi cy cle / r ick sh aw 38 .1 33 .8 15 .8 42 .2 39 .2 1. 4 9. 0 72 .2 0. 7 12 .5 70 .5 0. 5 5. 3 74 .5 0. 1 6. 0 68 .6 0. 0 0. 0 78 .0 M ot or cy cle / s co ot er 15 .6 34 .6 45 .6 29 .5 10 .8 1. 5 5. 1 17 .6 3. 6 31 .2 16 .7 12 .9 10 .4 20 .9 0. 6 2. 6 11 .7 0. 1 0. 3 16 .0 An im al- dr aw n ca rt 3. 0 1. 3 0. 2 1. 8 3. 4 0. 1 0. 4 4. 1 0. 0 0. 4 4. 7 0. 0 0. 0 5. 8 0. 0 0. 0 3. 6 0. 0 0. 0 21 .7 Ca r o r t ru ck 1. 9 5. 1 9. 9 2. 8 1. 2 0. 3 1. 1 0. 8 0. 3 6. 2 1. 0 2. 4 1. 7 1. 5 0. 4 0. 2 0. 8 0. 1 0. 0 2. 4 Bo at 0. 1 0. 1 0. 0 0. 2 0. 0 0. 1 0. 0 0. 1 0. 0 0. 1 0. 0 0. 0 0. 1 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 2 La pt op co m pu te r 8. 4 23 .9 38 .5 17 .2 4. 6 1. 8 3. 9 8. 2 2. 9 22 .3 5. 1 6. 5 8. 6 7. 3 1. 2 1. 3 4. 3 0. 2 0. 1 3. 2 Ba nk a cc ou nt 56 .9 78 .5 85 .5 75 .3 51 .5 33 .6 54 .6 67 .1 43 .5 71 .1 52 .8 53 .1 66 .8 54 .6 18 .5 33 .2 44 .6 29 .9 30 .6 56 .9 Ho us eh ol ds b y ow ne rs hi p of d we lli ng Ow ne d 86 .5 59 .4 43 .6 66 .7 93 .2 90 .6 92 .4 89 .4 95 .5 65 .9 91 .1 70 .0 83 .4 89 .5 94 .8 96 .4 94 .0 99 .1 98 .8 94 .5 No t o wn ed 13 .5 40 .6 56 .4 33 .3 6. 8 9. 3 7. 6 10 .3 4. 5 34 .1 8. 9 30 .0 16 .6 10 .5 5. 2 3. 6 6. 0 0. 9 1. 2 5. 5 Re nt ed 12 .1 38 .9 55 .4 31 .3 5. 4 6. 0 6. 6 8. 5 3. 7 32 .8 7. 8 17 .7 14 .2 9. 9 2. 8 2. 5 5. 1 0. 5 0. 4 4. 3 Ot he r 1. 4 1. 7 1. 0 2. 0 1. 3 3. 3 1. 0 1. 8 0. 8 1. 3 1. 1 12 .3 2. 4 0. 6 2. 5 1. 1 0. 9 0. 4 0. 8 1. 2 DK / M iss ing 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 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 10 0. 0 10 0. 0 10 0. 0 10 0. 0 Nu m be r o f ho us eh ol ds 12 ,4 05 2, 47 6 78 2 1, 69 4 9, 92 9 17 9 76 7 1, 84 5 29 9 2, 18 2 1, 92 4 10 1, 62 8 92 4 15 6 76 3 67 2 18 5 34 6 52 4 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201418 Table HH.8 shows the distribution of household members by wealth index quintiles, according to area of residence and regions. The proportions of households were evenly distributed between wealth index quintiles (20 percent in each quintile). Most urban households (67 percent) were in the richest quintile, with 89 percent of Kathmandu valley households and 57 percent of other urban households falling into this category. Urban households were 6.5 times more likely than rural households to be in the richest quintile. Some 23 percent of rural households were in the poorest quintile. Rural households were 5.8 times more likely than urban households to be in the poorest quintile. Table HH.8: Wealth quintiles Percentage of the household population by wealth index quintiles, according to area of residence and regions, Nepal, 2014 Wealth index quintile Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 56,824 Area Urban 4.0 5.1 5.6 18.4 66.8 100.0 9,753 Kathmandu valley 0.0 0.1 0.4 10.2 89.3 100.0 2,971 Other urban 5.8 7.4 7.8 22.0 57.0 100.0 6,782 Rural 23.3 23.1 23.0 20.3 10.3 100.0 47,071 Region Eastern Mountains 58.7 27.6 7.1 5.9 0.7 100.0 9,753 Eastern Hills 35.1 33.6 18.2 9.4 3.7 100.0 2,971 Eastern Terai 1.2 16.1 31.4 30.9 20.3 100.0 6,782 Central Mountains 31.4 48.5 11.1 5.2 3.8 100.0 47,071 Central Hills 9.3 13.5 7.2 18.6 51.4 100.0 8,746 Central Terai 1.4 19.7 35.1 26.5 17.3 100.0 10,248 Western Mountains 16.7 30.9 21.3 24.2 7.0 100.0 32 Western Hills 30.9 27.2 10.8 9.9 21.2 100.0 6,371 Western Terai 5.5 14.3 22.4 34.0 23.8 100.0 4,825 Mid-Western Mountains 79.5 15.3 3.8 1.4 0.0 100.0 798 Mid-Western Hills 74.3 14.3 5.4 3.7 2.3 100.0 3,591 Mid-Western Terai 8.7 29.2 28.4 22.8 10.9 100.0 3,276 Far Western Mountains 71.8 20.6 5.9 1.6 0.1 100.0 1,014 Far Western Hills 85.3 12.0 1.8 0.9 0.0 100.0 1,880 Far Western Terai 8.5 20.2 28.0 31.3 11.9 100.0 2,697 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 19 Child Mortality C H A P T E R4 One of the overarching goals of the MDGs is to reduce infant and under-5 mortality. Specifically, the MDGs call for the reduction of under-5 mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Mortality rates presented in this chapter are calculated from information collected in the birth histories of the Questionnaire for Individual Women. All interviewed women were asked whether they had ever given birth, and if yes, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of live births of children in chronological order starting with the firstborn. Women were asked whether births were single or multiple, the sex of the children, the date of birth (month and year), and survival status. Further, for children still alive, they were asked the current age of the child and, if not alive, the age at death. Childhood mortality rates are expressed by conventional age categories and are defined as follows: • Neonatal mortality (NN): probability of dying within the first month of life • Post-neonatal mortality (PNN): difference between infant and neonatal mortality rates • Infant mortality (1q0): probability of dying between birth and the first birthday • Child mortality (4q1): probability of dying between the first and fifth birthdays • Under-5 mortality (5q0): the probability of dying between birth and the fifth birthday Rates are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age 1, and post-neonatal mortality, which is the difference between infant and neonatal mortality rates. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201420 The table and figure also show a declining trend at the national level over the last 15 years, with under-5 mortality at 56 deaths per 1,000 live births during the 10–14 year period preceding the survey, and 38 deaths per 1,000 live births during the most recent five-year period, roughly referring to the years 2009–2014. A similar pattern is observed in all other indicators. Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, infant, child and under-5 mortality rates for five-year periods preceding the survey, Nepal, 2014 Neonatal mortality rate [1] Post-neonatal mortality rate [2] [a] Infant mortality rate [3] Child mortality rate [4] Under-5 mortality rate [5] Years preceding the survey 0–4 23 11 33 5 38 5–9 29 15 44 6 51 10–14 27 17 44 13 56 [1] MICS indicator 1.1 – Neonatal mortality rate [2] MICS indicator 1.3 – Post-neonatal mortality rate [3] MICS indicator 1.2; MDG indicator 4.2 – Infant mortality rate [4] MICS indicator 1.4 – Child mortality rate [5] MICS indicator 1.5; MDG indicator 4.1 – Under-5 mortality rate [a] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Table CM.2: Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child and under-5 mortality rates for the five-year period preceding the survey, by socioeconomic characteristics, Nepal, 2014 Neonatal mortality rate [1] Post-neonatal mortality rate [2] [a] Infant mortality rate [3] Child mortality rate [4] Under-5 mortality rate [5] Total 23 11 33 5 38 Area Urban 15 6 21 5 26 Rural 24 11 35 5 40 Mother’s education None 26 15 41 7 48 Primary 26 8 33 5 38 Secondary 22 7 28 3 31 Higher 12 7 19 1 20 Wealth index quintile Poorest 32 16 48 10 57 Second 22 14 36 7 42 Middle 20 8 28 3 31 Fourth 21 7 29 2 31 Richest 14 5 20 2 22 [1] MICS indicator 1.1 – Neonatal mortality rate [2] MICS indicator 1.3 – Post-neonatal mortality rate [3] MICS indicator 1.2; MDG indicator 4.2 – Infant mortality rate [4] MICS indicator 1.4 – Child mortality rate [5] MICS indicator 1.5; MDG indicator 4.1 – Under-5 mortality rate [a] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Nepal&MICS&2014&& 2" Figure'CM.1:'Early'childhood'mortality'rates,'Nepal,'2014' " The"table"and"figure"also"show"a"declining"trend"at"the"national"level"over"the"last"15"years,"with" under:five"mortality"at"56"deaths"per"1,000"live"births"during"the"10–14:year"period"preceding"the" survey,"and"38"deaths"per"1,000"live"births"during"the"most"recent"five:year"period,"roughly"referring" to"the"years"2009–2014."A"similar"pattern"is"observed"in"all"other"indicators." Table"CM.2"provides"estimates"of"child"mortality"by"socioeconomic"characteristics."Mortality"rates" are"higher"among"rural"children"than"urban"children."Mother’s"education"level"and"household"wealth" status"are"both"negatively"associated"with"mortality"rates:"the"likelihood"of"dying"decreases"with"an" increase"in"each"of"these"two"variables."" 27 17 44 13 56 29 15 44 6 51 23 11 33 5 38 Neonatal mortality rate Post-neonatal mortality rate Infant mortality rate Child mortality rate Under-five mortality rate Years'preceding'the' survey 10:14 5:9 0:4 Early childhood mortality rates per 1,000 live births Table CM.1 and Figure CM.1 present neonatal, post-neonatal, infant, child, and under-5 mortality rates for the three most recent five-year periods before the survey. Neonatal mortality in the most recent five- year period was estimated at 23 deaths per 1,000 live births, while the post-neonatal mortality rate was estimated at 11 deaths per 1,000 live births. The infant mortality rate in the five years preceding the survey was 33 deaths per 1,000 live births and under-5 mortality was 38 deaths per 1,000 live births for the same period, indicating that 87 percent of under-5 deaths were infant deaths. Figure CM.1: Early childhood mortality rates, Nepal, 2014 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 21 Figure CM.2 provides under-5 mortality rates by area. Figure CM.2: Under-5 mortality rates by area, Nepal, 2014 Nepal MICS 2014 3 Table CM.2: Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child and under-five mortality rates for the five-year period preceding the survey, by socioeconomic characteristics, Nepal, 2014 Neonatal mortality rate [1] Post-neonatal mortality rate [2] [a] Infant mortality rate [3] Child mortality rate [4] Under-five mortality rate [5] Total 23 11 33 5 38 Area Urban 15 6 21 5 26 Rural 24 11 35 5 40 Mother’s education None 26 15 41 7 48 Primary 26 8 33 5 38 Secondary 22 7 28 3 31 Higher 12 7 19 1 20 Wealth index quintile Poorest 32 16 48 10 57 Second 22 14 36 7 42 Middle 20 8 28 3 31 Fourth 21 7 29 2 31 Richest 14 5 20 2 22 [1] MICS indicator 1.1 – Neonatal mortality rate [2] MICS indicator 1.3 – Post-neonatal mortality rate [3] MICS indicator 1.2; MDG indicator 4.2 – Infant mortality rate [4] MICS indicator 1.4 – Child mortality rate [5] MICS indicator 1.5; MDG indicator 4.1 – Under-five mortality rate [a] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Figure CM.2 provides under-five mortality rates by area. Figure CM.2: Under-five mortality rates by area, Nepal, 2014 38 26 40 0 10 20 30 40 50 Nepal Area Urban Rural Under-5 Mortality Rates per 1,000 Births Table CM.2 provides estimates of child mortality by socioeconomic characteristics. Mortality rates are higher among rural children than urban children. Mother’s education level and household wealth status are both negatively associated with mortality rates: the likelihood of dying decreases with an increase in each of these two variables. Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, infant, child and under-5 mortality rates for five-year periods preceding the survey, Nepal, 2014 Neonatal mortality rate [1] Post-neonatal mortality rate [2] [a] Infant mortality rate [3] Child mortality rate [4] Under-5 mortality rate [5] Years preceding the survey 0–4 23 11 33 5 38 5–9 29 15 44 6 51 10–14 27 17 44 13 56 [1] MICS indicator 1.1 – Neonatal mortality rate [2] MICS indicator 1.3 – Post-neonatal mortality rate [3] MICS indicator 1.2; MDG indicator 4.2 – Infant mortality rate [4] MICS indicator 1.4 – Child mortality rate [5] MICS indicator 1.5; MDG indicator 4.1 – Under-5 mortality rate [a] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Table CM.2: Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child and under-5 mortality rates for the five-year period preceding the survey, by socioeconomic characteristics, Nepal, 2014 Neonatal mortality rate [1] Post-neonatal mortality rate [2] [a] Infant mortality rate [3] Child mortality rate [4] Under-5 mortality rate [5] Total 23 11 33 5 38 Area Urban 15 6 21 5 26 Rural 24 11 35 5 40 Mother’s education None 26 15 41 7 48 Primary 26 8 33 5 38 Secondary 22 7 28 3 31 Higher 12 7 19 1 20 Wealth index quintile Poorest 32 16 48 10 57 Second 22 14 36 7 42 Middle 20 8 28 3 31 Fourth 21 7 29 2 31 Richest 14 5 20 2 22 [1] MICS indicator 1.1 – Neonatal mortality rate [2] MICS indicator 1.3 – Post-neonatal mortality rate [3] MICS indicator 1.2; MDG indicator 4.2 – Infant mortality rate [4] MICS indicator 1.4 – Child mortality rate [5] MICS indicator 1.5; MDG indicator 4.1 – Under-5 mortality rate [a] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201422 Table CM.3 provides estimates of child mortality by demographic characteristics. Younger and older mothers had an increased likelihood of her child dying compared to mothers aged 20–34 years. Firstborn children had an increased chance of dying, especially during the neonatal period, and children whose birth order was seven or greater were more likely than other children to die by the age of five years. A short birth interval also greatly increased mortality rates. Table CM.3: Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child and under-5 mortality rates for the five-year period preceding the survey, by demographic characteristics, Nepal, 2014 Neonatal mortality rate [1] Post-neonatal mortality rate [2] [a] Infant mortality rate [3] Child mortality rate [4] Under-5 mortality rate [5] Total 23 11 33 5 38 Sex of child Male 24 11 35 6 40 Female 21 10 32 4 36 Mother’s age at birth Less than 20 years 29 13 42 2 44 20–34 years 21 9 30 4 34 35–49 years 26 19 46 22 67 Birth order 1 27 10 37 3 40 2–3 21 8 28 2 31 4–6 19 13 31 11 42 7+ 20 66 86 41 124 Previous birth interval [b] < 2 years 45 24 69 8 77 2 years 18 8 25 5 30 3 years 11 11 22 10 32 4+ years 13 5 18 3 21 [1] MICS indicator 1.1 – Neonatal mortality rate [2] MICS indicator 1.3 – Post-neonatal mortality rate [3] MICS indicator 1.2; MDG indicator 4.2 – Infant mortality rate [4] MICS indicator 1.4 – Child mortality rate [5] MICS indicator 1.5; MDG indicator 4.1 – Under-5 mortality rate [a] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates [b] Excludes first-order births NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 23 Figure CM.3 compares the findings of the Nepal MICS 2014 on under-5 mortality rates with those from other data sources. The Nepal MICS findings are obtained from Table CM.1. The MICS estimates indicate a decline in mortality during the last 15 years. The most recent U5MR estimate (38 deaths per 1,000 live births) from the MICS is about 16 points lower than the estimate from the Nepal Demographic and Health Survey 20111. The mortality trend depicted by the Nepal Demographic and Health Survey 2011 is also a declining one; however, the MICS results are lower. Further qualification of these apparent declines and differences as well as its determinants should be taken up in a more detailed and separate analysis. 1Ministry of Health and Population, New ERA, and ICF International Inc., 2012. Nepal Demographic and Health Survey 2011. Kathmandu: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland. Figure CM.3: Trend in under-5 mortality rates, Nepal, 2014 Nepal&MICS&2014&& 5" " Figure'CM.3:'Trend'in'under0five'mortality'rates,'Nepal,'2014 ' " " 0 20 40 60 80 100 120 140 160 180 1986 1990 1994 1998 2002 2006 2010 2014 Per"1,000"live" births Year NDHS"2011 NDHS"2006 NDHS"2001 MICS"2014 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201424 Nutrition C H A P T E R5 Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have the most impact: the mother’s poor nutritional status before conception, short stature (due mostly to undernutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.1 1For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E., 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2): 209–16. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 25 Ne pa l&M IC S&2 01 4& 2" " Ta bl e NU .1 : L ow b irt h we ig ht in fa nt s Pe rc en ta ge o f la st liv e- bo rn ch ild re n bo rn in th e tw o ye ar s p re ce din g th e su rv ey th at a re e sti m at ed to h av e we igh ed b elo w 2, 50 0 gr am s a t b irt h an d pe rc en ta ge o f li ve b irt hs w eig he d at b irt h, N ep al, 20 14 Pe rc en t o f b irt hs b y m ot he r’s a ss es sm en t o f s ize a t b irt h: To ta l Pe rc en t o f li ve b irt hs : Nu m be r o f la st liv e- bo rn ch ild re n in th e las t t wo ye ar s Ve ry sm all Sm all er th an av er ag e Av er ag e La rg er th an av er ag e or ve ry lar ge DK Be low 2 ,5 00 gr am s [ 1] W eig he d at bir th [2 ] To ta l 0. 9 12 .9 61 .4 23 .0 1. 8 10 0. 0 24 .2 60 .0 2, 04 8 Re gi on Ea ste rn M ou nt ain s 0. 4 16 .7 51 .4 30 .1 1. 4 10 0. 0 24 .4 30 .3 32 Ea ste rn H ills 1. 7 19 .0 48 .1 29 .4 1. 8 10 0. 0 26 .6 41 .5 12 3 Ea ste rn T er ai 0. 8 6. 2 64 .5 26 .3 2. 2 10 0. 0 20 .3 72 .4 27 7 Ce nt ra l M ou nt ain s 0. 8 9. 7 55 .4 33 .4 0. 7 10 0. 0 21 .0 52 .7 38 Ce nt ra l H ills 0. 8 13 .2 57 .3 27 .3 1. 4 10 0. 0 23 .7 76 .8 24 1 Ce nt ra l T er ai 0. 0 9. 8 75 .4 13 .1 1. 7 10 0. 0 23 .8 47 .8 40 0 W es te rn M ou nt ain s (0 .0 ) (1 7. 7) (5 7. 6) (2 1. 9) (2 .8 ) 10 0. 0 (2 6. 1) (5 6. 2) 1 W es te rn H ills 0. 7 12 .7 59 .4 25 .5 1. 7 10 0. 0 23 .3 66 .6 22 2 W es te rn T er ai 0. 4 9. 6 67 .6 22 .4 0. 0 10 0. 0 22 .3 69 .7 17 8 M id- W es te rn M ou nt ain s 3. 5 27 .3 43 .0 25 .6 0. 6 10 0. 0 32 .5 37 .6 43 M id- W es te rn H ills 2. 0 14 .0 47 .9 33 .2 3. 0 10 0. 0 23 .8 43 .7 16 6 M id- W es te rn T er ai 1. 0 19 .8 49 .5 29 .6 0. 1 10 0. 0 26 .5 73 .5 11 3 Fa r W es te rn M ou nt ain s 0. 6 16 .0 71 .4 10 .7 1. 3 10 0. 0 27 .2 36 .9 33 Fa r W es te rn H ills 1. 4 21 .4 72 .9 2. 2 2. 1 10 0. 0 32 .1 49 .3 75 Fa r W es te rn T er ai 2. 4 19 .2 53 .7 19 .5 5. 3 10 0. 0 28 .5 74 .2 10 6 Ar ea Ur ba n 0. 3 7. 6 65 .0 26 .0 1. 1 10 0. 0 20 .8 90 .4 26 2 Ka th m an du va lle y 0. 0 1. 5 76 .1 22 .4 0. 0 10 0. 0 18 .5 10 0. 0 65 Ot he r u rb an 0. 4 9. 7 61 .3 27 .1 1. 5 10 0. 0 21 .6 87 .2 19 7 Ru ra l 1. 0 13 .7 60 .8 22 .6 1. 9 10 0. 0 24 .7 55 .6 1, 78 6 M ot he r’s a ge a t b irt h Le ss th an 2 0 ye ar s 0. 7 17 .4 59 .4 19 .7 2. 7 10 0. 0 26 .6 62 .3 34 9 20 –3 4 ye ar s 0. 9 11 .3 62 .5 23 .8 1. 4 10 0. 0 23 .3 61 .0 1, 58 0 35 –4 9 ye ar s 0. 9 22 .0 51 .6 21 .8 3. 7 10 0. 0 28 .8 41 .2 11 9 Bi rth o rd er 1 0. 8 13 .6 59 .8 24 .2 1. 5 10 0. 0 24 .2 74 .5 76 8 2– 3 0. 6 11 .7 63 .4 22 .6 1. 8 10 0. 0 23 .4 56 .6 95 3 4– 5 2. 6 14 .0 62 .2 19 .3 1. 9 10 0. 0 26 .6 40 .4 24 8 6+ 0. 0 18 .2 50 .4 28 .1 3. 2 10 0. 0 25 .3 22 .0 79 Ne pa l&M IC S&2 01 4& 3" " Ta bl e NU .1 : L ow b irt h we ig ht in fa nt s Pe rc en ta ge o f la st liv e- bo rn ch ild re n bo rn in th e tw o ye ar s p re ce din g th e su rv ey th at a re e sti m at ed to h av e we igh ed b elo w 2, 50 0 gr am s a t b irt h an d pe rc en ta ge o f li ve b irt hs w eig he d at b irt h, N ep al, 20 14 Pe rc en t o f b irt hs b y m ot he r’s a ss es sm en t o f s ize a t b irt h: To ta l Pe rc en t o f li ve b irt hs : Nu m be r o f la st liv e- bo rn ch ild re n in th e las t t wo ye ar s Ve ry sm all Sm all er th an av er ag e Av er ag e La rg er th an av er ag e or ve ry lar ge DK Be low 2 ,5 00 gr am s [ 1] W eig he d at bir th [2 ] M ot he r’s e du ca tio n No ne 0. 7 16 .7 62 .4 18 .2 2. 1 10 0. 0 26 .5 39 .6 75 4 Pr im ar y 1. 0 13 .8 64 .1 19 .6 1. 5 10 0. 0 25 .3 55 .9 34 6 Se co nd ar y 1. 3 11 .8 58 .1 27 .2 1. 7 10 0. 0 23 .2 71 .7 50 3 Hi gh er 0. 8 7. 3 61 .2 29 .2 1. 5 10 0. 0 20 .5 84 .8 44 5 W ea lth in de x qu in til e Po or es t 2. 3 19 .4 54 .5 20 .9 2. 8 10 0. 0 28 .5 37 .7 45 8 Se co nd 0. 3 16 .8 58 .8 22 .7 1. 4 10 0. 0 25 .5 46 .8 42 5 M idd le 1. 2 10 .3 67 .5 19 .9 1. 0 10 0. 0 23 .8 60 .7 44 8 Fo ur th 0. 4 10 .4 64 .4 23 .0 1. 8 10 0. 0 22 .5 72 .0 40 5 Ri ch es t 0. 0 5. 3 62 .1 31 .0 1. 5 10 0. 0 18 .8 94 .3 31 2 [1 ] M IC S in di ca to r 2 .2 0 – Lo w bi rth w ei gh t i nf an ts [2 ] M IC S in di ca to r 2 .2 1 – In fa nt s we ig he d at b irt h ( ) F igu re s t ha t a re b as ed o n 25 –4 9 un we igh te d ca se s NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201426 2http://www.who.int/childgrowth/standards/technical_report Overall, 60 percent of live births were weighed at birth and approximately 24 percent of infants were estimated to weigh less than 2,500 grams (Table NU.1). There was some regional variation, ranging from 20 percent in the Eastern Terai to 33 percent in the Mid-Western Mountains. Mother’s education level and household wealth status were both positively correlated with the likelihood of having a child with low birth weight. Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate and nutritious food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Undernutrition is associated with more than half of all child deaths worldwide. Under-nourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished—showing no outward sign of their vulnerability. The MDG target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age 5. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards2. Each of the three nutritional status indicators—weight-for-age, height-for-age, and weight-for-height—can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 27 3See MICS Supply Procurement Instructions here: http://mics.unicef.org/tools#survey-design Weight-for-height can be used to assess wasting and overweight status. Children whose weight- for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS, weights and heights of all children under five were measured using the anthropometric equipment recommended3 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above-described categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. Children whose full birth date (month and year) were not obtained and children whose measurements were outside a plausible range are excluded from Table NU.2. Children were excluded from one or more of the anthropometric indicators when their weight or height had not been measured, whichever was applicable. For example, if a child had been weighed but his/her height had not been measured, the child was included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.12, DQ.13, and DQ.14 in Appendix D. The tables show that due to incomplete dates of birth, implausible measurements, and/or missing weight and/or height, 2 percent of children have been excluded from calculations of the weight-for-age indicator, 4 percent from the height-for-age indicator, and 4 percent for the weight-for-height indicator. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201428 Ta bl e NU .2 : N ut rit io na l s ta tu s of c hi ld re n Pe rc en ta ge o f c hil dr en u nd er fiv e by n ut rit ion al sta tu s a cc or din g to th re e an th ro po m et ric in dic es : w eig ht -fo r-a ge , h eig ht -fo r-a ge , a nd w eig ht -fo r-h eig ht , N ep al, 2 01 4 W eig ht -fo r-a ge He igh t-f or -a ge W eig ht -fo r-h eig ht Un de rw eig ht M ea n z- sc or e (S D) Nu m be r o f ch ild re n St un te d M ea n z- sc or e (S D) Nu m be r o f ch ild re n W as te d Ov er we igh t M ea n z- sc or e (S D) Nu m be r o f ch ild re n un de r f ive Pe rc en t b elo w Pe rc en t b elo w Pe rc en t b elo w Ab ov e - 2 S D [1 ] - 3 S D [2 ] - 2 S D [3 ] - 3 S D [4 ] - 2 SD [5 ] - 3 S D [6 ] + 2 SD [7 ] To ta l 30 .1 8. 6 -1 .4 5, 20 6 37 .4 15 .8 -1 .6 5, 11 4 11 .3 3. 2 2. 1 -0 .6 5, 11 3 Se x M ale 28 .8 7. 8 -1 .3 2, 68 6 36 .2 15 .6 -1 .5 2, 63 7 11 .6 3. 7 2. 2 -0 .6 2, 64 6 Fe m ale 31 .5 9. 4 -1 .4 2, 52 0 38 .6 16 .0 -1 .6 2, 47 7 10 .9 2. 7 2. 1 -0 .6 2, 46 6 Re gi on Ea ste rn M ou nt ain s 17 .2 3. 0 -0 .9 71 30 .9 10 .1 -1 .3 70 5. 9 1. 7 1. 7 -0 .2 70 Ea ste rn H ills 20 .1 5. 8 -0 .9 26 8 26 .9 9. 9 -1 .2 26 8 10 .8 4. 2 1. 6 -0 .3 2, 64 Ea ste rn T er ai 27 .4 7. 7 -1 .2 75 8 25 .0 9. 5 -1 .2 74 3 13 .3 4. 9 3. 0 -0 .7 7, 40 Ce nt ra l M ou nt ain s 19 .4 6. 3 -1 .1 94 36 .6 16 .4 -1 .4 93 7. 3 2. 0 1. 2 -0 .5 93 Ce nt ra l H ills 16 .7 1. 6 -0 .8 60 4 27 .7 11 .5 -1 .2 59 0 5. 9 2. 1 4. 4 -0 .1 59 3 Ce nt ra l T er ai 40 .7 13 .2 -1 .7 1, 09 2 41 .6 19 .1 -1 .6 1, 07 5 17 .0 3. 8 1. 6 -1 .0 1, 07 2 W es te rn M ou nt ain s 15 .5 6. 4 -0 .8 2 45 .6 22 .6 -2 .1 2 2. 5 0. 0 8. 4 0. 3 2 W es te rn H ills 25 .3 9. 0 -1 .3 56 0 37 .6 12 .9 -1 .7 55 4 7. 4 3. 8 1. 2 -0 .5 55 0 W es te rn T er ai 32 .8 8. 4 -1 .6 46 5 36 .0 12 .9 -1 .5 46 1 13 .1 2. 9 0. 2 -0 .9 46 3 M id- W es te rn M ou nt ain s 45 .2 15 .7 -1 .9 10 6 64 .2 38 .9 -2 .5 10 4 9. 0 2. 4 1. 9 -0 .6 10 5 M id- W es te rn H ills 33 .5 8. 6 -1 .5 40 7 50 .3 21 .7 -2 .0 40 5 6. 9 1. 0 2. 2 -0 .5 40 6 M id- W es te rn T er ai 31 .2 5. 8 -1 .5 28 3 41 .6 15 .0 -1 .8 28 1 10 .3 2. 2 1. 1 -0 .7 28 7 Fa r W es te rn M ou nt ain s 29 .0 7. 4 -1 .6 98 47 .8 19 .7 -1 .9 95 8. 6 2. 7 1. 8 -0 .6 95 Fa r W es te rn H ills 43 .7 17 .8 -1 .9 20 7 62 .7 37 .2 -2 .5 19 9 11 .0 3. 7 1. 8 -0 .7 19 9 Fa r W es te rn T er ai 22 .5 4. 8 -1 .1 18 9 30 .5 10 .1 -1 .2 17 4 12 .6 2. 4 5. 0 -0 .6 17 3 Ar ea Ur ba n 16 .5 3. 2 -0 .9 68 8 23 .7 7. 5 -1 .1 68 3 6. 0 1. 6 1. 9 -0 .3 67 7 Ka th m an du va lle y 6. 7 1. 5 -0 .5 17 6 19 .0 5. 6 -1 .0 17 5 5. 7 2. 4 3. 6 0. 1 17 5 Ot he r u rb an 19 .9 3. 8 -1 .0 51 2 25 .4 8. 2 -1 .2 50 7 6. 1 1. 4 1. 3 -0 .5 50 2 Ru ra l 32 .2 9. 4 -1 .4 4, 51 7 39 .4 17 .0 -1 .6 4, 43 1 12 .1 3. 5 2. 2 -0 .7 4, 43 5 Ag e 0– 5 m on th s 20 .9 7. 2 -1 .0 44 5 15 .1 7. 2 -0 .6 43 1 17 .3 8. 5 4. 9 -0 .7 42 4 6– 11 m on th s 18 .4 6. 3 -1 .0 51 0 15 .6 4. 7 -0 .8 50 9 14 .1 5. 4 2. 6 -0 .7 50 7 12 –1 7 m on th s 25 .2 6. 3 -1 .2 47 6 28 .9 8. 5 -1 .2 46 8 15 .5 3. 9 1. 5 -0 .8 46 9 18 –2 3 m on th s 34 .3 9. 1 -1 .5 51 1 39 .6 15 .6 -1 .7 50 0 16 .2 3. 1 1. 2 -0 .9 50 0 24 –3 5 m on th s 31 .0 7. 4 -1 .4 1, 04 8 41 .3 18 .0 -1 .7 1, 01 4 9. 5 2. 1 1. 9 -0 .6 1, 02 0 36 –4 7 m on th s 33 .5 10 .9 -1 .5 1, 10 5 48 .7 22 .2 -2 .0 1, 09 0 7. 9 2. 5 2. 1 -0 .5 1, 09 4 48 –5 9 m on th s 35 .1 9. 7 -1 .5 1, 11 1 43 .8 19 .0 -1 .8 1, 10 1 8. 5 1. 6 1. 8 -0 .6 1, 09 9 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 29 Ta bl e NU .2 : N ut rit io na l s ta tu s of c hi ld re n Pe rc en ta ge o f c hil dr en u nd er fiv e by n ut rit ion al sta tu s a cc or din g to th re e an th ro po m et ric in dic es : w eig ht -fo r-a ge , h eig ht -fo r-a ge , a nd w eig ht -fo r-h eig ht , N ep al, 2 01 4 W eig ht -fo r-a ge He igh t-f or -a ge W eig ht -fo r-h eig ht Un de rw eig ht M ea n z- sc or e (S D) Nu m be r o f ch ild re n St un te d M ea n z- sc or e (S D) Nu m be r o f ch ild re n W as te d Ov er we igh t M ea n z- sc or e (S D) Nu m be r o f ch ild re n un de r f ive Pe rc en t b elo w Pe rc en t b elo w Pe rc en t b elo w Ab ov e - 2 S D [1 ] - 3 S D [2 ] - 2 S D [3 ] - 3 S D [4 ] - 2 SD [5 ] - 3 S D [6 ] + 2 SD [7 ] M ot he r’s e du ca tio n No ne 39 .0 13 .0 -1 .7 2, 19 6 48 .3 22 .1 -1 .9 2, 16 5 13 .0 3. 6 1. 8 -0 .8 2, 17 2 Pr im ar y 34 .7 7. 0 -1 .5 90 3 41 .4 18 .6 -1 .7 88 6 12 .0 3. 5 2. 3 -0 .7 88 6 Se co nd ar y 23 .7 6. 3 -1 .2 1, 15 7 29 .7 9. 1 -1 .3 1, 13 1 11 .3 3. 6 1. 4 -0 .6 1, 12 3 Hi gh er 12 .7 2. 7 -0 .8 94 5 17 .3 6. 4 -1 .0 92 9 6. 2 1. 5 3. 6 -0 .3 92 8 W ea lth in de x qu in til e Po or es t 37 .1 12 .5 -1 .6 1, 15 5 54 .7 27 .2 -2 .1 1, 12 9 8. 6 2. 6 1. 9 -0 .6 1, 13 0 Se co nd 34 .0 9. 9 -1 .5 1, 04 2 41 .8 17 .2 -1 .7 1, 02 9 12 .3 2. 5 1. 5 -0 .7 1, 02 8 M idd le 37 .7 10 .0 -1 .6 1, 15 4 39 .6 15 .5 -1 .6 1, 12 8 16 .8 5. 5 2. 8 -0 .9 1, 13 3 Fo ur th 24 .6 6. 2 -1 .2 1, 05 1 28 .6 10 .2 -1 .3 1, 03 3 10 .8 3. 3 1. 5 -0 .7 1, 02 9 Ri ch es t 11 .3 2. 2 -0 .7 80 4 15 .2 5. 2 -0 .9 79 6 6. 4 1. 6 3. 0 -0 .3 79 2 [1 ] M IC S in di ca to r 2 .1 a an d M DG in di ca to r 1 .8 – U nd er we ig ht p re va le nc e (m od er at e an d se ve re ) [2 ] M IC S in di ca to r 2 .1 b – Un de rw ei gh t p re va le nc e (s ev er e) [3 ] M IC S in di ca to r 2 .2 a – St un tin g pr ev al en ce (m od er at e an d se ve re ) [4 ] M IC S in di ca to r 2 .2 b – St un tin g pr ev al en ce (s ev er e) [5 ] M IC S in di ca to r 2 .3 a – W as tin g pr ev al en ce (m od er at e an d se ve re ) [6 ] M IC S in di ca to r 2 .3 b – W as tin g pr ev al en ce (s ev er e) [7 ] M IC S in di ca to r 2 .4 – O ve rw ei gh t p re va le nc e No te : 3 ca se s o f m iss ing ‘m ot he r’s e du ca tio n’ no t s ho wn C on tin ue d NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201430 One in three children under five in Nepal were moderately or severely underweight (30 percent) and 9 percent were classified as severely underweight (Table NU.2). More than one-third (37 percent) were moderately or severely stunted or too short for their age and 16 percent were severely stunted, and 11 percent were moderately or severely wasted or too thin for their height and 3 percent were severely wasted. Only 2 percent of children were moderately or severely overweight. Children in the Mid-Western Mountains were more likely to be underweight and stunted than other children. In contrast, the percentage wasted is highest in the Central Terai. Children in rural areas were more likely than those in urban areas to be underweight, stunted or wasted. Those children whose mothers have secondary or higher education were the least likely to be underweight, stunted or wasted compared to children of mothers with no education. Older children were more likely than younger children to be underweight and/or stunted but less likely to be wasted. Figure NU.1 shows that a higher percentage of children aged 18–59 months were underweight or stunted in comparison to younger children. This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and the environment. Both underweight and stunting gradually increases with age until the age of 23 months and then more or less plateaus in contrast of wasting where it peaks at 23 months and gradually decreases. This signifies that the nutrition interventions need to reach the children as soon as possible in their infancy, within the critical window of 1,000 days. Figure NU.1: Underweight, stunted, wasted and overweight children under five (moderate and severe), Nepal, 2014 P er ce nt NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 31 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from conception to two years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, and do not breastfeed exclusively for the recommended six months or stop breastfeeding too soon. There are often tendencies to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water, are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of nutrient dense, adequate and safe solid, semi-solid and soft foods from the age of six months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.4 UNICEF and WHO recommend that infants be breastfed within one hour of birth, are breastfed exclusively for the first six months of life, and continue to be breastfed for up to two years of age and beyond.5 Starting at six months, breastfeeding should be combined with nutrient dense and diverse, safe, age-appropriate feeding of solid, semi-solid and soft foods.6 A summary of key guiding principles7,8, for feeding 6–23-month-olds is provided in the table below along with proximate measures for these guidelines collected in this survey. The guiding principles for which proximate measures and indicators exist are: • continued breastfeeding; • appropriate frequency of meals (but not energy density); and • appropriate dietary diversity and nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Diet diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For diet diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).9 4Bhuta Z. et al., 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 5WHO, 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3–5 February 2003. 6WHO, 2003. Global strategy for infant and young child feeding. 7PAHO, 2003. Guiding principles for complementary feeding of the breastfed child. 8WHO, 2005. Guiding principles for feeding non-breastfed children 6–24 months of age 9WHO, 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201432 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of ‘minimum acceptable diet’. To have a minimum acceptable diet in the previous day, a child must have received: • the appropriate number of meals/snacks/milk feeds; • food items from at least four food groups; and • breast milk or at least two milk feeds (for non-breastfed children). Nepal MICS 2014 9 Guiding principle (aged 6–23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children: Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children: Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups* eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists Na Appropriate consistency of food No standard indicator exists Na Use of vitamin–mineral supplements or fortified products for infant and mother No standard indicator exists Na Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists Na Note: * Food groups used for assessment of this indicator are: (1) grains, roots and tubers; (2) legumes and nuts; (3) dairy products (milk, yogurt, cheese); (4) flesh foods (meat, fish, poultry and liver/organ meats); (5) eggs; (6) vitamin-A rich fruits and vegetables; and (7) other fruits and vegetables. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 33 Table NU.3: Initial breastfeeding Percentage of last live-born children born in the two years preceding the survey who were ever breastfed, breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Nepal, 2014 Percent who were ever breastfed [1] Percent who were first breastfed: Percent who received a prelacteal feed Number of last live-born children in the last two years Within one hour of birth [2] Within one day of birth Total 97.3 48.7 85.9 15.9 2,048 Region Eastern Mountains 98.6 42.4 88.6 13.3 32 Eastern Hills 96.4 43.9 82.2 9.1 123 Eastern Terai 97.2 29.6 80.3 26.7 277 Central Mountains 98.6 74.6 95.9 1.9 38 Central Hills 97.4 45.6 83.5 20.8 241 Central Terai 97.1 58.2 82.5 18.8 400 Western Mountains (97.2) (41.9) (77.1) (27.1) 1 Western Hills 98.3 45.3 88.8 18.3 222 Western Terai 96.7 49.0 85.7 16.6 178 Mid-Western Mountains 96.2 67.5 88.9 3.8 43 Mid-Western Hills 96.3 51.1 92.0 4.9 166 Mid-Western Terai 99.9 41.4 84.9 15.8 113 Far Western Mountains 100.0 48.4 98.6 2.2 33 Far Western Hills 97.9 65.2 96.7 0.6 75 Far Western Terai 95.5 59.3 92.0 10.6 106 Area Urban 97.4 44.6 84.1 27.4 262 Kathmandu valley 98.6 36.8 80.0 43.5 65 Other urban 97.0 47.3 85.5 22.1 197 Rural 97.3 49.3 86.2 14.2 1,786 Months since last birth 0–11 97.8 48.5 85.7 17.0 995 12–23 96.9 48.8 86.2 14.9 1,053 Assistance at delivery Skilled attendant 98.5 48.7 86.9 16.5 1,138 Other health workers 98.9 55.5 85.8 18.1 122 Other 98.4 49.0 86.7 15.9 729 No one/ Missing 58.3 29.6 57.1 0.4 59 Place of delivery Home 98.9 49.8 87.0 15.6 872 Health facility 98.2 49.1 86.8 16.5 1,130 Public 98.2 53.5 89.4 13.5 915 Private 98.9 31.5 76.5 27.8 188 NGO (*) (*) (*) (*) 27 Other/ Missing 47.1 18.1 44.5 7.8 47 Mother’s education None 97.5 54.0 85.3 15.9 754 Primary 96.7 49.9 88.2 13.3 346 Secondary 97.2 48.5 88.5 13.8 503 Higher 97.6 38.8 82.4 20.4 445 Wealth index quintile Poorest 96.2 52.6 90.0 6.7 454 Second 98.9 53.6 87.2 15.7 436 Middle 97.4 49.5 83.7 14.4 441 Fourth 96.6 45.2 86.0 19.0 401 Richest 97.4 39.7 81.3 27.7 316 [1] MICS indicator 2.5 – Children ever breastfed [2] MICS indicator 2.6 – Early initiation of breastfeeding ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201434 Table NU.3 is based on mothers’ reports of what their last-born child, born in the two years preceding the survey, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.10 Some 97 percent of children were ever breast fed. Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 49 percent of babies were breastfed for the first time within one hour of birth, while 86 percent of newborns started breastfeeding within one day of birth. Some 16 percent received a prelacteal feed. There was considerable variation in initiation of breastfeeding by region, with the highest proportion of children breastfed within one hour of birth in the Central Mountains. In contrast, nearly one in three babies received a prelacteal feed in the Western Mountains. Children born to mothers with higher education and in the richest households were least likely to initiate early breastfeeding and most likely to receive a prelacteal feed. Figure NU.2 shows variation in initiation of breastfeeding by region and area. Figure NU.2: Initiation of breastfeeding, Nepal, 2014 10Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). Nepal  MICS  2014   14     Figure  NU.2  shows  variation  in  initiation  of  breastfeeding  by  region  and  area.   Figure  NU.2:  Initiation  of  breastfeeding,  Nepal,  2014       The  set  of  infant  and  young  child  feeding  indicators  reported  in  Tables  NU.4  through  NU.8  are  based   on  the  mother’s  report  of  consumption  of  food  and  fluids  during  the  day  or  night  prior  to  being   interviewed.  Data  are  subject  to  a  number  of  limitations,  some  are  related  to  the  respondent’s   ability  to  provide  a  full  report  on  the  child’s  liquid  and  food  intake  due  to  recall  errors  as  well  as  lack   of  knowledge  in  cases  where  the  child  was  fed  by  other  individuals.   In  Table  NU.4,  breastfeeding  status  is  presented  for  both  exclusively  breastfed  and  predominantly   breastfed;  this  refers  to  infants  aged  less  than  six  months  who  are  breastfed,  distinguished  by  the   former  only  allowing  vitamins,  mineral  supplements  and  medicine,  and  the  latter  allowing  also  plain   water  and  non-­‐milk  liquids.  The  table  also  shows  continued  breastfeeding  of  children  at  12–15   months  and  20–23  months  of  age.   89 82 80 96 84 83 77 89 86 89 92 85 99 97 92 84 86 86 42 44 30 75 46 58 42 45 49 68 51 41 48 65 59 45 49 49 0 20 40 60 80 100 Pe r  c en t Within  one  day Within  one  hour P er ce nt NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 35 The set of infant and young child feeding indicators reported in Tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to being interviewed. Data are subject to a number of limitations, some are related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. In Table NU.4, breastfeeding status is presented for both exclusively breastfed and predominantly breastfed; this refers to infants aged less than six months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements and medicine, and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12–15 months and 20–23 months of age. Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Nepal, 2014 Children aged 0–5 months Children aged 12–15 months Children aged 20–23 months Percent exclusively breastfed [1] Percent predomi- nantly breastfed [2] Number of children Percent breastfed (continued breastfee- ding at one year) [3] Number of children Percent breastfed (continued breastfee- ding at two years) [4] Number of children Total 56.9 74.9 455 93.6 318 86.7 338 Sex Male 63.8 76.8 251 92.3 178 90.0 173 Female 48.6 72.5 204 95.3 140 83.3 165 Region Eastern Mountains (46.4) (70.5) 8 (*) 5 (*) 4 Eastern Hills (*) (*) 21 (*) 16 (*) 23 Eastern Terai (56.0) (65.7) 59 (*) 39 (*) 39 Central Mountains (*) (*) 6 (*) 6 (*) 5 Central Hills (54.3) (66.9) 52 (93.1) 40 (*) 37 Central Terai 65.1 89.5 110 (94.6) 58 (79.2) 98 Western Mountains (*) (*) (*) (*) Western Hills (68.9) (86.8) 50 (*) 36 (*) 35 Western Terai (33.5) (66.0) 37 (*) 31 (*) 25 Mid-Western Mountains (69.6) (78.4) 9 (95.0) 8 (96.5) 6 Mid-Western Hills (53.6) (57.5) 27 (100.0) 24 (*) 18 Mid-Western Terai (*) (*) 22 (96.6) 21 (*) 15 Far Western Mountains (49.9) (66.3) 8 (*) 5 (86.1) 6 Far Western Hills (59.6) (70.5) 16 (*) 11 (96.5) 14 Far Western Terai (72.2) (80.2) 30 (*) 16 (*) 13 Area Urban 53.9 73.6 59 81.7 38 (92.1) 35 Kathmandu valley (*) (*) 18 (*) 12 (*) 9 Other urban 58.1 79.7 40 (77.0) 27 (93.8) 26 Rural 57.4 75.1 396 95.3 279 86.1 303 Mother’s education None 61.1 77.7 162 96.3 114 82.0 150 Primary 52.2 64.8 75 92.5 60 92.5 57 Secondary 58.8 79.5 132 97.3 66 86.7 71 Higher 50.4 71.1 86 87.1 76 92.9 60 Wealth index quintile Poorest 43.3 62.3 86 99.0 67 94.1 63 Second 70.8 83.0 106 96.5 67 83.5 81 Middle 57.5 80.4 111 97.8 67 (86.2) 75 Fourth 56.0 68.3 77 (90.8) 70 85.8 75 Richest 52.9 76.4 75 (80.1) 47 (84.7) 45 [1] MICS indicator 2.7 – Exclusive breastfeeding under 6 months [2] MICS indicator 2.8 – Predominant breastfeeding under 6 months [3] MICS indicator 2.9 – Continued breastfeeding at 1 year [4] MICS indicator 2.10 – Continued breastfeeding at 2 years Note: 3 cases of missing ‘mother’s education’ not shown ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases   NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201436 Some 57 percent of children aged less than six months were exclusively breastfed; however, 75 percent were predominantly breastfed, suggesting that a substantial proportion were receiving water- based liquids instead of breastmilk to some degree. Some 94 percent of children aged 12–15 months and 87 percent of children aged 20–23 months were still being breastfed. Boys were much more likely than girls to be exclusively breastfed. A cultural dimension partially explains this difference, as boys are usually introduced to semi-solid food at six months as compared to girls at five months. Mother’s education level was negatively associated with exclusive breastfeeding. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages (0–1 months), over 20 percent of children were receiving liquids or foods other than breast milk, with water being of the highest prevalence followed by milk formula. At the age of 4–5 months, the proportion of children exclusively breastfed fell below 40 percent. More than 80 percent of children were still receiving some breast milk at the age of two years. Figure NU.3: Infant feeding patterns by age, Nepal, 2014 Nepal  MICS  2014   16     dimension partially explains this difference, as boys are usually introduced to semi-solid food at six months as compared to girls at five months. Mother’s education level was negatively associated with exclusive breastfeeding. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages (0–1 months), over 20 percent of children were receiving liquids or foods other than breast milk, with water being of the highest prevalence followed by milk formula. At the age of 4–5 months, the proportion of children exclusively breastfed fell below 40 percent. More than 80 percent of children were still receiving some breast milk at the age of two years. Figure NU.3: Infant feeding patterns by age, Nepal, 2014 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children aged less than three years, the median duration was more than 36 months for any breastfeeding, 3.2 months for exclusive breastfeeding, and 4.8 months for predominant breastfeeding. Variation in median duration of any breastfeeding was unremarkable, as most children received breast milk for at least 36 months. Exclusive breastfeeding varied somewhat and was generally around 2–4 months; in no disaggregation did it reach six months. Interestingly, it was only 1.3 months for children in the poorest household population. Exclusively breastfed Breastfed and complementary foods Weaned (not breastfed) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0-­‐1 2-­‐3 4-­‐5 6-­‐7 8-­‐9 10-­‐11 12-­‐13 14-­‐15 16-­‐17 18-­‐19 20-­‐21 22-­‐23 Age in months Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk / formula Breastfed and complementary foods Weaned (not breastfed) NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 37 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children aged less than three years, the median duration was more than 36 months for any breastfeeding, 3.2 months for exclusive breastfeeding, and 4.8 months for predominant breastfeeding. Variation in median duration of any breastfeeding was unremarkable, as most children received breast milk for at least 36 months. Exclusive breastfeeding varied somewhat and was generally around 2–4 months; in no disaggregation did it reach six months. Interestingly, it was only 1.3 months for children in the poorest household population. Table NU.5: Duration of breastfeeding Median duration (in months) of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children aged 0–35 months, Nepal, 2014 Median duration (in months) of Number of children aged 0–35 monthss Any breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Median 36+ 3.2 4.8 3,065 Sex Male 36+ 3.8 4.8 1,609 Female 34.4 2.4 4.8 1,455 Region Eastern Mountains 36+ 2.4 4.6 44 Eastern Hills 36+ 1.9 3.9 168 Eastern Terai 32.6 3.0 3.9 431 Central Mountains 36+ 2.2 2.3 57 Central Hills 33.2 2.9 3.9 369 Central Terai 36+ 4.6 6.2 626 Western Mountains (36+) (5.9) (7.0) 1 Western Hills 33.8 3.9 5.1 341 Western Terai 36+ 1.5 3.4 280 Mid-Western Mountains 36+ 4.8 5.3 61 Mid-Western Hills 36+ 2.9 3.4 223 Mid-Western Terai 36+ 2.2 4.9 166 Far Western Mountains 36+ 2.5 4.4 55 Far Western Hills 36+ 4.6 6.2 112 Far Western Terai 36+ 5.0 5.8 129 Area Urban 32.3 2.8 4.2 397 Kathmandu valley 29.1 2.0 3.2 105 Other urban 33.2 3.0 4.6 292 Rural 36+ 3.3 4.8 2,667 Mother’s education None 36+ 3.9 5.6 1,151 Primary 36+ 2.7 4.3 537 Secondary 36+ 3.2 4.5 741 Higher 32.7 2.5 4.2 632 Wealth index quintile Poorest 36+ 1.3 4.0 647 Second 36+ 4.1 5.2 652 Middle 36+ 3.9 6.0 653 Fourth 36+ 3.0 3.7 622 Richest 30.2 2.7 4.2 490 Mean 30.7 3.8 5.1 3,065 [1] MICS indicator 2.11 – Duration of breastfeeding ( ) Figures that are based on 25–49 unweighted cases NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201438 The age-appropriateness of breastfeeding of children aged less than 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants aged 0–5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children aged 6–23 months are considered to be appropriately fed if they are receiving breast milk and solid, semi-solid or soft food. As a result of feeding patterns, only 86 percent of children aged 6–23 months were being appropriately breastfed and age-appropriate breastfeeding among all children aged 0–23 months dropped to 79 percent. Boys aged 0–23 months were more likely than girls aged 0–23 months to be appropriately breastfed (83 percent compared to 76 percent). There was some regional variation, with the highest proportion of appropriately breastfed under-2s living in the Mid-Western Hills (88 percent) and the lowest proportion in the Eastern Terai (74 percent). Table NU.6: Age-appropriate breastfeeding Percentage of children aged 0–23 months who were appropriately breastfed during the previous day, Nepal, 2014 Children aged 0–5 months Children aged 6–23 months Children aged 0–23 months Percent exclusively breastfed [1] Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed [2] Number of children Total 56.9 455 85.9 1,531 79.3 1,986 Sex Male 63.8 251 88.4 810 82.6 1,061 Female 48.6 204 83.1 720 75.5 925 Region Eastern Mountains 46.4 8 91.3 23 79.8 31 Eastern Hills 35.5 21 91.6 93 81.1 114 Eastern Terai 56.0 59 78.8 212 73.9 271 Central Mountains 38.9 6 91.4 30 82.4 36 Central Hills 54.3 52 89.7 175 81.5 227 Central Terai 65.1 110 79.6 295 75.7 405 Western Mountains (78.2) 0 (81.3) 1 (80.8) 1 Western Hills 68.9 50 90.0 173 85.3 223 Western Terai 33.5 37 90.9 142 79.0 179 Mid-Western Mountains 69.6 9 87.5 31 83.6 40 Mid-Western Hills 53.6 27 95.6 121 88.0 147 Mid-Western Terai 45.5 22 82.7 85 75.0 108 Far Western Mountains 49.9 8 82.7 25 75.0 33 Far Western Hills 59.6 16 86.6 60 80.9 76 Far Western Terai 72.2 30 79.2 65 77.0 96 Area Urban 53.9 59 85.5 190 78.0 248 Kathmandu valley 44.6 18 91.3 40 76.7 59 Other urban 58.1 40 83.9 149 78.4 190 Rural 57.4 396 86.0 1,341 79.4 1,737 Mother’s education None 61.1 162 81.3 586 76.9 748 Primary 52.2 75 87.5 255 79.5 330 Secondary 58.8 132 88.9 351 80.6 483 Higher 50.4 86 89.5 336 81.5 422 Wealth index quintile Poorest 43.3 86 91.9 330 81.8 416 Second 70.8 106 87.0 332 83.1 438 Middle 57.5 111 83.3 311 76.5 422 Fourth 56.0 77 82.4 330 77.4 407 Richest 52.9 75 84.3 228 76.6 303 [1] MICS indicator 2.7 – Exclusive breastfeeding under 6 months [2] MICS indicator 2.12 – Age-appropriate breastfeeding Note: 3 cases of missing ‘mother’s education’ not shown ( ) Figures that are based on 25–49 unweighted cases NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 39 Table NU.7 shows information on the introduction of solid, semi-solid or soft foods. Sample sizes were very small, so data are only available for a limited number of indicators. Overall, 74 percent of infants aged 6–8 months had received solid, semi-solid or soft foods at least once during the previous day. Boys were more likely than girls to receive solid, semi-solid or soft foods (83 percent compared to 65 percent). Table NU.8 shows infant and young child feeding practices for children aged 6–23 months. Overall, one-third of children (32 percent) were receiving solid, semi-solid and soft foods the minimum number of times. A slightly higher proportion of males (77 percent) were achieving the minimum meal frequency compared to females (72 percent). The proportion of children receiving the minimum dietary diversity, or foods from at least four food groups, was much lower than that for minimum meal frequency, indicating the need to focus on improving diet quality and nutrient intake among this vulnerable group. A higher proportion of older (18–23 months) children (48 percent) were achieving the minimum dietary diversity compared to younger (6–8 months) children (15 percent). The overall assessment using the indicator of minimum acceptable diet revealed that only 32 percent of all children were benefiting from a diet sufficient in both diversity and frequency. Breastfeeding children were more likely than non-breastfeeding children to receive a minimum acceptable diet (32 percent compared to 23 percent). Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants aged 6–8 months who received solid, semi-solid, or soft foods during the previous day, Nepal, 2014 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi- solid or soft foods Number of children aged 6–8 months Percent receiving solid, semi- solid or soft foods Number of children aged 6–8 months Percent receiving solid, semi- solid or soft foods [1] Number of children aged 6–8 months Total 73.5 278 (*) 10 73.5 288 Sex Male 82.2 137 (*) 3 82.6 141 Female 65.0 141 (*) 7 64.9 147 Area Urban (73.7) 41 (*) 1 (74.1) 41 Kathmandu valley (*) 6 (*) 1 (*) 6 Other urban (69.4) 35 0 0 (69.4) 35 Rural 73.5 238 (*) 9 73.5 247 [1] MICS indicator 2.13 – Introduction of solid, semi-solid or soft foods ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201440 Ta bl e NU .8 : I nf an t a nd y ou ng c hi ld fe ed in g pr ac tic es Pe rc en ta ge o f c hil dr en a ge d 6– 23 m on th s w ho re ce ive d ap pr op ria te liq uid s a nd so lid , s em i-s oli d or so ft fo od s t he m ini m um n um be r o f t im es o r m or e du rin g th e pr ev iou s d ay , b y b re as tfe ed ing st at us , N ep al, 20 14 Cu rre nt ly br ea stf ee din g Cu rre nt ly no t b re as tfe ed ing Al l Pe rc en t o f c hil dr en w ho re ce ive d Nu m be r o f ch ild re n ag ed 6 –2 3 m on th s Pe rc en t o f c hil dr en w ho re ce ive d Nu m be r o f ch ild re n ag ed 6 –2 3 m on th s Pe rc en t o f c hil dr en w ho re ce ive d: Nu m be r o f ch ild re n ag ed 6 –2 3 m on th s M ini m um die ta ry div er sit y [a ] M ini m um m ea l fre qu en cy [b ] M ini m um ac ce pt ab le die t [1 ] [ c] M ini m um die ta ry div er sit y [a ] M ini m um m ea l fre qu en cy [b ] M ini m um ac ce pt ab le die t [2 ] [ c] At le as t 2 m ilk fe ed s [3 ] M ini m um die ta ry div er sit y [4 ] [ a] M ini m um m ea l fre qu en cy [5 ] [ b] M ini m um ac ce pt ab le die t [c] To ta l 36 .1 74 .3 32 .3 1, 43 9 60 .4 76 .5 22 .8 59 .5 69 37 .0 74 .4 31 .9 1, 53 1 Se x M ale 36 .3 76 .8 32 .4 77 0 (*) (*) (*) (*) 24 36 .1 77 .0 31 .9 81 0 Fe m ale 35 .8 71 .3 32 .1 66 9 (6 6. 0) (7 4. 1) (2 6. 6) (5 0. 7) 45 37 .9 71 .5 31 .8 72 0 Re gi on Ea ste rn M ou nt ain s 42 .4 79 .1 38 .3 23 (*) (*) (*) (*) 0 42 .6 79 .3 38 .9 23 Ea ste rn H ills 47 .5 86 .8 47 .5 88 (*) (*) (*) (*) 4 46 .2 85 .6 46 .8 93 Ea ste rn T er ai 35 .9 64 .9 29 .7 20 1 (*) (*) (*) (*) 5 35 .0 64 .6 29 .0 21 2 Ce nt ra l M ou nt ain s 20 .5 81 .5 20 .5 30 (*) (*) (*) (*) 0 20 .3 81 .7 20 .3 30 Ce nt ra l H ills 46 .4 74 .1 40 .0 16 2 (*) (*) (*) (*) 9 46 .4 75 .0 38 .6 17 5 Ce nt ra l T er ai 22 .2 69 .3 19 .6 26 3 (*) (*) (*) (*) 22 24 .6 68 .9 18 .4 29 5 W es te rn M ou nt ain s (5 0. 4) (8 8. 1) (5 0. 4) 1 (*) (*) (*) (*) 1 (5 6. 1) (8 5. 3) (5 0. 2) 1 W es te rn H ills 42 .0 89 .5 39 .9 16 0 (*) (*) (*) (*) 13 46 .4 90 .3 41 .5 17 3 W es te rn T er ai 45 .6 83 .3 43 .8 13 6 (*) (*) (*) (*) 5 47 .9 83 .8 42 .8 14 2 M id- W es te rn M ou nt ain s 29 .1 70 .1 26 .1 30 (*) (*) (*) (*) 1 28 .8 69 .1 25 .2 31 M id- W es te rn H ills 36 .1 84 .3 35 .5 12 1 (*) (*) (*) (*) 0 36 .1 84 .3 35 .5 12 1 M id- W es te rn T er ai 33 .6 50 .1 16 .3 83 (*) (*) (*) (*) 2 33 .9 51 .4 17 .1 85 Fa r W es te rn M ou nt ain s 62 .7 81 .3 59 .5 23 (*) (*) (*) (*) 2 62 .3 80 .7 58 .3 25 Fa r W es te rn H ills 23 .9 52 .2 22 .1 59 (*) (*) (*) (*) 1 25 .2 53 .0 23 .4 60 Fa r W es te rn T er ai 28 .9 77 .8 28 .9 60 (*) (*) (*) (*) 4 28 .2 75 .6 28 .2 65 Ar ea Ur ba n 54 .6 82 .5 51 .2 17 4 (*) (*) (*) (*) 14 57 .2 83 .1 52 .8 19 0 Ka th m an du va lle y (7 1. 0) (8 5. 6) (6 3. 2) 37 (*) (*) (*) (*) 4 (7 0. 0) (8 4. 6) (6 0. 6) 40 Ot he r u rb an 50 .1 81 .7 48 .0 13 7 (*) (*) (*) (*) 10 53 .7 82 .7 50 .6 14 9 Ru ra l 33 .5 73 .1 29 .7 1, 26 5 (5 3. 8) (7 3. 0) (1 0. 5) (5 4. 8) 55 34 .1 73 .1 28 .9 1, 34 1 Ag e 6– 8 m on th s 15 .4 66 .0 15 .0 27 8 (*) (*) (*) (*) 8 14 .9 65 .4 14 .6 28 8 9– 11 m on th s 26 .2 66 .6 22 .7 23 2 (*) (*) (*) (*) 3 26 .7 66 .6 22 .4 23 5 12 –1 7 m on th s 42 .5 79 .6 38 .3 45 7 (*) (*) (*) (*) 16 42 .8 79 .9 38 .8 48 4 18 –2 3 m on th s 46 .9 77 .8 41 .4 47 2 (6 6. 2) (7 8. 2) (1 7. 1) (5 4. 9) 42 48 .3 77 .9 39 .4 52 4 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 41 Ta bl e NU .8 : I nf an t a nd y ou ng c hi ld fe ed in g pr ac tic es Pe rc en ta ge o f c hil dr en a ge d 6– 23 m on th s w ho re ce ive d ap pr op ria te liq uid s a nd so lid , s em i-s oli d or so ft fo od s t he m ini m um n um be r o f t im es o r m or e du rin g th e pr ev iou s d ay , b y b re as tfe ed ing st at us , N ep al, 20 14 Cu rre nt ly br ea stf ee din g Cu rre nt ly no t b re as tfe ed ing Al l Pe rc en t o f c hil dr en w ho re ce ive d Nu m be r o f ch ild re n ag ed 6 –2 3 m on th s Pe rc en t o f c hil dr en w ho re ce ive d Nu m be r o f ch ild re n ag ed 6 –2 3 m on th s Pe rc en t o f c hil dr en w ho re ce ive d: Nu m be r o f ch ild re n ag ed 6 –2 3 m on th s M ini m um die ta ry div er sit y [a ] M ini m um m ea l fre qu en cy [b ] M ini m um ac ce pt ab le die t [1 ] [ c] M ini m um die ta ry div er sit y [a ] M ini m um m ea l fre qu en cy [b ] M ini m um ac ce pt ab le die t [2 ] [ c] At le as t 2 m ilk fe ed s [3 ] M ini m um die ta ry div er sit y [4 ] [ a] M ini m um m ea l fre qu en cy [5 ] [ b] M ini m um ac ce pt ab le die t [c] M ot he r’s e du ca tio n No ne 25 .7 65 .9 22 .8 54 0 (5 6. 0) (7 2. 5) (8 .9 ) (5 5. 9) 38 27 .6 66 .3 21 .9 58 6 Pr im ar y 29 .0 75 .0 27 .7 24 3 (*) (*) (*) (*) 5 29 .9 74 .8 27 .6 25 5 Se co nd ar y 40 .0 79 .9 34 .9 33 7 (*) (*) (*) (*) 11 40 .2 79 .7 34 .2 35 1 Hi gh er 54 .4 82 .4 49 .3 31 6 (*) (*) (*) (*) 14 54 .8 82 .8 50 .0 33 6 W ea lth in de x qu in til e Po or es t 32 .5 74 .3 30 .8 32 3 (*) (*) (*) (*) 10 32 .8 74 .1 30 .6 33 0 Se co nd 33 .2 76 .1 29 .2 31 1 (*) (*) (*) (*) 14 35 .1 76 .6 28 .4 33 2 M idd le 27 .4 69 .5 24 .0 29 5 (*) (*) (*) (*) 9 29 .6 69 .2 23 .5 31 1 Fo ur th 39 .5 70 .9 33 .5 30 4 (*) (*) (*) (*) 21 38 .2 71 .4 31 .9 33 0 Ri ch es t 53 .1 83 .3 49 .3 20 7 (*) (*) (*) (*) 16 54 .1 83 .0 50 .2 22 8 [1 ] M IC S in di ca to r 2 .1 7a – M in im um a cc ep ta bl e di et (b re as tfe d) [2 ] M IC S in di ca to r 2 .1 7b – M in im um a cc ep ta bl e di et (n on -b re as tfe d) [3 ] M IC S in di ca to r 2 .1 4 – M ilk fe ed in g fre qu en cy fo r n on -b re as tfe d ch ild re n [4 ] M IC S in di ca to r 2 .1 6 – M in im um d ie ta ry d iv er si ty [5 ] M IC S in di ca to r 2 .1 5 – M in im um m ea l f re qu en cy [a ] M ini m um d iet ar y d ive rs ity is d ef ine d as re ce ivi ng fo od s f ro m a t le as t f ou r o f s ev en fo od g ro up s: (1 ) g ra ins , r oo ts an d tu be rs ; ( 2) le gu m es a nd n ut s; (3 ) d air y p ro du cts (m ilk , y og ur t, ch ee se ); (4 ) f les h fo od s (m ea t, fis h, p ou ltr y a nd liv er /o rg an m ea ts) ; ( 5) e gg s; (6 ) f ru its a nd ve ge ta ble s r ich in vi ta m in A; a nd (7 ) o th er fr uit s a nd ve ge ta ble s [b ] M ini m um m ea l fr eq ue nc y a m on g cu rre nt ly br ea stf ee din g ch ild re n is de fin ed a s c hil dr en w ho a lso re ce ive d so lid , s em i-s oli d or so ft fo od s t wo tim es o r m or e da ily fo r c hil dr en a ge d 6– 8 m on th s a nd th re e tim es or m or e da ily fo r c hil dr en a ge d 9– 23 m on th s. Fo r n on -b re as tfe ed ing ch ild re n ag ed 6 –2 3 m on th s, it i s d ef ine d as re ce ivi ng so lid , s em i-s oli d or so ft fo od s, or m ilk fe ed s, at le as t f ou r t im es a d ay . [c] T he m ini m um a cc ep ta ble d iet fo r b re as tfe d ch ild re n ag ed 6 –2 3 m on th s i s d ef ine d as re ce ivi ng th e m ini m um d iet ar y d ive rs ity a nd th e m ini m um m ea l fr eq ue nc y, wh ile fo r n on -b re as tfe d ch ild re n, it re qu ire s a t lea st tw o m ilk fe ed ing s a nd th at th e m ini m um d iet ar y d ive rs ity is a ch iev ed w ith ou t c ou nt ing m ilk fe ed s. No te : 3 ca se s o f m iss ing ‘m ot he r’s e du ca tio n’ no t s ho wn ( ) F igu re s t ha t a re b as ed o n 25 –4 9 un we igh te d ca se s (*) F igu re s t ha t a re b as ed o n fe we r t ha n 25 u nw eig ht ed ca se s C on tin ue d NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201442 The continued practice of bottle-feeding is a concern because of possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.9 shows that 12 percent of children aged 0–23 months in Nepal were fed using a bottle with a nipple. Urban children were much more likely than rural children to be bottle fed with a nipple (24 percent compared to 10 percent). Bottle feeding with a nipple was positively correlated with mother’s education and household wealth status. Salt Iodization Iodine deficiency disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual Table NU.9: Bottle feeding Percentage of children aged 0–23 months who were fed with a bottle with a nipple during the previous day, Nepal, 2014 Percent fed with a bottle with a nipple [1] Number of children aged 0–23 months Total 11.5 1,986 Sex Male 11.5 1,061 Female 11.6 925 Region Eastern Mountains 4.9 31 Eastern Hills 6.8 114 Eastern Terai 14.5 271 Central Mountains 1.8 36 Central Hills 21.1 227 Central Terai 7.8 405 Western Mountains (11.6) 1 Western Hills 11.4 223 Western Terai 9.9 179 Mid-Western Mountains 5.2 40 Mid-Western Hills 14.9 147 Mid-Western Terai 18.9 108 Far Western Mountains 7.1 33 Far Western Hills 4.7 76 Far Western Terai 7.6 96 Area Urban 24.0 248 Kathmandu valley 36.4 59 Other urban 20.1 190 Rural 9.8 1,737 Age 0–5 months 4.9 455 6–11 months 14.4 523 12–23 months 13.1 1,008 Mother’s education None 7.3 748 Primary 9.2 330 Secondary 11.1 483 Higher 21.5 422 Wealth index quintile Poorest 6.4 416 Second 8.6 438 Middle 5.2 422 Fourth 15.8 407 Richest 26.1 303 [1] MICS indicator 2.18 – Bottle feeding Note: 3 cases of missing ‘mother’s education’ not shown ( ) Figures that are based on 25–49 unweighted cases NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 43 ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (≥15 parts per million). In Nepal, three major subnational surveys (1965, 1979–82 and 1985–86) found a high prevalence of IDD. This provided an impetus for the establishment of the national IDD programme in 1998. The primary intervention implemented in Nepal to control IDD is the universal iodization of all edible salt. Other strategies include advocacy at national and district levels, mass media campaigns to promote the use of packet iodized salt with the ‘two-child logo’, demand creation for crushed salt and other varieties of packed salt, and awareness-raising among health workers and the general public. In nearly 100 percent of surveyed households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate. Table NU.10 shows that in less than 1 percent of households, there was no salt available. These households are included in the denominator of the indicator. In 82 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt was lowest in the Far Western Hills (54 percent) and highest in the Central Hills (92 percent). Almost all (96 percent) of urban households were found to be using adequately iodized salt as compared to only 78 percent in rural areas. Interestingly, the difference between the richest and poorest households in terms of iodized salt consumption is much greater than expected, varying from 64 percent for the poorest households to 98 percent for the richest households. Table NU.10: Iodized salt consumption Percentage of households by consumption of iodized salt, Nepal, 2014 Percent in which salt was tested Number of house- holds Percent with: Total Number of house- holds in which salt was tested or with no salt No salt Salt test result Not iodized 0 ppm >0 and <15 ppm 15+ ppm [1] Total 99.6 12,405 0.2 3.9 14.4 81.5 100.0 12,379 Region Eastern Mountains 99.4 179 0.1 4.4 19.6 75.9 100.0 178 Eastern Hills 99.8 767 0.2 2.7 23.1 74.0 100.0 767 Eastern Terai 99.3 1,845 0.3 2.3 22.6 74.8 100.0 1,837 Central Mountains 99.6 299 0.4 1.3 25.9 72.4 100.0 299 Central Hills 99.7 2,182 0.2 3.2 4.4 92.2 100.0 2,179 Central Terai 99.5 1,924 0.2 2.1 10.6 87.2 100.0 1,918 Western Mountains 98.6 10 0.5 21.5 5.4 72.6 100.0 10 Western Hills 99.6 1,628 0.3 2.8 5.5 91.4 100.0 1,626 Western Terai 99.7 924 0.1 2.0 14.0 83.9 100.0 923 Mid-Western Mountains 99.6 156 0.3 18.7 18.6 62.5 100.0 156 Mid-Western Hills 99.8 763 0.1 10.3 20.7 68.9 100.0 763 Mid-Western Terai 99.6 672 0.2 9.2 13.6 76.9 100.0 671 Far Western Mountains 99.2 185 0.1 2.4 17.7 79.8 100.0 184 Far Western Hills 99.9 346 0.1 2.6 43.8 53.5 100.0 346 Far Western Terai 99.2 524 0.4 9.3 18.0 72.3 100.0 522 Area Urban 99.3 2,476 0.3 0.6 2.6 96.4 100.0 2,467 Kathmandu valley 99.6 782 0.2 0.3 1.1 98.4 100.0 780 Other urban 99.2 1,694 0.4 0.8 3.4 95.5 100.0 1,686 Rural 99.6 9,929 0.2 4.7 17.3 77.8 100.0 9,912 Wealth index quintile Poorest 99.6 2,376 0.3 8.9 27.3 63.5 100.0 2,374 Second 99.4 2,558 0.4 5.1 18.0 76.5 100.0 2,551 Middle 99.8 2,289 0.0 3.6 18.0 78.4 100.0 2,285 Fourth 99.3 2,441 0.3 2.0 9.1 88.7 100.0 2,430 Richest 99.7 2,742 0.1 0.4 1.5 98.0 100.0 2,739 [1] MICS indicator 2.19 – Iodized salt consumption NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201444 Figure NU.4: Use of iodized salt, Nepal, 2014 For the Nepal MICS, country-specific information was collected on the type of salt used by households. Salt is sold in three main varieties: large crystal salt; powder salt either loose or packaged; and Tibetan salt. Although it can be iodized, large crystal salt has poor iodine retention, and during transportation, storage and handling, much of the iodine evaporates, often leaving a too-low content at the time of consumption. Powder salt can be iodized and retains iodine well if it is packaged. However, not all packaged salt is adequately iodized; therefore, the government runs a two-child logo campaign that endorses the iodine content of packaged salt bearing the logo. All salt supplied by Nepal’s Salt Trading Corporation is iodized at the level of 50 ppm so that it contains at least 15 ppm by the time it is used for household consumption. Table NU.11 shows the type of salt used by households. Some 76 percent of households used packaged salt with the two-child logo endorsing it as adequately iodized. An additional 7 percent used packaged salt with no logo and 4 percent used loose powder salt. Large crystal salt was used by 12 percent of households and a very small proportion used Tibetan salt (less than 1 percent). The type of salt used is closely linked to the type that is commonly available as well as most affordable; consequently, there is great regional variation in the type of salt used. Further, households are willing to use packaged salt with the two-child logo when it is available at an affordable price. When this is not the case, large crystal salt is most commonly used. Rural households were less likely than urban households to use packaged salt with the two-child logo. Household wealth was positively associated the use of packaged salt with the two-child logo. Figure NU.4 shows the variations by region, area and wealth quintile in the use of iodized salt and adequately iodized salt. Nepal  MICS  2014   25     Figure NU.4: Use of iodized salt, Nepal, 2014 For the Nepal MICS, country-specific information was collected on the type of salt used by households. Salt is sold in three main varieties: large crystal salt; powder salt either loose or packaged; and Tibetan salt. Although it can be iodized, large crystal salt has poor iodine retention, and during transportation, storage and handling, much of the iodine evaporates, often leaving a too-low content at the time of consumption. Powder salt can be iodized and retains iodine well if it is packaged. However, not all packaged salt is adequately iodized; therefore, the government runs a two-child logo campaign that endorses the iodine content of packaged salt bearing the logo. All salt supplied by Nepal’s Salt Trading Corporation is iodized at the level of 50 ppm so that it contains at least 15 ppm by the time it is used for household consumption. Table NU.11 shows the type of salt used by households. Some 76 percent of households used packaged salt with the two-child logo endorsing it as adequately iodized. An additional 7 percent used packaged salt with no logo and 4 percent used loose powder salt. Large crystal salt was used by 12 percent of households and a very small proportion used Tibetan salt (less than 1 percent). The type of salt used is closely linked to the type that is commonly available as well as most affordable; consequently, there is great regional variation in the 95 97 97 98 97 98 78 97 98 81 90 91 97 97 90 99 100 99 95 91 94 96 98 100 96 76 74 75 72 92 87 73 91 84 62 69 77 80 54 72 96 98 96 78 64 76 78 89 98 82 0 20 40 60 80 100 Pe r  c en t Any iodine 15+ PPM of iodine P er ce nt NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 45 Ne pa l&M IC S&2 01 4& 20 # # Ta bl e NU .1 1: T yp e of s al t u se d in h ou se ho ld s Pe rc en ta ge o f h ou se ho lds b y t yp e of sa lt u se d to co ok m ea ls, N ep al, 2 01 4 Pe rc en t in wh ich sa lt wa s o bs er ve d Nu m be r o f ho us eh old s Pe rc en t b y t yp e of sa lt To ta l Nu m be r o f ho us eh old s i n wh ich sa lt wa s o bs er ve d La rg e cr ys ta l sa lt Lo os e po wd er sa lt Pa ck ag ed po wd er sa lt wi th ou t lo go Pa ck ag ed po wd er w ith log o Ti be ta n sa lt Ot he r To ta l 97 .8 12 ,4 05 12 .4 3. 8 6. 9 76 .4 0. 1 0. 3 10 0. 0 12 ,1 33 Re gi on Ea ste rn M ou nt ain s 99 .4 17 9 15 .5 18 .9 2. 1 62 .0 1. 4 0. 0 10 0. 0 17 8 Ea ste rn H ills 99 .8 76 7 17 .3 22 .1 2. 3 58 .2 0. 0 0. 0 10 0. 0 76 5 Ea ste rn T er ai 98 .8 1, 84 5 0. 1 8. 1 20 .2 71 .4 0. 0 0. 1 10 0. 0 1, 82 2 Ce nt ra l M ou nt ain s 91 .1 29 9 38 .7 0. 5 2. 0 58 .8 0. 0 0. 0 10 0. 0 27 3 Ce nt ra l H ills 93 .5 2, 18 2 8. 9 0. 6 0. 8 89 .7 0. 0 0. 0 10 0. 0 2, 04 1 Ce nt ra l T er ai 99 .2 1, 92 4 0. 3 1. 0 10 .9 85 .9 0. 0 1. 9 10 0. 0 1, 90 9 W es te rn M ou nt ain s 97 .5 10 0. 6 0. 0 3. 5 75 .8 20 .1 0. 0 10 0. 0 10 W es te rn H ills 98 .7 1, 62 8 9. 3 0. 5 0. 4 89 .7 0. 1 0. 0 10 0. 0 1, 60 7 W es te rn T er ai 98 .0 92 4 5. 3 3. 1 15 .3 76 .3 0. 0 0. 0 10 0. 0 90 5 M id- W es te rn M ou nt ain s 99 .3 15 6 21 .0 2. 0 4. 0 70 .7 2. 3 0. 0 10 0. 0 15 5 M id- W es te rn H ills 99 .5 76 3 39 .4 0. 4 0. 6 59 .6 0. 0 0. 0 10 0. 0 76 0 M id- W es te rn T er ai 98 .3 67 2 22 .9 2. 8 2. 6 71 .2 0. 3 0. 2 10 0. 0 66 1 Fa r W es te rn M ou nt ain s 99 .3 18 5 24 .3 0. 2 12 .3 63 .0 0. 2 0. 0 10 0. 0 18 4 Fa r W es te rn H ills 99 .9 34 6 59 .4 0. 4 2. 2 38 .1 0. 0 0. 0 10 0. 0 34 5 Fa r W es te rn T er ai 98 .8 52 4 23 .8 3. 1 2. 6 70 .5 0. 0 0. 0 10 0. 0 51 7 Ar ea Ur ba n 97 .1 2, 47 6 1. 8 1. 0 1. 9 95 .1 0. 1 0. 0 10 0. 0 2, 40 4 Ka th m an du va lle y 95 .4 78 2 0. 3 0. 0 1. 0 98 .5 0. 1 0. 1 10 0. 0 74 6 Ot he r u rb an 97 .9 1, 69 4 2. 4 1. 5 2. 3 93 .6 0. 1 0. 0 10 0. 0 1, 65 8 Ru ra l 98 .0 9, 92 9 15 .1 4. 5 8. 1 71 .8 0. 1 0. 4 10 0. 0 9, 73 0 W ea lth in de x qu in til e Po or es t 98 .1 2, 37 6 41 .4 5. 0 2. 5 50 .9 0. 2 0. 0 10 0. 0 2, 33 0 Se co nd 96 .6 2, 55 8 14 .2 6. 2 10 .3 68 .8 0. 1 0. 3 10 0. 0 2, 47 0 M idd le 98 .2 2, 28 9 6. 2 5. 1 13 .5 74 .5 0. 0 0. 7 10 0. 0 2, 24 9 Fo ur th 98 .3 2, 44 1 2. 0 2. 7 7. 6 87 .0 0. 1 0. 6 10 0. 0 2, 39 8 Ri ch es t 98 .0 2, 74 2 0. 2 0. 5 1. 5 97 .7 0. 1 0. 0 10 0. 0 2, 68 6 NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 201446 Micronutrient Intake Nepal has made considerable progress in the control of micronutrient deficiencies; for example, vitamin A supplementation for children aged 6–59 months has been maintained at above 90-percent coverage over the last 15 years. Anaemia among women and children under five dropped significantly for a decade; however, the rate of decline has slowed over the last five years. Iron supplementation for pregnant and lactating women is one of the strategies adopted by the Ministry of Health and Population (MoHP) to prevent anaemia. It is recommended that women take iron/folic acid tablets for at least 180 days during pregnancy, preferably starting in the first trimester. Women need to continue taking iron/ folic acid tablets for 45 days after delivery to meet overall compliance of 225 tablets for pregnant and lactating women. It is also recommended that women receive deworming medication during pregnancy. Therefore, country-specific questions on whether women had taken iron folic tablets during pregnancy were asked to women with a live birth in the past two years. Of women aged 15–49 years with a live birth in the two years preceding the survey, 41 percent took iron/folic acid tablets for at least 180 days during their pregnancy and 34 percent took them for 90–179 days, giving a total of 75 percent of women taking tablets for at least 90 days. Another 8 percent took some tablets but for fewer than 90 days and 16 percent of women did not take any iron/ folic acid tablets. There were significant regional variations in the proportion of women taking iron/folic acid tablets for at least 180 days, ranging from 10 percent in the Mid-Western Mountains to 53 percent in the Central Terai. Urban women were more likely than rural women to take iron/folic acid tablets for at least 180 days (51 percent compared to 40 percent). Mother’s education and household wealth status were both positively correlated with the likelihood of taking iron/folic acid tablets for at least 180 days. Some 63 percent of women also received deworming medication. There was wide regional variation from 38 percent of women in the Central Hills to 82 percent of women in the Far Western Terai. Education level was positively associated with taking deworming medication. NEPAL MULTIPLE INDICATOR CLUSTER SURVEY 2014 47 Children’s Vitamin A Supplementation Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. Table NU.12: Micronutrient intake among mothers Percentage of women aged 15–49 years with a live birth in the two years preceding the survey by number of days they took iron/folic acid tablets during pregnancy for the last birth, and percentage who took deworming tablets during pregnancy for the last birth, Nepal, 2014 Percent who took iron/folic acid tablets by number of days Total Percent who took deworm- ing medica- tion Number of women with a live birth in the last two years None <60 60–89 90–179 180+ DK/ Missing Total 16.4 5.7 2.3 33.8 41.1 0.7 100.0 62.8 2,048 Region Eastern Mountains 22.6 9.5 7.8 31.4 28.7 0.0 100.0 68.1 32 Eastern Hills 20.8 11.0 1.0 25.2 42.0 0.0 100.0 78.9 123 Eastern Terai 11.8 2.9 0.3 32.2 52.8 0.0 100.0 61.3 277 Central Mountains 19.5 1.5 2.4 38.6 38.0 0.0 100.0 63.9 38 Central Hills 12.4 5.9 2.2 37.3 41.5 0.7 100.0 38.4 241 Central Terai 17.8 4.3 1.1 22.8 53.0 1.0 100.0 47.3 400 W

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