Nigeria - Demographic and Health Survey - 2009

Publication date: 2009

Nigeria 2008Demographic andHealth SurveyDemographic and H ealth Survey N igeria 2008 Nigeria Demographic and Health Survey 2008 National Population Commission Federal Republic of Nigeria Abuja, Nigeria ICF Macro Calverton, Maryland, USA November 2009 The 2008 Nigeria Demographic and Health Survey (2008 NDHS) was implemented by the National Population Commission (NPC) and fielded from June to October 2008. ICF Macro provided technical assistance as well as funding to the survey through MEASURE DHS, a project funded by the United States Agency for International Development (USAID) that provides support and technical assistance for the implementation of population and health surveys in countries worldwide. Funding for the survey was provided by USAID and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Funding for the household listing and additional fieldwork support was provided by the United Nations Population Fund (UNFPA). The views expressed in this publication are those of the authors and do not necessarily reflect the views of the Government of Nigeria, the United States Government, or donor organizations. Additional information about the 2008 NDHS may be obtained from the headquarters of the National Population Commission, Plot 2031, Olusegun Obasanjo Way, Zone 7 Wuse, PMB 0281, Abuja, Nigeria; Telephone: (234) 09 523-9173, Fax: (234) 09 523-1024. Information about the DHS programme may be obtained from the MEASURE DHS Project, ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572-0999, E- mail: reports@macrointernational.com, Internet: http://www.measuredhs.com. Recommended citation: National Population Commission (NPC) [Nigeria] and ICF Macro. 2009. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro. Contents | iii CONTENTS Page TABLES AND FIGURES .xi PREFACE . xxiii SUMMARY OF FINDINGS . xxv MILLENNIUM DEVELOPMENT GOAL INDICATORS .xxix MAP OF NIGERIA . xxx CHAPTER 1 INTRODUCTION 1.1 History, Geography, and Economy of Nigeria .1 1.1.1 History.1 1.1.2 Geography.1 1.1.3 Economy .2 1.2 Population and Basic Demographic Indicators.2 1.3 Population and Health Policies and Programmes.3 1.3.1 Population Policies and Programmes .3 1.3.2 Health Policies and Programmes.4 1.4 Education.5 1.5 Organisation and Objectives of the 2008 Nigeria Demographic and Health Survey .6 1.5.1 Sample Design.6 1.5.2` Questionnaires .7 1.5.3 Pre-test Activities .8 1.5.4 Training of Field Staff .8 1.5.5 Fieldwork .8 1.5.6 Data Processing .9 1.6 Response Rates .9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Population by Age and Sex.11 2.2 Household Composition .13 2.3 Education o the Household Population .13 2.3.1 Educational Attainment.14 2.3.2 School Attendance Rates .17 2.3.3 Grade Repetition and Drop-out Rates.19 2.4 Household Environment.20 2.4.1 Drinking Water.20 2.4.2 Household Sanitation Facilities .22 2.4.3 Housing Characteristics.23 iv │ Contents 2.5 Household Possessions.25 2.6 Wealth Index .25 2.7 Birth Registration.26 2.8 Neglected Tropical Diseases (NTDs) .28 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Characteristics of Survey Respondents.31 3.2 Educational Attainment by Background Characteristics.33 3.3 Literacy .34 3.4 Access to Mass Media .36 3.5 Employment .38 3.6 Occupation.41 3.7 Earnings, Employers, and Continuity of Employment .43 3.8 Health Insurance Coverage .44 3.9 Knowledge and Attitudes Regarding Tuberculosis .46 3.10 Tobacco Use.48 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4.1 Introduction.51 4.2 Current Fertility.51 4.3 Fertility Differentials .53 4.4 Fertility Trends .55 4.5 Children Ever Born and Living.56 4.6 Birth Intervals.57 4.7 Age at First Birth.59 4.8 Teenage Pregnancy and Motherhood.60 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods.63 5.2 Ever Use of Contraception .65 5.3 Current Use of Contraceptive Methods .68 5.4 Differentials in Contraceptive Use by Background Characteristics.69 5.5 Trends in Contraceptive Use .72 5.6 Number of Children at First Use of Contraception.73 5.7 Brands of Pills, Condoms, and Injectables Used.73 5.8 Knowledge of the Fertile Period .76 5.9 Timing of Sterilisation.77 5.10 Source of Contraception .78 5.11 Cost of Contraception .79 5.12 Informed Choice.80 5.13 Future Use of Contraception .81 5.14 Reasons for Not Intending to Use Contraception in the Future .82 5.15 Preferred Method for Future Use .83 5.16 Exposure to Family Planning Messages in the Media.83 5.16.1 Exposure to Specific Family Planning Messages .85 5.16.2 Exposure to Family Planning Information through Peer Groups, School, or Community Leaders.86 Contents | v 5.17 Contact of Non-users with Family Planning Providers .87 5.18 Husband/Partner’s Knowledge of Women’s Contraceptive Use .89 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status .91 6.2 Polygyny .92 6.3 Age at First Marriage .94 6.4 Median Age at First Marriage.95 6.5 Age at First Sexual Intercourse.96 6.6 Recent Sexual Activity .99 6.7 Postpartum Amenorrhoea, Abstinence, and Insusceptibility. 102 6.8 Menopause. 104 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 105 7.2 Desire to Limit Childbearing. 107 7.3 Need for Family Planning Services. 109 7.4 Ideal Family Size . 113 7.5 Fertility Planning . 115 7.6 Wanted Fertility Rates . 116 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Background and Assessment of Data Quality. 117 8.2 Infant and Child Mortality Levels and Trends. 118 8.3 Socio-Economic Differentials in Infant and Child Mortality . 120 8.4 Demographic Differentials in Childhood Mortality . 121 8.5 Perinatal Mortality. 122 8.6 High-Risk Fertility Behaviour . 124 CHAPTER 9 MATERNAL HEALTH AND OBSTETRIC FISTULA 9.1 Antenatal Care . 125 9.2 Number of ANC Visits and Timing of First Visit. 127 9.3 Components of Antenatal Care . 128 9.4 Tetanus Toxoid Injections . 130 9.5 Place of Delivery. 132 9.6 Assistance during Delivery. 133 9.7 Postnatal Care. 135 9.8 Perceived Problems in Accessing Health Care . 137 9.9 Obstetric Fistula . 139 9.9.1 Knowledge of Obstetric Fistula . 140 9.9.2 Characteristics of Labour Reported as Cause of Fistula Symptoms. 141 CHAPTER 10 CHILD HEALTH 10.1 Child’s Weight at Birth . 143 10.2 Vaccination of Children. 145 vi │ Contents 10.2.1 Trends in Vaccination Coverage. 147 10.2.2 Reasons for Not Receiving Vaccinations . 149 10.3 Acute Respiratory Infection . 151 10.4 Fever. 153 10.5 Prevalence of Diarrhoea. 155 10.6 Diarrhoea Treatment. 157 10.7 Feeding Practices . 158 10.8 Knowledge of ORS Packets . 160 10.9 Stool Disposal . 160 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 163 11.1.1 Measurement of Nutritional Status among Young Children . 163 11.1.2 Results of Data Collection . 164 11.1.3 Trends in Malnutrition . 167 11.2 Initiation of Breastfeeding. 167 11.3 Breastfeeding Status by Age. 170 11.4 Duration and Frequency of Breastfeeding . 172 11.5 Types of Complementary Foods . 173 11.6 Infant and Young Child Feeding (IYCF) Practices . 174 11.7 Micronutrient Intake among Children. 177 11.8 Presence of Iodised Salt in Households . 180 11.9 Nutritional Status of Women. 181 11.10 Foods Consumed by Mothers. 182 11.11 Micronutrient Intake among Mothers . 183 CHAPTER 12 MALARIA 12.1 Introduction. 187 12.2 Mosquito Nets . 187 12.2.1 Ownership of Mosquito Nets . 187 12.2.2 Use of Mosquito Nets by Children under Age Five . 189 12.2.3 Use of Mosquito Nets by All Women and Pregnant Women Age 15-49. 190 12.2.4 Trends in Mosquito Net Ownership and Use . 192 12.3 Prophylactic Use of Anti-malarial Drugs and Use of Intermittent Preventive Treatment in Pregnant Women. 192 12.4 Prevalence and Prompt Treatment of Fever in Children under Age Five . 194 12.5 Availability at Home of Anti-malarial Drugs Taken by Children with Fever. 196 CHAPTER 13 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 Introduction. 197 13.2 HIV and AIDS Knowledge, Transmission and Prevention Methods . 198 13.2.1 Awareness of HIV and AIDS . 198 Contents | vii 13.2.2 Knowledge of HIV Prevention. 199 13.2.3 Rejection of Misconceptions about HIV and AIDS . 200 13.3 Knowledge about Mother-to-Child Transmission . 203 13.4 Attitudes towards People Living with HIV and AIDS . 205 13.5 Attitudes towards Negotiating Safer Sexual Relations with Husbands . 207 13.6 Attitudes towards Condom Education for Youth . 209 13.7 Perceptions and Beliefs about Abstinence and Faithfulness. 210 13.8 Higher-Risk Sex. 210 13.9 Payment for Sex. 213 13.10 Coverage of HIV Testing Services . 215 13.11 Male Circumcision . 218 13.12 Self-Reporting of Sexually Transmitted Infections. 219 13.13 Prevalence of Medical Injections . 221 13.14 HIV and AIDS-Related Knowledge and Behaviour Among Youth. 223 13.14.1 Knowledge about HIV and AIDS and Sources for Condoms . 223 13.14.2 Age at First Sexual Intercourse . 225 13.14.3 Trends in Age at First Sexual Intercourse . 226 13.14.4 Condom Use at First Sex. 227 13.14.5 Premarital Sex . 228 13.14.6 Higher-Risk Sexual Intercourse . 229 13.14.7 Age-mixing in Sexual Relationships . 232 13.14.8 Drunkenness during Sexual Intercourse . 232 13.14.9 HIV Testing. 233 CHAPTER 14 ADULT AND MATERNAL MORTALITY 14.1 Data. 235 14.2 Direct Estimates of Adult Mortality . 236 14.3 Direct Estimates of Maternal Mortality. 237 CHAPTER 15 WOMEN’S EMPOWERMENT AND HEALTH OUTCOMES 15.1 Women’s and Men’s Employment . 239 15.1.1 Employment Status. 240 15.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s Earnings . 240 15.3 Women’s Participation in Decision-Making. 243 15.4 Attitudes towards Wife Beating . 247 15.5 Attitudes towards Refusing Sex with Husband . 250 15.6 Women’s Empowerment Indicators . 254 15.7 Current Use of Contraception By Woman’s Empowerment Status . 255 15.8 Ideal Family Size and Unmet Need by Women’s Status. 256 15.9 Women’s Status and Reproductive Health Care . 257 15.10 Women’s Status and Early Childhood Mortality . 258 CHAPTER 16 DOMESTIC VIOLENCE 16.1 Women Experiencing Physical Violence . 262 viii │ Contents 16.2 Perpetrators of Physical Violence. 264 16.3 Experience of Sexual Violence . 264 16.4 Age at First Experience of Sexual Violence. 265 16.5 Persons Committing Sexual Violence. 266 16.6 Experience of Different Forms of Violence . 267 16.7 Violence during Pregnancy. 267 16.8 Marital Control by Husband or Partner. 268 16.9 Forms of Spousal Violence . 271 16.10 Spousal Violence by Background Characteristics . 273 16.11 Violence by Spousal Characteristics and Women’s Indicators . 275 16.12 Frequency of Spousal Violence . 277 16.13 Onset of Spousal Violence . 278 16.14 Types of Injuries to Women because of Spousal Violence . 279 16.15 Violence by Women Against Their Spouse . 279 16.16 Help-seeking Behaviour by Women who Experience Violence. 282 16.17 Sources of Help . 284 CHAPTER 17 ORPHANS AND VULNERABLE CHILDREN 17.1 Orphaned and Vulnerable Children . 285 17.1.1 Children’s Living Arrangements and Orphanhood 17.1.2 Orphaned and Vulnerable Children. 286 17.2 Social and Economic Situation of Orphaned and Vulnerable Children. 288 17.2.1 School Attendance. 288 17.2.2 Basic Material Needs . 289 17.2.3 Orphans Living with Siblings . 290 17.2.4 Nutritional Status . 291 17.3 Care and Support for OVCs . 293 17.3.1 Succession Planning. 293 17.3.2 External Support for Households with OVCs . 296 CHAPTER 18 FEMALE GENITAL CUTTING 18.1 Knowledge and Prevalence of Female Genital Cutting. 299 18.2 Flesh Removal and Infibulation . 301 18.3 Age at Circumcision . 301 18.4 Person Who Performed Circumcision. 302 18.5 Circumcision of Daughters . 304 18.6 Reasons for Supporting Female Circumcision . 305 18.7 Attitudes towards Female Circumcision . 307 APPENDIX A STATE TABLES . 317 APPENDIX B SURVEY DESIGN .457 APPENDIX C ESTIMATES OF SAMPLING ERRORS.463 APPENDIX D DATA QUALITY TABLES. 477 Contents | ix APPENDIX E NUTRITIONAL STATUS OF CHILDREN: 2008 NDHS DATA ACCORDING TO THE NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION . 483 APPENDIX F PERSONS INVOLVED IN THE 2008 NIGERIA DEMOGRAPHIC AND HEALTH SURVEY. 485 APPENDIX G QUESTIONNAIRES .497 Tables and Figures | xi TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators. 3 Table 1.2 Results of the household and individual interviews. 9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence.12 Table 2.2 Household composition.13 Table 2.3.1 Educational attainment of the female household population .15 Table 2.3.2 Educational attainment of the male household population .16 Table 2.4 School attendance ratios .18 Table 2.5 Grade repetition and drop-out rates.19 Table 2.6 Household drinking water.21 Table 2.7 Household sanitation facilities.22 Table 2.8 Household characteristics .24 Table 2.9 Household durable goods .25 Table 2.10 Wealth quintiles.26 Table 2.11 Birth registration of children under age five .27 Table 2.12 Birth registration of children under age five by authority .28 Table 2.13 Neglected tropical diseases reported in households.30 Figure 2.1 Population Pyramid .12 Figure 2.2 Percent Distribution of Household Population with No Education by Sex.17 Figure 2.3 Age-Specific Attendance Rates of the De Facto Population Age 5 to 24 by Sex.20 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents .32 Table 3.2.1 Educational attainment: Women.33 Table 3.2.2 Educational attainment: Men .34 Table 3.3.1 Literacy: Women .35 Table 3.3.2 Literacy: Men .36 Table 3.4.1 Exposure to mass media: Women.37 Table 3.4.2 Exposure to mass media: Men .38 Table 3.5.1 Employment status: Women .39 Table 3.5.2 Employment status: Men.40 Table 3.6.1 Occupation: Women.41 Table 3.6.2 Occupation: Men .42 Table 3.7.1 Type of employment: Women.43 Table 3.7.2 Type of employment: Men .44 Table 3.8.1 Health insurance coverage: Women .45 Table 3.8.2 Health insurance coverage: Men.46 xii | Tables and Figures Table 3.9.1 Knowledge and attitudes concerning tuberculosis: Women.47 Table 3.9.2 Knowledge and attitudes concerning tuberculosis: Men .48 Table 3.10.1 Use of tobacco: Women.49 Table 3.10.2 Use of tobacco: Men .50 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS Table 4.1 Current fertility .52 Table 4.2 Fertility by background characteristics .54 Table 4.3 Trends in age-specific fertility rates.55 Table 4.4 Trends in age-specific and total fertility rates, various sources.55 Table 4.5 Children ever born and living.57 Table 4.6 Birth intervals.58 Table 4.7 Age at first birth .59 Table 4.8 Median age at first birth .60 Table 4.9 Teenage pregnancy and motherhood.61 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence.52 Figure 4.2 Total Fertility Rates of Selected West African Countries .53 Figure 4.3 Fertility Differentials by Zone .54 Figure 4.4 Trends in Age-Specific Fertility Rates, 1991-2008.56 Figure 4.5 Percentage of Teenagers Who Have Begun Childbearing and Who Are Pregnant With Their First Child, by Age .61 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods .64 Table 5.2 Knowledge of contraceptive methods by background characteristics .65 Table 5.3.1 Ever use of contraception: Women .66 Table 5.3.2 Ever use of contraception: Men .68 Table 5.4 Current use of contraception by age .70 Table 5.5 Current use of contraception by background characteristics .71 Table 5.6 Trends in current use of contraception.72 Table 5.7 Number of children at first use of contraception .73 Table 5.8 Use of social marketing brand pills and injectables: women .74 Table 5.9 1 Use of social marketing brand condoms: women .75 Table 5.9.2 Use of social marketing brand condoms: men.76 Table 5.10 Knowledge of fertile period.77 Table 5.11 Timing of sterilisation .77 Table 5.12 Source of modern contraception methods .78 Table 5.13 Cost of modern contraceptive methods.80 Table 5.14 Informed choice .81 Table 5.15 Future use of contraception .82 Table 5.16 Reason for not intending to use contraception in the future .82 Table 5.17 Preferred method of contraception for future use.83 Table 5.18 Exposure to family planning messages .84 Table 5.19 Exposure to specific family planning messages.86 Table 5.20 Exposure to family planning messages through peer groups, school, or community leaders .87 Table 5.21 Contact of non-users with family planning providers .88 Table 5.22 Husband/partner's knowledge of women's use of contraception .89 Tables and Figures | xiii Figure 5.1 Trends in Contraceptive Prevalence, NDHS 1990-2008.72 Figure 5.2 Source of Family Planning Methods among Current Users of Modern Methods .79 Figure 5.3 Percentage of Men and Women Exposed to Family Planning Messages.85 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status .91 Table 6.2.1 Number of women's co-wives .92 Table 6.2.2 Number of men's wives.93 Table 6.3 Age at first marriage .94 Table 6.4.1 Median age at first marriage: Women .95 Table 6.4.2 Median age at first marriage: Men.96 Table 6.5 Age at first sexual intercourse .97 Table 6.6.1 Median age at first intercourse: Women .98 Table 6.6.2 Median age at first intercourse: Men.98 Table 6.7.1 Recent sexual activity: Women .99 Table 6.7.2 Recent sexual activity: Men . 101 Table 6.8 Post-partum amenorrhoea, abstinence and insusceptibility . 102 Table 6.9 Median duration of amenorrhoea, post-partum abstinence and Post-partum insusceptibility . 103 Table 6.10 Menopause. 104 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 106 Table 7.2.1 Desire to limit childbearing: Women . 108 Table 7.2.2 Desire to limit childbearing: Men. 109 Table 7.3.1 Need and demand for family planning among currently married women . 110 Table 7.3.2 Need and demand for family planning for all women and for women who are not currently married . 112 Table 7.4 Ideal number of children . 114 Table 7.5 Mean ideal number of children. 115 Table 7.6 Fertility planning status. 116 Table 7.7 Wanted fertility rates. 116 Figure 7.1 Percentage of Currently Married Women and Men Who Want No More Children, by Number of Living Children . 107 Figure 7.2 Unmet Need for Family Planning for Currently Married Women by Residence and Zones . 111 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 119 Table 8.2 Trends in early childhood mortality. 120 Table 8.3 Childhood mortality rates by socio-economic characteristics . 121 Table 8.4 Early childhood mortality rates by demographic characteristics. 122 Table 8.5 Perinatal mortality. 123 Table 8.6 High-risk fertility behaviour . 124 xiv | Tables and Figures Figure 8.1 Mortality Trends. 119 CHAPTER 9 MATERNAL HEALTH AND OBSTETRIC FISTULA Table 9.1 Antenatal care. 126 Table 9.2 Number of antenatal care visits and timing of first visit . 128 Table 9.3 Components of antenatal care . 129 Table 9.4 Tetanus toxoid injections . 131 Table 9.5 Place of delivery . 132 Table 9.6 Assistance during delivery . 134 Table 9.7 Timing of first postnatal check-up . 136 Table 9.8 Provider of first postnatal check-up . 137 Table 9.9 Problems in accessing health care . 138 Table 9.10 Knowledge of fistula and experience of fistula-like symptoms. 140 Table 9.11 Characteristics of labour reported as cause of fistula symptoms . 141 Figure 9.1 Place of Delivery. 133 Figure 9.2 Problems in Accessing Health Care . 139 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth. 144 Table 10.2 Vaccinations by source of information. 146 Table 10.3 Vaccinations by background characteristics . 147 Table 10.4 Vaccinations in first year of life. 148 Table 10.5 Vaccinations received during national immunisation day campaigns . 149 Table 10.6 Reasons for child not receiving any vaccines . 150 Table 10.7 Reasons for child not receiving any polio vaccine. 151 Table 10.8 Prevalence and treatment of symptoms of ARI . 152 Table 10.9 Prevalence and treatment of fever. 154 Table 10.10 Availability at home of anti-malarial drugs taken by children . 155 Table 10.11 Prevalence of diarrhoea . 156 Table 10.12 Diarrhoeal treatment . 157 Table 10.13 Feeding practices during diarrhoea . 159 Table 10.14 Knowledge of ORS packets or pre-packaged liquids. 160 Table 10.15 Disposal of children's stools. 161 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 165 Table 11.2 Initial breastfeeding. 168 Table 11.3 Breastfeeding status by age . 170 Table 11.4 Median duration and frequency of breastfeeding . 172 Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview . 174 Table 11.6 Infant and young child feeding (IYCF) practices . 176 Table 11.7 Micronutrient intake among children . 179 Table 11.8 Presence of iodised salt in household. 180 Table 11.9 Nutritional status of women . 182 Table 11.10 Foods consumed by mothers in the day and night preceding the interview. 183 Tables and Figures | xv Table 11.11 Micronutrient intake among mothers . 184 Figure 11.1 Nutritional Status of Children by Age . 166 Figure 11.2 Trends in Nutritional Status of Children Under Five, 2003 NDHS and 2008 NDHS. 167 Figure 11.3 Among Last Children Born in the Five Years Preceding the Survey Who Ever Received a Prelacteal Liquid, the Percentage Who Received Specific Liquids. 169 Figure 11.4 Infant Feeding Practices by Age. 171 Figure 11.5 Trends in Infant Feeding Practices for Children 0-5 Months and 6-9 Months, 2003 NDHS and 2008 NDHS. 171 Figure 11.6 Infant and Young Child Feeding (IYCF) Practices . 177 CHAPTER 12 MALARIA Table 12.1 Ownership of mosquito nets . 188 Table 12.2 Use of mosquito nets by children. 189 Table 12.3 Use of mosquito nets by women. 190 Table 12.4 Use of mosquito nets by pregnant women . 191 Table 12.5 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy. 193 Table 12.6 Prevalence and prompt treatment of fever . 195 Table 12.7 Type and timing of anti-malarial drugs . 196 Table 12.8 Availability at home of anti-malarial drugs taken by children with fever. 196 Figure 12.1 Trends in Net Ownership and Use, NDHS 2003 AND NDHS 2008. 192 CHAPTER 13 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS. 198 Table 13.2 Knowledge of HIV prevention methods. 200 Table 13.3.1 Comprehensive knowledge about HIV and AIDS: Women . 201 Table 13.3.2 Comprehensive knowledge about HIV and AIDS: Men. 202 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV. 204 Table 13.5.1 Accepting attitudes towards persons living with HIV or AIDS: Women . 206 Table 13.5.2 Accepting attitudes towards persons living with HIV or AIDS: Men . 207 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 208 Table 13.7 Adult support of education about condom use to prevent transmission of HIV. 209 Table 13.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women . 211 Table 13.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men. 212 Table 13.9 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men . 214 Table 13.10.1 Coverage of prior HIV testing: Women . 215 Table 13.10.2 Coverage of prior HIV testing: Men. 216 Table 13.11 Pregnant women counselled and tested for HIV. 218 Table 13.12 Male circumcision. 219 xvi | Tables and Figures Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms. 220 Table 13.14 Prevalence of medical injections . 222 Table 13.15 Comprehensive knowledge about HIV and AIDS and of a source of condoms among youth . 224 Table 13.16 Age at first sexual intercourse among youth. 225 Table 13.17 Condom use at first sexual intercourse among youth. 227 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth. 228 Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Women . 230 Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Men. 231 Table 13.20 Age-mixing in sexual relationships among women age 15-19 . 232 Table 13.21 Drunkenness during sexual intercourse among youth. 233 Table 13.22 Recent HIV tests among youth . 234 Figure 13.1 Perception and Beliefs about Abstinence and Faithfulness . 210 Figure 13.2 Women and Men Seeking Advice or Treatment for STIs. 221 Figure 13.3 Trends in Age at First Sexual Intercourse . 226 CHAPTER 14 ADULT AND MATERNAL MORTALITY Table 14.1 Completeness of reporting on siblings . 235 Table 14.2 Adult mortality rates and trends . 236 Table 14.3 Direct estimates of maternal mortality . 237 Figure 14.1 Adult Mortality Rates among Women and Men Age 15-49. 237 CHAPTER 15 WOMEN’S EMPOWERMENT AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women and men . 240 Table 15.2.1 Control over women's cash earnings and relative magnitude of women's earnings: Women. 241 Table 15.2.2 Control over men's cash earnings . 242 Table 15.3 Women's control over their own earnings and the earnings of their husband. 243 Table 15.4.1 Women's participation in decision-making . 244 Table 15.4.2 Women's participation in decision-making according to men . 244 Table 15.5.1 Women's participation in decision-making by background characteristics . 245 Table 15.5.2 Men's attitude towards wives' participation in decision-making. 246 Table 15.6.1 Attitudes towards wife beating: Women. 248 Table 15.6.2 Attitudes towards wife beating: Men . 249 Table 15.7.1 Attitudes towards refusing sexual intercourse with husband: Women. 251 Table 15.7.2 Attitudes towards refusing sexual intercourse with husband: Men . 252 Table 15.7.3 Men's attitudes towards a husband's rights when his wife refuses to have sexual intercourse. 253 Table 15.8 Indicators of women's empowerment. 255 Table 15.9 Current use of contraception by women's status. 256 Tables and Figures | xvii Table 15.10 Women's empowerment and ideal number of children and unmet need for family planning . 257 Table 15.11 Reproductive health care by women's empowerment . 258 Table 15.12 Early childhood mortality rates by women's status . 259 CHAPTER 16 DOMESTIC VIOLENCE Table 16.1 Experience of physical violence. 263 Table 16.2 Persons committing physical violence . 264 Table 16.3 Experience of sexual violence . 265 Table 16.4 Age at first experience of sexual violence . 266 Table 16.5 Persons committing sexual violence . 266 Table 16.6 Experience of different forms of violence . 267 Table 16.7 Violence during pregnancy . 268 Table 16.8 Degree of marital control exercised by husbands . 270 Table 16.9 Forms of spousal violence . 272 Table 16.10 Spousal violence by background characteristics. 274 Table 16.11 Spousal violence by husband's characteristics and empowerment indicators. 276 Table 16.12 Frequency of spousal violence among those who report violence. 277 Table 16.13 Onset of marital violence . 278 Table 16.14 Injuries to women due to spousal violence. 279 Table 16.15 Violence by women against their spouse. 280 Table 16.16 Help-seeking to stop violence . 283 Table 16.17 Sources from where help was sought . 284 Figure 16.1 Forms of Spousal Violence . 273 CHAPTER 17 ORPHANS AND VULNERABLE CHILDREN Table 17.1 Children's living arrangements and orphanhood. 286 Table 17.2 Orphans and vulnerable children (OVC) . 287 Table 17.3 School attendance by survivorship of parents and by OVC status . 289 Table 17.4 Possession of basic material needs by orphans and vulnerable children. 290 Table 17.5 Orphan not living with siblings . 291 Table 17.6 Underweight orphans and vulnerable children. 292 Table 17.7 Sexual intercourse before age 15 among orphans and vulnerable children . 293 Table 17.8 Succession planning. 294 Table 17.9 Widows dispossessed of property. 295 Table 17.10 External support for very sick persons. 296 Table 17.11 External support for orphans and vulnerable children. 297 CHAPTER 18 FEMALE GENITAL CUTTING Table 18.1 Knowledge and prevalence of female circumcision . 300 Table 18.2 Age at circumcision. 302 Table 18.3 Person who performed circumcision . 303 Table 18.4 Daughter's circumcision experience and type of circumcision . 304 Table 18.5 Selected characteristics of daughter's circumcision . 305 Table 18.6.1 Perceived benefits of female circumcision: Women . 306 xviii | Tables and Figures Table 18.6.2 Perceived benefits of female circumcision: Men. 307 Table 18.7.1 Attitudes towards continuation of female circumcision: Women . 308 Table 18.7.2 Attitudes towards continuation of female circumcision: Men. 309 APPENDIX A STATE TABLES Table A-2.3.1 Educational attainment of the female household population: States . 317 Table A-2.3.2 Educational attainment of the male household population: States . 318 Table A-2.4 School attendance ratios: States . 319 Table A-2.6.1 Household drinking water: Zones . 321 Table A-2.6.2 Household drinking water: States. 322 Table A-2.7.1 Household sanitation facilities: Zones . 324 Table A-2.7.2 Household sanitation facilities: States. 325 Table A-2.8.1 Household access to electricity: Zones. 327 Table A-2.8.2 Household access to electricity: States . 328 Table A-2.11 Birth registration of children under age five: States. 330 Table A-2.12 Birth registration of children under age five by authority: States . 331 Table A-2.13 Neglected tropical diseases reported in households: States. 332 Table A-3.1 Background characteristics of respondents . 333 Table A-3.2.1 Educational attainment: Women by state. 334 Table A-3.2.2 Educational attainment: Men by state . 335 Table A-3.3.1 Literacy: Women by state . 336 Table A-3.3.2 Literacy: Men by state. 337 Table A-3.4.1 Exposure to mass media: Women by state . 338 Table A-3.4.2 Exposure to mass media: Men by state. 339 Table A-3.5.1 Employment status: Women by state . 340 Table A-3.5.2 Employment status: Men by state. 341 Table A-3.6.1 Occupation: Women by state . 342 Table A-3.6.2 Occupation: Men by state . 343 Table A-3.7.1 Type of earnings: Women by state . 344 Table A-3.7.2 Type of earnings: Men by state . 345 Table A-3.7.3 Type of employer: Women by state . 346 Table A-3.7.4 Type of employer: Men by state . 347 Table A-3.7.5 Continuity of employment: Women by state. 348 Table A-3.7.6 Continuity of employment: Men by state . 349 Table A-3.9.1 Knowledge and attitudes concerning tuberculosis: Women by state . 350 Table A-3.9.2 Knowledge and attitudes concerning tuberculosis: Men by state . 351 Table A-4.2 Fertility by state of residence: States. 352 Table A-4.5 Birth intervals: States. 353 Table A-4.8 Median age at first birth: States . 354 Table A-4.9 Teenage pregnancy and motherhood: States. 355 Table A-5.2 Knowledge of contraceptive methods by state of residence: States. 356 Table A-5.5 Current use of contraception by state of residence: States . 357 Table A-5.18 Exposure to family planning messages: States . 358 Table A-5.21 Contact of non-users with family planning providers: States . 359 Table A-5.22 Husband/partner's knowledge of women's use of contraception: States . 360 Tables and Figures | xix Table A-6.2.1 Number of women's co-wives: States . 361 Table A-6.2.2 Number of men's wives: States. 362 Table A-6.7.1 Recent sexual activity: Women by state . 363 Table A-6.7.2 Recent sexual activity: Men by state. 364 Table A-9.1 Antenatal care: States. 366 Table A-9.3 Components of antenatal care: States . 367 Table A-9.4 Tetanus toxoid injections: States . 368 Table A-9.5 Place of delivery: States . 369 Table A-9.6 Assistance during delivery: States . 370 Table A-9.7 Timing of first postnatal check-up: States . 371 Table A-9.8 Provider of first postnatal check-up: States . 372 Table A-9.9 Problems in accessing health care: States . 373 Table A-10.3 Vaccinations by state of residence: States. 374 Table A-10.5 Vaccinations received during national immunisation day campaigns: States. 375 Table A-10.6 Reasons for child not receiving any vaccines: States . 376 Table A-10.7 Reasons for child not receiving any polio vaccine: States. 377 Table A-10.9 Prevalence and treatment of fever: States. 378 Table A-10.11 Prevalence of diarrhoea: States . 379 Table A-10.14 Knowledge of ORS packets or pre-packaged liquids: States. 380 Table A-10.15 Disposal of children's stools: States. 381 Table A-11.1 Nutritional status of children: States . 382 Table A-11.2 Initial breastfeeding: States. 383 Table A-11.4 Median duration and frequency of breastfeeding: States . 384 Table A-11.6 Infant and young child feeding (IYCF) practices: States . 385 Table A-11.7 Micronutrient intake among children: States . 386 Table A-11.8 Presence of iodised salt in household: States. 387 Table A-11.9 Nutritional status of women: States . 388 Table A-11.10 Foods consumed by mothers in the day and night preceding the interview: States . 389 Table A-11.11 Micronutrient intake among mothers: States . 390 Table A-12.1 Ownership of mosquito nets: States . 392 Table A-12.2 Use of mosquito nets by children: States. 393 Table A-12.3 Use of mosquito nets by women: States. 394 Table A-12.4 Use of mosquito nets by pregnant women: States . 395 Table A-12.5 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy: States. 396 Table A-12.6 Prevalence and prompt treatment of fever: States . 397 Table A-12.7 Type and timing of anti-malarial drugs: States . 398 Table A-13.1 Knowledge of AIDS: States. 399 Table A-13.2 Knowledge of HIV prevention methods: States. 400 Table A-13.3.1 Comprehensive knowledge about HIV and AIDS: Women by state. 401 Table A-13.3.2 Comprehensive knowledge about HIV and AIDS: Men by state . 402 Table A-13.4 Knowledge of prevention of mother-to-child transmission of HIV: States. 403 Table A-13.5.1 Accepting attitudes towards persons living with HIV or AIDS: Women by state . 404 xx | Tables and Figures Table A-13.5.2 Accepting attitudes towards persons living with HIV or AIDS: Men by state . 405 Table A-13.6 Attitudes towards negotiating safer sexual relations with husband: States. 406 Table A-13.7 Adult support of education about condom use to prevent transmission of HIV: States. 407 Table A-13.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women by state. 408 Table A-13.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men by state . 410 Table A-13.9 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men by state. 412 Table A-13.10.1 Coverage of prior HIV testing: Women by state . 413 Table A-13.10.2 Coverage of prior HIV testing: Men by state. 414 Table A-13.11 Pregnant women counselled and tested for HIV: States. 415 Table A-13.12 Male circumcision: States. 416 Table A-13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms: States . 417 Table A-13.14 Prevalence of medical injections: States . 418 Table A-13.15 Comprehensive knowledge about HIV and AIDS and of a source of condoms among youth: States . 419 Table A-13.16 Age at first sexual intercourse among youth: States. 420 Table A-13.17 Condom use at first sexual intercourse among youth: States. 421 Table A-13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth: States. 422 Table A-13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Women by state. 423 Table A-13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Men by state . 424 Table A-13.20 Age-mixing in sexual relationships among women age 15-19: States . 425 Table A-13.21 Drunkenness during sexual intercourse among youth: States. 426 Table A-13.22 Recent HIV tests among youth: States . 427 Table A-15.2.1 Control over women's cash earnings and relative magnitude of women's earnings: Women by state . 429 Table A-15.2.2 Control over men's cash earnings: States . 430 Table A-15.5.1 Women's participation in decision-making by state of residence: States . 431 Table A-15.5.2 Men's attitudes towards wives' participation in decision-making: States . 432 Table A-15.6.1 Attitudes towards wife beating: Women by state. 433 Table A-15.6.2 Attitudes towards wife beating: Men by state . 434 Table A-15.7.1 Attitudes towards refusing sexual intercourse with husband: Women by state . 435 Table A-15.7.2 Attitudes towards refusing sexual intercourse with husband: Men by state . 436 Table A-15.7.3 Men's attitudes towards a husband's rights when his wife refuses to have sexual intercourse: States. 437 Table A-17.1 Children's living arrangements and orphanhood: States . 439 Table A-17.2 Orphans and vulnerable children (OVC): States . 440 Table A-17-3.1 School attendance by survivorship of parents: States . 441 Table A-17.3.2 School attendance by OVC status: States . 442 Tables and Figures | xxi Table A-17.4 Possession of basic material needs by orphans and vulnerable children: States. 443 Table A-17.5 Orphan not living with siblings: States. 444 Table A-17.8 Succession planning: States. 445 Table A-17.9 Widows dispossessed of property: States. 446 Table A-17.11 External support for orphans and vulnerable children: States. 447 Table A-18.1 Knowledge and prevalence of female circumcision: States . 448 Table A-18.2 Age at circumcision: States. 449 Table A-18.3 Person who performed circumcision: States . 450 Table A-18.4 Daughter's circumcision experience and type of circumcision: States . 451 Table A-18.6.1 Perceived benefits of female circumcision: Women by state . 452 Table A-18.6.2 Perceived benefits of female circumcision: Men by state. 453 Table A-18.7.1 Attitudes towards continuation of female circumcision: Women by state . 454 Table A-18.7.2 Attitudes towards continuation of female circumcision: Men by state. 455 APPENDIX B SURVEY DESIGN Table B.1 Allocation of completed interviews by region and state . 459 Table B.2 Sample implementation: Women . 461 Table B.3 Sample implementation: Men. 462 APPENDIX C ESTIMATES OF SAMPLING ERRORS Table C.1 List of selected variables for sampling errors, Nigeria 2008 . 466 Table C.2 Sampling errors for national sample, Nigeria 2008 . 467 Table C.3 Sampling errors for urban sample, Nigeria 2008. 468 Table C,4 Sampling errors for rural sample, Nigeria 2008. 469 Table C.5 Sampling errors for Central sample, Nigeria 2008. 470 Table C.6 Sampling errors for North East sample, Nigeria 2008. 471 Table C.7 Sampling errors for North West sample, Nigeria 2008. 472 Table C.8 Sampling errors for South East sample, Nigeria 2008. 473 Table C.9 Sampling errors for South South sample, Nigeria 2008. 474 Table C.10 Sampling errors for South West sample, Nigeria 2008 . 475 APPENDIX D DATA QUALITY TABLES Table D.1 Household age distribution . 477 Table D.2.1 Age distribution of eligible and interviewed women . 478 Table D.2.2 Age distribution of eligible and interviewed men. 478 Table D.3 Completeness of reporting . 479 Table D.4 Births by calendar years . 479 Table D.5 Reporting of age at death in days . 480 Table D.6 Reporting of age at death in months. 481 Table D.7 Data on siblings . 482 Table D.8 Sibship size and sex ratio of siblings . 482 APPENDIX E NUTRITIONAL STATUS OF CHILDREN: 2008 NDHS DATA ACCORDING TO THE NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION Table E.1 Nutritional status of children . 483 Preface | xxiii PREFACE The conduct of the 2008 Nigeria Demographic and Health Survey (2008 NDHS) is in furtherance of the National Population Commission’s (NPC) responsibility of collecting, collating, analysing, and disseminating population census and survey data at all levels that contribute to policy formulation and coordination of population activities in the country. I am delighted to present the final report for the 2008 NDHS. The survey is the latest in the periodic Demographic and Health Survey (DHS) series, which started in Nigeria at the national level in 1990. The 2008 NDHS is a national sample survey designed to provide up-to-date information on background characteristics of the respondents; fertility levels; nuptiality; sexual activity; fertility preferences; awareness and the use of family planning methods; breastfeeding practices; nutritional status of mothers and young children; early childhood mortality and maternal mortality; maternal and child health; and awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections. The target groups were women age 15-49 years and men age 15-59 years in randomly selected households across Nigeria. Information about children age 0-5 years was also collected, including weight and height. While the survey is expanded in scope and sample size, the 2008 NDHS is a follow-up to the 1990, 1999, and 2003 NDHS surveys and provides updated estimates of basic demographic and health indicators covered in the earlier surveys. The 2008 NDHS is the first DHS to include the collection of information on violence against women. In addition to presenting national estimates, the report provides estimates of key indicators for rural and urban areas in Nigeria, the six geo-political zones, and for the first time, the thirty-six states and the Federal Capital Territory (FCT). The unprecedented success of the 2008 NDHS was made possible by the contributions from a number of organisations and individuals. I wish to acknowledge the support of the United States Agency for International Development in Nigeria (USAID/Nigeria) and the President’s Emergency Plan for AIDS Relief (PEPFAR) for funding the survey, and to Akintola Williams Deloitte for providing accounting and disbursement services that allowed for the timely and efficient transfer of project funds throughout all components of the survey. Similarly, I wish to acknowledge the United Nations Population Fund (UNFPA) for funding the household listing exercise and additional field support. The support and collaboration witnessed by the 2008 NDHS from government, non- governmental, international development organisations, and other major stakeholders is hereby acknowledged. Special mention is given to the Federal Ministry of Health and its agencies, the National Bureau of Statistics, and the United Nations Children’s Fund (UNICEF) for their support. I would like to thank the NPC Federal Commissioners for their support during the implementation period for providing excellent leadership and advocacy support. The unflinching support and technical assistance provided by Dr. Wokoma D.C. Wokoma (Director-General), Dr. Emmanuel Enu Attah (Director, Planning and Research), and all other Directors are hereby acknowledged. On behalf of the Commission, I gratefully acknowledge the tireless dedication of the core 2008 NDHS team for their outstanding and enthusiastic management of all the technical, administrative, and logistical phases of the survey. The survey could not have been conducted without the leadership of Mr. Sani Ali Gar (Project Director) and Mr. Inuwa Bakari Jalingo (Project Coordinator). Similarly, I wish to express appreciation to ICF Macro for its technical assistance in all stages of the survey. The commitment of the ICF Macro Country Manager, Ms. Adrienne Cox, is greatly appreciated. Ms. Sherrell Goggin and Mr. Noureddine Abderrahim (Data Processing Specialists) handled data processing of the 2008 NDHS with great expertise. I wish to commend the xxiv | Preface efforts of Dr. Alfredo Aliaga (Sampling Specialist), who provided technical support during the sample selection exercise. Dr. Pav Govindasamy (Regional Coordinator) also deserves our deep appreciation for her contributions. Special gratitude goes to the Supervisors, Editors, Interviewers, Quality Control Interviewers, Drivers, and the Data Processing team for their tireless efforts. Finally, a special gratitude goes to all the respondents for their cooperation, patience, and generosity in providing the required information throughout the survey. Without their cooperation, this survey would not have been a success. Chief Samu’ila Danko Makama, CON Chairman National Population Commission Summary of Findings | xxv SUMMARY OF FINDINGS The 2008 Nigeria Demographic Health Sur- vey (NDHS) is a nationally representative survey of 33,385 women age 15-49 and 15,486 men age 15-59. The 2008 NDHS is the fourth comprehen- sive survey conducted in Nigeria as part of the Demographic and Health Surveys (DHS) pro- gramme. The data are intended to furnish pro- gramme managers and policymakers with de- tailed information on levels and trends in fertil- ity; nuptiality; sexual activity; fertility prefer- ences; awareness and use of family planning methods; infants and young children feeding practices; nutritional status of mothers and young children; early childhood mortality and maternal mortality; maternal and child health; and aware- ness and behaviour regarding HIV/AIDS and other sexually transmitted infections. Addition- ally, the 2008 NDHS collected information on malaria prevention and treatment, neglected tropical diseases, domestic violence, fistulae, and female genital cutting (FGC). FERTILITY The survey results show fertility in Nigeria has remained at a high level over the last 17 years from 5.9 births per woman in 1991 to 5.7 births in 2008. On average, rural women are hav- ing two children more than urban women (6.3 and 4.7 children, respectively). Fertility differen- tials by education and wealth are noticeable. Women who have no formal education and women in the lowest wealth quintile on average are having 7 children, while women with higher than a secondary education are having 3 children and women in the highest wealth quintile are having 4 children. Unplanned pregnancies are common in Nige- ria. Overall, 4 percent of births are unwanted, while 7 percent are mistimed (wanted later). If all unwanted births were prevented, women would have an average of 5.3 children, compared with the actual average of 5.7 children. Marriage patterns are an important determi- nant of fertility levels in a population. The me- dian age at first marriage in Nigeria among women age 25-49 is 18.3 years. Urban women marry four years later than rural women (21.1 and 16.9 years, respectively). The median age at first marriage varies substantially by level of education. For women age 25-49 with no educa- tion the median age at marriage is 15.5 years, compared with 22.0 years for women with more than secondary education. Men enter into first union at a later age than women; the median age at first marriage for men age 25-59 is more than 26 years of age. The initiation of sexual activity before mar- riage is not uncommon in Nigeria. Among re- spondents age 25-49, the median age at first sex- ual intercourse is 17.7 years for women and 20.6 years for men. Teenage pregnancy is high in Nigeria. Twenty-three percent of young women age 15-19 have begun childbearing, that is, they have given birth or are currently pregnant with their first child. The 2008 NDHS shows that 33 percent of currently married women are married to men who are in a polygynous union. Older women, women in rural areas, women with less educa- tion, and women in the lowest wealth quintiles are more likely than other women to have co- wives. The prevalence of polygyny varies mark- edly across zones, with South East having the lowest level (13 percent) and North East having the highest (43 percent). FAMILY PLANNING In the 2008 NDHS, 72 percent of all women and 90 percent of all men know at least one con- traceptive method. Male condoms, the pill, and injectables are the most widely known methods. Twenty-nine percent of currently married women have used a family planning method at least once in their lifetime. Fifteen percent of currently married women are using any contra- ceptive method and 10 percent are using a mod- ern method. The most commonly used methods among currently married women are injectables (3 percent), followed by male condoms and the pill (2 percent each). xxvi * Summary of Findings Current use of contraception in Nigeria has increased from 6 percent in 1990 and 13 percent in 2003 to 15 percent in 2008. There has been a corresponding increase in the use of modern con- traceptive methods, from 4 percent in 1990 and 8 percent in 2003 to 10 percent in 2008. Private chemists are the chief provider of contraceptive methods in Nigeria. The distribu- tion of sources of modern method supplies for current users shows that the majority of users (60 percent) obtain their contraceptive methods from the private sector. The participation of the public medical sector in family planning service deliv- ery has decreased steadily during the past 18 years from 37 percent in 1990 to 23 percent in 2008. Overall, 20 percent of currently married women have an unmet need for family plan- ning—15 percent for spacing and 5 percent for limiting. If all married women with an unmet need for family planning were to use a contra- ceptive method, the contraceptive prevalence rate for any method would increase from 15 to 35 percent. CHILD HEALTH Data from the 2008 NDHS indicate that the infant mortality rate is 75 deaths per 1,000 live births, while the under-five mortality rate is 157 per 1,000 live births for the five-year period im- mediately preceding the survey. The neonatal mortality rate is 40 per 1,000 births. Thus, almost half of childhood deaths occurred during infancy, with one-quarter taking place during the first month of life. Child mortality is consistently lower in urban areas than in rural areas. There is also variation in the mortality level across zones. The infant mortality and under-five mortality rates are high- est in the North East, and lowest in the South West. In Nigeria, children are considered fully vac- cinated when they receive one dose of BCG vac- cine, three doses of DPT vaccine, three doses of polio vaccine, and one dose of measles vaccine. Overall, 23 percent of children 12-23 months have received all vaccinations at the time of the survey. Fifty percent of children have received the BCG vaccination, and 41 percent have been vaccinated against measles. The coverage of the first dose of DPT vaccine and polio 1 is 52 and 68 percent, respectively). However, only 35 per- cent of children have received the third dose of DPT vaccine, and 39 percent have received the third dose of polio vaccine. A comparison of the 2008 NDHS results with those of the earlier sur- veys shows there has been an increase in the overall vaccination coverage in Nigeria from 13 percent in 2003 to the current rate of 23 percent. However, the percentage of children with no vaccinations has not improved for the same pe- riod, 27 percent in 2003 and 29 percent in 2008. Three percent of children under five years showed symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey. Treatment from a health facility or provider was sought for 45 percent of children with ARI symptoms. Twenty-three percent of children re- ceived antibiotics. Sixteen percent of children under five were reported to have had fever, a major manifestation of malaria, within the two weeks prior to the sur- vey. More than half of children (54 percent) were taken to a health facility or provider for treat- ment. A third of children with fever (33 percent) received anti-malarial drugs and 18 percent re- ceived antibiotics. At the time of the survey, 10 percent of chil- dren under age five had diarrhoea at some time within the two weeks before the survey. For 42 percent of children, advice or treatment was sought from a health facility or a health provider. More than a third of children (37 percent) were treated with some type of oral rehydration ther- apy (ORT) or increased fluids: 26 percent were treated with solution prepared from an oral rehy- dration salt (ORS) packet; 8 percent were given recommended home fluids (RHF) prepared at home; and 9 percent were given increased fluids. Twenty-nine percent of children with diarrhoea did not receive any type of treatment at all. MATERNAL HEALTH In Nigeria more than half of women who had a live birth in the five years preceding the survey received antenatal care from a health profes- sional (58 percent); 23 percent from a doctor, 30 percent from a nurse or midwife, and 5 percent from an auxiliary nurse or midwife. Thirty-six percent of mothers did not receive any antenatal care. Summary of Findings | xxvii Tetanus toxoid injections are given during pregnancy to prevent neonatal tetanus. Overall, 48 percent of last births in Nigeria were pro- tected against neonatal tetanus. More than one-third of births in the five years before the survey were delivered in a health facility (35 percent). Twenty percent of births occurred in public health facilities and 15 percent occurred in private health facilities. Al- most two-thirds (62 percent) of births occurred at home. Nine percent of births were assisted by a doctor, 25 percent by a nurse or midwife, 5 per- cent by an auxiliary nurse or midwife, and 22 percent by a traditional birth attendant. Nineteen percent of births were assisted by a relative and 19 percent of births had no assistance at all. Two percent of births were delivered by a caesarean section. Overall, 42 percent of mothers received a postnatal check-up for the most recent birth in the five years preceding the survey, with 38 per- cent having the check-up within the critical 48 hours after delivery. Results from the 2008 NDHS show that the estimated maternal mortality ratio during the seven-year period prior to the survey is 545 ma- ternal deaths per 100,000 live births. BREASTFEEDING AND NUTRITION Ninety-seven percent of Nigerian children under age five were breastfed at some point in their life. The median breastfeeding duration in Nigeria is long (18.1 months). On the other hand, the median duration for exclusive breastfeeding is only for half a month. A small proportion of babies (13 percent) are exclusively breastfed throughout the first six months of life. More than seven in ten (76 percent) children age 6-9 months receive complementary foods. Sixteen percent of babies less than six months of age are fed with a bottle with a nipple, and the proportion bottle-fed peaks at 17 percent among children in the age groups 2-3 months and 4-5 months. Anthropometric measurements carried out at the time of the survey indicate that, overall, 41 percent of Nigerian children are stunted (short for their age), 14 percent are wasted (thin for their height), and 23 percent are underweight. The indices show that malnutrition in young children increases with age, starting with wast- ing, which peaks among children age 6-8 months, underweight peaks among children age 12-17 months, and stunting is highest among children age 18-23 months. Stunting affects half of children in this age group and almost one-third of children age 18-23 months are severely stunted. Overall, 66 percent of women have a body mass index (BMI) in the normal range; 12 per- cent of women are classified as thin and 4 per- cent are severely thin. Twenty-two percent of women are classified as overweight or obese, with 6 percent in the latter category. MALARIA Seventeen percent of all households inter- viewed during the survey had at least one mos- quito net, while 8 percent had more than one. Sixteen percent of households had at least one net that had been treated at some time (ever- treated) with an insecticide. Eight percent of households had at least one insecticide-treated net (ITN). Mosquito net usage is low among young children and pregnant women, groups that are particularly vulnerable to the effects of malaria. Overall, 12 percent of children under five slept under a mosquito net the night before the survey. Twelve percent of children slept under an ever- treated net and 6 percent slept under an ITN. Among pregnant women, 12 percent slept under any mosquito net the night before the interview. Twelve percent slept under an ever-treated net and 5 percent slept under an ITN. Among women who had their last birth in the two years before the survey, 18 percent took an anti-malarial drug during the pregnancy. Eleven percent of all pregnant women took at least one dose of a sulphadoxine-pyrimethamine (SP) drug such as Fansidar, Amalar, or Maloxine, while 7 percent reported taking two or more doses of an SP drug. Eight percent of the women who took an SP drug were given the drug during an antena- tal care visit, a practice known as intermittent preventive treatment (IPT). HIV/AIDS KNOWLEDGE AND BEHAVIOUR The majority of women (88 percent) and men (94 percent) age 15-49 have heard of HIV or AIDS. However, only 23 percent of women and 36 percent of men have what can be considered xxviii * Summary of Findings comprehensive knowledge about the modes of HIV transmission and prevention. Comprehen- sive knowledge means knowing that using con- doms and having just one uninfected, faithful partner can reduce the chance of getting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about HIV transmission or pre- vention, that HIV and AIDS can be transmitted through supernatural means or through mosquito bites. Fifty-two percent of women and 59 percent of men age 15-49 know that HIV can be trans- mitted through breastfeeding. Twenty-eight per- cent of women and 39 percent of men know that the risk of mother-to-child transmission (MTCT) can be reduced by the mother taking special drugs during pregnancy. Given that most HIV cases in Nigeria occur as a result of heterosexual contact, information about the level of higher-risk sexual intercourse (i.e., sexual intercourse with a non-marital, non- cohabiting partner) in the past 12 months is im- portant for planning HIV prevention pro- grammes. The 2008 NDHS findings indicate that 1 percent of women and 10 percent of men had two or more sexual partners during the 12 months preceding the survey. Ten percent of women and 23 percent of men had higher-risk sexual intercourse in this period. Among these respondents, only 33 percent of women and 54 percent of men reported that they used a condom the last time they had sexual intercourse with a higher-risk sexual partner. Among the adult population age 15-49, 17 percent of women and 15 percent of men have been tested for HIV at some time. Seven percent of women and 7 of men received the results from their last HIV test that was taken in the past 12 months. DOMESTIC VIOLENCE One eligible woman in each household was asked questions on domestic violence. In Nige- ria, domestic violence occurs across all socio- economic and cultural backgrounds. Twenty- eight percent of all women reported experiencing physical violence since the age of 15, and 15 percent of women experienced physical violence in the 12 months preceding the survey. Among women who experienced violence since age 15, a total of 45 percent reported that their current husband or partner was the perpetrator and 7 per- cent reported that the perpetrator was a former husband or partner. Overall, 7 percent of women reported that they had experienced sexual violence at some time in their lives. Forty-three percent of women reported that their first experience with sexual intercourse occurred when they were less than 20 years of age. Half of women reported that their current or former husband, partner, or boyfriend committed the act of sexual violence. It is impor- tant to highlight that among women who were younger than age 15 when they first experienced sexual violence, 28 percent reported that the per- petrator was a stranger, 12 percent reported that the person was a friend or acquaintance, 11 per- cent reported that the person was a relative, and 7 percent reported that the person was a family friend. Thirty-four percent of Nigerian women who ever experienced physical or sexual violence sought help to stop the violence. Eight percent of abused women did not seek help but did tell someone about the violence, and 45 percent of the women did not seek help from any source and did not tell anyone about the violence. ORPHANS AND VULNERABLE CHILDREN Twelve percent Nigerian children under age 18 in the households sampled in the 2008 NDHS were not living with a biological parent. Six per- cent of children under age 18 are orphaned, that is, one or both parents are dead. Earlier NDHS surveys obtained information on orphanhood only for children under age 15. A comparison of the results from the 2003 and 2008 surveys for this age group indicates that there has been a slight decrease in orphanhood from 6.2 percent to 5.2 percent. The proportion of children who are not living with either parent decreased from 11 to 9 percent for children under age 15. Overall, 5 percent of children under age 18 are considered vulnerable, i.e., they live in a household in which at least one adult was chronically ill for three months during the past 12 months, or they had a parent living in the household (or elsewhere) who had experienced chronic illness in the past year. Overall, 11 per- cent of children under age 18 are considered or- phans and/or vulnerable. Millennium Development Goal Indicators | xxix MILLENNIUM DEVELOPMENT GOAL INDICATORS Value Goal Indicator Female Male Total 1. Eradicate extreme poverty and hunger 1.8-Prevalence of underweight children under five years of age1 21.7 24.5 23.1 2. Achieve universal primary education 2.1-Net attendance ratio in primary school2 2.2-Percentage of pupils starting grade 1 who reach grade 53 59.1 98.5 64.9 98.5 62.1 98.5 2.3-Literacy rate of 15-24 year-olds4 64.3 82.5 69.4 3. Promote gender equality and empower women 3.1-Ratio of girls to boys in primary, secondary and tertiary education na na 83.9 4. Reduce child mortality 4.1-Under-five mortality rate (per 1,000 live births) 166 175 157 4.2-Infant mortality rate (per 1,000 live births) 81 93 75 4.3-Percentage of 1 year-old children immunised against measles 41.4 41.5 41.4 5. Improve maternal health 5.1-Maternal mortality ratio (0-6 year period before survey) na na 545 5.2-Percentage of births attended by skilled health personnel5 39.3 38.6 38.9 5.3-Contraceptive prevalence rate (any contraceptive method, currently married women and men age 15-49) 14.6 na na 6. Combat HIV/AIDS, malaria and other diseases 6.2-Condom use at last higher-risk sex: youth 15-24 years6 35.5 49.4 40.8 6.3-Percentage of population 15-24 years with comprehensive knowledge of HIV/AIDS7 22.2 32.6 23.9 6.4-Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years 1.3 1.1 1.2 6.7-Percentage of children under five sleeping under ITN 5.6 5.3 5.5 6.8-Percentage of children under five with fever who are appropriately treated with anti-malarial drugs8 31.8 34.4 33.2 Value Urban Rural Total 7. Ensure environmental sustainability 7.8-Percentage of population using improved drinking water source, urban and rural (de jure population)9 79.7 43.8 55.8 7.9-Percentage of population using improved sanitation facility, urban and rural (de jure population)10 37.5 28.1 31.2 na = Not applicable 1 Proportion of children age 0-59 months who are below -2 standard deviations (SD) from the median of the WHO Child Growth Standards in weight-for-age 2 2008 NDHS data are based on reported attendance, not enrolment. 3 The cohort of people enrolled in grade 1 who are expected to reach grade 5. 4 Refers to respondents who attended secondary school or higher or who can read a whole sentence 5 Among births in the past 5 years 6 Higher-risk refers to sexual intercourse with a non-marital, non-cohabiting partner; time frame is 12 months preceding the survey. 7 A person is considered to have comprehensive knowledge about HIV/AIDS when s/he knows that consistent use of a condom during sexual intercourse and having just one HIV-negative and faithful partner can reduce the chances of getting HIV, knows that a healthy-looking person can have HIV, and rejects the two most common misconceptions about HIV, i.e., that HIV can be transmitted by mosquito bites and that a person can get HIV by eating from the same plate as someone who has HIV. 8 Malaria treatment is measured as the percentage of children age 0-59 months who were ill with a fever in the two weeks preceding the interview and received an anti-malarial drug. 9 Proportion whose main source of drinking water is a household connection (piped), public standpipe, borehole, protected dug well or spring, or rainwater collection. 10 Improved sanitation technologies are: flush toilet, ventilated improved pit latrine, traditional pit latrine with a slab, or composting toilet. xxx | Map of Nigeria Introduction | 1 INTRODUCTION 1 1.1 HISTORY, GEOGRAPHY, AND ECONOMY OF NIGERIA 1.1.1 History Nigeria came into existence as a nation-state in 1914 through the amalgamation of the Northern and Southern protectorates. Prior to that time, there were various separate cultural, ethnic, and linguistic groups, such as the Oyo, Benin, Nupe, Jukun, Kanem-Bornu, and Hausa-Fulani empires. These peoples lived in kingdoms and emirates with traditional but sophisticated systems of government. There were also other relatively small but strong—and indeed resistant—ethnic groups (e.g., Igbo, Ibibio, and Tiv). The British established a crown colony type of government after the amalgamation. The affairs of the colonial administration were conducted by the British until 1942, when a few Nigerians became involved in the administration of the country. In the early 1950s, Nigeria achieved partial self- government with a legislature in which the majority of the members were elected into an executive council of which most were Nigerians. Nigeria became fully independent in October 1960 as a federation of three regions (Northern, Western, and Eastern) under a constitution that provided for a parliamentary system of governance. The Lagos area became the Federal Capital Territory. On October 1, 1963, Nigeria became a republic with different administrative structures, social groups, and distinct cultural traits. There are about 374 identifiable ethnic groups, with the Igbo, Hausa, and Yoruba as major groups. Presently, Nigeria is made up of 36 states and a Federal Capital Territory (FCT), grouped into six geopolitical zones: North Central, North East, North West, South East, South South, and South West. There are also 774 constitutionally recognized local government areas (LGAs) in the country. 1.1.2 Geography Nigeria is in the West African sub-region, lying between latitudes 4º16' and 13º53' north and longitudes 2º40' and 14º41' east. It is bordered by Niger in the north, Chad in the northeast, Cameroon in the east, and Benin in the west. To the south, Nigeria is bordered by approximately 850 kilometres of the Atlantic Ocean, stretching from Badagry in the west to the Rio del Rey in the east. With a total land area of 923,768 square kilometres, Nigeria is the fourteenth largest country in Africa. Nigeria is diverse in climate and topography, encompassing uplands of 600 to 1,300 metres in the North Central and the east highlands, and lowlands of less than 20 metres in the coastal areas. The lowlands extend from the Sokoto plains to the Borno plains in the North, the coastal lowlands of Western Nigeria, and the Cross River basin in the east. The highland areas include the Jos Plateau and the Adamawa Highlands in the North, extending to the Obudu Plateau and Oban Hills in the South East. Other topographic features include the Niger-Benue Trough and Chad Basin. Nigeria has a tropical climate with distinct wet and dry seasons associated with the movement of the two dominant winds—the rain-bearing south westerly winds and the cold, dry, and dusty north easterly winds commonly referred to as the Harmattan. The dry season occurs from October to March with a spell of cool, dry, and dusty Harmattan wind felt mostly in the north in December and January. The wet season occurs from April to September. The temperature in Nigeria oscillates between 25° and 40°C, and rainfall ranges from 2,650 millimetres in the southeast to less than 600 millimetres in some parts of the north, mainly on the fringes of the Sahara Desert. The vegetation that results from 2 | Introduction these climatic differences consists of mangrove swamp forest in the Niger Delta and Sahel grassland in the north. Within a wide range of climatic, vegetation, and soil conditions, Nigeria possesses potential for growing a wide range of agricultural crops. 1.1.3 Economy Agriculture has been the mainstay of Nigeria’s economy. Before the discovery of oil, the country depended almost entirely on agricultural production for food and agro-industrial raw materials for foreign exchange earnings through the commodity trade. At the time of independence, over 75 percent of the country’s labour force was engaged in agriculture, which also provided gainful employment and a satisfactory livelihood to over 90 percent of the population. Over the years, the dominant role of agriculture in the economy, especially in terms of the country’s foreign exchange earnings, gave way to petroleum exports. The country’s economic strength is derived largely from its oil and gas reserves, which make up 99 percent of export revenues, 78 percent of government revenues, and 38.8 percent of the GDP (2006). The contributions of other sectors to the GDP in 2006 were as follows: agriculture (32.5 percent), wholesale and retail (13.5 percent), industry, excluding petroleum (2.9 percent) and other sectors (1.5 percent). Since 1980, oil production has accounted for more than two-thirds of the GDP and more than 80 percent of the total government revenues (FRN, 2008). Since the onset of the new democratic administration in 1999, economic policies have become more favourable to investment. Progress has been made toward establishing a market-based economy. Consequently, there has been an improvement in the performance of the domestic economy. Nigeria’s GDP growth rate was estimated at 2.7 percent in 1999, 2.8 percent in 2000, and 3.8 percent in 2001. By 2006, the real GDP growth rate was estimated at 6.0 percent (Central Bank of Nigeria, 2002). Before the advent of the civilian administration in 1999, Nigeria had a large public sector, comprising over 550 public enterprises in most sectors of the economy and dominating activities in the electric power, telecommunications, petroleum, and steel sectors. The public enterprise sector accounts for an estimated 50 percent of the total GDP, 57 percent of investments, and 33 percent of formal sector employment (Central Bank of Nigeria, 2002). Like other emerging democracies, the civilian administration in Nigeria has recognised the importance of privatisation in the restructuring of its economy. A number of policies were put in place to liberalise, deregulate, and privatise key sectors of the economy such as electric power, telecommunications, and downstream petroleum sectors. In recent years, Nigeria privatised the only government-owned petrochemical company and sold its interest in eight oil service companies. While it may be too early to determine the impact of privatization and liberalisation on the Nigerian economy, it is believed that these economic policy reforms, combined with investments in human capital and physical infrastructure, as well as the establishment of macroeconomic stability and good governance, are essential to achieve a high rate of self-sustaining, long-term economic growth. 1.2 POPULATION AND BASIC DEMOGRAPHIC INDICATORS Nigeria has, since the 19th century collected demographic statistics through censuses, vital registration systems and sample surveys. However, until the 1950s these were limited to certain parts of the country. Since then, there have been considerable improvements in the data collection process. The first attempt at a population census in Nigeria was in 1866. Subsequent censuses before 1952, such as the 1911 and 1922 censuses, were restricted to specific sections of the country. The 1952-1953 enumeration was the first nationwide census. The first post-independence census, conducted in 1962, was cancelled because of alleged irregularities in its conduct. Another census, conducted in 1963, was officially accepted (Table 1.1). The Population Census of 1973 was not acceptable and was therefore cancelled. The next census took place in 1991. The 2006 Population and Introduction | 3 Housing Census puts Nigeria’s population at 140,431,790, with a national growth rate estimated at 3.2 percent per annum. With this population, Nigeria is the most populous nation in Africa. Nigeria’s population is unevenly distributed across the country. Large areas in the Chad Basin, the middle Niger Valley, the grassland plains, among others, are sparsely populated. The average population density for the country in 2006 was estimated at 150 people per square kilometre. The most densely populated states are Lagos, Anambra, Imo, Abia, and Akwa Ibom. Most of the densely populated states are found in the South East, Kano state, with an average density of 442 persons per square kilometre, is the most densely populated state in the north. Table 1.1 Basic demographic indicators Demographic indicators from various sources, Nigeria 1963-2006 Indicators Census 1963 NFS 1981-1982 Census 1991 NDHS 20031 Census 2006 Population (millions) 55.7 84.7 88.9 u 140.4 Density (pop./sq.km) 60 92 96 u 150 Percent urban 19 23 36.3 u u Crude birth rate (CBR) 66 46 44.6 41.7 u Crude death rate (CDR) 27 16 14 u u Total fertility rate (TFR) u 6.3 5.9 5.7 u Infant mortality rate (IMR) u 85 93 100 u Life expectancy at birth 36 48 53.2 u u u = Unknown (not available) 1 Reported rates. See 2003 NDHS final report for information on data quality. Sources: National Population Commission; Federal Office of Statistics Numerous sample surveys have been conducted in an effort to generate reliable demographic data. These include the 1965-1966 Rural Demographic Sample Survey and the 1980 National Demographic Sample Survey (NDSS) conducted by the Federal Office of Statistics and the National Population Bureau, respectively. The 1981-1982 Nigeria Fertility Survey (NFS) was the first nationally representative survey on fertility, family planning, contraceptive use, and related topics. This was followed by the first Nigeria Demographic and Health Survey (NDHS) in 1990. In 1994, the first sentinel survey was conducted to serve as a baseline study to monitor the various projects designed to achieve the objectives of the National Population Policy. In 1999, another NDHS was conducted. This was followed by a sentinel survey conducted in 2000. Another sentinel survey was conducted in 2007 to further assess the implementation of the objectives of the population policy. 1.3 POPULATION AND HEALTH POLICIES AND PROGRAMMES 1.3.1 Population Policies and Programmes In response to the pattern of the population growth rate and its adverse effect on national development, the Federal Government of Nigeria approved the National Policy on Population for Development on February 4, 1988. Over the years, emerging issues such as HIV/AIDS, poverty, gender inequality, among others, gained wider recognition. This necessitated a review of the 1988 National Population Policy, giving way to the National Policy on Population for Sustainable Development launched in February 2005 by the then President and Commander-in-Chief of the armed forces of the Federal Republic of Nigeria, Chief Olusegun Obasanjo. The policy recognises that population factors, social and economic development, and environmental issues are irrevocably interconnected and are critical to the achievement of sustainable development in Nigeria. 4 | Introduction The overall goal of the National Policy on Population for Sustainable Development is to improve the quality of life and standard of living for the Nigerian population (NPC, 2004). This is to be achieved through the attainment of a number of specific goals that include: • Achievement of sustainable economic growth, protection and preservation of the environment, poverty eradication, and provision of quality social services, • Achievement of a balance between the rate of population growth, available resources, and social and economic development of the country, • Progress towards a complete demographic transition to a reasonable growth in birth rates and a low death rate, • Improvement in the reproductive health of all Nigerians at every stage of the life circle, • Acceleration of a strong and immediate response to the HIV/AIDS pandemic and other related infectious diseases, • Progress in achieving balance and integrated urban and rural development. The National Policy on Population for Sustainable Development operates on the principle that achieving a higher quality of life for people today should not jeopardise the ability of future generations to meet their own needs (NPC, 2004). To guide policy, programme planning, and implementation, the following targets were set: • Reduce the national population growth rate to 2 percent or lower by 2015. • Reduce the total fertility rate by at least 0.6 children every five years by encouraging child spacing through the use of family planning. • Increase the contraceptive prevalence rate for modern methods by at least two percentage points per year through the use of family planning. • Reduce the infant mortality rate to 35 per 1,000 live births by 2015. • Reduce the child mortality rate to 45 per 1,000 live births by 2010. • Reduce the maternal mortality ratio to 125 per 100,000 live births by 2010 and to 75 by 2015. • Achieve sustainable universal basic education as soon as possible before 2015. • Eliminate the gap between males and females in school enrolment at all levels and in vocational and technical education by 2015. • Eliminate illiteracy by 2020. • Achieve at least a 25 percent reduction in HIV/AIDS adult prevalence every five years. 1.3.2 Health Policies and Programmes A national health policy targeted at achieving health for all Nigerians was promulgated in 1988. In view of emerging issues and the need to focus on realities and trends, a review of the policy became necessary. The new policy, referred to as the Revised National Health Policy, launched in September 2004, describes the goals, structure, strategy, and policy direction of the health care delivery system in Nigeria (NPC, 2004a). Roles and responsibilities of different tiers of government, including non-governmental organisations are outlined. The policy’s long-term goal is to provide adequate access to primary, secondary, and tertiary health care services for the entire Nigerian population through a functional referral system. Introduction | 5 The following principles and values underpin the Revised National Health Policy: • Social justice, equity, and the ideals of freedom and opportunity affirmed in the 1999 Constitution of the Federal Republic of Nigeria are a basic right. • Health and access to quality and affordable health care is a human right. • Equity in health care for all Nigerians will be pursued as a goal. • Primary health care (PHC) shall remain the basic philosophy and strategy for national health development. • Good quality health care shall be assured through cost-effective interventions that are targeted at priority health problems. • A high level of efficiency and accountability shall be maintained in the development and management of the national health system. • Effective partnership and collaboration between various health sectors shall be pursued while safeguarding the identity of each. Because health is an integral part of overall development, inter-sectoral cooperation and collaboration between the different health-related ministries, development agencies and other relevant institutions shall be strengthened; and a gender-sensitive and responsive national health system shall be achieved by mainstreaming gender considerations in all health programmes. The overall objective of the Revised National Health Policy is to strengthen the national health system such that it will be able to provide effective, efficient, quality, accessible and affordable health services that will improve the health status of Nigerians through the achievement of the health- related Millennium Development Goals (MDGs). The main health policy targets are the following: • Reduce the under-five mortality rate by two-thirds between 1990 and 2015, • Reduce the maternal mortality rate by three-quarters between 1990 and 2015, • Reduce the spread of HIV/AIDS by 2015, • Reduce the burden of malaria and other major diseases by 2015. The national health policy regards primary health care as the framework to achieve improved health for the population. Primary health care services include health education; adequate nutrition; safe water and sanitation; reproductive health, including family planning; immunisation against five major infectious diseases; the provision of essential drugs; and disease control. The policy document requires that a comprehensive health care system delivered through the primary health centres should include maternal and child health care, including family planning services. The health sector is characterised by wide regional disparities in status, service delivery, and resource availability. More health services are located in the southern states than in the northern states. The current priorities in the health sector are in the area of childhood immunisation and HIV/AIDS prevention. 1.4 EDUCATION Education in Nigeria has been through a series of policy changes over time. The overall responsibility establishing national policies and guidelines for uniform standards throughout all levels of education is vested in the Federal Ministry of Education. These policies and guidelines are protected by various statutory instruments such as the National Policy on Education, the Education Decree No. 16 of 1985 and the 1999 Constitution of the Federal Republic of Nigeria. Accordingly, the Federal Ministry of Education focuses on six spheres of education—Early Childhood Education, 6 | Introduction Basic Education, Secondary Education, Tertiary Education, Adult and Non-formal Education, and Special Needs Education (Federal Ministry of Education, 2009). The National Policy on Education provides every child the right to tuition-free primary education. This has resulted in an increase in the school enrolment and in the number of educational institutions, particularly in the public sector. The 6-3-3-4 system introduced in 1981 provides six years of primary education, followed by three years of junior secondary education, and three years of senior secondary education. The last segment of four years is for university or polytechnic education. Subsequently, the National Literacy Programme for Adults was launched, followed by the establishment of Nomadic Education to address the needs of children of migrant cattle herders and fishermen in the riverine areas. The Universal Basic Education (UBE) system, launched in October 1999, made it compulsory for every child to be educated free of tuition up to the junior secondary school level in an effort to meet Nigeria’s manpower requirements for national development (Osuji, 2004). 1.5 ORGANISATION AND OBJECTIVES OF THE 2008 NIGERIA DEMOGRAPHIC AND HEALTH SURVEY The 2008 Nigeria Demographic and Health Survey (2008 NDHS) was implemented by the National Population Commission from June to October 2008 on a nationally representative sample of more than 36,000 households. All women age 15-49 in these households and all men age 15-59 in a sub-sample of half of the households were individually interviewed. While significantly expanded in content, the 2008 NDHS is a follow-up to the 1990, 1999, and 2003 NDHS surveys and provides updated estimates of basic demographic and health indicators covered in these earlier surveys. In addition, the 2008 NDHS includes the collection of information on violence against women. Although previous surveys collected data at the national and zonal levels, the 2008 NDHS is the first NDHS survey to collect data on basic demographic and health indicators at the state level. The primary objectives of the 2008 NDHS project were to provide up-to-date information on fertility levels; nuptiality; sexual activity; fertility preferences; awareness and use of family planning methods; breastfeeding practices; nutritional status of mothers and young children; early childhood mortality and maternal mortality; maternal and child health; and awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections. 1.5.1 Sample Design The sample for the 2008 NDHS was designed to provide population and health indicators at the national, zonal, and state levels. The sample design allowed for specific indicators, such as contraceptive use, to be calculated for each of the 6 zones and 37 states (36 states plus the Federal Capital Territory, Abuja). The sampling frame used for the 2008 NDHS was the 2006 Population and Housing Census of the Federal Republic of Nigeria conducted in 2006, provided by the National Population Commission (NPC). Administratively, Nigeria is divided into states. Each state is subdivided into local government areas (LGAs), and each LGA is divided into localities. In addition to these administrative units, during the 2006 Population Census, each locality was subdivided into convenient areas called census enumeration areas (EAs). The primary sampling unit (PSU), referred to as a cluster for the 2008 NDHS, is defined on the basis of EAs from the 2006 EA census frame. The 2008 NDHS sample was selected using a stratified two-stage cluster design consisting of 888 clusters, 286 in the urban and 602 in the rural areas1. A representative sample of 36,800 households was selected for the 2008 1 The final survey sample included 886 instead of 888 clusters. During fieldwork, access was not obtained in one cluster due to flooding, and in another cluster due to inter-communal disturbances. Introduction | 7 NDHS survey, with a minimum target of 950 completed interviews per state. In each state, the number of households was distributed proportionately among its urban and rural areas. A complete listing of households and a mapping exercise were carried out for each cluster from April to May 2008, with the resulting lists of households serving as the sampling frame for the selection of households in the second stage. All private households were listed. The NPC listing enumerators were trained to use Global Positioning System (GPS) receivers to take the coordinates of the 2008 NDHS sample clusters. In the second stage of selection, an average of 41 households was selected in each cluster, by equal probability systematic sampling. All women age 15-49 who were either permanent residents of the households in the 2008 NDHS sample or visitors present in the households on the night before the survey were eligible to be interviewed. In a sub-sample of half of the households, all men age 15-59 who were either permanent residents of the households in the 2008 NDHS sample or visitors present in the households on the night before the survey were eligible to be interviewed. In addition, a sub- sample of one eligible woman in each household was randomly selected to be asked additional questions about domestic violence. 1.5.2 Questionnaires Three questionnaires were used for the 2008 NDHS. They are the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. These questionnaires were adapted to reflect the population and health issues relevant to Nigeria at a series of meetings with various stakeholders from government ministries and agencies, non-governmental organisations, and international donors. In addition to English, the questionnaires were translated into three major Nigerian languages: Hausa, Igbo, and Yoruba. The Household Questionnaire was used to list all the usual members and visitors of selected households. Some basic information was collected on the characteristics of each person listed, including his or her age, sex, education, and relationship to the head of the household. For children under age 18, survival status of the parents was determined. If a child in the household had a parent who was sick for more than three consecutive months in the 12 months preceding the survey or a parent who had died, additional questions related to support for orphans and vulnerable children were asked. Additionally, if an adult in the household was sick for more than three consecutive months in the 12 months preceding the survey or an adult in the household died, questions were asked related to support for sick people or people in households where a household member has died. The data on the age and sex of household members obtained in the Household Questionnaire was used to identify women and men who were eligible for the individual interview. Additionally, the Household Questionnaire collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, and ownership and use of mosquito nets (to assess the coverage of malaria prevention programmes). The Household Questionnaire was also used to record height and weight measurements for children age 0-59 months and women age 15-49. The Women’s Questionnaire was used to collect information on all women age 15-49. These women were asked questions on the following main topics: • Background characteristics (education, residential history, media exposure, etc.) • Birth history and childhood mortality • Knowledge and use of family planning methods • Fertility preferences • Antenatal, delivery, and postnatal care • Breastfeeding and infant and young child feeding practices • Vaccinations and childhood illnesses • Marriage and sexual activity 8 | Introduction • Women’s work and husband’s background characteristics • Women’s and children’s nutritional status • Malaria prevention and treatment • Awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections (STIs) • Adult mortality including maternal mortality • Women’s status and health outcomes • Fistulae • Domestic violence • Female genital cutting The Men’s Questionnaire was administered to all men age 15-59 in every second household in the 2008 NDHS sample. The Men’s Questionnaire collected much of the same information found in the Women’s Questionnaire, but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health or nutrition. 1.5.3 Pre-test Activities The training for the pre-test took place March 3-12, 2008. Thirty-two interviewers (15 females and 17 males) were trained to administer the questionnaires and take anthropometric measurements. The pre-test training for the interviewers and supervisors consisted of a project overview and survey objectives, techniques of interviewing, field procedures, a detailed description of all sections of the household and individual questionnaires, and two days of field practice. The trainers/resource people included professionals from NPC and ICF Macro. The pre-test was conducted in 6 states by 6 teams March 15-22, 2008. The teams were divided according to languages. There were 2 Hausa teams in the North East and North West zones, 2 English teams in the South South and North Central zones, 1 Yoruba team in the South West, and 1 Igbo team in the South East. The supervisors and editors were drawn from the NPC core technical team. The teams covered 6 zones (one state in each zone) and aimed at completing 25 urban and 25 rural households per state. At the end of fieldwork, a debriefing session was held March 24-25, 2008 in Kaduna with all staff involved in the pre-test, and the questionnaires were amended based on the pre-test findings. 1.5.4 Training of Field Staff NPC recruited and trained 368 people for the fieldwork to serve as zonal coordinators, supervisors, field editors, female and male interviewers, reserve interviewers, and quality control interviewers. Training of field staff for the main survey was conducted during a three-week period in May-June 2008. The training course consisted of instruction regarding interviewing techniques and field procedures, a detailed review of items on the questionnaires, instruction and practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews with real respondents in areas outside the 2008 NDHS sample points. During this period, field editors, team supervisors, and quality control interviewers were provided with additional training in methods of field editing, data quality control procedures, and fieldwork coordination. Thirty-seven supervisors, 37 editors, 152 female interviewers, and 74 male interviewers were selected to make up 37 data collection teams for the 2008 NDHS. Thirty-seven people were selected to be quality control interviewers. 1.5.5 Fieldwork Thirty-seven interviewing teams carried out data collection for the 2008 NDHS. Each team consisted of 1 supervisor (team leader), 1 field editor, 4 female interviewers, 2 male interviewers, and 2 drivers. Nineteen senior staff members from NPC, designated as zonal coordinators, coordinated Introduction | 9 and supervised fieldwork activities. Data collection took place over a four-month period from June to October 2008. 1.5.6 Data Processing All questionnaires for the 2008 NDHS were returned to the NPC headquarters office in Abuja for data processing, which consisted of office editing, coding of open-ended questions, data entry, and editing computer-identified errors. The data were processed by a team of 30 data entry operators, 3 data coders, 4 data entry supervisors, and 8 secondary editors. Data entry and editing were accomplished using the CSPro software. The processing of data was initiated in July 2008 and completed in February 2009. 1.6 RESPONSE RATES The household and individual response rates for the 2008 NDHS are shown in Table 1.2. A total of 36,298 households were selected and of these 34,644 were occupied. Of the 34,644 households found, 34,070 were successfully interviewed, yielding a response rate of 98 percent. There is no significant difference between rural and urban areas in terms of response rates. In the interviewed households, a total of 34,596 women were identified to be eligible for the individual interview, and 97 percent of them were successfully interviewed. For men, 16,722 were identified as eligible in half the households, and 93 percent of them were successfully interviewed. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Nigeria 2008 Residence Result Urban Rural Total Household interviews Households selected 11,418 24,880 36,298 Households occupied 10,958 23,686 34,644 Households interviewed 10,724 23,346 34,070 Household response rate1 97.9 98.6 98.3 Interviews with women age 15-49 Number of eligible women 10,868 23,728 34,596 Number of eligible women interviewed 10,489 22,896 33,385 Eligible women response rate2 96.5 96.5 96.5 Interviews with men age 15-59 Number of eligible men 5,597 11,125 16,722 Number of eligible men interviewed 5,133 10,353 15,486 Eligible men response rate 91.7 93.1 92.6 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 The purpose of this chapter is to provide a summary of some demographic and socio- economic characteristics of the population in the households sampled in the 2008 NDHS. For the purpose of the 2008 NDHS, a household was defined as a person or a group of persons, related or unrelated, who live together and share common cooking and eating arrangements. The Household Questionnaire (see Appendix G) included a schedule for collecting basic demographic and socio- economic information (e.g., age, sex, educational attainment, and current school attendance) for all usual residents and visitors who slept in the household the night preceding the interview. This method of data collection allows the analysis of the results for either the de jure population (usual residents) or the de facto population (i.e., persons in the household at the time of the survey). The Household Questionnaire also obtained information on housing facilities, e.g., dwelling characteristics, source of water supply, and sanitation facilities and household possessions, and some neglected tropical diseases that affect the population of Nigeria.1 The information in this chapter is intended to facilitate interpretation of the key demographic, socio-economic, and health indices presented later in the report. It is also intended to assist in the assessment of the representativeness of the survey sample. 2.1 POPULATION BY AGE AND SEX Age and sex are important demographic variables and are the primary basis of demographic classification. They are also important variables in the study of mortality, fertility, and nuptiality. The distribution of the de facto household population in the 2008 NDHS is shown in Table 2.1 by five- year age groups, according to sex and residence. About 50 percent of the population is female, and 50 percent is male. The sex ratio (the number of men per 100 women) is 99. The ratio in rural areas is lower than that of urban areas (97 compared with 101). The results show that the household population has a greater number of younger people than older people. Forty-five percent of the total population is under 15 years of age while 4 percent is 65 or older. The proportion of the population in each age group declines as age increases; the lowest age group (0-4) has the largest proportion of the population (17 percent), while the highest five-year age group (75-79) has the smallest proportion (less than 1 percent). Figure 2.1 illustrates the age structure of the household population in a population pyramid. Another feature of population pyramids is their strength in illustrating whether a population is “young” or “old.” The broad base of the pyramid indicates that Nigeria’s population is young. This scenario is typical of countries with higher fertility rates. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 12 | Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Nigeria 2008 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 15.9 15.7 15.8 18.2 17.2 17.7 17.5 16.7 17.1 5-9 13.7 13.8 13.7 16.7 15.7 16.2 15.7 15.1 15.4 10-14 11.4 11.2 11.3 12.9 11.8 12.3 12.4 11.6 12.0 15-19 8.8 9.2 9.0 8.6 8.5 8.5 8.7 8.7 8.7 20-24 8.5 9.2 8.8 6.4 7.8 7.1 7.1 8.2 7.7 25-29 8.4 10.1 9.3 6.5 8.0 7.2 7.1 8.7 7.9 30-34 7.2 6.9 7.0 5.4 6.0 5.7 6.0 6.3 6.1 35-39 6.4 5.5 5.9 4.7 5.0 4.9 5.3 5.2 5.2 40-44 4.7 4.3 4.5 4.0 4.0 4.0 4.2 4.1 4.1 45-49 3.9 3.4 3.6 3.5 3.5 3.5 3.7 3.5 3.6 50-54 3.0 3.2 3.1 2.9 3.8 3.3 2.9 3.6 3.2 55-59 2.1 2.1 2.1 2.2 2.7 2.4 2.2 2.5 2.3 60-64 2.2 1.8 2.0 2.6 2.2 2.4 2.5 2.1 2.3 65-69 1.4 1.2 1.3 1.8 1.5 1.7 1.7 1.4 1.6 70-74 1.0 0.9 1.0 1.6 1.1 1.3 1.4 1.0 1.2 75-79 0.5 0.4 0.5 0.8 0.5 0.6 0.7 0.5 0.6 80 + 0.8 1.0 0.9 1.1 0.9 1.0 1.0 0.9 1.0 Don’t know/missing 0.0 0.1 0.1 0.1 0.0 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 25,069 24,846 49,915 49,499 50,781 100,284 74,568 75,627 150,199 Note: Total includes 4 persons whose sex was not stated. Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 NDHS 2008 Male Percent Female Age Household Population and Housing Characteristics | 13 2.2 HOUSEHOLD COMPOSITION Information on key aspects of the household composition, including the sex of the household head and the size of the household, is presented in Table 2.2. These characteristics are important because they are associated with household welfare. Female-headed households are, for example, typically poorer than male- headed households. Economic resources are often more limited in larger households. Moreover, where the size of the household is large, crowding also can lead to health problems. Table 2.2 shows that households in Nigeria are predominantly headed by men (81 percent) and less than one in five (19 percent) are headed by women. Female-headed house- holds are more common in urban areas (21 percent) than in rural areas (19 percent). There has been a slight increase in the proportion of female-headed households from 17 percent in the 2003 NDHS to 19 percent in the 2008 NDHS. The 2008 NDHS indicates that the average household size is 4.4 persons, compared with 5.0 persons in the 2003 NDHS. This shows a modest decline over the past five years. The table further shows that the average household size is slightly lower in urban areas (4.1 persons) and in rural areas (4.6 persons). The proportion of households with nine or more members is higher in rural areas (10 percent) than in urban areas (7 percent). Table 2.2 provides information on the proportion of households with foster children (that is, children who live in households with neither biological parent present), double orphans (children with both parents dead), and single orphans (children with one parent dead). Overall, one in five households contain foster children or orphans. The proportion of households with foster children (17 percent) is higher than the proportion with double orphans (1 percent) or single orphans (7 percent). Rural areas have a higher proportion of households with foster children and orphans than urban areas (21 percent compared with 19 percent). 2.3 EDUCATION O THE HOUSEHOLD POPULATION Education is a key determinant of the lifestyle and societal status an individual enjoys. Studies have consistently shown that educational attainment has a strong effect on health behaviours and attitudes. Results from the 2008 NDHS can be used to look at educational attainment among household members and school attendance, repetition, and drop-out rates among youth. For the purposes of the analysis presented below, the official age for entry into the primary level is six years old. Formal education in Nigeria is based on a three-tier system: primary education Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18, according to residence, Nigeria 2008 Residence Characteristic Urban Rural Total Household headship Male 79.3 81.4 80.7 Female 20.7 18.6 19.3 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Number of usual members 0 0.2 0.3 0.3 1 20.2 16.4 17.8 2 12.4 12.8 12.6 3 14.1 13.2 13.5 4 14.2 12.8 13.3 5 12.4 12.1 12.2 6 9.4 9.7 9.6 7 6.7 7.6 7.3 8 3.9 5.0 4.6 9+ 6.5 10.2 8.9 Total 100.0 100.0 100.0 Mean size of households 4.1 4.6 4.4 Percentage of households with orphans and foster children under 18 Foster children1 15.5 17.5 16.8 Double orphans 0.8 0.7 0.7 Single orphans 6.5 7.4 7.1 Foster and/or orphan children 18.7 21.3 20.4 Number of households 12,100 21,970 34,070 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 14 | Household Population and Housing Characteristics consisting of six years, junior secondary school consisting of three years, and senior secondary school consisting of three years. Upon completion of secondary school one may choose to further his or her education by either going to university or polytechnic or colleges of education for four to seven years, depending on the field of study, and obtain a degree or higher national diploma or certificate, or by attending a vocational or technical institute for a two- to three-year certificate or diploma course (Osuji, 2004). 2.3.1 Educational Attainment Tables 2.3.1 and 2.3.2 show data on educational attainment for female and male household members age six and older. Results from both tables indicate that, overall, more females than males have never attended school (40 percent compared with 28 percent). Figure 2.2 shows the percentage of males and females who have never attended school by age group. The proportion who have never attended school is higher for females than for males in all age groups. More than two in ten males (21 percent) and about two in ten females (19 percent) have some primary education. The proportion of males completing the primary level of education is 12 percent, compared with 11 percent of women. Fifteen percent of men have completed the secondary level of education, compared with 10 percent of women. There are urban-rural differences in educational attainment. Twenty-two percent of males in urban areas and 11 percent in rural areas have completed the secondary level, compared with 18 percent of females in urban areas and 7 percent in rural areas. Forty-nine percent of females and 35 percent of males in rural areas have no education. In urban areas, 22 percent of females and 14 percent of males have no education. With the exception of the youngest age group, some of whom will begin to attend school in the future, the proportion with no education increases with age. For example, the proportion of women who have never attended any formal schooling increases from 26 percent among those age 10- 14 to 78 percent among those age 65 and above. For men, the proportion increases from 20 percent of those age 10-14 to 62 percent of those age 65 and older. The proportion of the population that has attained any education varies among Nigeria’s geopolitical regions. The North West and North East have the highest proportion of persons with no education—roughly seven in ten women and half of men—while the South South has the lowest percentage who have never been to school, 15 percent among females and 8 percent among males. South West has the highest proportion of females and males who completed more than a secondary education (10 percent and 13 percent, respectively). As expected, educational attainment is positively related to household wealth status. Females and males in the highest wealth quintiles are more likely to be educated than those in the lowest wealth quintiles. Household Population and Housing Characteristics | 15 Table 2.3.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nigeria 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 43.9 52.8 0.3 0.6 0.0 0.0 2.4 100.0 9,292 0.0 10-14 25.8 45.3 7.7 19.9 0.3 0.0 1.0 100.0 8,775 3.1 15-19 24.1 7.5 8.9 46.4 11.1 1.3 0.7 100.0 6,587 7.0 20-24 29.8 3.9 11.4 16.6 27.0 10.5 0.8 100.0 6,235 8.0 25-29 33.1 4.8 15.8 11.0 21.7 12.6 1.1 100.0 6,567 5.7 30-34 37.3 5.4 16.8 9.2 17.8 12.1 1.5 100.0 4,733 5.4 35-39 37.2 6.5 20.3 8.6 15.6 10.6 1.2 100.0 3,899 5.3 40-44 46.0 5.8 17.2 7.4 12.6 9.6 1.3 100.0 3,071 3.2 45-49 54.9 7.0 16.5 4.3 8.1 7.9 1.1 100.0 2,616 0.0 50-54 62.1 7.8 15.0 2.4 5.0 4.3 3.4 100.0 2,700 0.0 55-59 64.1 9.9 15.4 1.4 3.2 3.0 3.1 100.0 1,876 0.0 60-64 69.5 8.3 10.2 1.7 2.9 2.3 5.2 100.0 1,574 0.0 65+ 77.9 5.7 6.5 0.7 0.9 1.3 7.1 100.0 2,915 0.0 Residence Urban 22.0 19.2 11.3 17.2 17.5 11.4 1.5 100.0 20,294 5.7 Rural 48.9 18.7 10.6 10.8 6.5 2.5 2.0 100.0 40,585 0.0 Zone North Central 39.3 23.8 10.9 12.4 7.1 4.8 1.7 100.0 8,861 1.7 North East 65.5 15.9 5.9 6.5 2.8 1.3 2.1 100.0 7,743 0.0 North West 67.5 13.1 6.8 4.6 3.1 1.5 3.4 100.0 14,977 0.0 South East 20.8 23.2 13.8 17.4 15.9 7.6 1.4 100.0 7,936 5.4 South South 14.9 22.0 15.7 22.3 16.2 7.9 0.9 100.0 9,255 5.7 South West 21.5 19.2 13.5 17.6 17.4 9.9 0.8 100.0 12,107 5.6 Wealth quintile Lowest 74.4 12.3 6.1 3.8 0.9 0.1 2.4 100.0 11,724 0.0 Second 58.6 19.2 9.7 7.5 2.4 0.3 2.4 100.0 12,188 0.0 Middle 39.0 23.4 13.0 14.1 7.1 1.4 2.0 100.0 12,575 1.9 Fourth 20.9 21.6 15.1 19.1 16.0 5.8 1.4 100.0 12,238 5.4 Highest 8.0 17.6 10.1 19.8 24.1 19.4 1.0 100.0 12,155 9.2 Total 39.9 18.9 10.9 12.9 10.2 5.4 1.8 100.0 60,879 2.1 Note: Total includes 37 unweighted cases with information missing on educational attainment. 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level 16 | Household Population and Housing Characteristics Table 2.3.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nigeria 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 39.7 57.3 0.4 0.5 0.0 0.0 2.1 100.0 9,459 0.0 10-14 19.6 52.2 7.3 19.8 0.2 0.1 0.8 100.0 9,251 3.2 15-19 15.0 9.7 8.5 54.6 10.5 1.2 0.5 100.0 6,465 7.4 20-24 14.8 3.1 8.7 24.9 34.9 13.0 0.6 100.0 5,300 10.8 25-29 18.6 3.2 13.5 12.5 32.7 18.7 0.7 100.0 5,330 11.1 30-34 21.1 3.6 16.4 10.6 29.0 18.8 0.5 100.0 4,457 9.8 35-39 21.3 4.2 19.9 9.6 26.6 17.6 0.8 100.0 3,941 8.4 40-44 25.2 5.0 20.3 8.1 23.5 17.1 0.9 100.0 3,149 6.0 45-49 28.9 4.4 20.7 7.6 19.2 18.2 1.0 100.0 2,724 5.8 50-54 39.6 6.1 23.6 3.8 12.1 13.7 1.1 100.0 2,173 5.2 55-59 44.3 7.0 23.4 3.8 9.0 11.4 1.3 100.0 1,605 3.6 60-64 51.6 6.9 21.0 3.1 7.7 6.6 3.0 100.0 1,851 0.0 65+ 61.5 7.6 16.4 2.0 4.8 4.0 3.7 100.0 3,567 0.0 Residence Urban 13.8 19.3 11.0 17.2 22.2 15.3 1.2 100.0 20,418 7.4 Rural 35.0 21.9 12.3 14.1 10.5 5.0 1.3 100.0 38,918 2.8 Zone North Central 25.3 24.5 10.4 17.2 12.6 8.8 1.2 100.0 8,746 4.9 North East 53.1 19.8 6.3 9.7 6.0 3.9 1.2 100.0 7,667 0.0 North West 48.8 18.4 9.4 9.1 6.6 5.5 2.3 100.0 14,590 0.0 South East 11.1 24.0 19.5 19.2 16.4 9.0 0.8 100.0 6,758 5.7 South South 7.5 22.2 14.2 21.9 22.0 11.4 0.7 100.0 9,367 7.3 South West 12.8 19.8 13.2 16.8 24.0 12.7 0.7 100.0 12,208 6.9 Wealth quintile Lowest 62.4 16.7 8.8 7.1 2.9 0.5 1.5 100.0 11,458 0.0 Second 41.6 23.5 12.4 12.3 6.9 1.7 1.6 100.0 11,088 1.0 Middle 23.0 26.9 14.2 18.1 12.2 4.4 1.3 100.0 11,786 4.9 Fourth 11.2 21.9 14.4 19.9 21.2 10.3 1.0 100.0 12,393 6.3 Highest 4.4 16.3 9.4 17.4 27.5 24.1 0.9 100.0 12,611 11.1 Total 27.7 21.0 11.8 15.1 14.5 8.6 1.2 100.0 59,336 5.1 Note: Total includes 68 unweighted cases with information missing on educational attainment 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level Household Population and Housing Characteristics | 17 2.3.2 School Attendance Rates Table 2.4 shows primary school and secondary school net and gross attendance ratios (NAR and GAR) for the 2007/2008 school year by household residence and zones. The NAR for primary school is the percentage of the primary-school-age (6-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (13-17 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. The GAR for primary school is the total number of primary school students, of any age, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, of any age, expressed as a percentage of the official secondary- school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. Youth are considered to be attending school currently if they attended formal academic school at any point during the given school year. The gender parity index (GPI) assesses sex-related differences in school attendance rates and is calculated by dividing the GAR for females by the GAR for males. A GPI less than one indicates a gender disparity in favour of males (i.e., a higher proportion of males than females attends that level of schooling). A GPI greater than one indicates a gender disparity in favour of females. A GPI of one indicates parity or equality between the rates of participation for males and females. Table 2.4 shows the NARs and GARs for the de facto household population by sex, level of schooling, and GPI, according to background characteristics. Results show that the overall NAR for primary schools is 62, while the GAR is 84. Analysis by urban and rural residence shows that the NAR is much higher in urban areas (74 percent) than in rural areas (57 percent). The GAR is also higher in urban areas than in rural areas (98 and 79 percent, respectively). There is a slight difference in the NAR between males and females at the primary school level (65 and 59 percent, respectively). Males also show a higher GAR at the primary school level (89 percent) than females (80 percent). There is significant variation at the zonal level; the primary NAR and GAR are highest in the South East (83 and 110 percent, respectively). North West has the lowest NAR and GAR, with 43 and 59 percent, respectively. According to wealth status, the NAR is 79 percent for the fourth quintile and 33 percent for the lowest quintile. The same trend applies to the GAR at the primary level (105 percent for the fourth quintile and 48 percent for the lowest quintile, respectively). Figure 2.2 Percent Distribution of Household Population with No Education by Sex 6-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Age 0 20 40 60 80 Percent Female Male NDHS 2008 18 | Household Population and Housing Characteristics Table 2.4 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Nigeria 2008 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 75.9 72.2 74.1 0.95 99.5 95.5 97.5 0.96 Rural 60.3 53.5 57.0 0.89 84.4 72.7 78.7 0.86 Zone North Central 71.7 69.2 70.5 0.97 104.4 97.8 101.2 0.94 North East 46.8 40.3 43.7 0.86 66.4 55.8 61.3 0.84 North West 49.8 37.1 43.4 0.75 68.4 49.2 58.7 0.72 South East 82.4 83.2 82.8 1.01 109.5 110.7 110.1 1.01 South South 80.1 80.1 80.1 1.00 109.1 105.6 107.4 0.97 South West 77.8 75.2 76.6 0.97 101.0 98.9 99.9 0.98 Wealth quintile Lowest 37.1 29.0 33.2 0.78 54.7 41.2 48.2 0.75 Second 59.1 49.3 54.2 0.83 84.8 68.3 76.5 0.81 Middle 76.2 70.5 73.5 0.93 105.0 95.7 100.5 0.91 Fourth 80.5 78.2 79.4 0.97 106.3 102.8 104.6 0.97 Highest 78.4 76.7 77.5 0.98 100.4 99.1 99.8 0.99 Total 64.9 59.1 62.1 0.91 88.9 79.5 84.3 0.89 SECONDARY SCHOOL Residence Urban 66.2 62.5 64.3 0.94 99.2 88.0 93.5 0.89 Rural 44.7 38.0 41.4 0.85 70.4 54.6 62.6 0.77 Zone North Central 50.1 41.6 46.0 0.83 84.9 62.2 73.9 0.73 North East 29.4 22.1 25.7 0.75 47.2 30.3 38.6 0.64 North West 33.8 19.3 26.7 0.57 54.6 28.7 42.0 0.52 South East 68.7 68.7 68.7 1.00 98.0 91.5 94.6 0.93 South South 66.7 65.5 66.1 0.98 100.6 93.6 97.2 0.93 South West 68.5 68.9 68.7 1.01 101.7 98.6 100.1 0.97 Wealth quintile Lowest 19.1 10.6 15.0 0.56 32.2 16.4 24.5 0.51 Second 37.4 27.3 32.3 0.73 61.7 38.3 49.9 0.62 Middle 56.7 50.8 53.8 0.90 90.4 70.3 80.4 0.78 Fourth 66.9 63.9 65.4 0.96 102.0 91.3 96.8 0.89 Highest 75.3 73.0 74.1 0.97 108.2 104.7 106.4 0.97 Total 51.8 46.4 49.1 0.89 80.0 65.9 73.0 0.82 1 The NAR for primary school is the percentage of the primary-school-age (1-6 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (1-6 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of over-age and under-age students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR(GAR) for males. The NAR at the secondary school level is 49 percent, while the GAR is 73 percent. This is an indication that fewer people attend secondary school than primary school. Both ratios are much higher in urban areas than in rural areas. The NAR and GAR at the secondary school level for males and females follow a similar pattern as the primary school level with males recording a higher proportion in both cases (52 versus 46 for the NAR and 80 versus 66 for the GAR). South East and South west have the highest NAR (69 percent each) for the secondary school level while North East has the lowest (26 percent). South West also has the highest GAR (100 percent) while North East has the lowest GAR (39 percent). The NAR and GAR are highest in the highest (wealthiest quintile) (74 and 106 percent, respectively) and lowest in the lowest (poorest) wealth quintile (15 and 25 percent, respectively). Household Population and Housing Characteristics | 19 2.3.3 Grade Repetition and Drop-out Rates Repetition rates and drop-out rates shown in Table 2.5 describe the flow of pupils through the educational system in Nigeria at the primary level. The repetition rates indicate the percentage of pupils who attended a particular grade during the 2006/2007 school year who again attended that same class during the following school year. The drop-out rates show the percentage of pupils in a grade during the 2006/2007 school year who no longer attended school the following school year. Table 2.5 shows that, overall, repetition in Nigeria is highest at grade six (5 percent). There are no significant differences in repetition rates between rural and urban areas at the sixth grade level. However, by sex, repetition rates are higher among males (6 percent) than among females (4 percent). Zonal differentials indicate that repetition rates are generally higher in North Central for primary school grades 1-6. The patterns for drop-out rates are similar to those for repetition rates. Drop-out rates are highest in the sixth grade (12 percent) and lowest in the second grade (less than 1 percent). Drop-out rates at grade 6 are higher among females (13 percent) than among males (10 percent). There is great variation by residence and zone. For example, rural children are twice as likely as urban children to drop out of school at grade 6. The drop-out rate in grade 6 is highest in the North East (18 percent) and lowest in the South West (5 percent). The table also shows that drop-out rates at grade 6 are highest among respondents in the lowest wealth quintile (25 percent) and lowest among children in the highest wealth quintile (5 percent). Figure 2.3 shows the age-specific attendance rates for the male and female de facto population age 5-24. The figure shows that there are no marked differences in the attendance rates between males and females age 5 to 15; however, after age 15 attendance rates for males are much higher than those for females. Table 2.5 Grade repetition and drop-out rates Repetition and drop-out rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics, Nigeria 2008 School grade Background characteristic 1 2 3 4 5 6 REPETITION RATE1 Sex Male 2.6 2.3 1.7 1.3 1.1 5.6 Female 2.5 2.1 2.3 2.1 1.4 3.5 Residence Urban 2.3 2.1 2.5 1.8 0.8 4.4 Rural 2.7 2.3 1.7 1.7 1.5 4.7 Zone North Central 4.0 3.4 4.7 2.4 2.2 11.1 North East 1.0 1.4 1.9 0.9 0.7 5.5 North West 2.9 3.1 2.0 2.5 1.2 3.0 South East 2.0 1.3 1.5 1.6 0.8 2.4 South South 2.6 1.9 0.5 1.0 1.4 1.4 South West 2.0 1.6 1.5 1.4 0.9 5.2 Wealth quintile Lowest 2.8 1.4 1.5 1.4 1.0 4.1 Second 2.7 2.9 2.7 1.3 1.2 4.9 Middle 2.8 2.2 1.8 1.4 1.2 5.4 Fourth 2.6 2.3 2.3 2.5 2.0 3.3 Highest 1.8 2.0 1.5 1.7 0.4 5.2 Total 2.6 2.2 2.0 1.7 1.2 4.6 DROP-OUT RATE2 Sex Male 0.4 0.2 0.3 0.4 0.4 10.3 Female 0.5 0.2 0.3 0.4 0.6 12.9 Residence Urban 0.7 0.5 0.1 0.1 0.4 7.5 Rural 0.3 0.0 0.4 0.6 0.5 14.1 Zone North Central 0.3 0.1 0.0 0.1 0.3 15.0 North East 1.2 0.2 0.5 0.4 0.5 17.9 North West 0.4 0.1 0.2 0.4 0.4 17.2 South East 0.1 0.5 0.0 0.1 0.6 9.9 South South 0.3 0.0 0.6 0.8 0.8 12.7 South West 0.3 0.4 0.4 0.4 0.2 4.7 Wealth quintile Lowest 0.6 0.2 1.0 1.4 0.3 24.8 Second 0.5 0.1 0.8 0.4 0.8 19.5 Middle 0.5 0.3 0.0 0.6 0.3 11.2 Fourth 0.4 0.1 0.0 0.0 0.3 8.3 Highest 0.2 0.3 0.2 0.0 0.5 5.0 Total 0.4 0.2 0.3 0.4 0.5 11.6 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The drop-out rate is the percentage of students in a given grade in the previous school year who are not attending school. 20 | Household Population and Housing Characteristics 2.4 HOUSEHOLD ENVIRONMENT The physical characteristics of household dwellings are important indicators of the socio- economic and health status of households. The 2008 NDHS asked a number of questions about the household environment, including the following: source of drinking water; type of sanitation facility; type of flooring, walls, and roof; and number of rooms in the dwelling. The results are presented both for households and for the de jure population. 2.4.1 Drinking Water Increasing access to improved drinking water is one of the Millennium Development Goals that Nigeria and other nations worldwide have adopted. Table 2.6 includes a number of indicators that are useful in monitoring household access to improved drinking water. The source of drinking water is an indicator of whether it is suitable for drinking. Sources that are likely to provide water suitable for drinking are identified as improved sources in Table 2.6; they include, piped source within the dwelling or plot, public tap, tube well or borehole, and protected well or spring. Lack of ready access to water may limit the quantity of suitable drinking water that is available to a household, even if the water is obtained from an improved source. Water that must be fetched from a source that is not immediately accessible to the household may be contaminated during transport or storage. Another factor in considering the accessibility of water sources is that the burden of fetching water often falls disproportionately on female members of the household. Finally, home water treatment can be effective in improving the quality of household drinking water. Figure 2.3 Age-Specific Attendance Rates of the De Facto Population Age 5 to 24 by Sex 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Female Male NDHS 2008 Household Population and Housing Characteristics | 21 Table 2.6 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and the de jure population by treatment of drinking water, according to residence, Nigeria 2008 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 75.1 45.3 55.9 75.4 43.6 54.2 Piped water into dwelling/ yard/plot 7.2 1.4 3.4 7.9 1.5 3.6 Public tap/standpipe 12.7 4.1 7.2 12.2 3.6 6.5 Tube well or borehole 38.2 22.4 28.0 37.8 21.0 26.6 Protected dug well 14.5 13.2 13.6 14.9 13.7 14.1 Protected spring 0.5 0.7 0.6 0.6 0.6 0.6 Rainwater 1.9 3.6 3.0 1.9 3.1 2.7 Non-improved source 14.6 53.4 39.6 16.9 55.5 42.6 Unprotected dug well 6.1 21.7 16.2 7.6 24.5 18.9 Unprotected spring 1.1 4.7 3.4 1.1 4.8 3.6 Tanker truck/cart with small tank 2.8 1.0 1.7 3.3 1.0 1.8 Surface water 4.6 26.0 18.4 4.8 25.2 18.4 Bottled water, improved source for cooking/washing1 6.0 0.4 2.4 4.4 0.3 1.6 Bottled water, non-improved source for cooking/washing 0.9 0.2 0.5 0.7 0.1 0.3 Other sources 3.3 0.7 1.7 2.7 0.5 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 81.1 45.6 58.2 79.7 43.8 55.8 Time to obtain drinking water (round trip) Water on premises 30.0 21.5 24.5 31.4 23.0 25.8 Less than 30 minutes 52.9 50.4 51.3 50.3 48.0 48.8 30 minutes or longer 14.6 26.8 22.5 15.3 27.8 23.7 Don't know/missing 2.6 1.2 1.7 3.0 1.2 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 23.6 26.7 25.6 20.8 24.5 23.3 Adult male 15+ 18.6 22.3 21.0 14.0 17.1 16.1 Female child under age 15 4.7 4.0 4.2 5.7 4.5 4.9 Male child under age 15 3.5 3.8 3.7 4.2 4.2 4.2 Adult woman with child 3.9 6.4 5.5 5.0 8.1 7.1 Other 4.2 1.9 2.7 4.3 1.6 2.5 Water on premises 32.6 24.6 27.4 35.3 27.4 30.0 Missing 0.2 0.2 0.2 0.3 0.2 0.2 Total 91.2 89.9 90.4 89.5 87.6 88.2 Water treatment prior to drinking2 Boiled 6.6 2.4 3.9 6.2 2.2 3.6 Bleach/chlorine 3.9 1.6 2.4 4.0 1.7 2.5 Strained through cloth 2.2 4.5 3.7 2.6 5.3 4.4 Ceramic, sand or other filter 1.3 0.7 0.9 1.4 0.8 1.0 Solar disinfection 0.1 0.1 0.1 0.1 0.1 0.1 Alum 3.1 4.3 3.9 3.3 4.0 3.8 Other 2.0 1.4 1.6 2.0 1.5 1.7 No treatment 82.7 85.8 84.7 82.1 85.3 84.3 Percentage using an appropriate treatment method3 12.9 8.9 10.3 13.2 9.6 10.8 Number 12,100 21,970 34,070 50,147 100,442 150,589 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 22 | Household Population and Housing Characteristics The table shows that only 56 percent of the households have access to improved sources of water. Households in urban areas are more likely to have access to improved sources of water than those in rural areas (75 percent compared with 45 percent). About two-fifths of households draw their water from an unimproved source. Thirty percent of urban households have water on their premises, compared with about one in five households (22 percent) in rural areas. Overall, 23 percent of the households take 30 or more minutes to obtain water: 15 percent of households in urban areas compared with 27 percent of households in the rural areas. Adult females collect drinking water more often than adult males (26 and 21 percent, respectively). Results also show that both male and female children below age 15 are involved in collecting drinking water. Most households (85 percent) do not treat their water; about 10 percent of households use an appropriate method to treat their drinking water. Alum, boiling, straining through cloth, and bleach or chlorine are the most common methods used by households for water treatment. 2.4.2 Household Sanitation Facilities Ensuring adequate sanitation facilities is another of the Millennium Development Goals that Nigeria shares with other countries. A household is classified as having an improved toilet if the toilet is used only by members of one household (i.e., it is not shared with other households) and if the facility used by the household separates the waste from human contact (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004). Table 2.7 shows that almost three in ten households in Nigeria (27 percent) use an improved toilet facility (31 percent in urban areas and 25 percent in rural areas), while seven in ten households (73 percent) use non-improved facilities (69 percent in urban areas and 75 percent in rural areas). Among households with improved toilet facilities, flush toilets (to pipe sewer system, to septic tank, or to pit latrine) are mainly found in urban areas and are used by 18 percent of households (4 percent in rural areas). Table 2.7 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Nigeria 2008 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility Total 31.4 24.6 27.0 37.5 28.1 31.2 Flush/pour flush to piped sewer system 5.3 1.0 2.5 5.9 1.0 2.6 Flush/pour flush to septic tank 10.9 2.3 5.3 11.1 1.9 5.0 Flush/pour flush to pit latrine 1.5 0.6 0.9 2.0 0.6 1.1 Ventilated improved pit (VIP) latrine 9.0 14.4 12.5 11.6 17.2 15.3 Pit latrine with slab 4.6 6.4 5.7 6.8 7.2 7.1 Composting toilet 0.0 0.0 0.0 0.0 0.0 0.0 Non-improved facility Total 68.6 75.4 73.0 62.5 71.9 68.8 Any facility shared with other households 44.2 15.7 25.8 38.8 13.0 21.6 Flush/pour flush not to sewer/septic tank/pit latrine 0.4 0.1 0.2 0.4 0.1 0.2 Pit latrine without slab/open pit 7.8 14.2 11.9 9.2 15.7 13.5 Bucket 0.1 0.1 0.1 0.1 0.0 0.1 Hanging toilet/hanging latrine 1.7 1.7 1.7 1.2 1.4 1.4 No facility/bush/field 13.6 42.2 32.1 11.8 40.2 30.8 Other 0.5 0.8 0.7 0.4 0.8 0.7 Missing 0.6 0.6 0.6 0.6 0.6 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 12,100 21,970 34,070 50,147 100,442 150,589 Household Population and Housing Characteristics | 23 Ventilated improved pit (VIP) latrines are more common in the rural areas (14 percent) than in urban areas (9 percent). Overall, 13 percent of households use VIP latrines. Six percent of households use a pit latrine with a slab (6 percent rural and 5 percent urban). Among households with a non-improved toilet facility, 26 percent use facilities that are shared with other households (44 percent urban and 16 percent rural). Less than 1 percent use a flush toilet (not to sewer/septic tank/pit latrine). Overall, 32 percent of households in Nigeria have no toilet facilities. This problem is more common in rural areas (42 percent) than in urban areas (14 percent). 2.4.3 Housing Characteristics Table 2.8 presents information on a number of household dwelling characteristics, the proportion of households using various types of fuel for cooking. These characteristics reflect the household’s socio-economic situation. They also may influence environmental conditions—for example, in the case of the use of biomass fuels, exposure to indoor pollution—that have a direct bearing on household members’ health and welfare. The proportion of households with electricity in Nigeria is 50 percent. There are more households with electricity in urban areas (85 percent) than in rural areas (31 percent). Cement is the most common material used for floors, with 42 percent of households having floors made of cement (49 percent urban and 39 percent rural). In rural areas, 46 percent of households have floors made out of earth/sand, compared with 9 percent in urban areas. About 43 percent of the households in Nigeria live in housing units with only one bedroom, while about three in ten households (29 percent) live in housing units with three or more bedrooms. About 40 percent of households cook inside the house, while about one-quarter (25 percent) cook outdoors. The percentage of households that cook in their dwelling is higher in urban areas (43 percent) than in rural areas (38 percent). Wood is the most common fuel used for cooking, reported by 66 percent of households. Wood is more commonly used in rural areas (83 percent) than in urban areas (37 percent). Twenty-six percent of all households use kerosene for cooking. More households in the urban areas (52 percent) use kerosene for cooking than those in rural areas (11 percent). The percentage of households using solid fuel is high (70 percent), including 86 percent of households in rural areas and 42 percent of households in urban areas. Among the households that reported use of solid fuel for cooking, the majority (94 percent) were using an open fire/stove without a chimney or hood—92 percent of urban households and 95 percent of rural households. 24 | Household Population and Housing Characteristics Table 2.8 Household characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Nigeria 2008 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 84.8 31.4 50.3 84.3 29.7 47.9 No 15.0 68.3 49.4 15.5 70.0 51.8 Missing 0.2 0.3 0.3 0.2 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 8.7 45.5 32.4 10.5 48.6 35.9 Dung 0.4 2.3 1.6 0.4 2.5 1.8 Wood/planks 0.1 0.6 0.5 0.1 0.7 0.5 Palm/bamboo 0.0 0.6 0.4 0.0 0.7 0.5 Parquet or polished wood 0.2 0.3 0.3 0.1 0.3 0.3 Vinyl or asphalt strips 0.0 0.0 0.0 0.1 0.0 0.0 Ceramic tiles 3.1 0.7 1.5 3.4 0.6 1.5 Cement 48.7 38.5 42.1 50.9 37.5 42.0 Carpet 38.0 11.1 20.6 33.7 8.7 17.0 Other 0.5 0.3 0.4 0.6 0.2 0.4 Missing 0.1 0.2 0.2 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 51.6 38.8 43.3 35.9 23.3 27.5 Two 24.0 28.8 27.1 27.8 29.9 29.2 Three or more 23.9 32.1 29.2 35.9 46.6 43.0 Missing 0.5 0.3 0.3 0.4 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 43.3 37.7 39.7 46.1 41.2 42.8 In a separate building 29.5 34.1 32.4 31.2 35.2 33.9 Outdoors 23.8 25.1 24.7 21.1 22.4 21.9 Other 0.6 0.4 0.5 0.6 0.3 0.4 Missing 2.8 2.8 2.8 1.0 1.0 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.7 0.1 0.3 0.7 0.1 0.3 LPG/natural gas/biogas 3.0 0.4 1.3 2.6 0.3 1.1 Kerosene 51.6 11.3 25.6 44.1 7.3 19.5 Coal/lignite 0.6 0.2 0.4 0.7 0.2 0.4 Charcoal 4.1 1.8 2.6 4.3 1.7 2.6 Wood 36.6 82.5 66.2 45.8 88.3 74.1 Straw/shrubs/grass 0.7 0.9 0.9 0.8 1.1 1.0 Agricultural crop 0.0 0.2 0.1 0.0 0.2 0.2 Animal dung 0.0 0.0 0.0 0.0 0.1 0.0 No food cooked in household 2.5 2.4 2.4 0.7 0.7 0.7 Other 0.1 0.0 0.1 0.1 0.0 0.1 Missing 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 42.1 85.6 70.1 51.7 91.5 78.3 Number of households 12,100 21,970 34,070 50,147 100,442 150,589 Type of fire/stove among households using solid fuel Closed stove with chimney 0.7 0.2 0.3 0.6 0.2 0.3 Open fire/stove with chimney 3.0 1.9 2.2 3.2 2.1 2.3 Open fire/stove with hood 3.6 2.4 2.7 4.3 2.8 3.2 Open fire/stove without chimney or hood 92.0 95.0 94.3 91.3 94.4 93.7 Other 0.2 0.0 0.1 0.2 0.0 0.0 Missing 0.5 0.4 0.4 0.4 0.5 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population using solid fuel 5,092 18,803 23,894 25,933 91,943 117,875 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung LPG = Liquid petroleum gas Household Population and Housing Characteristics | 25 2.5 HOUSEHOLD POSSESSIONS The availability of durable consumer goods is a good indicator of a household’s socio- economic status. Moreover, particular goods have specific benefits. For instance, having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs food storage; and a means of transport allows greater access to many services away from the local area. Table 2.9 shows the presence of selected consumer goods by residence; 74 percent of households own a radio (84 percent in urban areas and 69 percent in rural areas), and 39 percent own a television (69 percent in urban areas and 23 percent in rural areas). A mobile telephone is owned by 50 percent of households (76 percent in urban areas and 35 percent in rural areas), while 16 percent of households own a refrigerator. Table 2.9 also shows the proportion of households owning various means of transport. Twenty-three percent of the households own a bicycle (11 percent in urban areas and 29 percent in rural areas), while only 8 percent own a car, and 24 percent own a motorcycle. Only 3 percent own a canoe (1 percent urban and 4 percent rural), and 3 percent own an animal-drawn cart (1 percent urban and 4 percent rural). Less than 1 percent owns a boat with a motor. Among the means of transport listed , the bicycle, motorcycle/scooter, canoe, and animal drawn cart are more common in rural areas than in urban areas. Table 2.9 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Nigeria 2008 Households Population Possession Urban Rural Total Urban Rural Total Household effects Radio 83.5 69.4 74.4 85.5 72.6 76.9 Television 69.0 22.9 39.3 71.7 23.1 39.3 Mobile telephone 76.1 35.1 49.7 77.5 35.1 49.2 Non-mobile telephone 3.7 0.7 1.8 4.1 0.8 1.9 Refrigerator 32.4 6.7 15.9 36.0 6.9 16.6 Means of transport Canoe 1.0 3.8 2.8 1.1 3.7 2.8 Bicycle 11.3 29.3 22.9 15.8 35.2 28.7 Animal drawn cart 0.9 3.7 2.7 1.5 5.3 4.0 Motorcycle/scooter 23.5 24.9 24.4 29.5 30.0 29.8 Car/truck 14.9 4.5 8.2 18.2 5.2 9.5 Boat with a motor 0.4 0.5 0.4 0.5 0.5 0.5 Ownership of agricultural land 33.0 76.7 61.2 38.9 83.0 68.3 Ownership of farm animals1 29.0 62.9 50.8 36.1 72.5 60.4 Ownership of bank/savings account2 52.7 16.6 29.4 53.0 16.1 28.4 Number 12,100 21,970 34,070 50,147 100,442 150,589 1 Includes livestock and poultry. 2 At least one household member has an account. Agricultural land is owned by 61 percent of households (77 percent in rural areas and 33 percent in urban areas,), whereas farm animals are owned by 51 percent of households (63 percent in rural areas and 29 percent in urban areas). 2.6 WEALTH INDEX The wealth index is used throughout the report as a background characteristic. It serves as a proxy for measuring the long-term standard of living. It is based on data from the household’s ownership of consumer goods; dwelling characteristics; type of drinking water source; toilet facilities; and other characteristics that are related to a household’s socio-economic status. To construct the index, each of these assets was assigned a weight (factor score) generated through principal 26 | Household Population and Housing Characteristics component analysis, and the resulting asset scores were standardised in relation to a standard normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household. Individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed on the basis of data from the entire country sample and this index is used in all the tabulations presented. Table 2.10 shows the percent distribution of the de jure household population by wealth quintile according to residence and region. The distributions indicate the degree to which wealth is evenly (or unevenly) distributed geographically. The table shows that urban areas have higher proportions of people in the fourth and highest quintiles (30 and 47 percent, respectively) compared with rural areas (15 and 7 percent, respectively). On the other hand, rural areas have higher proportions of the population in the lowest and second quintiles (29 and 27 percent, respectively) than urban areas (3 and 5 percent, respectively). Table 2.10 Wealth quintiles Percent distribution of the jure population by wealth quintiles, according to residence and region, Nigeria 2008 Wealth quintile Residence/zone Lowest Second Middle Fourth Highest Total Number of population Residence Urban 2.5 5.4 15.3 29.9 46.9 100.0 50,147 Rural 28.7 27.3 22.3 15.1 6.6 100.0 100,442 Zone North Central 20.6 23.2 25.3 17.1 13.8 100.0 21,971 North East 47.4 22.7 16.4 10.3 3.2 100.0 20,353 North West 31.9 30.9 17.2 12.5 7.6 100.0 38,913 South East 4.6 9.9 28.1 31.6 25.8 100.0 17,430 South South 6.7 14.4 22.9 30.1 26.0 100.0 22,329 South West 4.2 11.6 15.3 24.3 44.6 100.0 29,594 Total 20.0 20.0 20.0 20.0 20.0 100.0 150,589 Considering these findings, it is not surprising that the three southern zones, which are more urbanised, have greater proportions of their populations in the higher wealth quintiles than the northern zones. Forty-five percent of the population in South West is concentrated in the highest wealth quintile. The percentage of the population in the highest wealth quintile is 26 percent in South South and South East. By contrast the proportion of the population in the highest wealth quintile in North East is only 3 percent. Eight percent of the population in North West and 14 percent of the population in North Central are in the highest wealth quintile. On the other hand, the proportion of the population in the lowest wealth quintile in North East is 47 percent, followed by 32 percent in North West and 21 percent in North Central. The proportion of the population in the lowest wealth quintile in South South, South East and South West zones is 6 percent, 5 percent, and 4 percent, respectively. 2.7 BIRTH REGISTRATION Birth registration is the formal inscription of the facts of a birth into an official log kept at the registrar’s office. A birth certificate is issued at the time of registration or later as proof of the registration of the birth. Birth registration is basic to ensuring a child’s legal status and, thus, basic rights and services (UNICEF, 2006; United Nations General Assembly, 2002). Over time, various forms of registrations of births and deaths have been implemented across Nigeria from the colonial period onward. The most recent being the “Births, Deaths, ETC (Compulsory) Registration” Decree (now Act) No. 69 of 1992 which went into effect 1st December 1992. The law gave the sole authority to register these events nationwide to the National Population Commission. The provisions were further reinforced by section 24 of the Third schedule of the 1999 Constitution of the Federal Republic of Nigeria. Household Population and Housing Characteristics | 27 Table 2.11 shows the percentage of children less than five years of age whose births were officially registered and the percentage who had a birth certificate seen at the time of the survey. Thirty percent of children under five were reported to have had their births registered and, of those, 38 percent had a birth certificate. More births are registered in urban areas (49 percent) than in rural areas (22 percent). At the zonal level, South East zone has the highest proportion of births being registered (54 percent) while North East zone has the lowest (14 percent). Children in wealthier households are more likely to be registered than those in poorer households; 62 percent of children in households in the highest wealth quintile are registered compared with 9 percent in households in the lowest wealth quintile. Table 2.12 shows the percent distribution of de jure children less than five years of age who are registered, according to the authority with which the birth is registered. Thirty-six percent of the children were registered at private clinics or hospitals, 36 percent were registered at the National Population Commission (NPC), and 17 percent were registered at the Local Government Area (LGA). The proportion of births registered with the NPC is higher in urban than rural areas (39 percent, compared with 33 percent). The same pattern is seen for births registered at private hospitals and clinics. In contrast, the proportion of births registered at the LGA is higher in rural (18 percent) than urban areas (14 percent). The North West zone has the highest percentage of births registered with the NPC (49 percent) and the LGA (30 percent), while the South East zone has the lowest percentage (19 and 8 percent, respectively). Birth registration at private clinics or hospitals was highest in the South East zone (63 percent) and lowest at the North West zone (17 percent). Birth registration at the LGA was highest for children in households in the lowest wealth quintile (36 percent) and lowest for children in the highest wealth quintile (12 percent). On the other hand, children in the fourth and highest wealth quintiles were more likely to be registered with the NPC or private hospitals or clinics than those in the lower wealth quintiles. Table 2.11 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered, and among children whose births are registered, percentage with a birth certificate seen, by background characteristics, Nigeria 2008 All children under age five Children under age five whose births were registered Background characteristic Percentage registered Number of children Percentage with birth certificate seen Number of children Age <2 28.8 10,434 39.9 3,010 2-4 30.8 15,292 36.1 4,717 Sex Male 29.6 13,067 38.3 3,867 Female 30.5 12,660 36.9 3,860 Residence Urban 48.8 7,949 45.1 3,878 Rural 21.7 17,777 30.0 3,850 Zone North Central 26.6 3,609 41.6 960 North East 13.9 4,141 47.3 575 North West 22.3 7,764 28.6 1,730 South East 54.4 2,468 28.0 1,342 South South 29.9 3,354 35.5 1,005 South West 48.2 4,391 47.7 2,116 Wealth quintile Lowest 8.9 5,794 20.1 513 Second 17.6 5,773 26.6 1,017 Middle 26.8 4,938 31.9 1,321 Fourth 44.0 4,670 38.3 2,056 Highest 61.9 4,552 46.9 2,820 Total 30.0 25,726 37.6 7,727 28 | Household Population and Housing Characteristics Table 2.12 Birth registration of children under age five by authority Among de jure children under five years of age whose births are registered with the civil authorities, percent distribution of children by the authority with which the birth is registered, according to background characteristics, Nigeria 2008 Authority where birth is registered Background characteristic National Population Commission Local Government Administration Private clinic/ hospital Other Missing Total registered Number of children Age <2 36.8 15.7 36.7 9.2 1.7 100.0 3,010 2-4 35.4 17.7 36.2 9.2 1.6 100.0 4,717 Sex Male 36.7 16.7 35.2 9.6 1.8 100.0 3,867 Female 35.1 17.1 37.5 8.7 1.5 100.0 3,860 Residence Urban 38.8 14.1 37.7 8.2 1.1 100.0 3,878 Rural 33.0 19.7 35.0 10.2 2.2 100.0 3,850 Zone North Central 30.5 15.7 42.7 9.5 1.4 100.0 960 North East 39.7 20.4 26.6 7.3 5.9 100.0 575 North West 48.6 30.0 17.3 2.0 2.2 100.0 1,730 South East 19.0 7.9 63.4 9.4 0.4 100.0 1,342 South South 31.0 8.5 46.0 12.9 1.7 100.0 1,005 South West 40.1 15.5 29.9 13.5 0.9 100.0 2,116 Wealth quintile Lowest 29.3 36.3 20.7 9.3 4.4 100.0 513 Second 33.9 27.9 25.7 8.8 3.9 100.0 1,017 Middle 34.0 16.2 38.3 10.3 1.2 100.0 1,321 Fourth 35.1 13.5 41.5 8.5 1.4 100.0 2,056 Highest 39.3 12.2 38.4 9.3 0.7 100.0 2,820 Total 35.9 16.9 36.4 9.2 1.6 100.0 7,727 2.8 NEGLECTED TROPICAL DISEASES (NTDS) Neglected Tropical Diseases (NTDs) are a group of communicable diseases of public health importance that cause severe pain, irreversible disability and even disfigurement. These diseases predominantly occur among populations that have little or no access to good housing, safe water supply and sanitation, formal health systems and other modern amenities. The 2008 NDHS included questions about four of these diseases—dracunculiasis (Guinea worm disease - GWD), onchocerciasis (river blindness), schistosomiasis (bilharziasis), and lymphatic filariasis (LF) (elephantiasis). More than 32 million Nigerians in 32 states and the Federal Capital Territory (FCT) are estimated to be at risk for onchoceriasis. Nigeria accounts for 40 percent of the 40 million people infected with onchoceriasis worldwide. LF is endemic in 28 states and the FCT out of the 32 states so far mapped with an estimated 80-100 million Nigerians needing treatment. Nigeria is third in the world’s burden for LF. The mean national prevalence for infections with schistosomiasis and soil transmitted helminthiasis ranges from 13 percent to 100 percent across the country. Seventy-three cases of GWD were reported in Nigeria in 2007. In 2008, there were 38 cases of GWD reported in five villages in Nigeria, a significant drop from over the 653,000 cases reported when the first case search was conducted in 1987/88 (Nigeria Guinea Worm Eradication Programme, 2007). Together, the NTDs constitute a tremendous disease burden in Nigeria, but can be treated collectively through large-scale integrated programmes that use safe and effective drugs and/or management and containment methods. Safe and cost-effective interventions for the prevention and control of these diseases are available. As a result, Mass Drug Administration (MDA) was initiated in Household Population and Housing Characteristics | 29 Nigeria in 1991 for these diseases. Ivermectin is used for onchocerciasis, and the current initiative uses Community Directed Treatment with Ivermectin (CDTI or ComDT).2 Ivermectin and albendazole are used for lymphatic filariasis, and praziquantel and albendazole are used for schistosomiasis and soil- transmitted helminthiasis. The national control programmes have also initiated Triple Drug Administration for co-endemic diseases (schistosomiasis, onchocerciasis and lymphatic filariasis). There are no vaccines or medications effective in preventing or treating GWD. Current eradication efforts for GWD are aimed at improving routine and active GWD surveillance with nationwide and local case searches and promotion of activities and practices that will ensure the zero GWD case status is maintained in Nigeria for a minimum of three consecutive years. All suspected cases are reported to health facilities and health workers, and investigated within 24 hours. Other eradication strategies taken include creating adequate public awareness to promote enhanced early case detection and reporting, provision of adequate safe water sources in the previously endemic villages and villages at risk, containment of cases, treatment of unsafe water sources with the chemical larvicide Abate (temephos), and distribution of water filters (cloth and pipe) to endemic communities. In the 2008 NDHS, information was collected for each household member on whether they had taken a drug for river blindness, elephantiasis, or bilharziasis, and whether they had seen a worm emerging from a skin lesion (blister or boil) in the 12 months preceding the survey. In addition, information was collected for children age 5-17 years on whether they had blood in their urine (haematuria) in the 30 days prior to the survey. The results are shown in Table 2.13. According to the 2008 NDHS, 4 percent of the household population received drugs for river blindness, 1 percent each received drugs for elephantiasis, and nilharziasis. Drug consumption for these diseases was almost equal among males and females but was more common in rural than urban areas. The Northern zones (North Central, North East, and North West) generally recorded higher percentages of the household population receiving drugs for these three diseases in the 12 months prior to the survey compared with the Southern zones. About one percent of children age 5-17 were reported to have had blood in their urine in the 30 days prior to the survey. The prevalence was higher in males (2 percent) than females (1 percent) and was more common in the Northern zones than in the Southern zones. Generally, people in the lower wealth quintiles were more likely to have received the drugs or to have had blood in their urine than those in the higher wealth quintiles. Less than 1 percent of the household populations were reported to have had a worm emerging from a skin lesion (blister or boil) in the 12 months prior to the survey. It is important to note that this figure represents information provided by household respondents, and not confirmed cases. Equal proportions of males and females were reported to have experienced worms emerging from skin lesions; however, this occurrence was more common in rural areas than urban areas. Generally, a higher proportion of the population in the Northern zones was reported to have seen a worm emerging from a skin lesion, with the highest proportion observed in the North Central (2 percent). As with the other NTDs, sighting the emergence of a worm from a blister decreases as wealth quintile increases. 2 CDTI is a programme for prevention and treatment of onchocerciasis and LF based on the concept of Community Directed Interventions. For more information, see Boatin, 2008. 30 | Household Population and Housing Characteristics Table 2.13 Neglected tropical diseases reported in households Percentage of de jure women, men, and children who reported taking drugs for onchoceriasis, lymphatic filariasis, and schistosomiasis, and the percentage who saw a worm emerging from a skin lesion (blister or boil) in the 12 months prior to the survey, by background characteristics, Nigeria 2008 Guinea worm disease Mass drug administration for onchoceriasis, lymphatic filariasis, and schistosomiasis Schistosomiasis in children ages 5-17 Background characteristic Percentage who took any drug for onchoceriasis (river blindness)1 Percentage who took any drug for lymphatic filariasis (elephantitis)2 Percentage who took any drug for schistosomiasis (bilharazia)3 Percentage who saw a worm emerging from a skin lesion (blister or boil) in the past 12 months Number Percentage of children age 5-17 who had blood in their urine in the past 30 days Number of children Age 0-4 2.2 0.6 0.5 0.4 25,726 na na 5-9 4.0 1.1 0.9 0.5 23,118 1.0 23,118 10-14 4.1 1.1 1.1 0.5 18,042 1.5 18,042 15-19 4.2 1.1 0.8 0.5 13,047 na na 15-17 4.2 1.1 0.8 0.5 7,901 1.4 7,901 18-19 4.2 1.0 0.7 0.5 5,146 na na 20-24 3.6 1.1 0.8 0.5 11,481 na na 25-29 3.8 1.1 0.8 0.5 11,940 na na 30-34 3.7 1.1 0.9 0.6 9,208 na na 35-39 4.4 1.2 0.9 0.6 7,905 na na 40-44 4.6 1.4 1.0 0.6 6,272 na na 45-49 4.8 1.2 0.8 0.5 5,402 na na 50-54 4.7 1.0 0.9 0.6 4,895 na na 55-59 4.6 1.2 0.8 0.8 3,488 na na 60+ 5.9 1.2 0.7 0.4 9,927 na na Don't know/missing 3.0 0.0 0.0 0.0 137 na na Sex Male 4.0 1.1 0.9 0.5 74,953 1.7 25,005 Female 3.8 1.0 0.7 0.5 75,635 0.8 24,056 Residence Urban 1.9 0.6 0.4 0.3 50,147 1.0 15,257 Rural 4.9 1.2 1.0 0.6 100,442 1.4 33,805 Zone North Central 9.3 4.0 2.3 1.8 21,971 2.1 7,670 North East 8.0 1.5 1.3 0.4 20,353 3.3 7,266 North West 3.0 0.7 0.9 0.4 38,913 1.2 13,610 South East 1.4 0.2 0.2 0.1 17,430 0.4 5,061 South South 1.3 0.2 0.1 0.1 22,329 0.2 6,705 South West 1.8 0.2 0.1 0.1 29,594 0.2 8,751 Wealth quintile Lowest 4.9 1.4 1.4 0.7 30,113 2.6 10,473 Second 5.0 1.6 1.2 0.7 30,120 1.6 10,408 Middle 5.2 1.2 0.8 0.5 30,127 0.9 10,116 Fourth 3.0 0.6 0.4 0.4 30,122 0.7 9,345 Highest 1.4 0.4 0.2 0.2 30,106 0.3 8,720 Total 3.9 1.0 0.8 0.5 150,589 1.3 49,062 na = Not applicable 1 River blindness is a disease that causes itchy skin, lumps in the skin, and blindness. 2 Elephantitis is a disease that causes swelling in the arms and legs. 3 Bilharazia is a disease that causes blood in the urine. Characteristics of Respondents | 31 CHARACTERISTICS OF RESPONDENTS 3 The purpose of this chapter is to provide a demographic and socio-economic profile of individual female and male respondents. This information is essential for interpretation of the findings presented later in the report and provides an indication of the representativeness of the survey. The chapter begins by describing basic background characteristics, including age, marital status, residence, education, religion, ethnicity, and economic status of respondents’ households. The chapter also includes more detailed information on education, employment, and indictors of women’s status. Information on health insurance coverage and knowledge and attitudes concerning tuberculosis is presented, and findings on the use of tobacco are provided as a lifestyle measure.1 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 shows the distribution of women and men age 15-49 by background characteristics. The proportions of women and men decline with increasing age. More than two-thirds (69 percent) of all women are currently married, and an additional 2 percent are in informal unions (living together). One-quarter of women age 15-49 have never been married, while 2 percent of women are divorced or separated, and 2 percent are widowed. Fifty-one percent of men are currently married or in informal unions (living together), 47 percent have never been married and 2 percent are divorced, separated, or widowed. The majority of women and men live in rural areas (64 percent of women and 62 percent of men). For both women and men, half live in the northern zones (North Central, North East, and North West) and half live in the southern zones (South East, South South, and South West). The majority of respondents have had some education; however, 36 percent of women and 19 percent of men have never attended school. One-fifth of both women and men have attained primary education only, while 45 percent of women and 61 percent of men have attended secondary school or higher. Table 3.1 shows that about 45 percent of all respondents are Muslim; 54 percent of respondents are Christian (12 percent Catholic); and 1 percent of respondents are Traditionalist. The ethnic composition of the sample indicates that Hausa (22 percent), Yoruba (18 percent), and Igbo (16 percent) are the major ethnic groups in Nigeria. Other ethnic groups constitute about 44 percent of the total sample, underscoring the multiplicity of ethnic groups in Nigeria. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 32 | Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Nigeria 2008 Women Men Background characteristic Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15-19 19.4 6,493 6,591 18.3 2,532 2,571 20-24 18.4 6,133 6,103 17.2 2,378 2,399 25-29 18.9 6,309 6,303 17.8 2,459 2,446 30-34 13.9 4,634 4,557 14.9 2,058 2,051 35-39 11.7 3,912 3,883 13.0 1,794 1,773 40-44 9.1 3,032 3,043 10.2 1,413 1,417 45-49 8.6 2,872 2,905 8.5 1,174 1,181 Marital status Never married 25.2 8,397 8,021 47.4 6,548 6,418 Married 69.1 23,062 23,479 49.0 6,765 6,922 Living together 1.5 516 475 1.8 253 264 Divorced/separated 1.9 651 646 1.3 184 176 Widowed 2.3 759 763 0.4 54 55 Missing 0.0 1 1 0.0 3 3 Residence Urban 35.7 11,934 10,489 37.8 5,215 4,643 Rural 64.3 21,451 22,896 62.2 8,593 9,195 Zone North Central 14.2 4,748 6,366 15.0 2,065 2,773 North East 12.8 4,262 6,217 11.9 1,645 2,444 North West 24.0 8,022 7,297 23.4 3,237 2,930 South East 12.3 4,091 3,667 10.5 1,448 1,237 South South 16.4 5,473 4,813 17.7 2,437 2,167 South West 20.3 6,789 5,025 21.6 2,977 2,287 Religion Catholic 11.5 3,848 3,583 11.6 1,597 1,490 Other Christian 42.1 14,060 13,588 42.1 5,806 5,694 Islam 44.4 14,826 15,449 44.7 6,173 6,406 Traditionalist 1.3 429 535 1.0 138 150 Other 0.2 53 53 0.4 60 61 Missing 0.5 171 177 0.2 34 37 Ethnicity Ekoi 1.7 555 583 1.5 205 208 Fulani 6.1 2,020 2,460 5.4 744 949 Hausa 22.3 7,431 7,086 22.5 3,107 2,956 Ibibio 2.5 819 693 2.5 340 290 Igala 1.4 476 529 1.7 230 256 Igbo 15.9 5,295 4,583 14.5 1,999 1,692 Ijaw/Izon 3.5 1,169 1,184 4.5 621 615 Kanuri/Beriberi 2.0 674 836 1.7 241 307 Tiv 2.4 801 896 2.6 362 397 Yoruba 17.7 5,924 4,861 18.5 2,555 2,168 Others 24.2 8,083 9,522 24.5 3,381 3,974 Missing 0.4 139 152 0.2 24 26 Education No education 35.8 11,942 13,242 18.8 2,597 2,907 Primary 19.7 6,566 6,591 20.0 2,761 2,769 Secondary 35.7 11,904 10,905 46.9 6,470 6,287 More than secondary 8.9 2,974 2,647 14.3 1,979 1,875 Total 15-49 100.0 33,385 33,385 100.0 13,808 13,838 50-59 na na na na 1,678 1,648 Total men 15-59 na na na na 15,486 15,486 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Respondents | 33 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Table 3.2.1 provides an overview of the relationship between women’s level of education and other background characteristics. The results show that younger women are more likely than older women to have some education. For example, more than twice as many women age 45-49 as women age 15-24 reported that they have no education (59 versus 27 percent, respectively). Women’s level of education varies by residence; women in rural areas are far less likely to be educated than their urban counterparts. For example, 47 percent of rural women have not attended school, compared with just 17 percent of their urban counterparts. Overall, the median years of school completed for women age 15-49 is 6 years. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Nigeria 2008 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Median years completed Number of women Age 15-24 27.3 5.3 9.3 31.8 20.4 5.8 100.0 7.5 12,626 15-19 24.7 6.4 8.2 45.6 13.9 1.2 100.0 7.4 6,493 20-24 30.0 4.1 10.5 17.2 27.4 10.8 100.0 8.0 6,133 25-29 34.1 5.3 14.6 12.5 21.1 12.4 100.0 5.7 6,309 30-34 37.6 6.7 15.9 9.8 17.8 12.2 100.0 5.4 4,634 35-39 38.3 7.2 19.4 10.1 14.4 10.6 100.0 5.2 3,912 40-44 46.3 7.2 17.1 8.6 11.7 9.1 100.0 3.0 3,032 45-49 59.1 7.6 14.8 4.9 6.8 6.8 100.0 a 2,872 Residence Urban 16.5 4.0 12.8 20.9 28.3 17.5 100.0 10.1 11,934 Rural 46.5 7.3 14.0 16.6 11.5 4.1 100.0 3.1 21,451 Zone North Central 35.5 8.3 16.8 18.5 12.9 8.0 100.0 5.4 4,748 North East 68.1 6.9 8.5 9.3 5.0 2.2 100.0 a 4,262 North West 74.2 3.8 8.1 6.1 5.3 2.5 100.0 a 8,022 South East 6.3 8.1 15.3 28.8 28.6 13.0 100.0 9.6 4,091 South South 6.0 7.6 17.7 30.4 26.1 12.2 100.0 8.7 5,473 South West 12.0 4.3 16.7 21.3 29.6 16.2 100.0 10.0 6,789 Wealth quintile Lowest 75.9 6.9 8.8 6.5 1.8 0.1 100.0 a 6,194 Second 59.5 9.0 14.1 12.1 4.7 0.7 100.0 a 6,234 Middle 34.8 8.8 17.5 23.1 13.2 2.6 100.0 5.4 6,341 Fourth 14.4 5.1 17.9 26.6 26.4 9.6 100.0 8.4 6,938 Highest 4.2 1.7 9.9 20.7 36.2 27.3 100.0 11.4 7,678 Total 35.8 6.1 13.6 18.1 17.5 8.9 100.0 5.6 33,385 a = Omitted because more than 50 percent of women had no formal schooling 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level The urban-rural difference is more pronounced at the level of secondary school or higher. For example, the percentage of women in urban areas who have completed secondary school or gone on to the post-secondary level is almost three times that of their rural counterparts (46 and 16 percent, respectively). In Table 3.2.2, the relationship between men’s level of education and other background characteristics also shows that men in urban areas have higher levels of educational attainment than their rural counterparts. Only 8 percent of urban males compared with 26 percent of their rural counterparts have no formal education. While 57 percent of urban males have completed secondary or higher education, only 29 percent of their rural counterparts have done so. Overall, the median years of school completed for men age 15-49 is 9 years. 34 | Characteristics of Respondents The level of educational attainment varies by zone, but it is higher for both women and men in the southern zones compared with the northern zones. Educational attainment also increases as household economic status increases. For example, 76 percent of the women in the poorest households have no formal education compared with just 4 percent of women in the most advantaged households. Almost two-thirds of women in the highest wealth quintile have completed secondary or higher education, compared with 2 percent of women in the lowest wealth quintile. A similar pattern is observed for men. Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Nigeria 2008 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Median years completed Number of men Age 15-24 13.3 5.3 8.8 39.8 25.8 7.0 100.0 8.9 4,910 15-19 13.0 7.2 9.4 54.9 14.5 1.0 100.0 8.0 2,532 20-24 13.7 3.1 8.2 23.7 37.9 13.3 100.0 11.0 2,378 25-29 17.8 3.3 13.9 13.9 30.7 20.3 100.0 11.0 2,459 30-34 20.3 4.3 17.9 12.3 26.1 19.1 100.0 8.8 2,058 35-39 21.6 4.9 21.8 11.0 23.8 16.9 100.0 7.1 1,794 40-44 25.2 6.3 21.3 7.6 22.7 16.9 100.0 5.9 1,413 45-49 29.2 5.7 21.8 7.7 18.3 17.3 100.0 5.7 1,174 Residence Urban 7.5 2.9 11.3 21.0 33.8 23.4 100.0 11.2 5,215 Rural 25.7 6.1 17.4 21.5 20.5 8.8 100.0 6.1 8,593 Zone North Central 15.4 5.4 15.0 26.6 23.4 14.3 100.0 8.8 2,065 North East 45.0 8.2 11.1 16.9 11.3 7.5 100.0 3.4 1,645 North West 40.7 4.3 17.4 13.9 13.6 10.0 100.0 5.3 3,237 South East 0.9 6.0 23.0 25.9 30.1 14.1 100.0 9.5 1,448 South South 2.3 4.1 13.4 29.1 34.5 16.5 100.0 11.0 2,437 South West 5.2 3.3 12.5 19.6 38.3 21.2 100.0 11.2 2,977 Wealth quintile Lowest 55.2 8.3 16.0 13.4 6.0 1.3 100.0 a 2,275 Second 32.5 7.8 20.5 20.7 15.1 3.3 100.0 5.5 2,332 Middle 15.6 6.2 18.6 27.5 23.5 8.6 100.0 8.0 2,570 Fourth 4.2 3.2 15.7 27.2 34.4 15.3 100.0 11.0 3,163 Highest 1.4 1.2 7.9 17.0 38.8 33.7 100.0 11.6 3,468 Total 15-49 18.8 4.9 15.1 21.3 25.5 14.3 100.0 8.7 13,808 50-59 41.3 8.6 23.1 4.7 9.3 13.1 100.0 5.0 1,678 Total men 15-59 21.2 5.3 16.0 19.5 23.8 14.2 100.0 8.2 15,486 a = Omitted because more than 50 percent of men had no formal schooling 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level 3.3 LITERACY The literacy status of respondents in the 2008 NDHS was determined by assessing their ability to read all or part of a simple sentence in any of the major language groups of Nigeria. The ability to read is crucial for exploring social and economic opportunities during a person’s lifetime. For programme planners, literacy statistics are critical for determining the best ways to get health and other messages to women and men in different subgroups. The literacy test was administered only to Characteristics of Respondents | 35 respondents who had less than a secondary education because those with some secondary education or higher were assumed to be literate. Tables 3.3.1 and 3.3.2 show the percent distribution of women and men by level of schooling attended, level of literacy, and percentage literate according to background characteristics. More than half (54 percent) of women are literate. The level of literacy is much higher for younger women than older women, ranging from a high of 67 percent for women age 15-19 to a low of 32 percent for women age 45-49. Urban women are nearly twice as likely to be literate as rural women (77 and 41 percent, respectively). Literacy levels also vary widely by zone, with the northern zones lagging behind the southern zones. The patterns of men’s literacy are similar to those of women. However, the disparity between women and men according to household economic status is marked; in the poorest households 40 percent of men are literate compared with 13 percent of women Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Nigeria 2008 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Percentage literate1 Number of women Age 15-19 60.7 2.1 4.6 31.9 0.2 0.0 0.5 100.0 67.3 6,493 20-24 55.3 1.6 4.2 38.3 0.2 0.0 0.5 100.0 61.1 6,133 25-29 46.0 2.2 6.4 44.4 0.4 0.0 0.4 100.0 54.7 6,309 30-34 39.8 2.8 7.2 49.0 0.4 0.1 0.6 100.0 49.9 4,634 35-39 35.1 3.8 8.7 51.2 0.2 0.2 0.7 100.0 47.7 3,912 40-44 29.4 4.3 8.2 57.1 0.4 0.2 0.4 100.0 41.9 3,032 45-49 18.5 4.9 8.3 66.5 0.5 0.4 0.8 100.0 31.7 2,872 Residence Urban 66.7 3.4 6.5 22.3 0.4 0.1 0.6 100.0 76.6 11,934 Rural 32.3 2.4 6.3 58.2 0.2 0.1 0.5 100.0 40.9 21,451 Zone North Central 39.3 2.1 6.3 51.2 0.5 0.1 0.6 100.0 47.6 4,748 North East 16.5 1.7 4.6 76.7 0.1 0.0 0.3 100.0 22.8 4,262 North West 14.0 2.5 4.6 78.1 0.1 0.2 0.6 100.0 21.1 8,022 South East 70.3 3.3 7.7 17.8 0.0 0.1 0.7 100.0 81.3 4,091 South South 68.6 2.1 7.0 21.3 0.1 0.2 0.5 100.0 77.8 5,473 South West 67.1 4.5 8.1 18.8 0.9 0.0 0.5 100.0 79.8 6,789 Wealth quintile Lowest 8.4 0.9 3.4 86.6 0.2 0.2 0.4 100.0 12.7 6,194 Second 17.4 2.0 6.5 73.3 0.3 0.1 0.5 100.0 25.8 6,234 Middle 38.9 3.4 8.2 48.3 0.3 0.2 0.7 100.0 50.5 6,341 Fourth 62.6 4.5 8.8 23.1 0.4 0.0 0.6 100.0 75.9 6,938 Highest 84.2 2.8 4.9 7.1 0.3 0.0 0.6 100.0 92.0 7,678 Total 44.6 2.8 6.4 45.3 0.3 0.1 0.6 100.0 53.7 33,385 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 36 | Characteristics of Respondents Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Nigeria 2008 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Percentage literate1 Number of men Age 15-19 70.4 4.3 7.0 17.5 0.3 0.0 0.5 100.0 81.7 2,532 20-24 74.9 2.7 5.7 15.8 0.6 0.1 0.3 100.0 83.3 2,378 25-29 65.0 4.8 8.6 20.9 0.6 0.0 0.1 100.0 78.3 2,459 30-34 57.5 6.3 11.5 23.3 1.0 0.0 0.4 100.0 75.3 2,058 35-39 51.7 7.9 12.1 27.2 0.7 0.0 0.4 100.0 71.7 1,794 40-44 47.2 9.3 13.3 28.6 1.0 0.1 0.5 100.0 69.9 1,413 45-49 43.3 10.9 14.7 30.2 0.4 0.3 0.3 100.0 68.9 1,174 Residence Urban 78.3 5.2 7.3 8.5 0.3 0.0 0.3 100.0 90.9 5,215 Rural 50.8 6.4 11.1 30.4 0.9 0.1 0.4 100.0 68.3 8,593 Zone North Central 64.3 4.5 6.8 23.3 0.7 0.1 0.3 100.0 75.6 2,065 North East 35.7 7.4 10.7 45.7 0.2 0.1 0.3 100.0 53.8 1,645 North West 37.6 8.3 14.7 36.9 1.7 0.0 0.7 100.0 60.6 3,237 South East 70.0 10.7 12.9 6.0 0.0 0.0 0.4 100.0 93.7 1,448 South South 80.2 3.0 6.2 10.5 0.0 0.0 0.1 100.0 89.3 2,437 South West 79.0 3.6 6.9 9.6 0.6 0.0 0.2 100.0 89.6 2,977 Wealth quintile Lowest 20.6 6.3 13.3 59.0 0.4 0.0 0.4 100.0 40.2 2,275 Second 39.2 7.5 14.1 37.9 0.9 0.0 0.4 100.0 60.7 2,332 Middle 59.6 6.4 12.0 19.8 1.5 0.1 0.6 100.0 78.1 2,570 Fourth 76.9 5.9 8.7 7.6 0.6 0.1 0.2 100.0 91.5 3,163 Highest 89.5 4.3 3.5 2.4 0.1 0.0 0.2 100.0 97.3 3,468 Total 15-49 61.2 5.9 9.7 22.1 0.7 0.0 0.3 100.0 76.8 13,808 50-59 27.0 14.5 13.1 42.6 0.9 0.3 1.5 100.0 54.6 1,678 Total men 15-59 57.5 6.9 10.0 24.4 0.7 0.1 0.5 100.0 74.4 15,486 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 3.4 ACCESS TO MASS MEDIA Information on the respondents’ exposure to common print and electronic media was collected in the 2008 NDHS. Respondents were asked how often they read a newspaper, listen to the radio, or watch television. This information is important because it provides an indication of the extent to which Nigerians are regularly exposed to mass media that are often used to convey messages on family planning and other health topics. Data on exposure to mass media for both women and men age 15-49 are presented in Tables 3.4.1 and 3.4.2. About one in ten women read a newspaper weekly compared with three in ten men. While half of male respondents watch television at least once a week, only about two-fifths of women do so. Women and men living in urban areas are much more likely to be exposed to mass media. The proportion of non-exposure to any media at least once a week increases with age for both women and men. The findings show that women are less likely than men to have had no exposure to any form of media at least once a week (39 versus 14 percent, respectively). Urban respondents are more likely than rural respondents to be exposed to all three types of media. By zone, exposure to all three types of media is highest for respondents in the southern zones compared with those in the northern zones. Higher levels of educational attainment are associated with increased exposure to mass media. Characteristics of Respondents | 37 Similarly, wealth status is positively related to exposure to mass media. For instance, 71 percent of women in the lowest quintile have no weekly exposure to any media source, while only 8 percent of those in the highest quintile have no exposure. For men, 38 percent in the lowest wealth quintile have no weekly exposure to any media source, compared with 2 percent of men in the highest wealth quintiles. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Nigeria 2008 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week All three media at least once a week No media at least once a week Number of women Age 15-19 11.9 43.5 53.5 9.0 36.2 6,493 20-24 15.0 43.5 55.4 11.9 35.8 6,133 30-34 12.0 39.6 54.5 9.9 38.5 4,634 35-39 10.8 37.7 53.5 8.8 39.4 3,912 40-44 9.1 33.0 52.5 7.7 42.1 3,032 45-49 6.9 27.2 47.2 5.3 47.6 2,872 Residence Urban 21.8 68.8 68.5 18.5 18.9 11,934 Rural 6.3 23.3 45.5 4.3 49.4 21,451 Zone North Central 9.9 32.1 47.5 8.2 47.0 4,748 North East 3.1 14.4 35.0 1.9 61.4 4,262 North West 3.8 17.8 47.9 2.7 49.9 8,022 South East 17.9 44.5 53.8 12.8 34.0 4,091 South South 19.6 58.3 53.6 15.5 30.1 5,473 South West 18.2 68.3 76.6 15.9 13.9 6,789 Education No education 0.2 9.6 36.0 0.1 61.9 11,942 Primary 3.1 32.7 50.4 1.8 41.6 6,566 Secondary 18.3 62.5 65.8 14.1 21.2 11,904 More than secondary 52.0 83.5 83.4 44.8 6.5 2,974 Wealth quintile Lowest 0.4 2.9 27.4 0.1 71.4 6,194 Second 2.0 7.6 39.5 0.8 58.0 6,234 Middle 6.1 23.8 50.7 3.1 43.2 6,341 Fourth 14.5 63.1 66.6 11.1 21.0 6,938 Highest 31.3 86.9 77.3 27.5 7.9 7,678 Total 11.8 39.6 53.7 9.4 38.5 33,385 38 | Characteristics of Respondents Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Nigeria 2008 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week All three media at least once a week No media at least once a week Number of men Age 15-19 20.7 52.0 74.1 15.9 18.4 2,532 20-24 32.8 58.5 82.5 26.4 11.8 2,378 25-29 33.8 55.1 83.1 27.6 12.2 2,459 30-34 33.4 52.9 83.2 27.4 13.3 2,058 35-39 30.3 48.0 82.6 24.1 13.5 1,794 40-44 29.0 45.9 82.9 24.1 14.6 1,413 45-49 29.3 43.9 82.2 23.9 15.9 1,174 Residence Urban 47.5 77.6 87.7 40.9 5.8 5,215 Rural 19.1 36.4 77.2 13.9 19.2 8,593 Zone North Central 26.2 44.3 79.2 18.7 15.8 2,065 North East 13.4 23.0 61.8 8.0 34.1 1,645 North West 16.4 31.5 80.0 12.2 17.4 3,237 South East 39.7 65.5 88.5 34.1 7.5 1,448 South South 36.0 71.1 80.9 30.2 10.7 2,437 South West 46.3 73.3 91.2 39.8 4.4 2,977 Education No education 0.9 11.5 61.2 0.4 37.3 2,597 Primary 10.2 38.1 77.9 7.2 18.0 2,761 Secondary 35.8 64.4 86.4 28.0 7.2 6,470 More than secondary 75.7 83.8 94.9 66.1 1.0 1,979 Wealth quintile Lowest 5.3 10.7 60.3 2.3 38.0 2,275 Second 10.5 19.9 75.1 5.4 22.3 2,332 Middle 20.2 38.7 82.2 13.1 13.2 2,570 Fourth 36.7 72.5 87.8 29.3 5.5 3,163 Highest 59.9 91.7 92.2 54.3 1.6 3,468 Total 15-49 29.8 52.0 81.2 24.1 14.1 13,808 50-59 24.1 37.0 77.3 19.8 20.8 1,678 Total men 15-59 29.2 50.4 80.8 23.6 14.9 15,486 3.5 EMPLOYMENT Employment is one source of empowerment for women, given that they exercise control over their own income. It is difficult to measure employment status because some work, especially work on family farms, in family businesses, or in the informal sector, is often not perceived as employment by women and men themselves, and hence not reported as such. The 2008 NDHS asked women and men detailed questions about their employment status in order to ensure complete coverage of employment in any sector, formal or informal. Women and men who reported that they were currently working and those who reported that they worked at sometime during the 12 months preceding the survey are considered to have been employed. Additional information was collected on the type of work women and men were doing, whether they worked continuously throughout the year or not, for whom they worked, and the form in which they received their earnings. Tables 3.5.1 and 3.5.2 show the percent distribution of women and men age 15-49 by employment status, according to background characteristics. Fifty-nine percent of women are currently employed. Four percent reported that they worked at some point during the past 12 months but were not working at the time of the survey. Thirty-seven percent did not work at all in the 12 months preceding the survey. Eighty percent of men are currently employed. Two percent of men reported that they worked during the past 12 months but were not working at the time of the survey. Eighteen percent of men did not work at all in the 12 months preceding the survey. Characteristics of Respondents | 39 Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Nigeria 2008 Employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Not employed in the 12 months preceding the survey Missing/ don't know Total Number of women Age 15-19 26.1 2.2 71.6 0.1 100.0 6,493 20-24 48.3 3.4 48.1 0.2 100.0 6,133 25-29 65.0 3.4 31.5 0.1 100.0 6,309 30-34 73.1 4.0 22.7 0.2 100.0 4,634 35-39 77.6 3.4 18.8 0.2 100.0 3,912 40-44 77.2 4.2 18.4 0.2 100.0 3,032 45-49 77.4 5.8 16.7 0.1 100.0 2,872 Marital status Never married 33.8 1.7 64.5 0.1 100.0 8,397 Married or living together 66.9 4.2 28.7 0.2 100.0 23,578 Divorced/separated/widowed 80.5 3.7 15.6 0.1 100.0 1,409 Missing 100.0 0.0 0.0 0.0 100.0 1 Number of living children 0 37.1 2.2 60.5 0.1 100.0 10,392 1-2 62.3 3.7 34.0 0.1 100.0 8,352 3-4 71.8 3.9 24.1 0.2 100.0 7,591 5+ 74.2 4.9 20.6 0.3 100.0 7,049 Residence Urban 59.7 2.4 37.7 0.2 100.0 11,934 Rural 58.8 4.2 36.8 0.2 100.0 21,451 Zone North Central 62.8 3.2 33.9 0.2 100.0 4,748 North East 57.1 4.1 38.6 0.2 100.0 4,262 North West 46.0 7.2 46.6 0.2 100.0 8,022 South East 58.7 1.0 40.0 0.3 100.0 4,091 South South 63.9 2.4 33.5 0.2 100.0 5,473 South West 69.9 1.4 28.7 0.0 100.0 6,789 Education No education 56.8 5.4 37.5 0.3 100.0 11,942 Primary 73.1 3.4 23.3 0.2 100.0 6,566 Secondary 52.9 2.2 44.8 0.1 100.0 11,904 More than secondary 62.5 1.9 35.6 0.0 100.0 2,974 Wealth quintile Lowest 55.8 5.0 39.0 0.2 100.0 6,194 Second 59.6 5.9 34.3 0.2 100.0 6,234 Middle 59.2 3.4 37.2 0.2 100.0 6,341 Fourth 59.3 2.2 38.3 0.2 100.0 6,938 Highest 61.2 1.8 36.9 0.1 100.0 7,678 Total 59.1 3.5 37.2 0.2 100.0 33,385 Note: Total includes 1 woman with information missing on marital status who is not shown separately. 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Tables 3.5.1 and 3.5.2 also show that current employment increases with age for both women and men. Women who are divorced, separated, or widowed (81 percent) are most likely to be employed, followed by those who are married or living together (67 percent), while never-married women are the least likely to be employed (34 percent). Men who are currently married or living together are most likely to be employed (98 percent), followed by those who are divorced, separated, or widowed (96 percent). Sixty percent of never-married men are currently employed. 40 | Characteristics of Respondents Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Nigeria 2008 Employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Not employed in the 12 months preceding the survey Missing/ don't know Total Number of men Age 15-19 44.8 3.7 51.6 0.0 100.0 2,532 20-24 65.4 2.9 31.6 0.0 100.0 2,378 25-29 85.7 2.1 12.1 0.1 100.0 2,459 30-34 94.9 1.2 3.8 0.1 100.0 2,058 35-39 98.0 0.8 1.2 0.0 100.0 1,794 40-44 98.1 0.8 1.1 0.1 100.0 1,413 45-49 98.4 0.3 1.4 0.0 100.0 1,174 Marital status Never married 60.3 3.1 36.6 0.0 100.0 6,548 Married or living together 97.9 0.8 1.2 0.1 100.0 7,018 Divorced/separated/widowed 95.9 2.0 2.1 0.0 100.0 238 Missing 100.0 0.0 0.0 0.0 100.0 3 Number of living children 0 64.2 2.8 32.9 0.0 100.0 7,272 1-2 96.5 1.2 2.3 0.0 100.0 2,505 3-4 98.0 1.0 1.0 0.0 100.0 2,043 5+ 98.8 0.5 0.6 0.1 100.0 1,989 Residence Urban 75.4 2.0 22.5 0.0 100.0 5,215 Rural 82.8 1.9 15.3 0.0 100.0 8,593 Zone North Central 84.9 2.6 12.5 0.0 100.0 2,065 North East 90.8 1.6 7.6 0.0 100.0 1,645 North West 86.4 1.7 11.8 0.1 100.0 3,237 South East 72.9 1.1 26.0 0.0 100.0 1,448 South South 69.4 3.5 27.0 0.0 100.0 2,437 South West 75.9 1.0 23.1 0.0 100.0 2,977 Education No education 97.3 0.9 1.9 0.0 100.0 2,597 Primary 90.9 1.3 7.7 0.1 100.0 2,761 Secondary 70.1 2.5 27.4 0.0 100.0 6,470 More than secondary 74.6 2.4 23.0 0.1 100.0 1,979 Wealth quintile Lowest 93.7 1.3 4.9 0.1 100.0 2,275 Second 87.3 1.9 10.8 0.0 100.0 2,332 Middle 77.7 2.4 19.9 0.0 100.0 2,570 Fourth 72.4 2.1 25.5 0.0 100.0 3,163 Highest 74.9 1.8 23.2 0.1 100.0 3,468 Total 15-49 80.0 1.9 18.0 0.0 100.0 13,808 50-59 96.6 1.0 2.2 0.2 100.0 1,678 Total men 15-59 81.8 1.8 16.3 0.1 100.0 15,486 Note: Total includes 3 men with information missing on marital status who are not shown separately. 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. There is no significant difference by urban-rural residence in the proportion of women currently employed (60 and 59 percent, respectively). However, the percentage of men currently employed is higher in rural areas than in urban areas (83 and 75 percent, respectively). Levels of employment vary by zone; for example, among women, current employment ranges from a low of 46 percent in the North West to a high of 70 percent in the South West. Among men, employment is lowest in the South South (69 percent) and highest in the North East (91 percent). Characteristics of Respondents | 41 3.6 OCCUPATION Respondents who reported being currently employed or who worked in the 12 months preceding the survey were asked what type of work they normally do. Tables 3.6.1 and 3.6.2 show the distribution of women and men by occupation according to background characteristics. Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Nigeria 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of women Age 15-19 1.8 2.0 46.5 17.3 1.3 30.3 0.8 100.0 1,839 20-24 4.3 2.7 49.9 18.3 1.1 22.9 0.8 100.0 3,172 25-29 6.2 2.5 51.9 17.3 0.4 20.8 0.7 100.0 4,315 30-34 8.8 1.8 54.8 12.9 0.2 20.7 0.7 100.0 3,573 35-39 7.9 1.6 54.4 11.7 0.2 23.6 0.7 100.0 3,166 40-44 8.1 1.7 53.3 8.9 0.2 27.5 0.4 100.0 2,469 45-49 7.1 0.6 52.0 8.6 0.1 30.7 0.9 100.0 2,387 Marital status Never married 10.4 6.2 47.6 14.1 1.9 19.1 0.7 100.0 2,975 Married or living together 5.9 1.2 53.1 14.2 0.2 24.7 0.7 100.0 16,758 Divorced/separated/widowed 7.0 1.6 50.3 8.4 0.1 32.1 0.4 100.0 1,187 Missing 0.0 0.0 100.0 0.0 0.0 0.0 0.0 100.0 1 Number of living children 0 9.8 4.9 47.4 16.2 1.5 19.4 0.8 100.0 4,089 1-2 7.2 1.9 51.7 16.0 0.3 22.1 0.7 100.0 5,508 3-4 6.3 1.1 54.1 13.4 0.2 24.2 0.7 100.0 5,749 5+ 3.9 0.6 54.2 10.5 0.1 30.0 0.7 100.0 5,574 Residence Urban 12.1 4.3 61.1 14.5 0.7 6.5 0.8 100.0 7,411 Rural 3.6 0.6 47.3 13.5 0.3 34.0 0.6 100.0 13,511 Zone North Central 5.7 1.3 37.4 7.5 0.4 47.2 0.5 100.0 3,132 North East 1.8 0.6 42.9 16.6 0.4 36.6 1.1 100.0 2,608 North West 2.6 0.2 62.1 25.4 0.3 8.7 0.7 100.0 4,268 South East 10.3 2.2 51.8 8.9 0.7 25.5 0.5 100.0 2,444 South South 7.0 2.8 49.8 9.3 0.6 29.9 0.6 100.0 3,628 South West 11.0 3.7 60.0 12.2 0.4 11.7 0.9 100.0 4,841 Education No education 0.5 0.0 51.9 16.7 0.3 29.8 0.8 100.0 7,426 Primary 0.6 0.2 51.3 13.6 0.2 33.7 0.5 100.0 5,026 Secondary 5.3 3.8 58.7 13.8 0.6 17.2 0.6 100.0 6,554 More than secondary 50.2 7.5 33.4 3.9 1.7 2.1 1.3 100.0 1,916 Wealth quintile Lowest 0.1 0.0 41.3 13.0 0.2 44.6 0.8 100.0 3,765 Second 0.7 0.0 45.6 15.4 0.3 37.4 0.6 100.0 4,081 Middle 3.0 0.7 50.2 12.8 0.3 32.2 0.8 100.0 3,970 Fourth 8.6 2.2 60.7 15.1 0.5 12.4 0.6 100.0 4,269 Highest 17.7 5.8 60.3 13.0 0.9 1.5 0.8 100.0 4,836 Total 6.6 1.9 52.2 13.9 0.5 24.3 0.7 100.0 20,921 42 | Characteristics of Respondents Among occupational categories, sales and services and agriculture are the most common for both women and men. Among women, the sales and services sector employs half (52 percent) of employed women and the agriculture sector employs 24 percent of women. Another 14 percent of women are engaged in skilled manual jobs. Table 3.6.2 shows that the highest proportion of men work in agriculture (40 percent), followed by sales and services (27 percent). Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Nigeria 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of men Age 15-19 1.7 0.7 14.9 18.6 13.2 50.1 0.7 100.0 1,227 20-24 5.3 1.9 23.2 22.8 6.9 39.0 0.9 100.0 1,626 25-29 7.9 1.9 31.7 20.5 2.3 35.1 0.7 100.0 2,160 30-34 9.3 1.7 32.9 18.8 0.7 35.7 0.8 100.0 1,978 35-39 11.4 1.9 29.6 16.9 0.1 39.4 0.7 100.0 1,772 40-44 12.6 1.5 25.8 16.9 0.2 42.3 0.6 100.0 1,397 45-49 15.1 2.2 24.7 16.0 0.0 41.4 0.6 100.0 1,158 Marital status Never married 7.6 2.1 25.9 22.8 7.7 33.1 0.9 100.0 4,150 Married or living together 9.8 1.5 27.9 16.6 0.3 43.2 0.7 100.0 6,931 Divorced/separated/widowed 8.1 1.6 26.5 15.8 0.8 47.1 0.0 100.0 233 Missing 0.0 0.0 0.0 0.0 0.0 100.0 0.0 100.0 3 Number of living children 0 7.5 2.0 26.4 21.8 6.6 34.9 0.9 100.0 4,874 1-2 10.7 2.0 30.8 17.3 0.4 38.1 0.7 100.0 2,447 3-4 9.5 1.2 27.6 19.3 0.2 41.4 0.7 100.0 2,023 5+ 10.0 1.3 23.8 13.2 0.1 51.2 0.4 100.0 1,974 Residence Urban 14.2 2.9 40.6 27.5 3.1 11.0 0.8 100.0 4,041 Rural 6.1 1.0 19.6 14.1 3.0 55.5 0.7 100.0 7,277 Zone North Central 8.1 1.3 15.9 11.8 7.3 55.0 0.6 100.0 1,806 North East 3.8 0.9 20.1 8.7 3.7 61.9 0.8 100.0 1,520 North West 6.3 1.4 23.2 11.7 3.3 53.3 0.7 100.0 2,852 South East 10.2 2.0 37.7 29.9 1.4 18.0 0.8 100.0 1,072 South South 10.9 2.3 35.8 28.1 1.2 21.2 0.5 100.0 1,778 South West 14.3 2.3 33.6 27.8 1.0 20.0 0.9 100.0 2,290 Education No education 1.0 0.7 16.3 7.5 0.6 73.3 0.7 100.0 2,548 Primary 2.2 0.6 26.0 21.3 1.5 47.8 0.7 100.0 2,547 Secondary 6.3 1.9 32.9 26.2 4.9 26.9 0.7 100.0 4,700 More than secondary 41.8 4.6 29.3 11.2 3.7 8.6 0.8 100.0 1,522 Wealth quintile Lowest 1.0 0.4 10.2 5.7 2.6 79.4 0.7 100.0 2,161 Second 3.1 0.4 13.8 10.5 2.8 68.4 1.0 100.0 2,080 Middle 6.0 1.3 25.9 18.1 4.0 44.3 0.4 100.0 2,059 Fourth 11.9 2.0 37.9 28.1 3.6 15.7 0.7 100.0 2,356 Highest 19.7 3.8 42.7 28.5 2.2 2.4 0.8 100.0 2,661 Total 15-49 9.0 1.7 27.1 18.9 3.0 39.6 0.7 100.0 11,317 50-59 11.1 1.8 24.8 13.0 0.5 48.3 0.5 100.0 1,638 Total men 15-59 9.2 1.7 26.8 18.1 2.7 40.7 0.7 100.0 12,955 Characteristics of Respondents | 43 Regardless of marital status, urban-rural residence, or number of living children, sales and services and agriculture are the most common occupations among both women and men. However, respondents with more than a secondary education (among both women and men) are more likely to be engaged in professional/technical/managerial jobs than in other occupations: 50 percent for women and 42 percent for men. There is considerable variation by zone; for example, men in the northern zones are more likely to be in agriculture compared with those in the southern zones. Generally, women in the southern zones are more likely to be in professional/technical/managerial occupations than their northern counterparts. Engaging in professional/technical/managerial occupations is positively related to household economic status; for example, in households in the lowest wealth quintile 1 percent or less of women and men are engaged in professional/technical/managerial occupations, compared with 18 and 20 percent, respectively, in households in the highest wealth quintile. 3.7 EARNINGS, EMPLOYERS, AND CONTINUITY OF EMPLOYMENT Tables 3.7.1 and 3.7.2 show the distribution of women and men by type of earnings, type of employer, and the continuity of employment. Table 3.7.1 presents information separately on women engaged in agricultural work or non-agricultural work. The two sectors influence the type of earnings women receive, the type of employer, and the continuity of employment. Forty-six percent of women employed in agricultural work are not paid. Almost two-thirds of women in this sector are self- employed (63 percent) and 56 percent work seasonally. Among women employed in the non- agricultural sector, 83 percent earn cash only, 75 percent are self-employed, and 82 percent work all year. Table 3.7.1 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Nigeria 2008 Employment characteristic Agricultural work Non-agricultural work Missing Total Type of earnings Cash only 23.4 82.8 71.0 68.3 Cash and in-kind 24.6 6.2 8.2 10.7 In-kind only 6.4 1.0 1.4 2.3 Not paid 45.5 9.6 10.1 18.3 Missing 0.1 0.4 9.3 0.4 Total 100.0 100.0 100.0 100.0 Type of employer Employed by family member 33.6 9.0 8.6 15.0 Employed by non-family member 3.5 15.5 16.4 12.6 Self-employed 62.9 75.2 66.7 72.2 Missing 0.1 0.3 8.3 0.3 Total 100.0 100.0 100.0 100.0 Continuity of employment All year 40.9 82.0 68.7 71.9 Seasonal 56.0 13.7 16.2 24.0 Occasional 2.8 3.9 4.6 3.6 Missing 0.3 0.5 10.5 0.5 Total 100.0 100.0 100.0 100.0 Number of women employed during the past 12 months 5,081 15,692 149 20,921 Note: Total includes women with information missing on type of employment who are not shown separately. 44 | Characteristics of Respondents Table 3.7.2 shows that 58 percent of men employed in agricultural work are not paid. Sixty- five percent of men in agricultural work are self-employed and 53 percent work seasonally. Among men employed in the non-agricultural sector, 78 percent are paid in cash only, 55 percent are self- employed, and 85 percent work all year. Table 3.7.2 Type of employment: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Nigeria 2008 Employment characteristic Agricultural work Non- agricultural work Missing Total Type of earnings Cash only 20.8 77.8 49.2 54.4 Cash and in-kind 15.5 9.3 10.2 11.8 In-kind only 5.9 1.2 2.4 3.1 Not paid 57.7 11.6 27.8 30.5 Missing 0.1 0.1 10.5 0.2 Total 100.0 100.0 100.0 100.0 Type of employer Employed by family member 30.6 8.0 15.9 17.3 Employed by non-family member 3.9 37.0 28.1 23.4 Self-employed 65.4 54.9 46.7 59.1 Missing 0.1 0.1 9.4 0.2 Total 100.0 100.0 100.0 100.0 Continuity of employment All year 43.3 84.9 59.0 67.8 Seasonal 53.4 10.0 27.9 27.8 Occasional 2.7 4.9 2.3 4.0 Missing 0.6 0.3 10.7 0.5 Total 100.0 100.0 100.0 100.0 Number of men employed during the past 12 months 5,274 7,591 90 12,955 Note: Total includes men with information missing on type of employment who are not shown separately. 3.8 HEALTH INSURANCE COVERAGE Health insurance improves access to health care, thus promoting good health. Reasonable access to health care encourages individuals to seek health maintenance services more regularly than they otherwise would, thereby preventing potentially serious illnesses. Additionally, health insurance protects individuals from financial hardship that may result from large or unexpected medical bills. In Nigeria, health insurance can be obtained from private organisations or from government agencies. Nigeria’s National Health Insurance Scheme (NHIS) was established by Decree Number 35 of 1999. The scheme, identified as a tool for achieving health-related Millennium Development Goals (MDGs), currently enrols only persons who are employees in the formal employment sector. However, as the scheme is mandated to offer universal coverage to all Nigerians by 2015, there are plans to extend health insurance schemes to the informal sector in the future. Characteristics of Respondents | 45 Tables 3.8.1 and 3.8.2 present information about specific types of insurance coverage for women and men by background characteristics. The tables show that the majority of women and men have no health insurance coverage (98 and 97 percent, respectively). Among all categories of insurance, employer-based insurance is used most commonly. However, only 2 percent of men and 1 percent of women are covered by this type of insurance. Women and men in urban areas (4 and 5 percent, respectively) and those in the highest wealth quintile (6 and 8 percent, respectively) are the most likely to have health insurance coverage. Level of education is also strongly associated with health care coverage. Table 3.8.1 Health insurance coverage: Women Percent distribution of women age 15-49 by type of health insurance coverage, according to background characteristics, Nigeria 2008 Background characteristic Employer- based insurance Mutual health organization/ community- based insurance Privately purchased commercial insurance Other No health insurance Number of women Age 15-19 0.5 0.1 0.1 0.2 99.0 6,493 20-24 0.7 0.1 0.3 0.2 98.8 6,133 25-29 1.4 0.1 0.3 0.2 98.0 6,309 30-34 1.7 0.2 0.2 0.1 97.9 4,634 35-39 2.1 0.3 0.2 0.2 97.3 3,912 40-44 2.6 0.1 0.1 0.1 97.1 3,032 45-49 1.0 0.1 0.1 0.1 98.7 2,872 Residence Urban 2.8 0.2 0.4 0.2 96.4 11,934 Rural 0.5 0.1 0.1 0.1 99.2 21,451 Zone North Central 2.0 0.2 0.2 0.2 97.4 4,748 North East 0.3 0.1 0.0 0.0 99.5 4,262 North West 0.4 0.2 0.0 0.0 99.3 8,022 South East 0.4 0.1 0.1 0.0 99.3 4,091 South South 2.0 0.2 0.5 0.7 96.6 5,473 South West 2.3 0.1 0.3 0.0 97.3 6,789 Education No education 0.1 0.0 0.0 0.0 99.9 11,942 Primary 0.4 0.1 0.1 0.0 99.3 6,566 Secondary 1.3 0.1 0.3 0.3 98.0 11,904 More than secondary 8.1 0.6 0.9 0.6 89.8 2,974 Wealth quintile Lowest 0.0 0.0 0.0 0.0 99.9 6,194 Second 0.0 0.0 0.0 0.0 99.9 6,234 Middle 0.2 0.1 0.1 0.1 99.5 6,341 Fourth 0.9 0.2 0.2 0.1 98.6 6,938 Highest 4.5 0.3 0.6 0.5 94.0 7,678 Total 1.3 0.1 0.2 0.2 98.2 33,385 46 | Characteristics of Respondents Table 3.8.2 Health insurance coverage: Men Percent distribution of men age 15-49 by type of health insurance coverage, according to background characteristics, Nigeria 2008 Background characteristic Employer- based insurance Mutual health organization/ community- based insurance Privately purchased commercial insurance Other No health insurance Number of men Age 15-19 0.2 0.0 0.3 0.3 99.1 2,532 20-24 1.1 0.1 0.3 0.4 98.2 2,378 25-29 1.8 0.4 0.3 0.4 97.2 2,459 30-34 2.3 0.3 0.4 0.1 96.8 2,058 35-39 3.8 0.0 0.2 0.5 95.4 1,794 40-44 2.9 0.7 0.6 0.5 95.4 1,413 45-49 2.6 0.0 0.5 0.8 96.2 1,174 Residence Urban 3.4 0.3 0.4 0.8 95.0 5,215 Rural 1.0 0.1 0.3 0.2 98.5 8,593 Zone North Central 2.1 0.1 0.3 0.2 97.2 2,065 North East 0.9 0.0 0.0 0.0 99.0 1,645 North West 1.2 0.4 0.2 0.2 97.9 3,237 South East 1.6 0.4 0.7 0.0 97.6 1,448 South South 3.3 0.1 0.7 0.8 95.2 2,437 South West 2.1 0.1 0.3 0.8 96.7 2,977 Education No education 0.1 0.0 0.2 0.0 99.8 2,597 Primary 0.6 0.0 0.2 0.0 99.3 2,761 Secondary 1.4 0.3 0.3 0.4 97.7 6,470 More than secondary 7.9 0.7 1.1 1.5 89.0 1,979 Wealth quintile Lowest 0.1 0.0 0.1 0.1 99.8 2,275 Second 0.3 0.0 0.1 0.0 99.6 2,332 Middle 0.6 0.2 0.3 0.0 98.8 2,570 Fourth 2.0 0.2 0.4 0.3 97.2 3,163 Highest 5.1 0.5 0.7 1.2 92.5 3,468 Total 15-49 1.9 0.2 0.4 0.4 97.2 13,808 50-59 2.2 0.4 0.3 0.5 96.7 1,678 Total men 15-59 1.9 0.2 0.4 0.4 97.1 15,486 3.9 KNOWLEDGE AND ATTITUDES REGARDING TUBERCULOSIS During the 2008 NDHS, respondents were asked if they had ever heard of tuberculosis (TB), a major public health concern worldwide. Women and men were also asked about how TB is spread, whether the disease is curable and through what methods, and several other TB-related questions. Additionally, respondents were asked whether or not they would want other people to know if a family member had TB. Tables 3.9.1 and 3.9.2 present information on knowledge and attitudes concerning TB for women and men age 15-49, by background characteristics. Although knowledge of TB is high among both women and men, it is substantially higher among men (84 percent) than women (71 percent). Among all respondents who report having heard of TB, 59 percent of women and 72 percent of men reported that TB is spread through the air by coughing. Knowledge of TB transmission increases with level of education and wealth quintile among both women and men. Characteristics of Respondents | 47 Among women and men who have heard of TB, 72 percent of women and 87 percent of men believe that it can be cured. Women are more likely than men to want to conceal the fact that a family member has TB (21 and 18 percent, respectively). Table 3.9.1 Knowledge and attitudes concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Nigeria 2008 Among women who have heard of TB, the percentage who: Among all women Background characteristic Percentage who have heard of TB Number of women Reported that TB is spread through the air by coughing Believe that TB can be cured Would want a family member's TB kept secret Number of women Age 15-19 59.2 6,493 57.7 69.2 24.3 3,846 20-24 69.9 6,133 58.3 72.2 22.6 4,287 25-29 73.3 6,309 59.1 73.1 20.6 4,622 30-34 74.8 4,634 60.1 73.6 19.2 3,465 35-39 76.1 3,912 58.4 72.9 18.6 2,975 40-44 76.5 3,032 61.0 73.5 18.9 2,319 45-49 76.3 2,872 57.7 69.1 16.4 2,191 Residence Urban 82.0 11,934 65.8 77.5 22.2 9,786 Rural 64.9 21,451 53.9 68.1 19.4 13,919 Zone North Central 58.9 4,748 67.2 76.2 22.4 2,798 North East 67.9 4,262 49.5 59.5 19.1 2,895 North West 63.4 8,022 44.8 64.5 20.3 5,089 South East 93.0 4,091 55.5 81.9 20.2 3,805 South South 73.3 5,473 70.5 77.2 22.6 4,014 South West 75.2 6,789 66.9 72.8 19.4 5,104 Education No education 56.8 11,942 45.6 58.8 20.0 6,777 Primary 71.6 6,566 55.8 70.7 19.0 4,700 Secondary 79.0 11,904 63.9 77.5 21.6 9,404 More than secondary 95.0 2,974 78.8 87.6 21.0 2,824 Wealth quintile Lowest 55.9 6,194 44.6 58.8 22.9 3,460 Second 60.6 6,234 49.7 63.9 20.6 3,775 Middle 70.0 6,341 56.0 71.0 17.5 4,436 Fourth 78.5 6,938 63.1 76.7 18.4 5,445 Highest 85.8 7,678 70.0 80.4 23.2 6,589 Total 71.0 33,385 58.8 72.0 20.6 23,705 48 | Characteristics of Respondents Table 3.9.2 Knowledge and attitudes concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentages who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Nigeria 2008 Among men who have heard of TB, the percentage who Among all men Background characteristic Percentage who have heard of TB Number of men Reported that TB is spread through the air by coughing Believe that TB can be cured Would want a family member's TB kept secret Number of men Age 15-19 65.7 2,532 70.5 84.8 23.9 1,664 20-24 82.2 2,378 72.3 86.8 20.9 1,956 25-29 86.7 2,459 71.3 86.9 17.5 2,131 30-34 89.0 2,058 72.2 87.9 16.3 1,831 35-39 89.7 1,794 73.6 89.0 14.3 1,609 40-44 90.8 1,413 70.8 87.0 12.7 1,283 45-49 91.8 1,174 71.8 85.2 13.8 1,078 Residence Urban 90.2 5,215 77.7 89.7 17.7 4,702 Rural 79.7 8,593 67.7 84.9 17.4 6,850 Zone North Central 80.2 2,065 80.3 88.5 11.1 1,656 North East 77.9 1,645 78.7 83.5 28.3 1,282 North West 81.6 3,237 62.7 83.6 26.3 2,642 South East 88.1 1,448 71.6 87.7 20.5 1,275 South South 82.7 2,437 63.0 88.6 12.0 2,017 South West 90.0 2,977 79.0 88.9 10.2 2,681 Education No education 73.1 2,597 58.6 76.1 24.0 1,898 Primary 79.9 2,761 67.1 84.7 18.5 2,207 Secondary 85.2 6,470 72.7 88.9 16.3 5,513 More than secondary 97.8 1,979 87.7 94.0 13.4 1,935 Wealth quintile Lowest 74.4 2,275 60.4 77.5 21.8 1,692 Second 79.8 2,332 66.1 82.7 21.1 1,862 Middle 81.7 2,570 71.3 87.9 16.6 2,099 Fourth 85.5 3,163 75.4 89.3 16.4 2,705 Highest 92.1 3,468 78.5 91.5 14.6 3,194 Total 15-49 83.7 13,808 71.8 86.9 17.5 11,552 50-59 91.9 1,678 68.8 85.0 10.1 1,542 Total men 15-59 84.6 15,486 71.5 86.6 16.6 13,094 3.10 TOBACCO USE Tobacco is used in various ways. It is dried and rolled into cigarettes and cigars for smoking, shredded and inserted into pipes (also for smoking), and finely pulverised for inhalation as snuff. Smoking has been shown to have significant adverse health effects including increased risk of respiratory and cardiovascular illnesses, both for the individual smoker and for other people exposed to second-hand or “environmental” tobacco smoke (WHO, 2002). Information on women’s and men’s use of tobacco was collected during the 2008 NDHS. Tables 3.10.1 and 3.10.2 show the percentage of women and men age 15-49 who smoke cigarettes, a pipe, or use other forms of tobacco. Additionally, Table 3.10.2 shows the percent distribution of male cigarette smokers age 15-49 by the number of cigarettes smoked in the past 24 hours, according to background characteristics. Characteristics of Respondents | 49 The majority of women (99 percent) and men (89 percent) reported that they do not use tobacco. Less than 1 percent of women reported using tobacco. Among men age 15-49, 14 percent reported use of tobacco products, with those smoking cigarettes constituting 9 percent. Cigarette smoking among men is highest in age group 30-34 (13 percent). By level of education, tobacco use is highest among men with a primary education (22 percent). Table 3.10.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, by background characteristics and maternity status, Nigeria 2008 Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of women Number of cigarette smokers Age 15-19 0.0 0.0 0.2 99.7 6,493 1 20-24 0.1 0.0 0.2 99.6 6,133 5 25-29 0.2 0.0 0.2 99.5 6,309 15 30-34 0.1 0.1 0.2 99.5 4,634 7 35-39 0.3 0.1 0.7 98.9 3,912 11 40-44 0.5 0.2 1.0 98.3 3,032 15 45-49 0.3 0.2 1.8 97.7 2,872 10 Residence Urban 0.2 0.0 0.2 99.5 11,934 20 Rural 0.2 0.1 0.6 99.1 21,451 44 Zone North Central 0.6 0.3 1.3 98.0 4,748 27 North East 0.1 0.1 0.2 99.6 4,262 6 North West 0.2 0.0 0.3 99.5 8,022 12 South East 0.2 0.0 1.2 98.5 4,091 7 South South 0.1 0.0 0.2 99.5 5,473 8 South West 0.1 0.0 0.2 99.7 6,789 4 Education No education 0.2 0.1 1.0 98.6 11,942 27 Primary 0.3 0.1 0.5 99.1 6,566 17 Secondary 0.1 0.0 0.1 99.8 11,904 13 More than secondary 0.3 0.0 0.0 99.6 2,974 8 Maternity status Pregnant 0.1 0.0 0.5 99.3 3,494 4 Breastfeeding (not pregnant) 0.1 0.1 0.3 99.4 8,702 12 Neither 0.2 0.1 0.5 99.1 21,189 48 Wealth quintile Lowest 0.3 0.2 1.0 98.5 6,194 18 Second 0.2 0.1 0.8 98.9 6,234 9 Middle 0.2 0.1 0.5 99.3 6,341 12 Fourth 0.2 0.0 0.3 99.5 6,938 16 Highest 0.1 0.0 0.0 99.8 7,678 9 Total 0.2 0.1 0.5 99.2 33,385 64 50 | Characteristics of Respondents Table 3.10.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in past 24 hours, according to background characteristics, Nigeria 2008 Number of cigarettes in the past 24 hours Background characteristic Cigarettes Pipe Other tobacco Does not use tobacco Number of men 0 1-2 3-5 6-9 10+ Don't know/ missing Total Number of cigarette smokers Age 15-19 1.4 0.1 0.8 98.0 2,532 (0.0) (46.8) (34.2) (4.7) (3.9) (10.5) 100.0 36 20-24 6.0 0.5 2.5 92.8 2,378 4.3 29.5 39.6 10.5 14.7 1.4 100.0 142 25-29 12.0 0.9 3.2 86.3 2,459 3.8 25.7 40.1 10.5 16.2 3.7 100.0 294 30-34 12.6 0.9 4.0 85.0 2,058 1.9 23.2 40.7 17.2 15.8 1.2 100.0 260 35-39 11.0 0.5 4.8 85.7 1,794 5.7 23.1 40.9 12.9 15.8 1.7 100.0 197 40-44 12.4 2.0 7.4 81.7 1,413 2.2 19.8 35.2 18.2 23.0 1.6 100.0 175 45-49 10.4 0.7 8.5 82.5 1,174 0.0 23.5 43.2 13.1 17.7 2.4 100.0 122 Residence Urban 8.5 0.7 3.1 89.4 5,215 4.2 21.0 41.6 13.0 17.6 2.6 100.0 444 Rural 9.1 0.7 4.3 87.9 8,593 2.4 26.9 38.7 13.8 16.1 2.2 100.0 783 Zone North Central 9.6 0.9 8.0 84.4 2,065 1.0 23.8 40.1 13.7 16.7 4.7 100.0 199 North East 6.1 1.3 3.5 91.2 1,645 1.1 22.5 40.4 10.4 22.8 2.8 100.0 101 North West 6.3 1.5 1.2 93.4 3,237 2.0 13.3 34.8 14.9 34.0 1.0 100.0 204 South East 12.4 0.1 9.2 80.3 1,448 4.6 32.4 40.1 10.4 9.8 2.7 100.0 179 South South 12.1 0.3 3.2 86.2 2,437 6.8 32.1 39.3 11.7 9.1 1.0 100.0 296 South West 8.4 0.2 1.9 90.4 2,977 0.8 21.6 43.4 17.7 13.9 2.7 100.0 249 Education No education 7.9 1.0 4.0 89.4 2,597 2.4 19.2 35.1 16.0 25.3 2.0 100.0 206 Primary 13.0 1.3 7.5 81.5 2,761 1.7 22.7 45.0 13.9 14.6 2.2 100.0 360 Secondary 8.0 0.4 2.8 90.3 6,470 3.2 29.5 39.8 11.6 13.0 2.9 100.0 518 More than secondary 7.3 0.6 2.1 91.2 1,979 7.0 20.5 33.0 15.7 22.6 1.1 100.0 144 Wealth quintile Lowest 9.0 0.8 5.3 87.2 2,275 1.7 21.5 43.3 11.5 21.5 0.5 100.0 205 Second 9.1 1.2 4.7 87.6 2,332 2.5 24.4 40.0 15.8 12.3 5.0 100.0 211 Middle 9.4 0.6 4.6 87.2 2,570 1.8 29.9 35.8 13.6 17.0 1.9 100.0 241 Fourth 9.5 0.8 3.2 88.8 3,163 4.0 24.8 42.9 10.5 15.6 2.2 100.0 300 Highest 7.8 0.4 2.3 90.6 3,468 4.6 22.8 36.7 16.3 17.3 2.2 100.0 270 Total 15-49 8.9 0.7 3.9 88.5 13,808 3.1 24.8 39.7 13.5 16.7 2.3 100.0 1,227 50-59 9.5 0.5 9.5 82.3 1,678 0.9 17.6 46.7 10.8 21.9 2.2 100.0 160 Total men 15-59 9.0 0.7 4.5 87.8 15,486 2.8 23.9 40.5 13.2 17.3 2.3 100.0 1,387 Note: Figures in parentheses are based on 25-29 unweighted cases. Fertility Levels, Trends, and Differentials | 51 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4 4.1 INTRODUCTION This chapter looks at a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women begin childbearing. Information on current and cumulative fertility is essential to monitoring population growth. The data on birth intervals are important because short intervals are associated with higher childhood mortality. The age at which childbearing begins can also have a major impact on the health and wellbeing of both the mother and the child. Data on childbearing patterns were collected in the 2008 NDHS in several ways. First, each woman was asked a series of questions on the number of sons and daughters currently living with her, the number living elsewhere, and the number who were born alive and later died. Next, a complete history of all of the woman’s births was obtained, including the name, sex, month and year of birth, age, and survival status for each of the births. For living children, a question was asked about whether the child was living in the household or away. For dead children, the age at death was recorded. Finally, information was collected on whether female respondents were pregnant at the time of the survey.1 4.2 CURRENT FERTILITY The level of current fertility is one of the most important topics in this report because of its direct relevance to population policies and programmes. Measures of current fertility presented in this chapter include age-specific fertility rates (ASFR), the total fertility rate (TFR), the general fertility rate (GFR), and the crude birth rate (CBR). The rates are generally presented for the period 1-36 months preceding the survey, determined from the date of interview and a child’s birth date. A three- year period is chosen for calculating these rates to provide the most current information, to reduce sampling error, and to avoid problems of the displacement of births. Age-specific fertility rates show the age pattern of fertility. Numerators for the ASFRs are calculated by identifying live births that occurred in the three-year period preceding the survey and classifying them by the age of the mother (in five-year age groups) at the time of the child’s birth. The denominators of the rates represent the number of woman-years lived by the survey respondents in each of the five-year age groups during the specified period. The TFR refers to the number of live births a woman would have if she were subject to the current age-specific fertility rates throughout her reproductive years (15-49 years). The GFR represents the number of live births per 1,000 women of reproductive age. The CBR is the number of live births per 1,000 population. The latter two measures are based on the birth history data for the three-year period before the survey and the age-sex distribution of the household population. Current fertility rates for the three years preceding the survey are presented in Table 4.1 for the country as a whole and by urban-rural residence. The 2008 NDHS results indicate that the TFR is 5.7 births per woman. This means that, on average, a Nigerian woman will give birth to 5.7 children by the end of her childbearing years. The current TFR of 5.7 is the same as that reported for the 2003 NDHS. Fertility peaks in age group 25-29 with 265 births per 1,000 women and declines thereafter 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 52 | Fertility Levels, Trends, and Differentials Table 4.1 Current fertility Age-specific and total fertility rate, the general fertility rate and the crude birth rate for the three years preceding the survey, by residence, Nigeria 2008 Residence Age group Urban Rural Total 15-19 70 148 121 20-24 177 254 225 25-29 245 277 265 30-34 223 252 241 35-39 130 177 161 40-44 60 101 87 45-49 36 48 44 TFR (15-49) 4.7 6.3 5.7 GFR 162 212 194 CBR 36.8 42.5 40.6 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR = Total fertility rate expressed per woman GFR = General fertility rate expressed per 1,000 women CBR = Crude birth rate, expressed per 1,000 population The general fertility rate is 194, which means that there were 194 births for every 1,000 women during the three-year period preceding the survey. Table 4.1 shows that the crude birth rate was 40.6 per 1,000 population for the same period. Rural areas have a much higher TFR than urban areas (6.3 compared with 4.7) and there are large urban-rural differences in ASFRs for all age groups. The largest variations are in age groups 15-19 and 20-24; in these groups the rates for rural women exceed those for urban women by 78 and 77 births per thousand women, respectively. Figure 4.1 shows age-specific fertility rates by urban- rural residence. # # # # # # # ( ( ( ( ( ( ( ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 250 300 Births per 1,000 women Urban Rural Total) ( # NDHS 2008 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence Fertility Levels, Trends, and Differentials | 53 Figure 4.2 shows the fertility levels of selected countries in West Africa. Nigeria’s fertility rate falls roughly in the middle of this group of countries whose TFRs range from 4.0 in Ghana to 7.0 in Niger. 4.3 FERTILITY DIFFERENTIALS Table 4.2 presents several fertility indicators (the TFR, the percentage of women who are currently pregnant, and the mean number of births among women age 40-49), by background characteristics. These indicators provide a basis for inferring long-term trends in fertility by comparing the TFR with the mean number of children ever born to women age 40-49 (CEB). The latter indicator summarises the fertility behaviour of older women who are nearing the end of their reproductive period. It serves as an indicator of average completed fertility for women who began childbearing in the three decades preceding the survey. If fertility is stable over time in a population, the TFR and the mean number of children ever born for women age 40-49 will be similar. If fertility levels have been falling, the TFR will be lower than the mean number of children ever born. The mean number of children ever born in Nigeria to women age 40-49 is 6.5. This is about one child more than the current TFR, suggesting that fertility has decreased over the past few decades. Some caution should be taken when assessing trends in fertility from comparison of the TFR and mean number of children ever born because older women may understate their total childbearing experience. Table 4.2 shows the variations in the TFR by residence, zone, education, and wealth quintile. Figure 4.3 shows the variations in TFR by zone. The more urbanised zones, South East (4.8), South South (4.7), and South West (4.5), have lower fertility rates than the three northern zones, which are mostly rural. The highest TFR is seen in North West (7.3), followed by North East (7.2). The TFR decreases with increasing level of education. Women with more than secondary education have a TFR of 2.9, compared with women with no education who have a TFR of 7.3. Women in the highest wealth quintile have an average of three children fewer than women in the lowest quintile (4.0 and 7.1 births per woman, respectively). 4 5.2 5.3 5.7 5.7 5.7 5.9 6.6 7 Ghana 2008 Liberia 2007 Senegal 2005 Benin 2006 Nigeria 2008 Guinea 2005 Burkina Faso 2003 Mali 2006 Niger 2006 0 2 4 6 8 Percent Figure 4.2 Total Fertility Rates of Selected West African Countries Source: MEASURE DHS Stat Compiler 7.0 4.0 54 | Fertility Levels, Trends, and Differentials Table 4.2 shows that 11 percent of interviewed women reported that they were pregnant at the time of the survey. The percentage of women who are currently pregnant provides another measure of current fertility, although it is recognised that the survey may not capture all pregnancies because some women may not know they are pregnant or may be reluctant to report early-stage pregnancies. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Nigeria 2008 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 4.7 9.0 5.7 Rural 6.3 11.3 6.9 Zone North Central 5.4 10.4 6.4 North East 7.2 12.6 7.5 North West 7.3 13.5 7.7 South East 4.8 8.8 5.8 South South 4.7 8.5 6.2 South West 4.5 8.2 5.0 Education No education 7.3 12.6 7.3 Primary 6.5 11.6 6.6 Secondary 4.7 8.3 5.1 More than secondary 2.9 8.4 4.1 Wealth quintile Lowest 7.1 13.3 7.3 Second 7.0 11.5 7.3 Middle 5.9 10.5 6.7 Fourth 5.0 8.7 6.3 Highest 4.0 8.8 4.8 Total 5.7 10.5 6.5 Note: Total fertility rates are for the period 1-36 months prior to interview. 5.7 5.4 7.2 7.3 4.8 4.7 4.5 Nigeria North Central North East North West South East South South South West 0 2 4 6 8 Births per woman Figure 4.3 Fertility Differentials by Zone NDHS 2008 Fertility Levels, Trends, and Differentials | 55 4.4 FERTILITY TRENDS Table 4.3 uses information from the retrospective birth histories obtained from the 2008 NDHS respondents to examine trends in age-specific fertility rates for successive five-year periods before the survey. To calculate these rates, births are classified according to the period of time in which the birth occurred and the mother’s age at the time of the birth. Because birth histories were not collected for women age 50 and older, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years or more preceding the survey because women in that age group would have been 50 years or older at the time of the survey. Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Nigeria 2008 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 123 140 140 144 20-24 231 249 254 256 25-29 269 287 297 288 30-34 243 265 266 [289] 35-39 163 196 [216] - 40-44 91 [130] - - 45-49 [45] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. The results in Table 4.3 show that fertility decreased steadily in all age groups over the 20 years preceding the survey. Another way to examine fertility trends is to compare current estimates with earlier surveys and censuses. Table 4.4 and Figure 4.3 show estimates of ASFRs from the 1991 Census, the 2003 NDHS, and the 2008 NDHS. Table 4.4 .Trends in age-specific and total fertility rates, various sources Trends in age-specific and total fertility rates from the 1991 Census, 2003 NDHS, and 2008 NDHS Age group Census 1991 NDHS 2003 NDHS 2008 15-19 112 126 121 20-24 234 229 225 25-29 266 274 265 30-34 217 244 241 35-39 167 168 161 40-44 100 72 87 45-49 83 18 44 TFR 15-49 5.9 5.7 5.7 Note: The ASFRs for the 1991 Census were adjusted using Trussell Variant (see NPC, 1998). Sources: 1991: NPC, 1998; 2003: NPC, 2003 56 | Fertility Levels, Trends, and Differentials 4.5 CHILDREN EVER BORN AND LIVING Table 4.5 shows the distribution of all women and currently married women by the number of children ever born, according to five-year age groups. The table also shows the mean number of children ever born and the mean number of living children. Information on the number of children ever born reflects the accumulation of births over a woman’s entire reproductive period (parity) and therefore has limited reference to current fertility levels, particularly when the country has experienced a decline in fertility. However, as an indicator, the number of children ever born to all women is useful for observing how average family size varies across age groups, and for observing the level of primary infertility. Comparison of the mean number of children ever born to all women and the mean number of living children shows the cumulative effects of mortality during the childbearing period. More than three-fourths of women age 15-19 (82 percent) have never given birth (Table 4.5). However, this proportion declines to 9 percent for women age 30-34 and 5 percent or less among women age 35 and older, indicating that childbearing among Nigerian women is nearly universal. On average, Nigerian women nearing the end of their reproductive years have attained a parity of about seven (6.9) children. The same pattern is seen for currently married women, except that the mean number of children ever born is higher (4.0 children) compared with all women (3.1 children). The difference in the mean number of children ever born between all women and currently married women can be attributed to a substantial proportion of young and unmarried women in the former category who exhibit lower fertility. The percentage of women in their forties who have never had children is an indicator of the level of primary infertility—that is, the proportion of women who are unable to bear children at all. Voluntary childlessness is rare in Nigeria; therefore, it is likely that married women with no births are unable to have children. The 2008 NDHS results suggest that primary infertility is low, with 3 percent of all women unable to have children. It should be noted, however, that this estimate of primary infertility does not include women who have had one or more births, but who are unable to have more children (secondary infertility). % % % % % % % ( ( ( ( ( ( ( ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 250 300 Births per 1,000 women Census 1991 NDHS 2003 NDHS 2008) ( % Figure 4.4 Trends in Age-Specific Fertility Rates, 1991-2008 Fertility Levels, Trends, and Differentials | 57 Table 4.5 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born and mean number of living children, according to age group, Nigeria 2008 Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number of women Mean number of children ever born Mean number of living children ALL WOMEN 15-19 82.0 13.4 3.9 0.7 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 6,493 0.23 0.21 20-24 43.1 20.5 19.0 11.1 4.7 1.3 0.2 0.1 0.0 0.0 0.0 100.0 6,133 1.19 1.01 25-29 19.9 13.7 16.7 18.8 15.3 9.4 4.0 1.5 0.4 0.1 0.1 100.0 6,309 2.51 2.14 30-34 8.5 7.5 12.1 15.4 15.7 15.3 11.8 7.2 4.0 1.8 0.8 100.0 4,634 3.95 3.26 35-39 4.8 3.7 7.0 10.2 13.7 14.7 13.4 11.1 10.2 5.9 5.3 100.0 3,912 5.26 4.26 40-44 3.4 2.7 5.1 7.6 10.6 13.2 12.3 11.9 10.7 8.3 14.2 100.0 3,032 6.17 4.90 45-49 2.6 2.8 2.9 5.7 8.6 11.5 11.4 11.7 12.1 9.4 21.4 100.0 2,872 6.86 5.22 Total 29.9 10.9 10.6 10.2 9.2 8.0 6.1 4.7 3.8 2.5 3.9 100.0 33,385 3.05 2.48 CURRENTLY MARRIED WOMEN 15-19 45.7 38.9 12.8 2.2 0.3 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,863 0.72 0.63 20-24 13.0 28.5 30.0 18.2 7.6 2.1 0.3 0.2 0.0 0.0 0.0 100.0 3,659 1.88 1.59 25-29 6.8 14.3 19.3 22.5 18.3 11.4 4.9 1.8 0.5 0.1 0.1 100.0 5,112 2.98 2.54 30-34 4.0 6.9 12.2 16.0 16.8 16.3 12.9 7.8 4.4 1.9 0.9 100.0 4,173 4.21 3.48 35-39 3.0 3.1 6.5 10.2 13.8 15.3 13.9 11.5 10.9 6.2 5.6 100.0 3,575 5.45 4.41 40-44 2.4 2.4 4.7 6.9 10.5 13.4 12.4 12.3 11.1 8.6 15.3 100.0 2,711 6.35 5.02 45-49 2.1 2.3 2.8 5.8 8.2 11.1 11.7 11.6 12.2 9.0 23.3 100.0 2,484 7.02 5.31 Total 8.8 12.8 13.8 13.7 12.3 10.7 8.2 6.2 5.1 3.2 5.2 100.0 23,578 4.04 3.27 4.6 BIRTH INTERVALS A birth interval is defined as the period of time between two successive live births. Information about birth intervals is important in understanding health status of young children. Research has shown that short birth intervals (<24 months) are associated with poor health outcomes, especially during infancy. Children born too soon after a previous birth, especially if the interval between the births is less than two years, have an increased risk of sickness and death at an early age. Longer birth intervals (more than two years), on the other hand, contribute to improved health status for both the mother and child. Table 4.6 presents the distribution of second- and higher-order births in the five years preceding the survey by the number of months since the previous birth, according to background characteristics. The median number of months since the last birth is also shown. Table 4.6 shows that 8 percent of births are less than 18 months apart and 24 percent have an interval of less than two years. Two in five births (38 percent) are born 24-35 months after the previous birth, and 20 percent are born 36-47 months after the previous birth. The median birth interval is 31.4 months, roughly the same as the median birth interval in the 2003 NDHS (31.2 months). Thirty-eight percent of all non-first births occur at least 36 months after the previous birth. The median number of months since the preceding birth increases markedly with age, from 26.6 months among mothers age 15-19 to 37.8 months among mothers age 40-49. The median birth interval does not vary much by birth order or sex of the preceding birth. However, there are notable variations in the median birth interval according to survival of the preceding birth and zone. 58 | Fertility Levels, Trends, and Differentials The median birth interval is higher (32.4 months) if the preceding birth’s survival status is living rather than dead (26.4 months). Variation by zone shows that the median birth interval ranges from 27.7 months among women in South East to 34.7 months among women in South West. There is little variation in the median birth interval by educational attainment or wealth quintile. Table 4.6 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Nigeria 2008 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48-59 60+ Total Number of non-first births Median number of months since preceding birth Age 15-19 17.1 22.0 45.6 12.3 3.0 0.0 100.0 347 26.6 20-29 8.7 18.5 42.4 19.1 6.6 4.7 100.0 9,770 29.3 30-39 7.2 14.7 36.6 21.2 9.4 10.9 100.0 9,674 32.9 40-49 5.1 11.4 29.7 21.8 11.5 20.5 100.0 2,902 37.8 Sex of preceding birth Male 8.0 15.8 38.6 20.0 8.3 9.4 100.0 11,570 31.3 Female 7.5 16.3 38.1 20.5 8.5 9.2 100.0 11,124 31.4 Survival of preceding birth Living 5.3 15.0 39.7 21.5 8.8 9.7 100.0 19,004 32.4 Dead 20.4 21.1 31.6 13.8 6.1 7.0 100.0 3,690 26.4 Birth order 2-3 7.8 17.2 39.7 19.3 7.4 8.6 100.0 9,295 30.5 4-6 7.3 15.1 38.1 20.9 9.0 9.7 100.0 8,699 32.2 7+ 8.6 15.5 36.0 21.0 9.1 9.8 100.0 4,701 31.8 Residence Urban 7.5 16.2 38.6 19.3 8.3 10.0 100.0 6,516 31.2 Rural 7.8 16.0 38.2 20.6 8.4 9.0 100.0 16,178 31.4 Zone North Central 5.5 14.2 36.9 22.4 9.4 11.6 100.0 3,096 33.5 North East 8.0 17.1 39.6 20.9 7.8 6.6 100.0 3,863 30.5 North West 8.0 16.6 39.5 20.4 8.1 7.4 100.0 7,363 30.8 South East 12.3 22.2 36.9 15.5 5.7 7.6 100.0 2,122 27.7 South South 9.0 16.3 37.9 17.8 8.3 10.7 100.0 2,845 30.4 South West 5.1 11.2 37.0 22.3 10.4 14.0 100.0 3,406 34.7 Education No education 7.5 16.5 39.0 20.6 8.1 8.3 100.0 11,149 31.2 Primary 7.4 15.0 38.4 21.0 8.5 9.6 100.0 5,558 31.8 Secondary 8.7 16.1 37.1 18.8 9.1 10.1 100.0 4,993 31.0 More than secondary 8.4 16.2 36.7 18.5 6.6 13.8 100.0 995 32.1 Wealth quintile Lowest 7.5 15.8 38.5 21.6 8.4 8.1 100.0 5,424 31.5 Second 7.8 16.7 39.1 20.6 7.3 8.5 100.0 5,379 31.0 Middle 7.8 15.7 38.5 19.8 8.7 9.5 100.0 4,475 31.4 Fourth 7.7 15.3 38.3 20.2 9.0 9.5 100.0 3,882 31.8 Highest 8.1 16.4 36.9 18.1 8.7 11.7 100.0 3,534 31.1 Total 7.8 16.0 38.3 20.2 8.4 9.3 100.0 22,694 31.4 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Fertility Levels, Trends, and Differentials | 59 4.7 AGE AT FIRST BIRTH The age at which childbearing commences is an important determinant of the overall level of fertility as well as the health and welfare of the mother and child. In some societies, the delay of first births as a result of an increase in the age at marriage has contributed to a decrease in fertility. Table 4.7 shows the percentage of women who have given birth by specific ages, according to age at the time of the survey. Overall, the median age at first birth for women age 25-49 in Nigeria is 20.4 years. The median age at first birth has increased from 19.8 years for women age 45-49 to 20.9 years for women age 25-29. In Nigeria, 9 percent of women age 25-49 have given birth by age 15, and 47 percent have become mothers by age 20. Comparing the proportions of women who have given birth by age 15 across age groups provides another way to view trends in age at first birth over time. Whereas 3 percent of women age 15-19 gave birth by age 15, the corresponding proportion for women age 45-49 is 9 percent. This reduction in the percentage of women giving birth early supports the findings that age at first childbirth has been increasing slowly. Table 4.7 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Nigeria 2008 Percentage who gave birth by exact age Current age 15 18 20 22 25 Percentage who have never given birth Number of women Median age at first birth 15-19 3.0 na na na na 82.0 6,493 a 20-24 6.5 27.7 42.9 na na 43.1 6,133 a 25-29 6.9 28.5 44.1 57.6 72.0 19.9 6,309 20.9 30-34 8.3 31.5 46.3 60.1 74.8 8.5 4,634 20.5 35-39 8.9 31.5 46.5 61.4 76.6 4.8 3,912 20.4 40-44 11.2 35.5 50.3 65.1 79.6 3.4 3,032 20.0 45-49 8.9 34.1 51.5 65.6 79.8 2.6 2,872 19.8 20-49 8.0 30.7 46.1 na na 17.3 26,892 a 25-49 8.5 31.5 47.0 61.0 75.7 9.7 20,759 20.4 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.8 shows the median age at first birth across age cohorts for key sub-groups of women. The measures are presented for women age 25-49 to ensure that half of the women have already had a birth. Urban women age 25-49 have a higher median age at first birth (22.3 years) than their rural counterparts (19.5 years). A comparison of the zones shows that the median age at first birth for women age 25-49 ranges from 18.2 years in North East and 18.3 years in North West to 23.6 years in South East. The median age at first birth increases with level of education. Women with no education have their first birth at a median age of 18.3 years, while women who have attended secondary education have a median age at first birth of 22.8 years, a difference of almost five years. There is also a positive correlation between age at first birth and wealth quintile. As the socioeconomic status of households increases, so does the median age at first birth (from 18.5 to 24.1 years). 60 | Fertility Levels, Trends, and Differentials Table 4.8 Median age at first birth Median age at first birth among women age 20-49 (25-49) years, according to background characteristics, Nigeria 2008 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Residence Urban a 23.5 22.8 21.8 21.0 20.8 a 22.3 Rural 19.7 19.5 19.4 19.8 19.4 19.3 19.5 19.5 Zone North Central a 19.9 19.8 20.1 20.3 19.7 a 20.0 North East 18.2 18.3 18.0 18.3 18.1 18.8 18.2 18.2 North West 18.1 18.3 18.0 18.7 17.9 18.8 18.3 18.3 South East a a 24.9 23.2 22.2 21.0 a 23.6 South South a 23.3 22.3 20.5 19.3 19.3 a 21.4 South West a 23.5 22.9 22.7 22.3 21.3 a 22.7 Education No education 17.6 18.0 18.0 18.8 18.3 18.9 18.2 18.3 Primary 18.9 19.5 19.7 19.7 19.7 19.9 19.5 19.7 Secondary a 23.2 23.0 22.3 21.8 22.2 a 22.8 More than secondary a a 28.1 26.7 25.1 23.8 a a Wealth quintile Lowest 18.2 18.4 18.1 18.6 18.6 18.9 18.4 18.5 Second 18.3 18.4 18.5 19.3 19.0 19.3 18.7 18.8 Middle a 19.8 19.5 19.7 19.7 20.0 19.9 19.7 Fourth a 22.1 21.6 21.0 19.5 19.6 a 21.1 Highest a a 24.8 23.6 22.4 21.4 a 24.1 Total a 20.9 20.5 20.4 20.0 19.8 a 20.4 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 4.8 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy is a major health concern because of its association with higher morbidity and mortality for both the mother and child. Additional childbearing during the teenage years frequently has adverse social consequences, particularly regarding educational attainment, because women who become mothers in their teens are more likely to curtail their education. Table 4.9 shows the percentage of women age 15-19 who are mothers or who are pregnant with their first child. Overall, 23 percent of women age 15-19 have begun childbearing; 18 percent have had a child and 5 percent are pregnant with their first child. A larger proportion of teenagers in rural areas (29 percent) have begun childbearing compared with teenagers in urban areas (12 percent). A comparison of the geopolitical zones shows that North West has the largest proportion (45 percent) of teenagers who have started childbearing, while South East (8 percent) and South West (9 percent) have the lowest proportions. The percentage of teenagers who have started childbearing decreases with increasing level of education. Teenagers with no education are more than twice as likely to start childbearing early as those with primary education (55 and 27 percent, respectively), and only 3 percent of teenagers with more than secondary education have begun childbearing. Teenagers in the lowest wealth quintile are more than twice as likely to have started childbearing as those in the middle wealth quintile (46 and 21 percent, respectively) and almost 10 times as likely as those in the highest wealth quintile. Fertility Levels, Trends, and Differentials | 61 The 2008 NDHS findings on teenage pregnancy and motherhood by age are shown in Figure 4.4. The rates for teen motherhood increase steadily from age 15 to 19, with especially large increases between the ages of 16 and 17 and between the ages of 17 and 18. Table 4.9 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child and percentage who have begun childbearing, by background characteristics, Nigeria 2008 Percentage who: Background characteristic Have had a live birth Are pregnant with first child Percentage who have begun childbearing Number of women Age 15 2.8 3.5 6.3 1,555 16 8.9 4.1 13.0 1,211 17 18.9 5.3 24.2 1,130 18 29.4 6.3 35.7 1,595 19 33.6 4.7 38.4 1,002 Residence Urban 8.9 3.1 12.0 2,268 Rural 22.9 5.8 28.7 4,225 Zone North Central 17.1 5.1 22.2 959 North East 31.1 8.3 39.3 856 North West 34.7 9.9 44.6 1,379 South East 6.3 1.8 8.1 852 South South 10.4 1.5 11.9 1,127 South West 6.9 1.9 8.8 1,321 Education No education 44.0 11.2 55.3 1,604 Primary 21.0 5.5 26.5 950 Secondary 6.8 2.1 8.9 3,864 More than secondary 2.7 0.0 2.7 76 Wealth quintile Lowest 35.7 10.1 45.8 1,140 Second 26.3 6.3 32.5 1,207 Middle 16.2 4.5 20.7 1,344 Fourth 13.0 2.7 15.8 1,411 Highest 3.1 1.7 4.9 1,390 Total 18.0 4.8 22.9 6,493 3 9 19 29 34 4 4 5 6 5 15 16 17 18 19 Age 0 10 20 30 40 50 Percent Had a live birth Pregnant with first child Figure 4.5 Percentage of Teenagers Who Have Begun Childbearing and Who Are Pregnant With Their First Child, by Age NDHS 2008 Family Planning | 63 FAMILY PLANNING 5 Family planning refers to a conscious effort by a couple to limit or space the number of children they want to have through the use of contraceptive methods. This chapter presents results from the 2008 NDHS on a number of aspects of contraception including knowledge of specific contraceptive methods, attitudes and behaviour regarding contraceptive use, ever use and current use, sources of contraceptive methods, and cost of methods. The focus in this chapter is on women who are sexually active because these women have the greatest risk of exposure to pregnancy and the need for regulating their fertility. However, the results of interviews with men are presented alongside those with women because men play an equally important role in the realisation of reproductive health and family planning decisions and behaviour. Comparisons are also made, where feasible, with findings from previous surveys to evaluate changes in the contraceptive measures over time in Nigeria.1 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Information on knowledge and use of family planning methods was obtained from female and male respondents by asking them to mention ways or methods by which a couple can delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent had heard of it. For each method known, respondents were asked if they had ever used the method. Respondents who reported ever use of family planning were asked whether they or their partners were using a method at the time of the survey. Contraceptive methods are classified as modern or traditional methods. Modern methods include female sterilisation, male sterilisation, the pill, intra-uterine device (IUD), injectables, implants, male condom, female condom, diaphragm, foam/jelly, lactational amenorrhoea method (LAM), and emergency contraception. Methods such as rhythm (periodic abstinence) and withdrawal are grouped as traditional methods. Provision was also made in the questionnaire to record any other methods mentioned by the respondent, including folk methods. Table 5.1 shows that knowledge of any contraceptive method is widespread in Nigeria, with 72 percent of all women and 90 percent of all men knowing at least one method of contraception. Modern methods are more widely known than traditional methods; 71 percent of all women know of a modern method while only 36 percent know a traditional method. Among modern methods for women, the male condom is the most commonly known method (58 percent). Foam/jelly and the diaphragm are the least known modern methods, 6 percent for both. Sexually active unmarried women are more likely to know of a contraceptive method than currently married women (95 percent compared with 68 percent, respectively). Among traditional methods, withdrawal and rhythm are the most commonly known among all women (25 percent). Overall, women know a mean of 3.5 contraceptive methods. Like women, a larger proportion of all men (90 percent) know a modern method than a traditional method (58 percent). Similar to women, the most commonly known modern method among all men is the male condom (86 percent). Withdrawal is the most commonly known traditional method (50 percent). It is worth noting that knowledge of implants is similar for both men and women (10 and 11 percent, respectively). Overall, men know a mean of 4.8 contraceptive methods. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 64 | Family Planning Table 5.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents and sexually active unmarried respondents age 15-49 who know any contraceptive method, by specific method, Nigeria 2008 Women Men Method All women Currently married women1 Sexually active unmarried woman All men Currently married men Sexually active unmarried men1 Any method 72.1 68.4 95.3 89.8 89.7 98.6 Any modern method 70.8 67.0 94.4 89.1 88.8 98.4 Female sterilisation 23.9 25.0 27.3 36.5 40.7 40.5 Male sterilisation 7.9 8.0 10.5 20.5 21.5 27.4 Pill 51.8 53.9 65.9 57.0 62.1 67.0 IUD 24.9 27.2 30.9 18.1 21.4 21.0 Injectables 50.9 54.0 62.2 55.4 61.8 60.8 Implants 10.1 10.8 11.9 10.7 12.5 13.9 Male condom 58.0 50.9 92.2 86.2 84.8 97.9 Female condom 14.7 13.0 27.7 25.9 26.6 38.3 Diaphragm 6.0 6.2 7.7 11.0 12.5 12.6 Foam/jelly 6.1 5.9 11.0 14.0 15.2 17.5 Lactational amenorrhoea (LAM) 20.6 23.4 19.4 19.5 25.3 21.9 Emergency contraception 15.4 14.1 37.7 25.5 26.9 39.1 Any traditional method 36.3 35.0 65.3 58.4 64.7 76.6 Rhythm 24.5 22.9 45.3 40.8 46.0 54.2 Withdrawal 25.0 24.0 52.2 49.9 55.3 71.2 Folk method 10.7 11.3 21.1 9.2 12.1 9.0 Mean number of methods known by respondents 15-49 3.5 3.5 5.2 4.8 5.2 5.9 Number of respondents 33,385 23,578 1,607 13,808 7,018 1,297 Mean number of methods known by respondents 15-59 na na na 4.8 5.2 5.9 Number of respondents na na na 15,486 8,618 1,311 na = Not applicable 1 Had last sexual intercourse within 30 days preceding the survey Table 5.2 shows knowledge of contraceptive methods among women and men by background characteristics. Variations in contraceptive knowledge by background characteristics are greater for women than men. Younger women age 15-19 and women living in the North West are least likely to know of a contraceptive method (43 and 45 percent, respectively). Similarly, knowledge of contraceptive methods is lowest among women with no education and those in the lowest wealth quintile (45 and 41 percent, respectively). For men, knowledge of any contraceptive method shows only small differences by age group, but the differentials are greater by place of residence, zone, educational level, and wealth quintile. Family Planning | 65 Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method by background characteristics, Nigeria 2008 Women Men Background characteristic Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number Age 15-19 42.7 41.6 1,863 (59.9) (59.9) 23 20-24 62.8 61.6 3,659 82.2 80.5 354 25-29 73.1 71.8 5,112 88.2 87.3 1,076 30-34 73.9 72.3 4,173 91.9 91.2 1,504 35-39 74.2 73.1 3,575 91.3 90.3 1,618 40-44 71.8 69.9 2,711 90.3 89.3 1,316 45-49 65.4 63.2 2,484 88.6 87.5 1,127 Residence Urban 87.9 87.1 7,375 97.1 96.9 2,309 Rural 59.6 57.8 16,203 86.2 84.8 4,709 Zone North Central 64.3 63.2 3,320 90.6 89.5 1,040 North East 58.6 57.2 3,585 81.2 80.1 1,002 North West 45.1 43.1 7,189 82.3 80.8 1,951 South East 85.5 84.3 2,139 91.9 91.1 607 South South 89.9 88.2 2,978 97.6 97.4 989 South West 95.0 94.4 4,366 98.9 98.4 1,430 Education No education 45.1 42.8 11,120 74.1 71.5 1,917 Primary 81.7 80.7 5,143 91.6 90.9 1,806 Secondary 93.6 93.1 5,621 97.7 97.5 2,323 More than secondary 98.2 98.0 1,693 98.2 98.1 973 Wealth quintile Lowest 40.9 38.7 5,408 74.0 71.4 1,512 Second 52.7 50.6 5,052 86.2 84.7 1,378 Middle 73.2 72.0 4,311 93.4 92.8 1,244 Fourth 87.6 86.6 4,216 96.9 96.9 1,284 Highest 96.2 95.7 4,590 99.2 99.2 1,600 Total 15-49 68.4 67.0 23,578 89.7 88.8 7,018 50-59 na na na 84.1 81.8 1,599 Total men 15-59 na na na 88.7 87.5 8,618 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, diaphragm, foam or jelly, lactational amenorrhoea method (LAM), and emergency contraception 5.2 EVER USE OF CONTRACEPTION Ever use of contraception provides a measure of the cumulative experience of a population with family planning. Ever use of family planning methods in the 2008 NDHS thus refers to use of a method at any time, with no distinction between past and current use. The 2008 NDHS collected data on the level of ever use of family planning methods from respondents. All women interviewed in the 2008 NDHS who said that they had heard of a method of family planning were asked whether they had ever used that method. Men were only asked about ever use of male sterilisation, male condom, LAM, the rhythm method, and withdrawal. Table 5.3.1 shows the percentage of all women, currently married women, and sexually active unmarried women who have ever used specific methods of family planning, by age. Table 5.3.2 presents comparable information for men. T ab le 5 .3 .1 E ve r u se o f c on tra ce pt io n: W om en P er ce nt ag e of a ll w om en , c ur re nt ly m ar rie d w om en , a nd s ex ua lly a ct iv e un m ar rie d w om en a ge 1 5- 49 w ho h av e ev er u se d an y co nt ra ce pt iv e m et ho d by m et ho d, a cc or di ng to a ge , N ig er ia 2 00 8 M od er n m et ho d Tr ad iti on al m et ho d A ge An y m et ho d An y m od er n m et ho d Fe m al e st er ili - sa tio n M al e st er ili - sa tio n Pi ll IU D In je ct - ab le s Im - pl an ts M al e co nd om Fe m al e co nd om D ia - ph ra gm Fo am / je lly LA M Em er - ge nc y co nt ra - ce pt io n An y tra di - tio na l m et ho d Rh yt hm W ith - dr aw al Fo lk m et ho d N um be r of w om en AL L W O M EN 15 -1 9 10 .5 9. 1 0. 0 0. 0 1. 1 0. 0 0. 5 0. 0 7. 1 0. 1 0. 0 0. 1 0. 5 1. 6 4. 4 1. 9 2. 3 1. 8 6, 49 3 20 -2 4 30 .2 25 .7 0. 0 0. 0 4. 7 0. 4 2. 2 0. 1 18 .8 0. 3 0. 0 0. 3 2. 6 3. 8 14 .1 7. 3 8. 2 3. 4 6, 13 3 25 -2 9 34 .6 29 .0 0. 1 0. 0 6. 2 0. 7 5. 2 0. 1 16 .8 0. 3 0. 1 0. 1 6. 2 3. 9 16 .6 9. 1 9. 0 3. 7 6, 30 9 30 -3 4 36 .3 30 .0 0. 2 0. 0 7. 1 1. 8 8. 1 0. 1 13 .7 0. 4 0. 1 0. 1 7. 3 3. 6 18 .4 10 .7 11 .3 3. 0 4, 63 4 35 -3 9 36 .4 30 .3 0. 5 0. 0 8. 7 3. 4 9. 9 0. 3 10 .8 0. 1 0. 1 0. 3 8. 8 2. 5 17 .4 9. 9 10 .5 2. 6 3, 91 2 40 -4 4 32 .9 26 .8 1. 0 0. 0 8. 0 4. 3 9. 7 0. 2 6. 6 0. 1 0. 1 0. 3 6. 8 1. 6 14 .1 7. 9 6. 7 2. 9 3, 03 2 45 -4 9 25 .9 21 .5 1. 2 0. 0 6. 2 4. 3 6. 9 0. 1 4. 2 0. 1 0. 1 0. 0 6. 3 0. 7 9. 7 5. 8 4. 2 2. 0 2, 87 2 To ta l 28 .6 24 .0 0. 3 0. 0 5. 5 1. 6 5. 2 0. 1 12 .1 0. 2 0. 1 0. 2 5. 0 2. 8 13 .3 7. 3 7. 4 2. 8 33 ,3 85 C U RR EN TL Y M A RR IE D W O M EN 15 -1 9 6. 9 6. 1 0. 0 0. 0 0. 9 0. 1 0. 6 0. 0 3. 5 0. 0 0. 0 0. 2 1. 6 0. 7 2. 1 0. 9 1. 4 0. 9 1, 86 3 20 -2 4 22 .9 18 .6 0. 0 0. 1 4. 6 0. 5 2. 6 0. 1 10 .2 0. 1 0. 0 0. 1 4. 0 2. 1 10 .5 5. 2 5. 8 2. 6 3, 65 9 25 -2 9 31 .0 25 .3 0. 1 0. 0 6. 1 0. 8 5. 8 0. 1 11 .8 0. 2 0. 1 0. 1 7. 3 2. 7 14 .3 7. 8 8. 0 3. 1 5, 11 2 30 -3 4 35 .3 28 .9 0. 2 0. 0 6. 9 1. 9 8. 4 0. 1 12 .1 0. 4 0. 1 0. 1 7. 6 2. 9 17 .6 10 .3 10 .5 2. 7 4, 17 3 35 -3 9 35 .7 29 .7 0. 5 0. 0 8. 5 3. 4 10 .1 0. 3 9. 9 0. 1 0. 2 0. 2 9. 0 2. 0 16 .8 9. 3 10 .1 2. 3 3, 57 5 40 -4 4 32 .7 26 .4 1. 0 0. 0 8. 0 4. 4 9. 8 0. 2 6. 1 0. 1 0. 1 0. 3 6. 7 1. 6 14 .0 7. 9 6. 5 3. 0 2, 71 1 45 -4 9 25 .0 20 .9 1. 3 0. 0 6. 1 4. 8 7. 0 0. 1 4. 2 0. 1 0. 1 0. 0 5. 7 0. 7 9. 1 5. 4 4. 0 1. 8 2, 48 4 To ta l 28 .9 23 .7 0. 4 0. 0 6. 2 2. 1 6. 6 0. 1 9. 2 0. 2 0. 1 0. 1 6. 4 2. 1 13 .1 7. 3 7. 3 2. 5 23 ,5 78 SE XU A LL Y AC TI V E U N M A RR IE D W O M EN 1 15 -1 9 64 .5 55 .9 0. 0 0. 0 6. 5 0. 3 2. 6 0. 0 46 .8 0. 7 0. 0 0. 0 0. 0 12 .3 30 .9 13 .2 17 .6 14 .2 44 8 20 -2 4 79 .6 72 .2 0. 0 0. 0 12 .4 0. 5 4. 1 0. 3 63 .6 1. 3 0. 2 1. 5 0. 6 15 .4 43 .3 24 .1 27 .8 12 .1 58 6 25 -2 9 79 .4 73 .1 0. 0 0. 0 11 .7 1. 2 4. 3 0. 0 62 .5 1. 6 0. 0 0. 5 1. 8 19 .9 43 .5 22 .9 23 .8 14 .1 33 4 30 -3 4 77 .7 72 .8 0. 9 0. 0 16 .6 2. 7 6. 8 0. 0 55 .1 0. 0 0. 0 1. 9 8. 1 25 .0 43 .8 23 .4 32 .9 13 .3 10 2 35 -3 9 66 .7 60 .8 0. 0 0. 0 22 .3 7. 5 14 .8 0. 0 41 .9 1. 1 0. 0 2. 6 4. 2 12 .1 38 .3 19 .0 24 .9 14 .5 73 40 -4 4 (6 3. 2) (5 4. 7) (0 .0 ) (0 .0 ) (1 8. 4) (1 0. 3) (1 4. 9) (0 .0 ) (2 2. 6) (0 .0 ) (0 .0 ) (0 .0 ) (1 2. 9) (2 .0 ) (3 0. 9) (1 5. 7) (2 0. 0) (2 .4 ) 47 45 -4 9 35 .6 * * * * * * * * * * * * * * * * * 17 To ta l 73 .7 66 .5 0. 1 0. 0 11 .5 1. 4 4. 8 0. 1 55 .4 1. 0 0. 1 0. 9 1. 8 15 .5 39 .0 20 .0 23 .9 13 .0 1, 60 7 N ot e: F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. A n as te ris k in di ca te s th at a fi gu re s is ba se d on fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. LA M = L ac ta tio na l a m en or rh oe a m et ho d 1 W om en w ho h ad s ex ua l i nt er co ur se w ith in 3 0 da ys p re ce di ng th e su rv ey 66 | Family Planning Family Planning | 67 Overall, 29 percent of all women reported ever using a method of contraception at some time; 24 percent used a modern method and 13 percent used a traditional method. The male condom (12 percent), is the most commonly used modern method, followed by the pill (6 percent), injectables (5 percent), and LAM (5 percent). Implants, female condom, diaphragm, and foam/jelly are the least used modern methods with less than one percent of women having ever used any of these methods. Among traditional methods, withdrawal and the rhythm method are the most commonly used by women (7 percent each), while folk methods are the least used (3 percent). Ever use of a modern contraceptive method is 11 percent for women age 15-19. Ever use increases sharply with increasing age to reach a peak of 36 percent among women age 30-39, and then decreases to 26 percent at age 45-49. Contraceptive use differs slightly among married women and sexually active unmarried women. Twenty-nine percent of currently married women have used a method of contraception at some time; 24 percent used a modern method, while 13 percent used a traditional method. Among sexually active unmarried women, three-quarters have used a method of contraception at some time, with two-thirds using a modern method, and two-fifths using a traditional method. Table 5.3.2 shows that 41 percent of all men age 15-49 reported having used a method of contraception at some time; 33 percent used a modern method and 27 percent used a traditional method. The male condom is the most commonly used method (33 percent), while less than 1 percent of men have used male sterilisation. For the traditional methods, withdrawal (21 percent) is more common than the rhythm method (15 percent). The male condom is reported as the most commonly used method among currently married men (32 percent). Similarly, male condoms are the most common method ever used by sexually active unmarried men (80 percent). Ever use of any contraceptive method is 11 percent for men age 15-19. Ever use among all men increases sharply with age, peaks at 52 percent among men age 30-34, and then decreases to 42 percent at age 45-49. 68 | Family Planning Table 5.3.2 Ever use of contraception: Men Percentage of all men, currently married men, and sexually active unmarried men age 15-49 who have ever used any contraceptive method by method, according to age, Nigeria 2008 Modern method Traditional method Age Any method Any modern method Male sterili- sation Male condom Any tradi- tional method Rhythm With- drawal Folk method Number of men ALL MEN 15-19 11.4 9.4 0.3 9.3 5.1 1.7 4.1 0.0 2,532 20-24 40.1 36.6 0.7 36.2 20.5 10.0 17.1 0.5 2,378 25-29 51.0 44.6 0.6 44.3 33.4 16.8 27.4 1.0 2,459 30-34 52.3 44.5 0.7 44.1 37.6 21.8 29.6 1.0 2,058 35-39 50.6 38.3 0.6 37.9 37.7 22.2 29.0 1.8 1,794 40-44 45.5 33.1 0.9 32.5 33.6 19.9 24.9 1.6 1,413 45-49 41.7 26.6 1.3 25.7 33.0 19.7 23.8 2.0 1,174 Total 15-49 40.7 33.2 0.7 32.8 27.2 14.9 21.3 1.0 13,808 50-59 36.3 19.1 0.7 18.7 30.5 19.0 20.4 2.8 1,678 Total men 15-59 40.2 31.7 0.7 31.3 27.5 15.3 21.2 1.2 15,486 CURRENTLY MARRIED MEN 15-19 (7.0) (2.2) (0.0) (2.2) (4.8) (4.8) (0.0) (0.0) 23 20-24 33.4 26.9 0.3 26.5 20.6 9.8 15.0 0.4 354 25-29 42.5 32.0 0.6 31.5 30.8 16.2 23.1 1.6 1,076 30-34 45.1 35.9 1.0 35.3 33.3 19.2 25.6 0.6 1,504 35-39 49.4 36.2 0.5 35.8 37.7 22.3 28.8 1.6 1,618 40-44 45.3 32.3 0.7 31.8 33.9 20.2 25.1 1.6 1,316 45-49 42.0 26.3 1.3 25.4 33.3 19.9 24.1 2.0 1,127 Total 15-49 44.5 32.6 0.8 32.0 33.3 19.2 25.0 1.4 7,018 50-59 36.1 18.7 0.7 18.3 30.4 18.9 20.4 2.9 1,599 Total men 15-59 42.9 30.0 0.8 29.5 32.8 19.2 24.2 1.7 8,618 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 65.2 58.6 1.5 58.3 32.0 10.8 30.2 0.0 159 20-24 83.4 79.6 1.7 79.1 49.6 23.8 45.2 0.7 371 25-29 88.4 86.5 0.8 86.3 60.7 31.5 54.0 1.0 453 30-34 89.3 87.1 0.0 87.1 64.9 39.1 57.2 2.1 230 35-39 (79.7) (77.4) (0.0) (77.4) (55.8) (29.5) (52.5) (10.4) 55 40-44 * * * * * * * * 22 45-49 * * * * * * * * 8 Total 15-49 83.7 80.6 1.2 80.3 54.5 28.0 48.9 1.5 1,297 50-59 * * * * * * * * 14 Total men 15-59 83.3 80.0 1.2 79.7 54.1 27.8 48.4 1.5 1,311 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Men who had sexual intercourse within 30 days preceding the survey 5.3 CURRENT USE OF CONTRACEPTIVE METHODS This section presents information on the prevalence of current contraceptive use among women age 15- 49. The level of current use is a measure of actual contraceptive practice at the time of the survey. It is also the most widely used and valuable measure of the success of family planning programmes. Furthermore, it can be used to estimate the reduction in fertility attributable to contraception. The contraceptive prevalence rate (CPR) is usually defined as the percentage of currently married women who are currently using a method of contraception. This section focuses on the levels and differentials in current use of contraception in Nigeria. Family Planning | 69 Table 5.4 shows the percent distribution of all women, currently married women, and sexually active unmarried women who are currently using specific family planning methods by age. The overall contraceptive prevalence among all women in Nigeria is 15 percent. The use of any family planning method increases with age from 7 percent among women age 15-19 to 20 percent among women age 35-39, and then declines to 10 percent for women age 45-49. Most women currently using contraception use a modern method (11 percent), while 5 percent are using traditional methods. The male condom is the most commonly used modern method (5 percent), followed by the injectables and pills (2 percent for each), while the IUD, and female sterilisation are the least used modern methods (less than one percent each). Among the traditional methods, the rhythm method and withdrawal are the most commonly used (2 percent each). The most commonly used modern method among currently married women is injectables (3 percent), followed by the male condom (2 percent), while the rhythm method is the most commonly used traditional method (2 percent). Among sexually active unmarried women, the most commonly used modern method is the male condom (35 percent), followed by the pill (4 percent), while the rhythm method and folk methods are the most widely used traditional methods (7 percent each). As expected, the use of modern family planning methods is higher for sexually active unmarried women than for currently married women (61 percent versus 15 percent). The most notable difference among these two groups of women is that 35 percent of sexually active unmarried women use male condoms, compared with 2 percent of married women. The contraceptive prevalence rate for modern methods has increased from 6 percent in 1990 to 13 percent in 2003, and to 15 percent in 2008. 5.4 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS Table 5.5 presents information on current use of contraception among married women by background characteristics. Current use of contraception varies with residence, zone, education, number of living children, and wealth quintile. Contraceptive use among women in urban areas is three times that of women in rural areas (26 and 9 percent, respectively). The South West zone has the highest proportion of women currently using a family planning method (32 percent), followed by South South zone (26 percent). The lowest proportion of married women using a family planning method is in the North West (3 percent). In general, women do not begin to use contraception until they have had at least one child. Contraceptive use increases with educational attainment. Thirty- seven percent of women who have been educated above the secondary level use a contraceptive method compared with 4 percent of women who are uneducated. By wealth quintile, women in the lowest quintile are least likely to use a contraceptive method (3 percent), and women in the highest quintile are most likely to use a contraceptive method (35 percent). T ab le 5 .4 C ur re nt u se o f c on tra ce pt io n by a ge P er ce nt d ist rib ut io n of a ll w om en , c ur re nt ly m ar rie d w om en , a nd s ex ua lly a ct iv e un m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to a ge , N ig er ia 2 00 8 M od er n m et ho d Tr ad iti on al m et ho d A ge An y m et ho d An y m od er n m et ho d Fe m al e st er ili - sa tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M An y tra di - tio na l m et ho d Rh yt hm W ith - dr aw al Fo lk m et ho d N ot cu rr en tly us in g To ta l N um be r o f w om en AL L W O M EN 1 5- 19 6. 9 4. 7 0. 0 0. 5 0. 0 0. 2 0. 0 3. 8 0. 0 0. 2 2. 2 0. 5 0. 7 0. 9 93 .1 10 0. 0 6, 49 3 2 0- 24 17 .6 12 .8 0. 0 1. 8 0. 2 0. 7 0. 1 8. 9 0. 1 1. 0 4. 8 2. 0 1. 5 1. 3 82 .4 10 0. 0 6, 13 3 2 5- 29 18 .1 12 .1 0. 1 1. 7 0. 3 1. 9 0. 0 6. 3 0. 0 1. 9 5. 9 2. 2 2. 3 1. 4 81 .9 10 0. 0 6, 30 9 3 0- 34 19 .3 12 .8 0. 2 2. 0 0. 8 3. 5 0. 0 4. 2 0. 0 1. 9 6. 4 2. 7 2. 8 0. 9 80 .7 10 0. 0 4, 63 4 3 5- 39 19 .7 13 .3 0. 5 2. 5 1. 5 3. 8 0. 1 3. 2 0. 0 1. 6 6. 4 2. 9 2. 6 0. 9 80 .3 10 0. 0 3, 91 2 4 0- 44 18 .0 11 .0 1. 0 1. 7 2. 2 4. 1 0. 0 1. 3 0. 0 0. 7 7. 0 3. 8 1. 8 1. 4 82 .0 10 0. 0 3, 03 2 4 5- 49 9. 7 7. 0 1. 2 0. 9 1. 8 1. 5 0. 1 1. 2 0. 0 0. 3 2. 7 1. 3 0. 6 0. 8 90 .3 10 0. 0 2, 87 2 T ot al 15 .4 10 .5 0. 3 1. 6 0. 7 2. 0 0. 0 4. 7 0. 0 1. 1 4. 9 2. 1 1. 8 1. 1 84 .6 10 0. 0 33 ,3 85 C U RR EN TL Y M A RR IE D W O M EN 1 5- 19 3. 0 2. 4 0. 0 0. 2 0. 0 0. 2 0. 0 1. 2 0. 0 0. 8 0. 6 0. 1 0. 3 0. 2 97 .0 10 0. 0 1, 86 3 2 0- 24 10 .1 7. 1 0. 0 1. 7 0. 3 0. 8 0. 0 2. 7 0. 0 1. 6 3. 1 1. 0 1. 3 0. 7 89 .9 10 0. 0 3, 65 9 2 5- 29 14 .6 9. 6 0. 1 1. 6 0. 3 2. 1 0. 0 3. 2 0. 1 2. 2 5. 1 1. 8 2. 3 1. 0 85 .4 10 0. 0 5, 11 2 3 0- 34 18 .5 12 .2 0. 2 2. 0 0. 9 3. 7 0. 0 3. 2 0. 0 2. 2 6. 4 2. 6 3. 0 0. 8 81 .5 10 0. 0 4, 17 3 3 5- 39 19 .9 13 .4 0. 5 2. 5 1. 7 4. 1 0. 1 2. 7 0. 0 1. 7 6. 6 3. 1 2. 8 0. 8 80 .1 10 0. 0 3, 57 5 4 0- 44 19 .0 11 .5 1. 0 1. 8 2. 3 4. 3 0. 0 1. 2 0. 0 0. 8 7. 4 4. 0 1. 9 1. 6 81 .0 10 0. 0 2, 71 1 4 5- 49 10 .6 7. 7 1. 3 1. 0 2. 0 1. 8 0. 1 1. 2 0. 0 0. 3 2. 9 1. 5 0. 7 0. 7 89 .4 10 0. 0 2, 48 4 T ot al 14 .6 9. 7 0. 4 1. 7 1. 0 2. 6 0. 0 2. 4 0. 0 1. 6 4. 9 2. 1 2. 0 0. 9 85 .4 10 0. 0 23 ,5 78 SE XU AL LY A C TI VE U N M AR RI ED W O M EN 1 1 5- 19 56 .1 36 .9 0. 0 3. 8 0. 0 1. 5 0. 0 31 .6 0. 0 0. 0 19 .2 5. 0 5. 9 8. 3 43 .9 10 0. 0 44 8 2 0- 24 68 .2 50 .2 0. 0 5. 0 0. 3 1. 8 0. 2 42 .3 0. 7 0. 0 17 .9 7. 9 3. 8 6. 2 31 .8 10 0. 0 58 6 2 5- 29 65 .1 43 .5 0. 0 4. 3 0. 6 1. 6 0. 0 36 .6 0. 0 0. 4 21 .6 8. 8 4. 6 8. 2 34 .9 10 0. 0 33 4 3 0- 34 61 .0 42 .3 0. 9 5. 8 0. 4 3. 3 0. 0 31 .9 0. 0 0. 0 18 .7 9. 8 2. 0 6. 9 39 .0 10 0. 0 10 2 3 5- 39 (4 4. 2) (3 1. 6) (0 .0 ) (5 .3 ) (1 .1 ) (3 .6 ) (0 .0 ) (2 1. 6) (0 .0 ) (0 .0 ) (1 2. 6) (4 .5 ) (2 .7 ) (5 .4 ) (5 5. 8) 10 0. 0 73 4 0- 44 * * * * * * * * * * * * * * * 10 0. 0 47 4 5- 49 * * * * * * * * * * * * * * * 10 0. 0 17 T ot al 61 .0 42 .4 0. 1 4. 4 0. 5 1. 9 0. 1 35 .1 0. 2 0. 1 18 .6 7. 2 4. 4 7. 1 39 .0 10 0. 0 1, 60 7 N ot e: I f m or e th an o ne m et ho d is us ed , on ly t he m os t ef fe ct iv e m et ho d is co ns id er ed i n th is ta bu la tio n. F ig ur es i n pa re nt he se s ar e ba se d on 2 5- 49 u nw ei gh te d ca se s. A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. LA M = L ac ta tio na l a m en or rh oe a m et ho d 1 W om en w ho h av e ha d se xu al in te rc ou rs e w ith in 3 0 da ys p re ce di ng th e su rv ey 70 | Family Planning T ab le 5 .5 C ur re nt u se o f c on tra ce pt io n by b ac kg ro un d ch ar ac te ris tic s P er ce nt d ist rib ut io n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, N ig er ia 2 00 8 M od er n m et ho d Tr ad iti on al m et ho d B ac kg ro un d ch ar ac te ris tic An y m et ho d An y m od er n m et ho d Fe m al e st er ili - sa tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M An y tra di - tio na l m et ho d Rh yt hm W ith - dr aw al Fo lk m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en R es id en ce U rb an 25 .9 16 .7 0. 4 3. 3 2. 2 3. 7 0. 1 4. 8 0. 1 2. 2 9. 1 3. 6 4. 0 1. 5 74 .1 10 0. 0 7, 37 5 Ru ra l 9. 4 6. 5 0. 4 1. 0 0. 4 2. 0 0. 0 1. 4 0. 0 1. 3 3. 0 1. 4 1. 0 0. 6 90 .6 10 0. 0 16 ,2 03 Z on e N or th C en tra l 13 .0 10 .5 1. 2 1. 4 0. 8 3. 9 0. 1 1. 9 0. 0 1. 2 2. 5 1. 2 0. 7 0. 6 87 .0 10 0. 0 3, 32 0 N or th E as t 4. 0 3. 5 0. 2 0. 6 0. 0 0. 9 0. 0 0. 2 0. 0 1. 5 0. 5 0. 1 0. 1 0. 3 96 .0 10 0. 0 3, 58 5 N or th W es t 2. 8 2. 5 0. 1 0. 6 0. 2 1. 1 0. 0 0. 1 0. 0 0. 4 0. 3 0. 2 0. 0 0. 1 97 .2 10 0. 0 7, 18 9 So ut h Ea st 23 .4 11 .8 0. 6 1. 6 1. 4 2. 0 0. 3 4. 6 0. 0 1. 4 11 .6 5. 8 5. 5 0. 2 76 .6 10 0. 0 2, 13 9 So ut h So ut h 26 .2 15 .5 0. 6 2. 6 0. 7 4. 2 0. 1 4. 4 0. 1 2. 9 10 .7 5. 3 3. 5 1. 9 73 .8 10 0. 0 2, 97 8 So ut h W es t 31 .7 21 .0 0. 2 4. 0 3. 1 4. 5 0. 0 6. 1 0. 0 3. 0 10 .7 3. 5 4. 8 2. 3 68 .3 10 0. 0 4, 36 6 E du ca tio n N o ed uc at io n 3. 6 2. 6 0. 2 0. 4 0. 2 0. 6 0. 0 0. 2 0. 0 0. 9 1. 0 0. 3 0. 3 0. 4 96 .4 10 0. 0 11 ,1 20 Pr im ar y 17 .2 12 .0 0. 5 2. 2 1. 0 4. 0 0. 0 2. 0 0. 0 2. 2 5. 2 2. 0 2. 0 1. 2 82 .8 10 0. 0 5, 14 3 Se co nd ar y 27 .4 17 .4 0. 4 3. 1 1. 6 4. 4 0. 1 5. 5 0. 0 2. 3 9. 9 4. 2 4. 3 1. 5 72 .6 10 0. 0 5, 62 1 M or e th an s ec on da ry 36 .6 23 .5 1. 0 3. 7 4. 0 4. 9 0. 0 8. 3 0. 3 1. 2 13 .0 7. 1 5. 2 0. 7 63 .4 10 0. 0 1, 69 3 N um be r of li vi ng c hi ld re n 0 3. 3 2. 0 0. 0 0. 2 0. 0 0. 2 0. 0 1. 6 0. 0 0. 0 1. 3 0. 7 0. 3 0. 2 96 .7 10 0. 0 2, 40 2 1- 2 13 .0 8. 3 0. 1 1. 4 0. 4 1. 2 0. 0 3. 7 0. 0 1. 5 4. 7 1. 6 2. 2 0. 8 87 .0 10 0. 0 7, 41 4 3- 4 18 .8 12 .5 0. 4 2. 3 1. 6 3. 6 0. 1 2. 4 0. 0 2. 1 6. 3 2. 7 2. 5 1. 1 81 .2 10 0. 0 7, 18 1 5+ 15 .9 11 .0 0. 9 1. 8 1. 4 3. 9 0. 1 1. 3 0. 0 1. 6 4. 9 2. 4 1. 7 0. 8 84 .1 10 0. 0 6, 58 1 W ea lth q ui nt ile Lo w es t 3. 2 2. 5 0. 1 0. 5 0. 0 0. 5 0. 0 0. 3 0. 0 1. 1 0. 7 0. 2 0. 2 0. 3 96 .8 10 0. 0 5, 40 8 Se co nd 5. 2 3. 8 0. 2 0. 6 0. 1 1. 3 0. 0 0. 5 0. 0 1. 0 1. 4 0. 5 0. 4 0. 5 94 .8 10 0. 0 5, 05 2 M id dl e 11 .4 7. 8 0. 6 1. 2 0. 5 2. 7 0. 0 1. 3 0. 0 1. 4 3. 6 1. 6 1. 3 0. 8 88 .6 10 0. 0 4, 31 1 Fo ur th 21 .3 14 .1 0. 5 2. 4 1. 4 4. 0 0. 0 3. 8 0. 0 1. 9 7. 3 3. 0 3. 0 1. 3 78 .7 10 0. 0 4, 21 6 H ig he st 35 .0 22 .3 0. 5 4. 0 3. 1 4. 9 0. 1 6. 9 0. 1 2. 5 12 .7 5. 6 5. 5 1. 6 65 .0 10 0. 0 4, 59 0 T ot al 14 .6 9. 7 0. 4 1. 7 1. 0 2. 6 0. 0 2. 4 0. 0 1. 6 4. 9 2. 1 2. 0 0. 9 85 .4 10 0. 0 23 ,5 78 N ot e: If m or e th an o ne m et ho d is us ed , o nl y th e m os t e ffe ct iv e m et ho d is co ns id er ed in th is ta bu la tio n. LA M = L ac ta tio na l a m en or rh oe a m et ho d Family Planning | 71 72 | Family Planning 5.5 TRENDS IN CONTRACEPTIVE USE Table 5.6 and Figure 5.1 present trends in current use of specific contraceptive methods among currently married women between 1990 and 2008. Over the 18-year period, contraceptive prevalence increased from 6 percent in 1990 to 15 percent in 2008. Use of modern methods increased from 4 percent in 1990 to 10 percent in 2008. The largest increase was in the use of injectables, from 1 percent in 1990 to 3 percent in 2008. Condom use increased from less than 1 percent in 1990 to 2 percent in 2008. Table 5.6 Trends in current use of contraception Percent distribution of currently married women age 15- 49 by contraceptive method currently used, according to several surveys, Nigeria 1990, 2003, and 2008 Method 1990 NDHS 2003 NDHS 2008 NDHS Any method 6.0 12.6 14.6 Any modern method 3.5 8.2 9.7 Female sterilisation 0.3 0.2 0.4 Pill 1.2 1.8 1.7 IUD 0.8 0.7 1.0 Injectables 0.7 2.0 2.6 Male condom 0.4 1.9 2.4 LAM u 1.4 1.6 Any traditional method 2.5 4.3 4.9 Rhythm 2.1 2.1 2.1 Withdrawal 2.0 1.3 2.0 Folk method 0.6 1.0 0.9 Not currently using 94.0 87.4 85.4 Total 100.0 100.0 100.0 Number of women 6,880 5,336 23,578 LAM = Lactational amenorrhoea method u = Unknown (not available) Figure 5.1 Trends in Contraceptive Prevalence, NDHS 1990-2008 6 4 3 13 8 4 15 10 5 Any method Modern methods Traditional methods 0 2 4 6 8 10 12 14 16 Percent 1990 2003 2008 Family Planning | 73 5.6 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION Couples use family planning methods either to limit family size or to delay the next birth. Couples using family planning as a means to control family size (i.e., to stop having children) adopt contraception when they have already had the number of children they want. When contraception is used to space births, couples may start to use family planning earlier, with the intention of delaying a pregnancy. This may be done before a couple has had their desired number of children. Women interviewed in the 2008 NDHS were asked how many children they had at the time they first used a method of family planning. Table 5.7 shows the percent distribution of women by number of living children at the time of first use of contraception, according to current age. While 71 percent of women have never used contraception, 12 percent of women reported using contraception before they began childbearing. Women age 20-24 with no children have the highest level of contraceptive use (21 percent). Seventeen percent of women reported using a method of contraception the first time when they had at least one living child. Table 5.7 Number of children at first use of contraception Percent distribution of women age 15-49 by number of living children at the time of first use of contraception, according to current age, Nigeria 2008 Number of living children at time of first use of contraception Current age Never used 0 1 2 3 4+ Missing Total Number of women 15-19 89.5 9.0 1.2 0.1 0.0 0.0 0.1 100.0 6,493 20-24 69.8 21.4 5.8 1.9 0.5 0.2 0.4 100.0 6,133 25-29 65.4 16.2 9.6 4.3 2.3 1.9 0.3 100.0 6,309 30-34 63.7 11.1 9.8 5.4 4.0 5.9 0.2 100.0 4,634 35-39 63.6 6.9 8.6 4.9 3.9 11.5 0.5 100.0 3,912 40-44 67.1 4.7 6.6 4.0 3.3 13.9 0.3 100.0 3,032 45-49 74.1 3.8 4.8 2.8 2.9 11.3 0.3 100.0 2,872 Total 71.4 11.8 6.5 3.1 2.1 4.8 0.3 100.0 33,385 5.7 BRANDS OF PILLS, CONDOMS, AND INJECTABLES USED Women who were currently using oral contraceptives, injectables, and condoms were asked for the brand name of the pills and condoms they last used. Information on women’s use of social marketing brand contraceptives is useful for monitoring the success of social marketing programmes. Table 5.8 shows the percent distribution of women using pills and injectables by social marketing brand, according to background characteristics. Among pill users, the brands most commonly used are Confidence (38 percent) and Duofem (27 percent). Among women using injectables, Depo Provera (63 percent) and Noristerat (21 percent) are the most commonly used brands. T ab le 5 .8 U se o f s oc ia l m ar ke tin g br an d pi lls a nd in je ct ab le s: w om en P er ce nt d ist rib ut io n of w om en a ge 1 5- 49 u sin g th e pi ll an d us in g in je ct ab le s by s oc ia l m ar ke tin g br an d us ed , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, N ig er ia 2 00 8 Br an d of p ill Br an d/ ty pe o f i nj ec ta bl es B ac kg ro un d ch ar ac te ris tic D uo fe m M ic ro by no n Lo fe m en al N eo gy no n C on fid en ce O th er D on 't kn ow / m iss in g To ta l N um be r o f w om en u sin g th e pi ll N or ist er at (2 m on th s) N or ig yn on (2 m on th s) D ep o pr ov er a (3 m on th s) M iss in g To ta l N um be r o f w om en us in g in je ct ab le s A ge 15 -1 9 (2 4. 8) (0 .0 ) (1 .2 ) (7 .4 ) (4 4. 7) (1 2. 0) (9 .9 ) 10 0. 0 32 * * * * 10 0. 0 12 20 -2 4 20 .7 1. 9 1. 8 3. 1 46 .1 13 .9 12 .4 10 0. 0 10 8 (3 0. 9) (2 0. 2) (4 6. 7) (2 .2 ) 10 0. 0 44 25 -2 9 31 .7 4. 2 3. 7 3. 2 33 .4 9. 8 14 .0 10 0. 0 11 0 30 .0 14 .9 49 .1 6. 0 10 0. 0 11 8 30 -3 4 36 .2 4. 4 5. 3 4. 2 35 .7 9. 1 5. 2 10 0. 0 95 21 .6 17 .3 55 .5 5. 5 10 0. 0 16 2 35 -3 9 23 .3 4. 0 4. 5 3. 1 37 .2 13 .4 14 .4 10 0. 0 97 21 .4 6. 1 67 .8 4. 6 10 0. 0 15 0 40 -4 4 (1 9. 2) (2 .5 ) (1 0. 0) (3 .2 ) (4 3. 2) (1 2. 5) (9 .5 ) 10 0. 0 52 12 .7 6. 8 79 .4 1. 1 10 0. 0 12 3 45 -4 9 (3 2. 1) (1 2. 2) (1 1. 8) (0 .0 ) (2 4. 5) (0 .0 ) 19 .4 10 0. 0 27 (8 .8 ) (6 .5 ) (7 8. 1) (6 .5 ) 10 0. 0 44 R es id en ce U rb an 28 .7 4. 1 5. 4 3. 2 33 .8 15 .2 9. 5 10 0. 0 31 0 29 .3 8. 9 58 .6 3. 2 10 0. 0 29 1 Ru ra l 24 .6 3. 1 3. 5 3. 8 45 .1 5. 1 14 .9 10 0. 0 21 0 14 .7 14 .1 65 .8 5. 4 10 0. 0 36 3 Z on e N or th C en tra l 34 .4 5. 0 12 .0 10 .4 26 .8 3. 2 8. 1 10 0. 0 63 32 .8 14 .3 49 .9 3. 0 10 0. 0 14 1 N or th E as t (3 0. 2) (0 .0 ) (9 .1 ) (0 .0 ) (4 9. 9) (0 .0 ) (1 0. 7) 10 0. 0 24 32 .8 9. 5 55 .7 2. 0 10 0. 0 37 N or th W es t (2 7. 3) (9 .1 ) (7 .8 ) (0 .0 ) (3 6. 1) (3 .6 ) (1 6. 1) 10 0. 0 46 26 .8 13 .0 54 .9 5. 4 10 0. 0 80 So ut h Ea st (3 2. 9) (3 .8 ) (0 .0 ) (6 .1 ) (1 5. 0) (1 2. 6) (2 9. 6) 10 0. 0 44 (1 0. 3) (1 1. 4) (6 4. 3) (1 4. 1) 10 0. 0 44 So ut h So ut h 20 .9 2. 6 4. 7 2. 1 45 .2 14 .6 9. 9 10 0. 0 13 2 19 .1 16 .5 58 .0 6. 4 10 0. 0 14 4 So ut h W es t 27 .1 3. 2 2. 2 2. 7 41 .6 13 .8 9. 4 10 0. 0 21 1 12 .8 6. 9 78 .2 2. 1 10 0. 0 20 7 E du ca tio n N o ed uc at io n 25 .0 3. 5 9. 5 1. 3 34 .5 5. 2 21 .0 10 0. 0 47 14 .5 9. 1 69 .2 7. 3 10 0. 0 80 Pr im ar y 33 .0 3. 2 1. 9 0. 0 42 .2 7. 3 12 .4 10 0. 0 12 2 16 .5 11 .8 66 .7 5. 0 10 0. 0 21 0 Se co nd ar y 21 .4 3. 5 3. 7 5. 0 39 .9 14 .6 12 .0 10 0. 0 26 3 23 .2 13 .2 59 .3 4. 3 10 0. 0 27 1 M or e th an s ec on da ry 36 .9 5. 3 8. 8 4. 6 30 .6 8. 8 5. 0 10 0. 0 88 32 .0 10 .1 56 .8 1. 0 10 0. 0 92 W ea lth q ui nt ile Lo w es t (2 6. 9) (0 .0 ) (1 .6 ) (0 .0 ) (4 2. 2) (0 .0 ) (2 9. 2) 10 0. 0 27 (1 8. 0) (1 5. 2) (6 0. 6) (6 .3 ) 10 0. 0 31 Se co nd (3 2. 8) (4 .2 ) (3 .8 ) (2 .4 ) (3 4. 2) (7 .5 ) (1 5. 1) 10 0. 0 40 9. 6 12 .9 72 .0 5. 5 10 0. 0 77 M id dl e 28 .4 3. 7 3. 6 5. 7 40 .7 1. 5 16 .3 10 0. 0 73 17 .4 16 .9 56 .2 9. 5 10 0. 0 12 7 Fo ur th 22 .6 1. 3 4. 3 2. 3 43 .3 12 .7 13 .5 10 0. 0 14 8 19 .6 10 .1 67 .4 2. 8 10 0. 0 18 4 H ig he st 28 .5 5. 6 5. 7 4. 0 34 .8 15 .0 6. 5 10 0. 0 23 3 28 .7 9. 5 59 .3 2. 5 10 0. 0 23 5 T ot al 27 .1 3. 7 4. 7 3. 4 38 .4 11 .1 11 .7 10 0. 0 52 0 21 .2 11 .8 62 .6 4. 4 10 0. 0 65 3 N ot e: T ab le e xc lu de s pi ll an d in je ct ab le s us er s w ho d o no t k no w th e br an d na m e. F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. 74 | Family Planning Family Planning | 75 Women who reported that they currently use condoms (male or female) for contraception were asked which brand of condoms they use. Table 5.9.1 shows the percent distribution for women condom users age 15-49 by social marketing brand of condoms used, according to background characteristics. The most common brand of condom used is the Gold Circle male condom (73 percent). Eight percent of women use Rough Rider and 4 percent of women use Durex. Thirteen percent of women do not know the brand of condom they use. Table 5.9 1 Use of social marketing brand condoms: women Percent distribution of women condom users age 15-49 by social marketing brand used, according to background characteristics, Nigeria 2008 Brand of condom Background characteristic Gold circle Durex Rough Rider Twin Lotus Other Don’t know/ missing Total Number of women using condoms Age 15-19 75.2 3.4 7.9 0.5 0.0 13.1 100.0 244 20-24 70.6 5.5 9.6 0.3 1.6 12.5 100.0 546 25-29 74.8 4.9 6.7 0.5 0.5 12.5 100.0 395 30-34 71.9 2.9 12.6 0.0 1.0 11.6 100.0 196 35-39 78.4 3.0 5.1 0.0 0.0 13.6 100.0 126 40-44 (74.8) (0.0) (1.1) (0.0) (0.0) (24.0) 100.0 40 45-49 (72.9) (4.2) (0.0) (2.3) (0.0) (20.6) 100.0 34 Residence Urban 75.1 5.0 8.6 0.3 1.0 10.0 100.0 947 Rural 70.7 3.3 7.5 0.4 0.5 17.6 100.0 634 Zone North Central 73.3 4.1 8.5 2.0 0.0 12.2 100.0 163 North East (90.4) (3.5) (2.6) (0.0) (0.0) (3.5) 100.0 21 North West * * * * * * 100.0 18 South East 61.6 4.9 7.7 0.0 1.9 23.9 100.0 252 South South 69.0 3.0 12.0 0.4 0.0 15.6 100.0 537 South West 81.4 4.9 5.3 0.0 1.3 7.1 100.0 590 Education No education (61.2) (0.0) (0.0) (2.9) (7.3) (28.6) 100.0 27 Primary 81.1 2.9 1.0 0.0 0.0 15.0 100.0 158 Secondary 73.5 4.0 7.1 0.4 0.7 14.3 100.0 940 More than secondary 71.0 5.6 13.5 0.2 0.9 8.8 100.0 457 Wealth quintile Lowest (71.3) (0.0) (3.3) (0.0) (0.0) (25.5) 100.0 30 Second 76.2 1.0 7.4 0.0 0.0 15.4 100.0 92 Middle 74.5 2.8 5.3 0.9 0.5 16.0 100.0 212 Fourth 73.4 4.6 6.4 0.5 0.1 14.9 100.0 485 Highest 72.7 5.1 10.4 0.1 1.4 10.2 100.0 762 Total 73.3 4.3 8.2 0.3 0.8 13.0 100.0 1,581 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Men age 15-49 who reported that they had had sex within the 12 months preceding the survey and used a condom the last time they had sex were asked which brand of condoms they used. Table 5.9.2 shows the percent distribution of these men by social marketing brand used, according to background characteristics. As reported for women, the majority of men use Gold Circle male condoms (81 percent), while 9 percent use Rough Rider. Five percent of men do not know the brand of condom used. 76 | Family Planning Table 5.9.2 Use of social marketing brand condoms: men Percent distribution of men condom users age 15-49 by social marketing brand used, according to background characteristics, Nigeria 2008 Brand of condom Background characteristic Gold circle Durex Rough Rider Twin Lotus Other Don’t know/ missing Total Number of men using condoms Age 15-19 89.3 0.0 3.2 0.0 3.3 4.1 100.0 142 20-24 81.7 1.8 9.9 0.2 2.9 3.5 100.0 519 25-29 81.6 0.7 9.4 0.1 2.8 5.4 100.0 579 30-34 78.6 2.3 8.4 0.0 4.9 5.7 100.0 327 35-39 74.9 3.7 9.8 0.4 5.8 5.3 100.0 199 40-44 74.3 2.2 9.8 0.0 1.0 12.7 100.0 89 45-49 (79.5) (2.5) (10.6) (0.0) (0.0) (7.5) 100.0 53 Residence Urban 80.5 1.4 10.2 0.1 4.2 3.6 100.0 1,100 Rural 80.8 2.0 7.4 0.1 2.2 7.5 100.0 808 Zone North Central 81.1 2.3 5.7 0.6 2.3 8.1 100.0 237 North East 83.5 1.3 3.8 0.0 0.0 11.5 100.0 57 North West 75.8 1.8 3.5 0.0 1.9 17.0 100.0 64 South East 77.3 4.0 10.9 0.0 5.3 2.4 100.0 262 South South 73.9 1.3 13.5 0.2 3.6 7.5 100.0 484 South West 85.8 0.9 7.4 0.0 3.3 2.6 100.0 803 Education No education (62.3) (1.9) (1.3) (0.0) (0.0) (34.5) 100.0 39 Primary 80.3 3.5 4.7 0.0 0.9 10.6 100.0 191 Secondary 82.6 1.1 9.3 0.1 2.6 4.2 100.0 1,112 More than secondary 78.0 2.2 10.3 0.2 5.9 3.5 100.0 566 Wealth quintile Lowest 76.0 0.8 2.3 0.0 0.0 20.9 100.0 67 Second 84.8 0.0 5.8 0.0 0.0 9.4 100.0 139 Middle 85.2 1.2 6.5 0.3 2.5 4.4 100.0 254 Fourth 82.0 2.5 7.0 0.3 2.3 5.8 100.0 558 Highest 78.1 1.6 11.9 0.0 5.1 3.3 100.0 889 Total 80.6 1.7 9.0 0.1 3.4 5.2 100.0 1,907 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 5.8 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for the successful practice of coitus-associated methods such as withdrawal and condoms. Such knowledge is particularly critical in the use of the rhythm method. The 2008 NDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during her menstrual cycle. Respondents were asked, “From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?” If the reply was “yes,” the respondent was further asked whether that time was just before a woman’s period begins, during her period, right after her period has ended, or halfway between two periods. Table 5.10 shows the results for women who use the rhythm method and those who do not use it. Family Planning | 77 Among all women, only 19 percent correctly reported when the fertile period occurs, i.e., a woman is most likely to conceive halfway between two periods. Users of natural family planning methods are more knowledgeable about the fertile period than non-users; 39 percent of users of the rhythm method correctly identified the middle of the cycle as the fertile time, compared with 19 percent of non-users of the method. Table 5.10 Knowledge of fertile period Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Nigeria 2008 Perceived fertile period Users of rhythm method Non-users of rhythm method All women Just before her menstrual period begins 5.9 6.5 6.5 During her menstrual period 0.7 2.4 2.4 Right after her menstrual period has ended 42.0 36.9 37.0 Halfway between two menstrual periods 39.3 18.5 18.9 Other 0.1 0.3 0.3 No specific time 3.8 12.9 12.7 Don't know 8.0 22.1 21.8 Missing 0.1 0.4 0.4 Total 100.0 100.0 100.0 Number of women 688 32,697 33,385 5.9 TIMING OF STERILISATION Women who reported that they use female sterilisation as a contraceptive method were asked additional questions about how old they were when the procedure was performed. The results in Table 5.11 indicate that one-third of women had the sterilisation procedure when they were in their early thirties; however, 16 percent were age 25-29 at the time of sterilisation. The median age at the time of sterilisation is 33.2 years. Table 5.11 Timing of sterilisation Percent distribution of sterilised women age 15-49 by age at the time of sterilisation and median age at sterilisation, according to the number of years since the operation, Nigeria 2008 Age at time of sterilisation Years since operation <25 25-29 30-34 35-39 40-44 45-49 Total Number of women Median age1 <2 5.3 6.0 15.6 39.3 12.0 21.8 100.0 18 35.5 2-3 0.0 18.1 17.3 29.5 35.2 0.0 100.0 20 33.4 4-5 0.0 0.0 48.7 30.0 21.3 0.0 100.0 16 33.7 6-7 16.3 5.4 42.1 24.9 11.3 0.0 100.0 17 34.1 8-9 0.0 13.9 33.9 18.6 33.6 0.0 100.0 6 32.1 10+ 2.2 43.8 40.9 13.1 0.0 0.0 100.0 20 a Total 4.4 15.6 32.3 26.6 17.1 4.0 100.0 97 33.2 a = Not calculated due to censoring 1 Median age at sterilisation is calculated only for women sterilised before age 40 to avoid problems of censoring. 78 | Family Planning 5.10 SOURCE OF CONTRACEPTION Information on where women obtain their contraceptive methods is useful for family planning programme managers and implementers for logistic planning. In the 2008 NDHS, women who reported using a modern contraceptive method at the time of the survey were asked where they obtained the method the last time they acquired it. Interviewers were instructed to note the full name of the source or facility, because some women may not know exactly in which category the source falls (e.g., government or private, health centre, or clinic). Supervisors and field editors were trained to verify that the name and source type were consistent, asking informants in the clusters for the names of local family planning outlets, if necessary. This practice was designed to improve the accuracy of source reporting. Table 5.12 and Figure 5.2 show that for users of modern contraceptive methods, the private medical sector is the most common source (60 percent). Less than one-quarter (23 percent) of current users of modern methods obtain their method from the public sector—mostly public government hospitals (12 percent). Other sources are used by 13 percent of users of modern methods. Table 5.12 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Nigeria 2008 Source Female sterilisation Pill IUD Injectables Male condom Total Public sector 46.6 18.8 65.9 54.0 4.0 23.3 Public government hospital 41.3 9.0 37.4 25.5 0.9 11.7 Public government health centre 5.3 5.1 14.3 21.0 1.6 7.3 Public family planning clinic 0.0 3.3 13.1 5.8 0.8 3.2 Public mobile clinic 0.0 0.5 0.0 0.6 0.2 0.3 Public fieldworker 0.0 0.4 0.3 0.8 0.2 0.5 Other public 0.0 0.4 0.7 0.3 0.3 0.3 Private medical sector 52.4 73.6 32.7 41.5 68.9 60.4 Private hospital/clinic 48.5 5.0 27.1 19.5 0.8 9.1 Private pharmacy 0.0 16.6 0.5 4.2 11.7 9.7 Private chemist/ PMS store 0.0 49.9 0.8 11.0 55.1 38.6 Private doctor 0.9 0.9 4.0 3.4 0.2 1.4 Private mobile clinic 0.0 0.4 0.4 0.6 0.0 0.2 Private fieldworker 0.0 0.4 0.0 1.2 0.3 0.5 NGO 2.0 0.0 0.0 0.1 0.7 0.5 Other private 1.0 0.4 0.0 1.5 0.0 0.4 Other source 0.0 5.7 1.5 1.5 22.8 13.0 Other source shop 0.0 2.0 0.7 0.3 3.9 2.5 Other source church 0.0 0.0 0.0 0.0 0.1 0.0 Other source friend/relative 0.0 3.6 0.8 1.2 18.8 10.5 Other 1.0 0.7 0.0 1.8 2.8 2.0 Missing 0.0 1.2 0.0 1.2 1.5 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 97 520 244 653 1,581 3,126 Note: Total includes other modern methods but excludes lactational amenorrhoea method (LAM). The total number of women includes 27 unweighted cases that are not shown in the table (1 diaphragm, 3 foam/jelly, 10 female condom, and 13 implants). Family Planning | 79 5.11 COST OF CONTRACEPTION In the 2008 NDHS, women using modern methods of contraception were asked how much they paid in total the last time they obtained their method. Table 5.12 shows the percentage of women who obtained their method for free, those who paid for their method, and the median cost by source of method. The findings on costs of contraception are presented in Table 5.13 according to source. Among respondents who use modern contraceptive methods, 7 percent got their method for free and 28 percent did not recall how much they paid for their method. For respondents who reported the cost of their method, the median cost of all methods together was 119 Naira. One in ten women who obtain modern methods from the public sector receive them for free. The median cost for women who paid for their method from the public sector is 246 Naira. Six percent of women who obtain methods from the private medical sector or other sources get them for free. The median cost for women who got methods from the private sector or other sources is 57 Naira. Figure 5.2 Source of Family Planning Methods among Current Users of Modern Methods NDHS 2008 Other sources 13% Public sector 23% Private medical sector 61% Unknown/ missing 3% 80 | Family Planning Table 5.13 Cost of modern contraceptive methods Percentage of current users of modern contraceptive method age 15-49 who did not pay for the method, who do not know the cost of the method, and the median cost of the method, by current method, source of method, and cost of method, Nigeria 2008 Source of method/cost Female sterilisation Pill IUD Injectables Implants Male condom Female condom Total Public sector Percentage free 8.7 6.9 13.9 3.8 38.9 29.6 100.0 9.7 Do not know cost 27.8 11.2 7.6 2.8 0.0 41.5 0.0 9.8 Median cost [in Naira]1 9,992.0 69.0 493.0 243.0 393.0 39.0 na 246 Number of women 45 98 161 353 7 63 2 730 Private medical sector/other Percentage free 2.1 4.3 8.3 4.5 23.7 6.5 23.2 5.9 Do not know cost 13.0 9.0 9.2 4.5 39.1 48.3 45.1 33.7 Median cost [in Naira]1 9,997.0 72.0 694.0 297.0 792.0 24.0 392.0 57 Number of women 52 422 83 300 7 1,518 12 2,397 Total Percentage free 5.2 4.8 12.0 4.2 31.2 7.4 34.4 6.8 Do not know cost 19.9 9.4 8.1 3.6 19.9 48.0 38.5 28.1 Median cost [in Naira]1 9,996.0 72.0 496.0 292.0 396.0 24.0 392.0 119 Number of women 97 520 244 653 14 1,581 14 3,126 Note: Table excludes users of lactational amenorrhoea method (LAM). Costs are based on the last time current users obtained method. Costs include consultation costs, if any. For condom, costs are per package; for pills, per cycle. For sterilisation, data are based on women who received the operation in the 5 years before the survey. Total includes 3 foam/jelly users and 1 diaphragm user who are not shown separately. na = Not applicable 1 Median cost is based on women who reported a cost. 5.12 INFORMED CHOICE Women currently using a modern method of contraception were asked whether they were informed about side effects or problems they might have with the method, what to do if they experienced side effects, and other methods they could use. This is a measure of the quality of family planning service provision. Table 5.14 shows the results by method type and source of the method. Fifty-nine percent of contraceptive users were informed of the side effects of the method they use, 54 percent were informed about what to do if they experienced side effects, and 65 percent were informed of other available methods of contraception. Seventy-two percent of women who obtained their current family planning method from public sector facilities were informed about side effects or method-related problems and 68 percent were told what to do if they experienced side effects. In contrast, only half of women who obtained their method from the private medical sector were informed of method-related problems and how to deal with them should they occur. Family Planning | 81 Table 5.14 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods they could use, by method and source; and among sterilised women, the percentage who were informed that the method is permanent, by initial source of method, Nigeria 2008 Among women who started last episode of use of modern method within the past five years: Method/source Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilisation1 (61.9) (54.2) (64.1) 47 Pill 46.9 40.2 54.6 477 IUD 82.1 80.9 86.2 165 Injectables 60.8 56.5 68.8 589 Implants * * * 9 Other * * * 16 Initial source of method2 Public sector 72.1 67.9 80.0 543 Government hospital 74.6 72.1 79.7 262 Government health centre 69.2 64.1 82.3 184 Family planning clinic 80.5 74.8 82.7 74 Mobile clinic * * * 11 Fieldworker * * * 11 Private medical sector 50.6 45.2 57.3 563 Private doctor 70.9 64.4 72.8 226 Private hospital or clinic 38.9 38.3 45.9 91 Pharmacy 36.0 29.8 47.3 246 Other private sector 42.4 33.1 56.2 55 Shop * * * 16 Church * * * 0 Friends relatives (49.4) (36.0) (64.3) 38 Other * * * 16 Total 58.6 53.7 65.3 1,303 Note: Table includes users of the following modern methods: female sterilisation, pill, IUD, injectables, implants, and other (foam/jelly, diaphragm, female condom). Modern methods not included in the table are the male condom, male sterilisation, and LAM. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Women who were sterilised in the five years preceding the survey 2 Source at start of current episode of use 5.13 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which non-users plan to use contraceptive methods in the future. Currently married women who were not using a contraceptive method at the time of the survey were asked about their intention to use family planning in the future. Table 5.15 shows that 21 percent of currently married non-users intend to use a method of contraception in the future, 23 percent are unsure of their intentions, and 55 percent have no intention of using any method in the future. The proportion of women who intend to use a contraceptive method varies with the number of living children they have. For instance, the proportion of currently married women who intend to use contraception is 15 percent for women with no children, 25 percent for women with two children, and 23 percent for women with three children. 82 | Family Planning Table 5.15 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Nigeria 2008 Number of living children1 Intention 0 1 2 3 4+ Total Intends to use 14.5 22.5 25.0 23.2 19.1 20.9 Unsure 27.9 26.1 24.6 23.7 19.9 22.9 Does not intend to use 57.3 50.7 49.2 52.0 60.2 55.3 Missing 0.2 0.6 1.2 1.1 0.9 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,571 3,281 3,344 3,241 8,702 20,139 1 Includes current pregnancy 5.14 REASONS FOR NOT INTENDING TO USE CONTRACEPTION IN THE FUTURE Table 5.16 shows the main reasons currently married women who are not using a contra- ceptive method do not intend to use one in the future. The results show that 39 percent of women do not intend to use a method in the future because of opposition to use of contraception. This opposition could be from the respondent or other people. The second largest category of reasons why women do not intend to use a method of contraception is fertility-related reasons (29 percent); the third category is women who are not intending to use a method for method-related reasons (16 percent). Table 5.16 Reason for not intending to use contraception in the future Percent distribution of currently married women age 15-49 who are not using contraception and who do not intend to use a method in the future by main reason for not intending to use, Nigeria 2008 Reason Percent distribution Fertility-related reasons 28.6 Infrequent sex/no sex 2.7 Menopausal/had hysterectomy 4.0 Subfecund/infecund 5.4 Wants as many children as possible 16.5 Opposition to use 39.4 Respondent opposed 20.8 Husband/partner opposed 9.8 Others opposed 0.9 Religious prohibition 7.9 Lack of knowledge 9.1 Knows no method 8.1 Knows no source 1.0 Method-related reasons 15.5 Health concerns 2.7 Fear of side effects 8.1 Lack of access/too far 0.2 Costs too much 0.2 Inconvenient to use 0.6 Interferes with body's normal process 3.7 Other 4.7 Don't know 2.6 Missing 0.4 Total 100.0 Number of women 11,132 Family Planning | 83 5.15 PREFERRED METHOD FOR FUTURE USE Demand for specific methods can be assessed by asking non-users which method they intend to use in the future. Table 5.17 presents information on method preferences for married women who are not currently using contraception, but say they intend to use in the future. Currently married women most commonly prefer to use injectables in the future (32 percent), followed by the pill (14 percent), and male condoms (8 percent). The order of preferred methods for currently married women has not changed substantially since the 2003 NDHS, except for the recent preference for male condom use over periodic abstinence. The proportion of non-users preferring the pill has decreased from 23 percent in 2003, to 14 percent in 2008. On the other hand, the proportion of non-users who prefer to use injectables has increased from 28 percent in 2003 to 32 percent in 2008. 5.16 EXPOSURE TO FAMILY PLANNING MESSAGES IN THE MEDIA The media can be a major source of family planning messages. Information on the level of public exposure to a particular type of media allows policymakers to use the most effective media for various target groups in the population. To assess the effectiveness of such media on the dissemination of family planning information, all respondents in the 2008 NDHS were asked whether they had heard or seen family planning messages on the radio, on television, or in a newspaper or magazine in the few months before the survey. Table 5.18 and Figure 5.3 show that radio is the most frequent source of family planning messages for both women (40 percent) and men (59 percent) age 15-49 years. One-quarter of women and one-third of men reported seeing a family planning message on television in the past few months. Newspapers and magazines are the least common source of family planning messages for both women and men (9 and 21 percent, respectively). More than half of women (57 percent) and less than four in ten men (36 percent) were not exposed to any family planning messages through radio, television, newspapers, or magazines. Exposure to family planning messages is more common among men than women and is more common in urban areas than rural areas. Among the zones, women in South West and men in South East have the highest exposure to family planning messages through any media. The more education a respondent has, the greater the likelihood that he or she has been exposed to family planning messages through each of the three types of mass media. Media exposure also increases with increasing wealth quintile for both women and men. Table 5.17 Preferred method of contraception for future use Percent distribution of currently married women age 15-49 who are not using a contraceptive method but who intend to use in the future by preferred method, Nigeria 2008 Method Percent distribution Female sterilisation 2.5 Male sterilisation 0.0 Pill 14.2 IUD 4.2 Injectables 32.1 Implants 0.9 Condom 8.2 Female condom 0.3 Diaphragm 0.0 Foam/jelly 0.1 Lactation amenorrhoea 0.4 Periodic abstinence 3.8 Withdrawal 2.6 Other 5.0 Unsure 25.5 Missing 0.2 Total 100.0 Number of women 4,216 84 | Family Planning Table 5.18 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on the radio or television or in a newspaper in the past few months, according to background characteristics, Nigeria 2008 Women Men Background characteristic Radio Tele- vision News- paper/ magazine Other None of these media sources Number Radio Tele- vision News- paper/ magazine Other None of these media sources Number Age 15-19 28.1 17.4 5.3 11.3 67.3 6,493 40.4 21.6 9.4 19.3 53.8 2,532 20-24 39.8 25.7 10.9 18.8 55.6 6,133 56.0 32.8 21.1 29.5 37.0 2,378 25-29 43.7 28.2 11.1 21.9 51.8 6,309 62.1 36.9 25.2 31.8 33.1 2,459 30-34 45.4 28.0 10.8 22.9 50.5 4,634 65.9 36.6 23.0 31.9 29.1 2,058 35-39 43.9 28.3 10.6 22.8 51.8 3,912 65.8 35.1 24.7 31.6 30.3 1,794 40-44 42.7 24.9 9.6 19.2 54.7 3,032 65.9 35.3 23.6 29.2 30.4 1,413 45-49 36.3 19.1 6.2 13.9 61.7 2,872 65.3 33.4 22.1 28.6 31.6 1,174 Residence Urban 54.4 44.1 17.5 32.8 38.4 11,934 66.8 50.9 32.1 36.5 25.7 5,215 Rural 31.2 13.7 4.7 10.7 66.5 21,451 53.9 21.6 13.9 23.7 42.6 8,593 Zone North Central 19.0 13.4 6.1 10.1 77.6 4,748 54.8 31.4 21.9 32.9 39.7 2,065 North East 15.4 6.4 2.6 11.1 81.4 4,262 44.7 12.6 9.4 23.9 51.3 1,645 North West 29.7 6.5 3.0 7.5 69.3 8,022 53.8 13.8 11.7 20.0 43.7 3,237 South East 54.8 35.3 15.5 19.1 42.4 4,091 70.8 49.5 27.2 31.3 25.6 1,448 South South 44.1 34.5 12.4 21.6 48.6 5,473 62.7 46.1 27.8 36.0 30.1 2,437 South West 67.5 50.6 16.9 39.5 25.7 6,789 65.7 46.0 27.1 30.1 27.3 2,977 Education No education 20.8 3.2 0.5 5.1 78.1 11,942 37.3 3.5 1.1 8.7 61.2 2,597 Primary 36.6 19.1 3.0 13.3 60.2 6,566 53.8 19.4 6.6 19.8 42.7 2,761 Secondary 50.7 37.9 13.0 25.6 42.7 11,904 62.6 39.3 23.4 33.0 30.9 6,470 More than secondary 76.2 68.5 43.2 56.3 16.1 2,974 81.2 67.8 58.0 52.3 11.6 1,979 Wealth quintile Lowest 14.1 1.5 0.4 3.4 84.8 6,194 36.8 5.0 3.7 12.0 60.8 2,275 Second 23.5 3.4 1.1 6.2 75.0 6,234 52.1 10.9 7.7 20.2 45.4 2,332 Middle 35.6 12.9 3.9 11.8 61.8 6,341 57.1 22.2 14.0 27.5 38.6 2,570 Fourth 51.9 35.1 11.1 22.0 43.3 6,938 67.2 43.9 25.0 33.5 27.7 3,163 Highest 65.0 60.4 25.9 43.3 26.0 7,678 71.2 63.0 41.9 41.3 19.9 3,468 Total 15-49 39.5 24.5 9.3 18.6 56.5 33,385 58.8 32.7 20.8 28.6 36.2 13,808 50-59 na na na na na na 60.0 29.2 20.0 23.4 38.0 1,678 Total men 15-59 na na na na na na 58.9 32.3 20.7 28.0 36.4 15,486 na = Not applicable Family Planning | 85 5.16.1 Exposure to Specific Family Planning Messages In the 2008 NDHS, women were asked if they had listened to specific radio programmes or watched specific programmes on television within the past six months. Table 5.19 shows the percentage of women age 15-49 who heard or saw specific radio or television programmes, by background characteristics. Overall, 17 percent of women heard or saw “Well-spaced children are every parent’s joy,” 16 percent heard or saw “Unspaced children makes the going tough,” and 14 percent heard or saw “We dey kampe with female condom.” Most of these family planning messages were heard or seen more often in the South West, South East and South South zones. Figure 5.3 Percentage of Men and Women Exposed to Family Planning Messages 59 33 21 29 36 40 25 9 19 57 Radio Television Newspapers/ magazines Others None of the above 0 20 40 60 80 Percent Men Women NDHS 2008 86 | Family Planning Table 5.19 Exposure to specific family planning messages Percentage of women age 15-49 who heard or saw specific family planning messages in the past few months, by background characteristics, Nigeria 2008 Family planning message heard or seen Background characteristic As for me and my partner we "dey kampe" with female condom Unspaced children makes the going tough. For the love of your family, go for child spacing today Well- spaced children are every parent's joy It's not too late to prevent unwanted pregnancy Why is your wife looking so good Other programme Total Age 15-19 9.8 10.5 11.3 9.2 7.2 3.6 6,493 20-24 15.1 14.8 17.2 12.7 10.7 4.2 6,133 25-29 16.5 17.4 20.5 14.1 12.6 4.4 6,309 30-34 16.4 19.4 21.3 14.5 11.5 4.9 4,634 35-39 14.3 19.3 18.9 13.0 12.3 4.9 3,912 40-44 13.1 16.5 19.2 11.8 10.6 5.6 3,032 45-49 11.0 13.6 14.8 9.4 7.6 4.8 2,872 Residence Urban 20.2 25.1 25.9 18.1 15.5 4.9 11,934 Rural 10.4 10.4 12.7 8.9 7.6 4.2 21,451 Zone North Central 8.8 8.8 9.1 5.8 5.5 1.2 4,748 North East 5.1 5.5 8.1 3.8 5.2 3.2 4,262 North West 4.1 8.3 10.9 3.8 5.4 7.0 8,022 South East 22.3 23.8 27.5 14.8 7.3 1.6 4,091 South South 22.9 19.3 22.8 23.6 17.0 2.4 5,473 South West 22.1 27.8 26.5 21.1 19.5 8.0 6,789 Education No education 3.1 5.5 6.5 3.0 4.0 5.6 11,942 Primary 11.3 11.8 15.2 9.7 8.1 4.0 6,566 Secondary 20.0 21.1 23.8 18.3 14.7 3.7 11,904 More than secondary 38.3 43.2 40.9 30.2 24.0 4.2 2,974 Wealth quintile Lowest 2.6 3.3 4.2 2.3 2.6 3.9 6,194 Second 5.7 6.6 7.9 4.3 4.9 5.3 6,234 Middle 11.6 11.2 14.7 9.9 7.7 3.8 6,341 Fourth 19.1 21.1 25.1 16.6 12.9 3.8 6,938 Highest 26.7 31.8 31.2 24.4 21.2 5.5 7,678 Total 15-49 13.9 15.7 17.4 12.2 10.4 4.5 33,385 5.16.2 Exposure to Family Planning Information through Peer Groups, School, or Community Leaders Other sources of respondent exposure to information on family planning collected in the 2008 NDHS include messages from peer groups, schools, and community leaders. Table 5.20 shows the percentage of women age 15-49 who were exposed to family planning messages through peer groups, schools, or community leaders. Three in ten women age 15-49 received information about family planning from peer groups, compared with 10 percent and 3 percent of women who received information from schools and community leaders, respectively. Women in urban areas are more likely than women in rural areas to receive information on family planning messages from any of the three sources. Women with more than secondary education and those in the highest wealth quintiles are most likely to be exposed to family planning messages through peer groups, schools and community leaders than those with lower educational attainment and those in the other groups. Family Planning | 87 Table 5.20 Exposure to family planning messages through peer groups, school, or community leaders Percentage of women age 15-49 who were exposed to family planning messages in the past few months through peer groups, school, or community leaders, by background characteristics, Nigeria 2008 Background characteristic Peer group discussions School Community leaders Total Age 15-19 22.6 18.7 1.8 6,493 20-24 31.7 15.4 2.2 6,133 25-29 33.5 9.2 3.2 6,309 30-34 32.6 5.7 3.5 4,634 35-39 32.1 4.7 3.4 3,912 40-44 30.4 4.7 4.7 3,032 45-49 24.0 3.6 3.6 2,872 Residence Urban 37.8 15.9 4.0 11,934 Rural 25.1 7.1 2.4 21,451 Zone North Central 25.0 8.6 1.5 4,748 North East 25.8 4.4 2.1 4,262 North West 21.7 4.3 2.0 8,022 South East 35.4 17.2 6.0 4,091 South South 37.6 15.6 3.0 5,473 South West 34.9 13.7 3.9 6,789 Education No education 17.2 0.8 1.1 11,942 Primary 28.6 2.4 2.9 6,566 Secondary 36.7 17.8 3.5 11,904 More than secondary 54.0 35.7 8.6 2,974 Wealth quintile Lowest 17.3 1.6 1.0 6,194 Second 20.4 4.0 1.4 6,234 Middle 27.6 8.5 2.8 6,341 Fourth 35.7 13.8 4.4 6,938 Highest 43.4 20.6 4.8 7,678 Total 15-49 29.7 10.3 3.0 33,385 5.17 CONTACT OF NON-USERS WITH FAMILY PLANNING PROVIDERS In the 2008 NDHS, women who were not using any family planning method were asked whether they had been visited by a health worker who talked with them about family planning in the 12 months preceding the survey. This information is especially useful for determining whether family planning outreach programmes are reaching non-users. Non-users were also asked if they had visited a health facility in the past 12 months for any reason other than family planning, and if so, whether any health worker at the facility had spoken to them about family planning. These questions help to assess the level of so-called “missed opportunities” to inform women about contraception. The results shown in Table 5.21 indicate that 4 percent of non-users reported discussing family planning when a fieldworker visited them. Six percent of non-users reported that they had visited a health facility and discussed family planning, while 13 percent of the non-users visited a health facility but did not discuss family planning. Staff at health facilities are more likely to discuss family planning with women age 20-39 than with younger women age 15-19 or older women age 44-49 years. Overall, the majority of non-users (92 percent) did not discuss family planning with a fieldworker or at a health facility during the 12 months prior to the survey. 88 | Family Planning Table 5.21 Contact of non-users with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the past 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who neither discussed family planning with a fieldworker nor at a health facility, by background characteristics, Nigeria 2008 Percentage of women who visited a health facility in the past 12 months and who: Background characteristic Percentage of women who were visited by fieldworker who discussed family planning Discussed family planning Did not discuss family planning Percentage of women who neither discussed family planning with fieldworker nor at a health facility Number of women Age 15-19 1.8 1.5 7.1 97.1 6,046 20-24 3.1 5.0 15.1 93.3 5,056 25-29 5.3 9.3 17.7 88.0 5,168 30-34 4.9 9.5 16.0 88.1 3,741 35-39 5.1 6.9 13.5 90.0 3,142 40-44 4.9 4.8 12.1 92.1 2,487 45-49 2.3 2.2 9.6 96.2 2,594 Residence Urban 5.9 8.6 17.7 88.0 9,083 Rural 2.8 4.1 10.8 94.2 19,151 Zone North Central 3.6 5.6 12.9 92.3 4,151 North East 1.8 3.0 14.1 96.1 4,090 North West 1.9 1.6 11.0 97.0 7,802 South East 7.8 3.5 13.0 90.9 3,366 South South 3.2 7.9 13.7 90.6 3,914 South West 6.3 13.4 14.9 83.7 4,912 Education No education 1.4 1.8 9.8 97.2 11,521 Primary 4.8 6.8 15.5 90.5 5,557 Secondary 5.5 8.2 13.5 88.7 9,265 More than secondary 7.1 12.1 23.5 84.7 1,891 Wealth quintile Lowest 1.1 1.8 8.6 97.6 5,964 Second 1.6 2.9 10.3 96.1 5,848 Middle 3.9 4.8 12.7 92.7 5,583 Fourth 5.6 8.0 15.0 88.7 5,470 Highest 7.2 10.9 19.3 85.2 5,367 Total 3.8 5.6 13.0 92.2 28,234 The proportion of women who were visited by a fieldworker is twice as high in urban areas as in rural areas (6 versus 3 percent, respectively). Similarly, women in urban areas are more than twice as likely as women in rural areas to visit a health facility and discuss family planning (9 versus 4 percent, respectively). The proportion of non-users who visited a health facility and discussed family planning is highest in South West (13 percent) and lowest in North West (2 percent). Women with higher levels of education and those in higher wealth quintiles are more likely to visit a health facility and discuss family planning with a provider than women with less education and those in lower wealth quintiles. Family Planning | 89 5.18 HUSBAND’S/PARTNER’S KNOWLEDGE OF WOMEN’S CONTRACEPTIVE USE The 2008 NDHS asked married women whether their husband or partner knew that they were using a method of family planning. Table 5.22 shows that 84 percent of currently married women age 15-49 who are using a method reported that their husband or partner knows about their use of contraception, 7 percent reported that their husband or partner does not know, and 9 percent reported that they were unsure whether their husband or partner knows about their use of contraception. Women with the highest educational attainment (91 percent) and women in the highest wealth quintile (88 percent) are most likely to share information about their method choice with their husband or partner. Table 5.22 Husband/partner's knowledge of women's use of contraception Percent distribution of currently married women age 15-49 who are using a contraceptive method by whether their husband/partner knows about their use, according to background characteristics, Nigeria 2008 Background characteristic Knows1 Does not know Unsure whether knows/ missing Total Number of women Age 15-19 83.2 6.9 10.0 100.0 56 20-24 84.8 6.7 8.5 100.0 370 25-29 83.6 7.5 8.9 100.0 749 30-34 85.8 7.5 6.7 100.0 774 35-39 82.8 6.4 10.8 100.0 713 40-44 84.5 5.7 9.8 100.0 514 45-49 83.6 6.3 10.0 100.0 263 Residence Urban 85.9 6.4 7.8 100.0 1,908 Rural 82.1 7.4 10.5 100.0 1,531 Zone North Central 80.8 5.5 13.8 100.0 433 North East 75.4 6.6 18.0 100.0 145 North West 61.8 9.3 29.0 100.0 198 South East 90.7 3.0 6.3 100.0 500 South South 84.1 7.5 8.4 100.0 781 South West 87.1 7.9 5.0 100.0 1,383 Education No education 73.5 10.7 15.8 100.0 398 Primary 82.1 8.1 9.8 100.0 883 Secondary 85.4 7.0 7.6 100.0 1,539 More than secondary 91.1 2.2 6.7 100.0 619 Wealth quintile Lowest 71.6 11.7 16.7 100.0 174 Second 78.2 11.6 10.2 100.0 265 Middle 79.4 7.1 13.5 100.0 493 Fourth 84.6 7.7 7.7 100.0 899 Highest 87.8 4.9 7.3 100.0 1,608 Total 84.2 6.8 9.0 100.0 3,439 1 Includes women who reported use of male sterilisation, male condoms, and withdrawal Other Proximate Determinants of Fertility | 91 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter focuses on the principal factors other than contraception that affect a woman’s risk of becoming pregnant; they are referred to as other proximate determinants of fertility. Marriage is among the most important of these proximate determinants. Besides marriage, this chapter also explores several other factors that influence fertility, including polygyny, onset and frequency of sexual activity, postpartum amenorrhoea, abstinence from sexual activity, and the onset of menopause. Postpartum amenorrhoea and postpartum abstinence determine the length of time a woman is protected from the risk of becoming pregnant after childbirth, affecting birth intervals and thus fertility levels. Menopause is important because it marks the end of a woman’s period of exposure to the risk of pregnancy.1 6.1 CURRENT MARITAL STATUS Marriage is a primary indication of women’s regular exposure to the risk of pregnancy and therefore is important for understanding fertility estimates. Populations in which age at first marriage is low tend to have early childbearing and high fertility rates. However, because a union is not a prerequisite to childbearing, some women have children before entering a formal union. Table 6.1 shows the percent distribution of women and men by marital status at the time of the survey. In this context, the term “married” refers to legal or formal unions, while “living together” refers to informal unions in which a man and a woman live together, even if a formal civil, religious or traditional ceremony has not been contracted. Widowed, divorced, and separated women make up the remainder of the “ever-married” or “ever-in-union” category. In later tables and text, the term “currently married” refers to both formal and informal unions. Table 6.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Nigeria 2008 Marital status Age Never married Married Living together Divorced Separate d Widowed Total Percentage of respondents currently in union Number of respondents WOMEN 15-19 70.6 27.8 0.9 0.3 0.2 0.1 100.0 28.7 6,493 20-24 38.4 57.1 2.6 0.9 0.8 0.4 100.0 59.7 6,133 25-29 16.2 78.8 2.2 0.9 1.2 0.7 100.0 81.0 6,309 30-34 5.8 88.5 1.5 1.1 1.3 1.8 100.0 90.1 4,634 35-39 2.6 90.4 1.0 0.9 1.9 3.2 100.0 91.4 3,912 40-44 1.4 88.5 0.9 1.1 1.5 6.5 100.0 89.4 3,032 45-49 0.8 85.6 0.8 1.2 1.8 9.7 100.0 86.5 2,872 Total 25.2 69.1 1.5 0.8 1.1 2.3 100.0 70.6 33,385 MEN 15-19 99.0 0.9 0.0 0.0 0.0 0.0 100.0 0.9 2,532 20-24 84.4 13.8 1.1 0.2 0.4 0.0 100.0 14.9 2,378 25-29 54.3 42.0 1.7 0.6 1.1 0.1 100.0 43.8 2,459 30-34 24.5 69.9 3.2 0.7 1.1 0.6 100.0 73.1 2,058 35-39 7.8 88.1 2.1 0.4 1.0 0.6 100.0 90.2 1,794 40-44 2.8 90.0 3.1 1.0 1.8 1.3 100.0 93.1 1,413 45-49 1.4 93.0 3.0 1.1 0.9 0.7 100.0 96.0 1,174 Total 15-49 47.4 49.0 1.8 0.5 0.8 0.4 100.0 50.8 13,808 50-59 0.5 92.2 3.2 0.8 1.2 2.2 100.0 95.3 1,678 Total 15-59 42.3 53.7 2.0 0.5 0.9 0.6 100.0 55.6 15,486 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 92 | Other Proximate Determinants of Fertility Table 6.1 shows that 75 percent of women age 15-49 have been married at some time (ever- married women). Sixty-nine percent are currently married, 2 percent are living together, 2 percent are either divorced or separated, and 2 percent are widowed. The proportion of women who are married increases rapidly from 28 percent of women age 15-19 to 57 percent of women age 20-24 and 79 percent among women age 25-29. By age 30-34, 94 percent of Nigerian women are currently or formerly in union. The percentage of women who are widowed also increases with age, from less than 1 percent for women age 15-29 to 10 percent of women age 45-49. The proportion of men age 15-49 who have never married is higher than that for women (47 percent compared with 25 percent). This is a reflection of men’s later age at marriage. About half (49 percent) of men are married, 2 percent are living together with a woman, 1 percent are divorced or separated, and less than 1 percent are widowers. 6.2 POLYGYNY Having more than one wife at the same time, polygyny, has implications for the frequency of sexual intercourse, and thus, may have an effect on fertility. In the 2008 NDHS, polygyny was measured by asking all currently married female respondents whether their husband or partner had other wives (co-wives), and if so, how many. Married men were asked whether they had one or more wives or partners with whom they were living. Table 6.2.1 shows the percent distribution of currently married women by number of co-wives. The percent distribution of currently married men by number of wives is shown in Table 6.2.2. Table 6.2.1 Number of women's co-wives Percent distribution of currently married women age 15-49 by number of co-wives, according to background characteristics, Nigeria 2008 Number of co-wives Background characteristic 0 1 2+ Missing Total Number of women Age 15-19 73.4 22.2 3.8 0.6 100.0 1,863 20-24 73.4 21.7 4.0 0.9 100.0 3,659 25-29 71.7 23.0 4.7 0.6 100.0 5,112 30-34 66.7 26.2 6.5 0.5 100.0 4,173 35-39 62.9 28.4 8.0 0.7 100.0 3,575 40-44 58.4 30.1 10.8 0.7 100.0 2,711 45-49 55.7 31.0 12.7 0.7 100.0 2,484 Residence Urban 77.1 17.4 4.7 0.8 100.0 7,375 Rural 61.9 29.6 7.9 0.6 100.0 16,203 Zone North Central 62.3 26.5 10.8 0.4 100.0 3,320 North East 56.5 33.9 9.3 0.3 100.0 3,585 North West 57.4 35.0 6.9 0.8 100.0 7,189 South East 86.2 9.1 3.5 1.2 100.0 2,139 South South 81.9 13.6 3.2 1.3 100.0 2,978 South West 73.5 20.0 6.1 0.4 100.0 4,366 Education No education 53.6 36.5 9.3 0.6 100.0 11,120 Primary 68.2 24.1 6.9 0.8 100.0 5,143 Secondary 84.0 11.8 3.5 0.7 100.0 5,621 More than secondary 90.1 7.0 1.9 0.9 100.0 1,693 Wealth quintile Lowest 61.1 32.9 5.5 0.6 100.0 5,408 Second 55.8 33.8 9.6 0.7 100.0 5,052 Middle 62.2 27.8 9.3 0.7 100.0 4,311 Fourth 71.4 21.2 6.7 0.7 100.0 4,216 Highest 84.9 10.9 3.4 0.7 100.0 4,590 Total 66.7 25.8 6.9 0.7 100.0 23,578 Other Proximate Determinants of Fertility | 93 Table 6.2.1 shows that 33 percent of married women in Nigeria are in polygynous unions. Twenty-six percent of women reported they have one co-wife, while 7 percent have two or more co- wives. The level of polygyny increases with age, from 26 percent among women age 15-19 to 44 percent among women age 45-49. A higher proportion of rural women are in polygynous unions (38 percent) than their urban counterparts (22 percent). There are marked zonal differences in the level of polygyny, with the practice being more common in the northern zones: 43 percent in North East, 42 percent in North West, and 37 percent in North Central. Polygyny decreases with level of education. Nearly half of women with no education (46 percent) are in polygynous unions, compared with 9 percent of women with more than secondary education. Women in the lower wealth quintiles are more likely to have polygynous marriages than those in the higher wealth quintiles. Sixteen percent of married men age 15-49 reported having two or more wives (Table 6.2.2). Older men, those in rural areas, those in the northern zones, those with lower levels of education, and those in the lowest two wealth quintiles are more likely to have two or more wives than are other men. Table 6.2.2 Number of men's wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Nigeria 2008 Number of wives Background characteristic 1 2+ Missing Total Number of men Age 15-19 (96.9) (0.0) (3.1) 100.0 23 20-24 96.8 2.7 0.6 100.0 354 25-29 93.2 6.4 0.5 100.0 1,076 30-34 88.3 11.5 0.2 100.0 1,504 35-39 83.3 16.4 0.3 100.0 1,618 40-44 75.0 24.3 0.7 100.0 1,316 45-49 74.0 25.5 0.5 100.0 1,127 Residence Urban 90.6 9.0 0.4 100.0 2,309 Rural 80.1 19.5 0.5 100.0 4,709 Zone North Central 81.3 18.2 0.5 100.0 1,040 North East 77.2 22.5 0.3 100.0 1,002 North West 76.4 23.3 0.4 100.0 1,951 South East 92.9 6.8 0.3 100.0 607 South South 90.3 8.6 1.1 100.0 989 South West 90.8 9.0 0.2 100.0 1,430 Education No education 75.2 24.3 0.5 100.0 1,917 Primary 82.9 16.8 0.3 100.0 1,806 Secondary 88.5 11.1 0.4 100.0 2,323 More than secondary 89.3 10.1 0.7 100.0 973 Wealth quintile Lowest 79.0 20.6 0.3 100.0 1,512 Second 75.9 23.7 0.5 100.0 1,378 Middle 81.5 18.3 0.3 100.0 1,244 Fourth 87.0 12.4 0.7 100.0 1,284 Highest 93.2 6.3 0.5 100.0 1,600 Total 15-49 83.5 16.0 0.5 100.0 7,018 50-59 68.9 30.3 0.8 100.0 1,599 Total 15-59 80.8 18.7 0.5 100.0 8,618 Note: Figures in parentheses are based on 25-49 unweighted cases. 94 | Other Proximate Determinants of Fertility 6.3 AGE AT FIRST MARRIAGE Marriage is generally associated with fertility because it is correlated with exposure to the risk of pregnancy. The duration of exposure to the risk of pregnancy depends primarily on the age at which women first marry. Women who marry earlier, on average, are more likely to have their first child earlier and give birth to more children overall, contributing to higher fertility rates. Table 6.3 shows the percentage of women and men who have married by specific ages, and the median age at first marriage by current age. The results show that almost half (46 percent) of women age 20-49 were married by age 18, and 58 percent were married by age 20. The proportion of women getting married by age 15 decreases from 30 percent among women currently age 45-49 to 12 percent among those age 15-19, while the median age at first marriage increases from 17.3 years among women age 45-49 to 19.8 years among women age 20-24. These two findings provide evidence of an increase in age at marriage in Nigeria over the past generation. A comparison with results from the 2003 NDHS survey indicates that the median age at first marriage among women age 20-24 has increased from 19.1 to 19.8 years. The lower panel of Table 6.3 shows the distribution of age at first marriage among men. Men marry considerably later than women. About one in four women age 25-49 (24 percent) were married by age 15 compared with less than 1 percent of men. Only 13 percent of men age 25-49 had married by age 20, compared with 60 percent of women. By age 25, only 39 percent of men were married. Table 6.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages, and median age at first marriage, according to current age, Nigeria 2008 Percentage first married by exact age Current age 15 18 20 22 25 Percentage never married Number of respondents Median age at first marriage WOMEN 15-19 12.4 na na na na 70.6 6,493 a 20-24 16.4 39.4 51.4 na na 38.4 6,133 19.8 25-29 18.8 42.3 53.5 64.2 76.5 16.2 6,309 19.3 30-34 23.3 47.7 58.7 68.3 78.7 5.8 4,634 18.4 35-39 22.8 49.0 60.6 70.9 82.1 2.6 3,912 18.2 40-44 28.2 52.8 64.3 74.7 84.9 1.4 3,032 17.5 45-49 29.9 55.4 68.8 78.5 87.0 0.8 2,872 17.3 20-49 21.9 46.1 57.8 na na 14.2 26,892 18.6 25-49 23.5 48.1 59.7 69.9 80.7 7.0 20,759 18.3 MEN 15-19 0.1 na na na na 99.0 2,532 a 20-24 0.1 3.0 7.8 na na 84.4 2,378 a 25-29 0.1 4.3 10.0 18.9 34.8 54.3 2,459 a 30-34 0.1 4.8 11.9 21.0 38.6 24.5 2,058 26.9 35-39 0.0 6.4 14.1 23.3 40.5 7.8 1,794 26.5 40-44 0.2 6.8 16.2 27.3 44.5 2.8 1,413 25.9 45-49 0.1 5.1 12.7 22.9 39.8 1.4 1,174 26.5 20-49 0.1 4.9 11.6 na na 35.8 11,276 a 25-49 0.1 5.4 12.6 22.2 39.0 22.8 8,898 a 20-59 0.1 5.1 12.0 na na 31.3 12,954 a 25-59 0.1 5.5 12.9 22.6 39.7 19.3 10,576 a Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner na = Not applicable due to censoring a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Other Proximate Determinants of Fertility | 95 6.4 MEDIAN AGE AT FIRST MARRIAGE The median age at first marriage by current age and background characteristics is shown for women in Table 6.4.1 and for men in Table 6.4.2. The results show considerable variation in age at first marriage by background characteristics. For women age 25-49, those who reside in urban areas marry roughly four years later than their counterparts in rural areas (21.1 years compared with 16.9 years). By zone, the median age at first marriage ranges from 15.2 years in North West to 22.8 years in South East. The median age at first marriage increases from 15.5 years among women with no education to 22.0 years among women with secondary education. By wealth quintile, median age at first marriage increases from 15.4 to 23.1 years. Table 6.4.1 Median age at first marriage: Women Median age at first marriage among women age 20-49 by five-year age groups, according to background characteristics, Nigeria 2008 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Residence Urban a 22.6 21.8 20.6 20.0 19.3 a 21.1 Rural 18.0 17.5 16.8 16.9 16.6 16.2 17.2 16.9 Zone North Central a 18.6 18.4 18.3 18.1 17.8 18.7 18.3 North East 15.9 15.9 15.4 15.6 15.3 15.5 15.6 15.6 North West 15.7 15.6 15.1 15.3 14.8 14.6 15.3 15.2 South East a 24.5 24.4 22.3 21.5 19.6 a 22.8 South South a 22.8 22.2 20.0 18.7 18.3 a 20.9 South West a 22.8 22.1 21.6 21.0 20.4 a 21.8 Education No education 15.5 15.5 15.3 15.6 15.4 15.5 15.5 15.5 Primary 17.6 18.4 18.2 18.1 18.0 18.6 18.1 18.3 Secondary a 22.5 22.2 21.4 21.1 21.1 a 22.0 More than secondary a a 26.8 25.5 24.3 24.0 a a Wealth quintile Lowest 15.8 15.6 15.3 15.4 15.2 15.2 15.5 15.4 Second 16.4 16.1 15.8 16.2 15.9 15.8 16.0 15.9 Middle 19.0 18.3 17.5 18.1 17.7 17.9 18.2 17.9 Fourth a 21.2 20.4 19.7 18.2 18.3 a 19.9 Highest a 24.1 24.1 22.5 21.8 20.4 a 23.1 Total 19.8 19.3 18.4 18.2 17.5 17.3 18.6 18.3 Note: The age at first marriage is defined as the age at which the respondent began living with her first husband/partner a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Because of the tendency for men to marry at older ages, the median age at first marriage cannot be calculated for men age 25-49 for most background characteristics; instead, it is calculated for men age 25-59. However, an examination of differentials among men in the five-year age groups shows similar patterns to those observed for women. It is interesting to note that the differentials in age at first marriage among men, by level of education and wealth quintile, are smaller than those observed for women. 96 | Other Proximate Determinants of Fertility Table 6.4.2 Median age at first marriage: Men Median age at first marriage among men age 25-59 by five-year age groups, according to background characteristics, Nigeria 2008 Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 50-59 Men age 25-59 Residence Urban a a 29.4 29.2 29.1 27.5 a Rural a 25.1 24.9 24.4 25.5 25.4 a Zone North Central a 25.1 25.0 25.7 26.0 25.0 a North East 23.9 23.7 24.0 22.8 24.0 23.7 23.7 North West a 24.2 24.8 22.4 23.5 24.2 24.3 South South a 29.9 28.0 29.2 27.8 26.0 a South West a a 28.5 28.5 28.5 27.7 a Education No education 23.1 23.2 24.7 22.2 23.2 24.2 23.5 Primary a 25.1 25.2 26.3 26.5 27.0 a Secondary a 28.4 26.8 27.6 28.3 28.1 a More than secondary a a a 28.5 a 27.6 a Wealth quintile Lowest 23.4 23.3 23.8 22.3 23.9 24.1 23.5 Second 24.7 23.9 24.1 23.4 24.4 25.4 24.3 Middle a 25.5 25.6 25.6 27.7 26.0 a Fourth a 28.9 28.0 27.2 27.7 26.9 a Highest a a a 29.8 a 27.8 a Total a 26.9 26.5 25.9 26.5 26.0 a Note: The age at first marriage is defined as the age at which the respondent began living with his first wife/partner a = Omitted because less than 50 percent of the men married for the first time before reaching the beginning of the age group 6.5 AGE AT FIRST SEXUAL INTERCOURSE While age at first marriage is often used as a proxy for first exposure to sexual intercourse, the two events do not necessarily occur at the same time. Women and men sometimes engage in sexual relations before marriage. To obtain information on the age at first sexual intercourse, women and men were asked how old they were when they first had sexual intercourse. Table 6.5 presents information from the 2008 NDHS on the percentage of women and men who initiated intercourse for the first time by specific ages, and the median age at first intercourse according to current age. Table 6.5 shows that the median age at first sexual intercourse is 17.8 years for women age 20-49. One in five women age 20-49 initiated sexual intercourse by age 15 (20 percent), and more than half of women (52 percent) first had sexual intercourse by age 18. The results show that as with age at first marriage, age at first sexual intercourse has been increasing over time. The median age at first sexual intercourse increases from 16.9 years among women age 45-49 to 18.2 years among women age 20-24. In addition, while 28 percent of women age 45-49 had first sexual intercourse by age 15, only 15 percent of women age 15-19 have done so. Among women age 20-49, the median age at first sexual intercourse is about one year younger than the median age at first marriage (17.8 compared with 18.6 years). Other Proximate Determinants of Fertility | 97 Table 6.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first intercourse, according to current age, Nigeria 2008 Percentage who had first sexual intercourse by exact age Current age 15 18 20 22 25 Percentage who never had intercourse Number of respondents Median age at first intercourse WOMEN 15-19 15.3 na na na na 53.8 6,493 a 20-24 16.2 47.8 67.8 na na 14.3 6,133 18.2 25-29 17.8 48.5 64.6 77.4 86.4 3.9 6,309 18.1 30-34 21.2 51.4 66.3 77.9 84.3 0.9 4,634 17.8 35-39 20.4 54.3 68.2 77.8 84.2 0.6 3,912 17.4 40-44 26.1 55.4 68.6 77.2 82.8 0.1 3,032 17.2 45-49 27.5 58.4 71.6 80.4 85.2 0.1 2,872 16.9 20-49 20.4 51.5 67.3 na na 4.4 26,892 17.8 25-49 21.6 52.6 67.2 78.0 84.8 1.5 20,759 17.7 15-24 15.7 na na na na 34.6 12,626 a MEN 15-19 6.2 na na na na 77.9 2,532 a 20-24 5.3 25.6 45.6 na na 38.1 2,378 a 25-29 4.8 24.6 44.6 61.6 76.6 15.8 2,459 20.4 30-34 5.8 25.1 42.5 61.6 77.0 3.5 2,058 20.6 35-39 3.9 22.8 42.4 60.3 72.4 1.1 1,794 20.6 40-44 3.6 21.2 42.0 59.5 71.9 0.4 1,413 20.6 45-49 3.1 18.2 35.3 53.6 67.7 0.2 1,174 21.3 20-49 4.6 23.5 42.8 na na 12.4 11,276 a 25-49 4.4 23.0 42.0 59.9 73.9 5.5 8,898 20.6 15-24 5.7 na na na na 58.6 4,910 a 20-59 4.3 22.6 41.5 na na 10.8 12,954 a 25-59 4.0 22.0 40.6 58.7 73.0 4.6 10,576 20.7 na = Not applicable a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group As with marriage, sexual activity among women starts at an earlier age than it does among men. The median age at first sexual intercourse for men age 25-49 is 20.6 years. Only 4 percent of men age 25-49 have had sexual intercourse by age 15; however, this percentage increases rapidly to 42 percent by age 20 and to 60 percent by age 22. Looking at men age 30-34, the median age at first sexual intercourse is 20.6 years, a full six years younger than their age at first marriage (26.9 years). These findings suggest that, on average, men are sexually active for six years before getting married. Differentials in age at first sexual intercourse by background characteristics are shown in Tables 6.6.1 and 6.6.2 for women and men, respectively. For women age 25-49 living in urban areas, the first sexual encounter is delayed by almost three years compared with their rural counterparts (19.2 and 16.5 years, respectively). By zone, age at first sexual intercourse for women ranges from 15.4 years in North West to 20.4 years in South East. Median age at first sexual intercourse increases with educational attainment and wealth quintile. For men age 25-59, differences in the median age at first sexual intercourse by background characteristics are generally small. It is worth noting that there are differences by zone, with the highest median age at first sexual intercourse being reported in North West (24 years) and the lowest median age in South South (19 years). 98 | Other Proximate Determinants of Fertility Table 6.6.1 Median age at first intercourse: Women Median age at first sexual intercourse among women by age 20-49 by five-year age groups, according to background characteristics, Nigeria 2008 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Residence Urban 19.4 19.8 19.4 18.9 18.7 18.5 19.3 19.2 Rural 17.2 16.9 16.5 16.5 16.4 15.9 16.7 16.5 Zone North Central 19.0 18.7 18.7 18.4 18.3 17.4 18.6 18.4 North East 16.0 15.8 15.4 15.6 15.4 15.5 15.7 15.6 North West 15.9 15.7 15.4 15.4 15.1 14.9 15.5 15.4 South East a 20.6 20.9 20.2 20.0 20.0 a 20.4 South South 18.3 18.5 18.3 17.6 17.5 17.3 18.2 18.1 South West 19.3 20.0 19.6 19.4 19.3 19.3 19.5 19.6 Education No education 15.7 15.7 15.5 15.6 15.5 15.5 15.6 15.6 Primary 17.1 17.5 17.7 17.3 17.5 18.2 17.5 17.6 Secondary 19.3 19.5 19.2 19.4 19.4 19.6 19.3 19.4 More than secondary a 21.9 21.3 21.5 20.9 21.0 a 21.5 Wealth quintile Lowest 15.9 15.7 15.4 15.5 15.4 15.4 15.6 15.5 Second 16.3 16.0 15.9 15.9 16.1 15.7 16.0 15.9 Middle 17.9 17.6 17.3 17.3 17.1 17.1 17.5 17.4 Fourth 18.9 19.0 18.7 18.5 17.7 18.1 18.6 18.5 Highest a 20.4 20.2 19.9 20.1 19.5 a 20.1 Total 18.2 18.1 17.8 17.4 17.2 16.9 17.8 17.7 a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group Table 6.6.2 Median age at first intercourse: Men Median age at first sexual intercourse among men age 20-59 by five-year age groups, according to background characteristics, Nigeria 2008 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 50-59 Men age 20-59 Men age 25-59 Residence Urban a 20.5 20.5 20.7 20.8 21.8 21.7 a 20.8 Rural a 20.4 20.6 20.6 20.5 21.0 21.5 a 20.7 Zone North Central 19.4 19.7 19.8 20.1 20.2 21.0 21.0 a 20.3 North East a 21.2 21.2 21.6 20.8 21.2 21.9 a 21.3 North West a 24.5 23.8 24.7 22.6 23.6 24.1 a 24.0 South East a 20.5 20.9 21.6 22.1 24.6 22.8 a 21.7 South South 18.8 18.7 18.8 18.9 19.0 19.6 19.9 18.9 19.0 South West 19.5 19.3 19.6 19.4 19.9 20.2 20.4 19.7 19.8 Education No education a 22.1 22.2 22.9 21.0 22.1 22.8 a 22.3 Primary a 20.3 20.5 20.4 20.5 21.8 20.8 a 20.6 Secondary a 19.8 20.1 20.2 20.3 20.8 20.9 a 20.2 More than secondary a 20.8 20.7 20.6 20.8 20.9 21.0 a 20.8 Wealth quintile Lowest a 20.9 20.8 20.8 20.3 21.4 22.2 a 20.9 Second a 20.5 21.2 21.2 20.9 20.7 22.8 a 21.0 Middle a 20.7 20.6 20.8 20.5 22.4 20.9 a 20.8 Fourth a 20.3 20.3 20.6 20.9 21.6 21.3 a 20.7 Highest a 20.2 20.4 20.2 20.4 21.0 20.9 a 20.4 Total a 20.4 20.6 20.6 20.6 21.3 21.6 a 20.7 a = Omitted because less than 50 percent of the men had intercourse for the first time before reaching the beginning of the age group Other Proximate Determinants of Fertility | 99 6.6 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the frequency of sexual intercourse. Thus, information on sexual activity is useful in refining measures of exposure to pregnancy. Men and women who have had sexual intercourse were asked how long ago their last sexual contact occurred. Tables 6.7.1 and 6.7.2 show the percent distribution of women and men by timing of last sexual intercourse, according to background characteristics. More than half (56 percent) of women age 15-49 were sexually active during the four weeks preceding the interview. Another 20 percent reported that they had been sexually active in the 12 months preceding the survey but not in the past month. Eight percent said that they had not been sexually active for one or more years, and 14 percent reported that they had never had sex. Table 6.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Nigeria 2008 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Never had sexual intercourse Total Number of women Age 15-19 29.7 12.0 3.8 0.7 53.8 100.0 6,493 20-24 53.3 24.4 6.9 1.2 14.3 100.0 6,133 25-29 64.2 23.0 7.3 1.6 3.9 100.0 6,309 30-34 67.5 22.1 7.4 2.1 0.9 100.0 4,634 35-39 69.1 19.0 9.7 1.6 0.6 100.0 3,912 40-44 66.3 19.6 12.2 1.8 0.1 100.0 3,032 45-49 57.7 21.3 19.5 1.4 0.1 100.0 2,872 Marital status Never married 16.7 18.8 8.0 0.7 55.7 100.0 8,397 Married or living together 72.7 20.1 5.5 1.6 0.0 100.0 23,578 Divorced/separated/widowed 14.5 26.7 57.4 1.3 0.0 100.0 1,409 Marital duration2 0-4 years 72.3 22.5 4.1 1.0 0.1 100.0 5,026 5-9 years 72.4 20.7 4.9 1.9 0.0 100.0 4,471 10-14 years 72.8 19.8 5.3 2.1 0.0 100.0 3,539 15-19 years 73.0 19.1 5.7 2.2 0.0 100.0 2,914 20-24 years 72.0 19.2 7.6 1.1 0.0 100.0 2,053 25+ years 68.3 20.6 9.1 1.9 0.0 100.0 2,516 Married more than once 77.5 16.8 4.4 1.3 0.0 100.0 3,061 Residence Urban 51.4 20.8 7.6 1.6 18.6 100.0 11,934 Rural 58.8 19.7 8.7 1.3 11.5 100.0 21,451 Zone North Central 47.1 22.2 12.8 1.3 16.6 100.0 4,748 North East 69.1 15.4 5.3 1.0 9.3 100.0 4,262 North West 77.1 10.8 2.8 2.3 6.9 100.0 8,022 South East 36.1 23.7 15.1 1.6 23.5 100.0 4,091 South South 50.0 26.2 9.4 0.8 13.7 100.0 5,473 South West 46.7 25.4 8.7 1.1 18.1 100.0 6,789 Education No education 72.7 15.5 7.4 1.9 2.5 100.0 11,942 Primary 54.5 23.1 11.9 1.3 9.1 100.0 6,566 Secondary 41.6 21.7 7.2 0.9 28.6 100.0 11,904 More than secondary 51.8 25.3 8.7 1.5 12.7 100.0 2,974 Wealth quintile Lowest 69.4 16.5 7.0 1.3 5.9 100.0 6,194 Second 62.4 18.2 8.2 1.8 9.4 100.0 6,234 Middle 50.6 21.6 11.3 1.3 15.2 100.0 6,341 Fourth 49.5 22.5 9.3 1.4 17.3 100.0 6,938 Highest 51.1 21.0 6.2 1.3 20.5 100.0 7,678 Total 56.2 20.1 8.3 1.4 14.0 100.0 33,385 Note: Total includes 1 woman with information missing on marital status. 1 Excludes women who had sexual intercourse within the past 4 weeks 2 Excludes women who are not currently married 100 | Other Proximate Determinants of Fertility The proportion of women who were sexually active in the four weeks preceding the survey increases with age, peaking in age group 35-39 (69 percent), and decreases thereafter. As expected, sexual activity among teenagers and women who are not currently in union is lower compared with older women and women who are married or living with a man. Thirty percent of women age 15-19 were sexually active in the four weeks preceding the survey, and 17 percent of never-married women were sexually active in the same period. Women in urban areas were less likely to be sexually active during the past four weeks (51 percent) than their counterparts in rural areas (59 percent). By zone the proportion of women sexually active during the four weeks preceding the survey is highest in North West (77 percent) and lowest in South East (36 percent). The results show that women with no education (73 percent) are more likely to have been sexually active in the past four weeks than educated women. Women with secondary education are least likely to have been sexually active in the past four weeks (42 percent). The prevalence of recent sexual activity decreases with increasing wealth status, being high in the two lowest wealth quintiles and low in the three highest wealth quintiles. By marital duration, women who have married more than once were most likely to have been sexually active during the past four weeks (78 percent) while those who have been married for 25 years or more were least likely (68 percent). About half (48 percent) of men age 15-49 were sexually active in the four weeks preceding the survey, while 20 percent had sexual intercourse in the past year but not in the past month. Seven percent had not been sexually active for one or more years, and 24 percent had never had sex. The proportion of men who were sexually active in the four weeks preceding the survey increases with age, peaking in age group 40-44. Men in union are much more likely to have been sexually active in the past four weeks than men who have never married or lived together with a woman (75 and 19 percent, respectively). Men in urban areas are also less likely to have been sexually active in the past four weeks than men in rural areas (44 and 50 percent, respectively). Recent sexual activity is highest in North East (56 percent) and lowest in South East (34 percent). As with women, recent sexual activity among men decreases with increasing wealth quintile (from 59 to 39 percent), but then increases in the highest wealth quintile (49 percent). Men with marital durations of 20-24 years were most likely to be sexually active in the four weeks preceding the interview (79 percent), while those with marital durations of 10-14 years were least likely (73 percent). Other Proximate Determinants of Fertility | 101 Table 6.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Nigeria 2008 Timing of last sexual intercourse Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Never had sexual intercourse Total Number of men Age 15-19 6.8 9.8 5.3 0.2 77.9 100.0 2,532 20-24 27.8 24.9 8.9 0.3 38.1 100.0 2,378 25-29 50.6 23.9 9.1 0.5 15.8 100.0 2,459 30-34 65.9 23.2 6.2 1.1 3.5 100.0 2,058 35-39 70.9 20.9 5.8 1.2 1.1 100.0 1,794 40-44 72.9 19.7 5.6 1.3 0.4 100.0 1,413 45-49 71.2 19.4 7.2 1.9 0.2 100.0 1,174 Marital status Never married 19.0 19.6 9.8 0.3 51.4 100.0 6,548 Married or living together 75.2 20.1 3.4 1.2 0.1 100.0 7,018 Divorced/separated/widowed 23.3 39.3 35.8 1.6 0.0 100.0 238 Marital duration2 0-4 years 74.7 22.4 1.8 1.0 0.2 100.0 1,742 5-9 years 73.7 21.9 3.8 0.7 0.0 100.0 1,589 10-14 years 73.0 21.1 4.5 1.3 0.1 100.0 1,152 15-19 years 77.7 17.8 3.6 0.8 0.0 100.0 856 20-24 years 79.2 14.4 4.2 2.2 0.0 100.0 548 25+ years 74.4 15.4 7.6 2.6 0.0 100.0 250 Married more than once 77.0 18.2 2.8 1.9 0.0 100.0 883 Residence Urban 43.5 23.2 7.1 0.8 25.3 100.0 5,215 Rural 50.1 18.4 6.9 0.8 23.8 100.0 8,593 Zone North Central 42.2 22.9 9.9 0.5 24.4 100.0 2,065 North East 56.3 12.3 5.2 0.6 25.6 100.0 1,645 North West 53.7 7.2 3.2 1.7 34.2 100.0 3,237 South East 33.6 29.0 12.2 0.7 24.4 100.0 1,448 South South 49.0 23.8 7.9 0.3 19.0 100.0 2,437 South West 45.6 29.6 6.8 0.5 17.5 100.0 2,977 Education No education 62.6 10.9 4.6 1.4 20.6 100.0 2,597 Primary 51.8 19.9 7.8 0.9 19.6 100.0 2,761 Secondary 37.4 23.4 7.4 0.4 31.4 100.0 6,470 More than secondary 55.6 22.4 7.8 1.2 13.1 100.0 1,979 Wealth quintile Lowest 58.7 12.6 5.4 1.1 22.3 100.0 2,275 Second 51.4 17.1 5.8 0.8 24.9 100.0 2,332 Middle 43.0 19.7 8.8 0.7 27.8 100.0 2,570 Fourth 39.2 24.2 8.3 0.6 27.6 100.0 3,163 Highest 48.9 23.9 6.3 0.8 20.0 100.0 3,468 Total 15-49 47.6 20.2 7.0 0.8 24.4 100.0 13,808 50-59 67.7 19.4 11.0 1.9 0.0 100.0 1,678 Total 15-59 49.8 20.1 7.4 0.9 21.8 100.0 15,486 Note: Total includes 3 men with information missing on marital status. 1 Excludes men who had sexual intercourse within the past 4 weeks 2 Excludes men who are not currently married 102 | Other Proximate Determinants of Fertility 6.7 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Among women who are not using contraception, exposure to the risk of pregnancy in the period after a birth is influenced primarily by two factors: breastfeeding and sexual abstinence. Breastfeeding prolongs postpartum protection from conception through its effect on the length of the period of amenorrhoea (the period between the birth and the return of menses) after a birth. More frequent breastfeeding for longer durations is associated with longer periods of postpartum amenorrhoea. Delaying the resumption of sexual relations after a birth also prolongs the period of postpartum protection. Women are considered insusceptible to pregnancy if they are not at risk of conception, either because they are amenorrhoeic or abstaining from sexual activity after a birth. The percentage of births occurring during the three years preceding the survey for which mothers are postpartum amenorrhoeic, postpartum abstaining, and postpartum insusceptible is shown in Table 6.8, by the number of months since the birth. The results presented in the table are based on cross-sectional analysis, representing the experience of mothers of all births at a single point in time rather than the experience of a cohort of mothers over time. The data are grouped in two-month intervals to minimise the fluctuations in the estimates. The median- and mean-duration estimates shown at the bottom of Table 6.8 are calculated from the current status distributions presented in the table. Table 6.8 shows that at the time of the survey, 43 percent of the mothers who had given birth during the three years preceding the survey were insusceptible because they were either amenorrhoeic or still abstaining (or both). The median duration of postpartum insusceptibility to pregnancy is 13.8 months. The median duration of amenorrhoea is 11.5 months, while the median duration of postpartum abstinence is much lower (3.5 months). By 10-11 months after the birth, 59 percent of mothers are insusceptible to pregnancy, but only 23 percent are abstaining from sexual relations. Table 6.8 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Nigeria 2008 Percentage of births for which the mother is: Months since birth Amenorrhoeic Abstaining Insusceptible1 Number of births < 2 93.4 86.5 97.0 778 2-3 86.5 61.5 92.5 1,053 4-5 76.7 37.5 82.3 1,152 6-7 70.1 25.9 75.3 1,088 8-9 60.2 26.3 67.9 984 10-11 51.7 22.7 58.9 934 12-13 48.8 16.8 54.5 1,189 14-15 40.2 16.1 47.5 992 16-17 32.7 14.1 39.8 917 18-19 24.4 9.4 29.2 856 20-21 18.5 7.8 22.9 740 22-23 9.4 6.4 13.8 676 24-25 8.3 4.9 11.9 1,124 26-27 6.0 4.2 9.1 1,050 28-29 5.0 4.8 8.9 977 30-31 5.0 3.5 7.9 838 32-33 3.3 4.2 6.8 666 34-35 1.2 2.2 3.3 623 Total 38.0 20.4 43.0 16,640 Median 11.5 3.5 13.8 na Mean 13.1 7.4 14.9 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth Other Proximate Determinants of Fertility | 103 Table 6.9 shows the median durations of postpartum amenorrhoea, abstinence, and insus- ceptibility by background characteristics. The duration of postpartum amenorrhoea is slightly shorter among younger women age 15-29 (11.1 months), compared with older women age 30-49 (12.1 months). The duration of amenorrhoea is five months shorter among urban women than among rural women (8.3 compared with 13.3 months). Postpartum amenorrhoea is considerably shorter among mothers in South East (7.0 months) and longer among mothers in North West, (15.9 months). The length of postpartum amenorrhoea decreases with increasing level of mother’s education and wealth quintile. Differences in the median duration of postpartum abstinence are not notable, except by zone. The duration of postpartum abstinence is more than nine months for mothers in North Central, compared with around two months for the other northern zones (2.4 months for North East and 2.1 months for North West). The median length of postpartum abstinence in the three southern zones is around five months. Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Nigeria 2008 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 11.1 3.6 13.5 30-49 12.1 3.4 14.1 Residence Urban 8.3 3.5 9.9 Rural 13.3 3.5 15.3 Zone North Central 11.8 9.2 17.2 North East 14.3 2.4 15.2 North West 15.9 2.1 16.2 South East 7.0 4.6 8.9 South South 8.2 4.9 9.9 South West 10.2 5.4 12.4 Education No education 15.8 2.6 16.8 Primary 10.6 4.4 13.4 Secondary 8.1 4.7 10.9 More than secondary 6.4 3.1 7.5 Wealth quintile Lowest 15.9 3.0 17.1 Second 14.8 3.0 16.4 Middle 12.1 4.2 14.9 Fourth 8.9 4.3 10.3 Highest 6.5 3.2 8.2 Total 11.5 3.5 13.8 Note: Medians are based on the status at the time of the survey (current status) 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth 104 | Other Proximate Determinants of Fertility 6.8 MENOPAUSE Another factor influencing the risk of pregnancy among women is menopause. Table 6.10 shows the proportion of women age 30 and older who are menopausal. A woman is considered menopausal if she is neither pregnant nor amenorrhoeic and has not had her menses for six or more months. Table 6.10 shows that 9 percent of women age 30-49 are menopausal. The proportion of women who are menopausal increases with age from 1 percent among women age 30-34 to 48 percent among women age 48-49. These findings indicate that the onset of infertility with increasing age substantially reduces the proportion of women exposed to the risk of pregnancy. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Nigeria 2008 Age Percentage menopausal1 Number of women 30-34 1.0 4,634 35-39 2.2 3,912 40-41 6.9 1,809 42-43 9.8 889 44-45 19.0 1,307 46-47 29.1 729 48-49 47.9 1,171 Total 9.4 14,450 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 105 FERTILITY PREFERENCES 7 One of the objectives of Nigeria’s National Policy on Population is to reduce the high level of fertility in the country (NPC, 2004). The guiding principle in achieving this objective is to emphasise the voluntary acceptance of family planning methods, in accordance with fundamental human rights, that all couples and individuals should decide freely and responsibly on the timing, number, and spacing of their children for a manageable family size, and that the Government has a responsibility to facilitate people’s ability to make informed choices and to create an enabling environment in which they can effectively manage their lives. The 2008 NDHS collected information from both women and men on a number of aspects of fertility preferences, including their current desire to have a/another child, the length of time they would like to wait before the birth, and what they consider to be the ideal number of children. Although survey information on fertility preferences may be influenced by the respondent’s current family size and is subject to change over time, it still provides useful information to family planning programmes for assessing the needs for contraception (for spacing or limiting births) and the extent of unwanted and mistimed pregnancies. Survey questions on fertility preferences have often been the subject of criticism. It is argued that the answers respondents give are misleading because they may reflect uninformed, ephemeral views, which are held with little conviction. It is also argued that questions do not take into account the effect of social pressures or the attitudes of other family members, particularly the husband, who may exert a major influence on his wife’s reproductive choices. The first argument has greater force in a country where contraceptive prevalence is low, and where the idea of conscious reproductive choice may still be unfamiliar. Thus, preference data from these settings should be interpreted with caution. The second argument is correct in principle. In practice, however, its importance is doubtful; for instance, the evidence from surveys in which both husbands and wives are interviewed suggests that there is no substantial difference between the views of the two sexes (NPC and ORC Macro, 2004: 95). 7.1 DESIRE FOR MORE CHILDREN Information on desire for more children is important in understanding future reproductive behaviour. The provision of adequate and accessible family planning services is dependent on the availability of such information. Women and men surveyed in the 2008 NDHS were asked questions to determine their desire to have a/another child. Sterilised women and men, who had undergone tubal ligation or vasectomy operations, were considered to want no more children, and therefore not asked questions on fertility desires. Table 7.1 and Figure 7.1 show the distribution of currently married women and men age 15- 49 by desire for more children, according to the number of living children. The proportion of women and men who want another child generally decreases with increasing number of living children. At the same time, the proportion of women and men who want to stop childbearing (including those sterilised) increases with increasing number of living children. Among women and men with no children, more women than men want to have a child soon (76 percent of women compared with 57 percent of men). By the fourth child, however, this pattern is reversed and more men than women want another child soon (23 percent of men and 22 percent of women). Among women and men with six or more living children, only 13 percent of women compared with 25 percent of men want another child soon. 106 | Fertility Preferences There are marked differences between women and men who want no more children (or are sterilised) by number of living children. The proportion of women who want no more children (or are sterilised) increases steadily from 2 percent among those with one child to 46 percent among those with six or more living children. In contrast, the proportion of men who want no more children (or are sterilised) increases from 1 percent among those with one child to just 28 percent among those with five children, and then decreases to 20 percent among men with six or more living children (see Figure 7.1). Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Nigeria 2008 Number of living children Desire for children 0 1 2 3 4 5 6+ Total 15-49 50-59 Total 15-59 WOMEN1 Have another soon2 75.9 37.0 34.4 28.9 22.1 16.5 13.0 29.1 na na Have another later3 6.4 47.3 44.0 39.8 30.9 25.4 16.5 32.2 na na Have another, undecided when 5.2 5.3 6.3 5.7 5.5 3.8 3.7 5.1 na na Undecided 8.5 6.6 7.8 10.0 12.8 13.0 15.8 10.8 na na Want no more 0.6 2.0 4.9 12.7 25.2 36.8 45.1 19.3 na na Sterilised4 0.0 0.0 0.1 0.2 0.6 0.7 0.9 0.4 na na Declared infecund 2.8 1.3 1.7 2.1 2.4 3.0 4.5 2.5 na na Missing 0.8 0.6 0.8 0.6 0.5 0.8 0.5 0.6 na na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 na na Number of women 1,650 3,675 3,911 3,900 3,517 2,688 4,238 23,578 na na MEN5 Have another soon2 57.4 34.1 34.1 26.7 23.2 20.9 25.3 30.0 21.9 28.5 Have another later3 13.7 50.3 47.2 42.9 35.3 30.8 30.9 38.3 14.5 33.9 Have another, undecided when 18.3 10.4 7.6 11.3 10.3 9.1 12.6 10.9 9.4 10.6 Undecided 5.9 3.2 5.4 7.7 9.3 10.5 10.2 7.4 12.2 8.3 Want no more 1.0 0.4 4.1 9.7 20.2 27.0 19.0 11.6 39.5 16.8 Sterilised4 1.0 0.7 0.7 0.7 0.8 0.8 1.1 0.8 0.9 0.8 Declared infecund 0.0 0.0 0.2 0.3 0.3 0.7 0.3 0.2 0.5 0.3 Missing 2.7 0.8 0.5 0.8 0.7 0.2 0.5 0.8 1.1 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 482 1,162 1,244 1,102 933 734 1,362 7,018 1,599 8,618 na = Not applicable 1 The number of living children includes current pregnancy for women 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilisation 5 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). It is striking that 59 percent of women with four living children want to have another child. Twenty-nine percent of all currently married women and 30 percent of currently married men want a child soon, i.e. they want to have another child within the next two years. Thirty-two percent of women and 38 percent of men age 15-49 want another child later, i.e. they want to delay having another child for more than two years. Twenty percent of married women and 12 percent of married men want no more children or have been sterilised. Similar patterns were observed in the 1999 NDHS and 2003 NDHS surveys (NPC, 2000; NPC and ORC Macro, 2004). Fertility Preferences | 107 7.2 DESIRE TO LIMIT CHILDBEARING Tables 7.2.1 and 7.2.2 show the percentage of currently married women and men age 15-49 who want no more children by number of living children, according to background characteristics. The results provide information on variations in the potential demand for fertility control. Women who have been sterilised are considered to want no more children. Men who have been sterilised, or who report that their wife/partner has been sterilised, are considered to want no more children. Overall, 20 percent of women age 15-49 indicate no desire for more children, and more women in urban areas (25 percent) than in rural areas (17 percent) want to limit childbearing. The percentage of women who want to limit childbearing increases with the number of living children, and it increases rapidly among women with three or more children in both urban and rural areas. Overall, more than one-third (38 percent) of women with five living children want to limit childbearing, compared with 2 percent of women with one living child. At the zonal level, the proportion of women who want no more children varies from 10 percent in the North West to 32 percent in South West. In all the southern zones, the majority of women do not wish to have more children once they have had five children. At parity six and above, over two-thirds of currently married women in the southern zones do not want any more children. In contrast, in the North West and North East, only one-third or fewer women want to limit childbearing, regardless of the number of living children they already have. This is especially true of women in the North West where only 26 percent of women with six or more children say that they want no more children. The desire to limit childbearing is higher among women with some education than among women with no education. Among women with at least four living children, 14 percent of those with no education want to limit childbearing, compared with 55 percent of women with more than a secondary education. Similarly, the desire to limit childbearing increases with increasing wealth quintile. Overall, one in eight women in households in the lowest wealth quintile want to limit childbearing, compared with over one-quarter of women in households in the highest wealth quintile. Among women with at least four living children, 12 percent of those in the lowest wealth quintile want to limit childbearing, compared with 50 percent of women in the highest wealth quintile. 1 2 5 13 26 38 46 2 1 5 10 21 28 20 0 1 2 3 4 5 6+ 0 10 20 30 40 50 Percent Women Men Figure 7.1 Percentage of Currently Married Women and Men Who Want No More Children, by Number of Living Children NDHS 2008 108 | Fertility Preferences Women and men exhibit similar patterns of desired fertility by background characteristics. Men’s desire to limit childbearing increases with urban residence, the number of living children, level of education, and wealth quintile. This is particularly true at parity three and above for women and men. Table 7.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children by number of living children, according to background characteristics, Nigeria 2008 Number of living children1 Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 0.2 2.2 6.3 18.3 39.5 53.2 55.1 24.9 Rural 0.7 1.9 4.4 10.1 19.3 30.4 42.9 17.3 Zone North Central 0.4 1.4 3.6 11.5 22.0 32.8 51.8 19.5 North East 1.3 2.7 3.6 5.8 13.0 22.4 33.1 13.4 North West 0.6 2.3 4.6 6.8 8.8 14.4 26.2 10.1 South East 0.5 1.9 2.8 12.5 31.7 49.1 70.1 28.2 South South 0.0 1.5 5.2 14.7 32.0 56.9 67.8 27.1 South West 0.0 1.7 8.4 24.5 50.9 71.2 74.0 31.6 Education No education 0.8 3.0 5.2 9.0 13.9 21.8 34.5 14.8 Primary 0.0 1.0 3.8 11.1 26.0 44.4 58.8 25.8 Secondary 0.5 1.1 3.0 16.8 39.8 60.4 64.6 22.0 More than secondary 0.0 1.8 13.6 27.4 55.2 63.8 75.7 26.2 Wealth quintile Lowest 0.9 2.0 5.6 6.5 12.3 18.1 33.0 12.4 Second 0.3 2.6 3.5 9.1 16.4 25.9 39.4 15.9 Middle 1.0 2.2 3.0 11.4 20.7 34.9 49.3 20.7 Fourth 0.4 2.0 3.9 14.3 31.0 47.0 56.0 23.4 Highest 0.0 1.3 8.2 22.3 50.1 68.7 66.5 28.2 Total 0.6 2.0 5.1 13.0 25.7 37.5 46.0 19.7 Note: Women who have been sterilised are considered to want no more children. 1 The number of living children includes the current pregnancy. Fertility Preferences | 109 Table 7.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Nigeria 2008 Number of living children1 Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 2.7 1.3 4.8 15.8 33.4 45.3 25.5 16.6 Rural 1.7 1.0 4.9 7.4 14.7 19.4 18.6 10.4 Zone North Central 0.0 2.3 5.6 8.8 20.6 24.9 31.0 14.7 North East 3.6 1.2 2.5 3.4 8.0 7.0 8.7 5.3 North West 0.9 0.7 2.3 0.8 3.6 1.8 2.9 2.0 South East 0.0 2.9 6.2 9.4 29.4 52.0 46.4 20.2 South South 6.4 0.8 11.5 18.5 31.3 44.0 48.9 21.9 South West 2.0 0.0 3.3 20.7 35.8 54.2 35.4 20.2 Education No education 1.0 0.8 1.8 3.4 3.9 6.8 6.5 3.7 Primary 2.8 1.8 5.8 5.1 20.7 27.7 27.1 14.5 Secondary 2.9 0.3 4.5 14.0 26.1 34.3 29.7 14.8 More than secondary 1.5 2.3 9.2 22.6 41.6 49.3 26.3 19.8 Wealth quintile Lowest 1.9 0.2 4.3 2.3 3.9 8.2 10.2 4.8 Second 2.0 1.2 2.2 3.3 11.1 12.2 11.2 6.8 Middle 2.9 1.5 6.6 7.5 21.1 18.9 23.0 13.1 Fourth 0.0 1.0 4.4 13.5 23.8 39.2 33.8 16.1 Highest 2.9 1.4 6.2 21.7 40.1 56.4 38.6 21.1 Total 15-49 2.0 1.1 4.9 10.4 21.0 27.8 20.2 12.4 50-59 3.8 23.5 16.3 38.7 52.8 50.3 38.7 40.4 Total 15-59 2.1 1.8 5.4 13.1 26.6 32.7 27.8 17.6 Note: Men who have been sterilised or who report that their wife has been sterilised are considered to want no more children. 1 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). 7.3 NEED FOR FAMILY PLANNING SERVICES This section discusses the extent of need and potential demand for family planning services in Nigeria. Family planning methods can be used to space or limit childbearing. In the 2008 NDHS, women who indicate that they either want no more children (limiters) or want to wait for two or more years before having another child (spacers), but are not using contraception, are a group identified as having an unmet need for family planning. Pregnant women are considered to have unmet need for spacing or limiting if their pregnancy was mistimed or unwanted, respectively. Similarly, amenorrhoeic women are classified as having unmet need if their last birth was mistimed or unwanted. Women who are currently using a family planning method are said to have a met need for family planning. Women with unmet need for family planning and those who are currently using contraception together constitute the total demand for family planning. This information is important not only to determine the total demand for family planning but to measure the percentage of that demand satisfied. Table 7.3.1 presents information on unmet need, met need, and the total demand for family planning among currently married women surveyed in the 2008 NDHS. 110 | Fertility Preferences Overall, 20 percent of currently married women have an unmet need for family planning – 15 percent for spacing, and 5 percent for limiting. Unmet need does not vary much by age except for women age 45-49, who have the lowest unmet need (16 percent). Unmet need for spacing is highest in the 20-24 age group, with 21 percent of women having an unmet need for spacing their births, while the unmet need for limiting is highest in the 40-44 age group, with 13 percent of women wanting no more children. It is notable that up to age 39, a sizeable proportion of unmet need for family planning is for spacing purposes. After age 39, most unmet need is for limiting childbearing. Table 7.3.1 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage for the demand for contraception that is satisfied, by background characteristics, Nigeria 2008 Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Percentage of demand satisfied Number of women Age 15-19 18.5 0.6 19.0 3.0 0.0 3.0 21.5 0.6 22.0 13.6 1,863 20-24 20.8 0.6 21.4 9.6 0.5 10.1 30.4 1.1 31.5 32.1 3,659 25-29 18.4 2.0 20.4 13.3 1.3 14.6 31.7 3.3 35.1 41.8 5,112 30-34 15.8 4.3 20.1 13.2 5.3 18.5 29.0 9.6 38.6 48.0 4,173 35-39 13.0 8.3 21.3 8.4 11.6 19.9 21.4 19.9 41.2 48.4 3,575 40-44 8.8 12.6 21.4 3.6 15.3 19.0 12.4 27.9 40.4 47.0 2,711 45-49 5.1 11.1 16.2 1.1 9.5 10.6 6.2 20.6 26.8 39.6 2,484 Residence Urban 13.5 5.8 19.3 15.3 10.6 25.9 28.8 16.4 45.2 57.2 7,375 Rural 15.7 4.9 20.6 5.8 3.7 9.4 21.5 8.6 30.1 31.4 16,203 Zone North Central 13.1 5.6 18.7 7.1 5.9 13.0 20.2 11.5 31.7 41.0 3,320 North East 13.6 4.0 17.6 2.9 1.1 4.0 16.5 5.1 21.6 18.7 3,585 North West 17.9 2.9 20.8 1.7 1.1 2.8 19.5 4.0 23.5 11.7 7,189 South East 11.5 6.6 18.1 13.9 9.5 23.4 25.4 16.1 41.5 56.3 2,139 South South 18.0 7.9 25.9 17.7 8.6 26.2 35.7 16.5 52.2 50.3 2,978 South West 12.6 7.1 19.7 17.9 13.8 31.7 30.5 20.9 51.3 61.7 4,366 Education No education 15.4 3.9 19.2 1.9 1.7 3.6 17.2 5.6 22.8 15.7 11,120 Primary 15.0 7.7 22.6 9.3 7.8 17.2 24.3 15.5 39.8 43.1 5,143 Secondary 16.0 5.6 21.6 18.0 9.4 27.4 33.9 15.0 49.0 55.9 5,621 More than secondary 9.6 5.1 14.6 21.6 15.0 36.6 31.1 20.1 51.2 71.4 1,693 Wealth quintile Lowest 14.9 3.4 18.4 2.0 1.2 3.2 17.0 4.6 21.6 14.9 5,408 Second 15.7 4.6 20.3 3.1 2.2 5.2 18.7 6.8 25.5 20.5 5,052 Middle 15.6 6.2 21.8 6.6 4.9 11.4 22.1 11.1 33.3 34.4 4,311 Fourth 16.3 6.8 23.1 13.4 8.0 21.3 29.7 14.7 44.4 48.0 4,216 Highest 12.6 5.6 18.2 20.8 14.3 35.0 33.3 19.8 53.2 65.9 4,590 Total 15.0 5.2 20.2 8.8 5.8 14.6 23.8 11.0 34.8 41.9 23,578 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. Fertility Preferences | 111 Figure 7.2 shows unmet need for family planning for currently married women by residence and zones. More women in rural areas (21 percent) have an unmet need for family planning (16 percent for spacing and 5 percent for limiting), compared with urban women (19 percent), whose unmet need for spacing births is 14 percent and for limiting childbearing is 6 percent. Total unmet need for family planning is highest in the South South zone, where over one-quarter of currently married women have an unmet need for family planning, and lowest in the North East and South East zones (18 percent each). Fifteen percent of married women are using contraception, which constitutes met need. The total demand for family planning is estimated at 35 percent, and the percentage of demand satisfied is 42 percent. For currently married women, the percentage of total demand for family planning increases with an increase in the level of education and household wealth. The percentage of women whose demand has been satisfied increases from 16 percent for women with no education to 71 percent for women with more than a secondary education. Table 7.3.2 presents data on family planning need and demand for all women and for women who are not currently married. Overall, 16 percent of all women have an unmet need for family planning. Total demand for family planning is 31 percent, with 50 percent of the demand satisfied. Among women who are not currently married, 5 percent have an unmet need for family planning. For these women, total demand for family planning is 22 percent, with 78 percent of the demand satisfied. 14 16 13 14 18 12 18 13 6 5 6 4 3 7 8 7 Urban Rural North Central North East North West South East South South South West 0 5 10 15 20 25 30 Percent For spacing For limiting Figure 7.2 Unmet Need for Family Planning for Currently Married Women by Residence and Zones NDHS 2008 112 | Fertility Preferences Table 7.3.2 Need and demand for family planning for all women and for women who are not currently married Percentage of all women and not currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning and the percentage of the demand for contraception that is satisfied, by background characteristics, Nigeria 2008 Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Percentage of demand satisfied Number of women ALL WOMEN Age 15-19 8.2 0.2 8.3 6.8 0.1 6.9 15.0 0.3 15.2 45.2 6,493 20-24 14.9 0.4 15.3 17.1 0.4 17.6 32.1 0.9 32.9 53.4 6,133 25-29 16.2 1.6 17.9 16.8 1.3 18.1 33.0 3.0 36.0 50.3 6,309 30-34 14.5 4.0 18.5 14.2 5.1 19.3 28.7 9.0 37.8 51.0 4,634 35-39 12.0 7.9 19.9 8.7 11.0 19.7 20.7 18.9 39.6 49.7 3,912 40-44 8.0 11.5 19.5 3.4 14.6 18.0 11.3 26.1 37.4 48.0 3,032 45-49 4.4 9.7 14.1 1.0 8.7 9.7 5.4 18.3 23.7 40.7 2,872 Residence Urban 9.8 3.6 13.4 16.9 7.0 23.9 26.7 10.6 37.3 64.1 11,934 Rural 13.1 3.9 17.0 7.7 3.0 10.7 20.8 6.8 27.7 38.7 21,451 Zone North Central 10.7 4.1 14.8 7.9 4.7 12.6 18.6 8.8 27.3 46.0 4,748 North East 12.1 3.4 15.5 3.0 1.1 4.0 15.1 4.4 19.5 20.7 4,262 North West 16.2 2.6 18.8 1.8 1.0 2.7 18.0 3.6 21.6 12.7 8,022 South East 7.7 3.6 11.3 12.3 5.4 17.7 20.1 9.0 29.1 61.0 4,091 South South 12.6 4.5 17.1 23.5 5.0 28.5 36.1 9.6 45.6 62.4 5,473 South West 9.6 4.6 14.3 18.4 9.3 27.7 28.0 13.9 41.9 66.0 6,789 Education No education 14.5 3.7 18.1 1.8 1.7 3.5 16.3 5.3 21.7 16.3 11,942 Primary 12.4 6.3 18.7 8.8 6.5 15.4 21.2 12.8 34.0 45.2 6,566 Secondary 10.3 2.7 13.0 17.4 4.8 22.2 27.7 7.5 35.2 63.0 11,904 More than secondary 7.1 2.9 10.0 27.4 9.0 36.4 34.5 12.0 46.5 78.4 2,974 Wealth quintile Lowest 13.6 3.1 16.7 2.5 1.2 3.7 16.2 4.3 20.4 18.1 6,194 Second 13.6 3.8 17.4 4.2 1.9 6.2 17.9 5.7 23.6 26.2 6,234 Middle 12.3 4.4 16.8 8.3 3.6 11.9 20.7 8.1 28.7 41.6 6,341 Fourth 11.9 4.2 16.1 15.9 5.2 21.2 27.9 9.4 37.3 56.7 6,938 Highest 8.8 3.4 12.2 21.2 8.9 30.1 30.0 12.3 42.3 71.2 7,678 Total 11.9 3.8 15.7 11.0 4.4 15.4 22.9 8.2 31.1 49.6 33,385 Continued… Fertility Preferences | 113 Table 7.3.2—Continued Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Percentage of demand satisfied Number of women WOMEN NOT CURRENTLY MARRIED Age 15-19 4.0 0.0 4.0 8.3 0.1 8.4 12.3 0.1 12.5 67.6 4,630 20-24 6.2 0.2 6.3 28.3 0.3 28.6 34.4 0.5 34.9 81.9 2,474 25-29 6.8 0.2 7.0 31.6 1.2 32.8 38.4 1.3 39.8 82.4 1,197 30-34 2.9 1.1 4.0 23.4 2.4 25.8 26.3 3.5 29.8 86.6 461 35-39 1.4 3.7 5.2 12.2 4.9 17.1 13.6 8.6 22.2 76.8 337 40-44 0.9 2.2 3.1 1.2 8.5 9.7 2.2 10.7 12.9 75.6 321 45-49 0.1 0.4 0.5 0.4 3.3 3.7 0.5 3.7 4.2 88.3 388 Residence Urban 3.7 0.1 3.8 19.6 1.1 20.7 23.3 1.2 24.5 84.5 4,560 Rural 5.2 0.5 5.8 13.8 0.9 14.7 19.0 1.4 20.4 71.8 5,247 Zone North Central 5.0 0.6 5.6 9.7 1.8 11.5 14.7 2.4 17.1 67.3 1,427 North East 4.3 0.1 4.4 3.5 0.6 4.1 7.7 0.8 8.5 48.0 677 North West 1.8 0.0 1.8 2.5 0.2 2.7 4.3 0.2 4.5 59.3 832 South East 3.6 0.3 3.9 10.6 1.0 11.6 14.2 1.3 15.5 74.7 1,952 South South 6.1 0.5 6.6 30.4 0.8 31.2 36.5 1.3 37.8 82.5 2,495 South West 4.2 0.3 4.5 19.4 1.1 20.4 23.6 1.3 24.9 82.0 2,423 Education No education 2.4 0.8 3.2 1.4 1.3 2.8 3.8 2.2 6.0 46.1 821 Primary 3.1 1.1 4.3 7.0 1.9 8.9 10.1 3.0 13.1 67.5 1,423 Secondary 5.2 0.1 5.4 16.8 0.7 17.5 22.0 0.8 22.9 76.6 6,282 More than secondary 3.9 0.1 4.0 35.1 1.1 36.2 39.0 1.2 40.2 90.1 1,281 Wealth quintile Lowest 4.4 1.2 5.6 6.2 0.9 7.1 10.6 2.1 12.7 55.6 786 Second 5.0 0.2 5.2 9.2 1.0 10.2 14.2 1.2 15.4 66.2 1,181 Middle 5.4 0.6 6.0 12.1 0.9 13.0 17.5 1.5 19.0 68.5 2,030 Fourth 5.2 0.2 5.4 19.9 1.0 20.9 25.1 1.2 26.2 79.6 2,722 Highest 3.2 0.1 3.3 21.8 1.0 22.8 24.9 1.1 26.1 87.4 3,089 Total 4.5 0.3 4.8 16.5 1.0 17.5 21.0 1.3 22.3 78.3 9,807 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 7.4 IDEAL FAMILY SIZE The discussion on fertility preferences earlier in this chapter focused on respondents’ current childbearing preferences. These preferences are influenced by the number of children a respondent already has. The 2008 NDHS asked women and men about the total number of children they would like to have in their lifetime. For respondents who already had living children, the question was posed hypothetically: “If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?” Table 7.4 shows the distribution of women and men age 15-49 by their ideal number of children, according to the number of living children. 114 | Fertility Preferences The ideal number of children is 6.1 for all women and 6.7 for currently married women. More than half of all women consider five or more children to be ideal. Only 9 percent of women think three or less children is ideal. Among all women, the mean ideal number of children increases with the number of living children, from 4.9 for those without any children to 8.3 among those with six or more children. Clearly, Nigerian women consider a large family to be desirable. Table 7.4 Ideal number of children Percent distribution of women and men 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to number of living children, Nigeria 2008 Number of living children Ideal number of children 0 1 2 3 4 5 6+ Total WOMEN1 0 1.7 1.2 1.4 1.4 1.6 2.2 2.3 1.7 1 0.2 0.3 0.1 0.2 0.1 0.0 0.1 0.1 2 2.6 1.7 2.3 0.7 0.6 0.5 0.4 1.5 3 10.8 7.8 5.5 5.0 0.9 1.3 0.7 5.7 4 33.5 25.3 23.7 18.6 17.8 7.3 3.8 21.3 5 18.2 16.6 15.9 17.2 13.0 16.9 5.5 15.2 6+ 23.8 34.2 38.2 43.7 51.4 55.3 66.0 40.9 Non-numeric responses 9.4 12.8 12.7 13.2 14.6 16.5 21.1 13.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 9,563 4,366 4,229 4,124 3,708 2,861 4,534 33,385 Mean ideal number children for: 2 All women 4.9 5.8 6.0 6.3 6.7 7.1 8.3 6.1 Number 8,663 3,809 3,691 3,578 3,168 2,389 3,576 28,874 Currently married women 6.4 6.0 6.1 6.3 6.7 7.2 8.3 6.7 Number 1,373 3,160 3,408 3,383 3,002 2,233 3,335 19,894 MEN3 0 2.1 0.9 1.0 1.3 1.8 1.9 2.8 1.9 1 0.1 0.2 0.2 0.2 0.2 0.1 0.2 0.1 2 2.3 2.1 2.5 0.7 0.5 0.7 0.5 1.8 3 11.2 11.8 6.5 5.2 2.8 2.2 0.9 8.2 4 25.6 22.8 24.2 16.4 16.6 8.8 3.2 20.7 5 18.4 16.2 17.1 20.7 16.1 17.0 5.3 16.7 6+ 32.0 34.3 38.2 41.8 48.2 52.2 61.4 38.7 Non-numeric responses 8.3 11.6 10.2 13.6 13.8 17.1 25.6 11.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 7,006 1,297 1,305 1,134 948 744 1,373 13,808 Mean ideal number children for: 2 All men 6.1 6.9 7.1 7.6 7.9 8.7 12.7 7.2 Number 6,427 1,147 1,173 980 817 617 1,020 12,181 Currently married men 8.2 7.1 7.1 7.7 7.9 8.7 12.8 8.5 Number 415 1,020 1,117 948 804 607 1,012 5,923 Mean ideal number children for men 15-59: 2 All men 6.1 6.9 7.1 7.6 7.8 8.4 12.8 7.5 Number 6,441 1,174 1,224 1,085 980 772 1,697 13,438 Currently married men 8.2 7.1 7.1 7.7 7.7 8.4 12.9 8.8 Number 429 1,048 1,168 1,053 966 763 1,689 7,115 1 The number of living children includes current pregnancy for women 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). Fertility Preferences | 115 Nigerian men, on average, want more children than women: 7.2 children for all men age 15-49 compared with 6.1 children for all women age 15-49. Currently married men report a mean ideal number of children that is almost two children more than the ideal reported by currently married women (8.5 children compared with 6.7 children). These findings are similar to those from the 1999 NDHS and 2003 NDHS surveys (NPC, 2000; NPC and ORC Macro, 2004). Among all women and men and currently married women and men who currently have no children, the ideal number of children is about 6 and 8, respectively. Table 7.5 shows the mean ideal number of children for all women, by background characteristics. The mean ideal number of children increases steadily with age, from 5.5 children among women age 15-19 to 7.3 children among women age 45-49. Urban women prefer to have fewer children than rural women (5.2 children compared with 6.7 children, respectively). The mean ideal number of children is lowest in the South West and South South (4.6 and 5.2 children, respectively) and highest in the North East and North West (8.1 and 8 children, respectively). The mean ideal number of children desired decreases as women’s level of education and wealth status increase. Women with no education want 8.0 children, while those with more than secondary education want only 4.3 children. Women in the lowest wealth quintile want 7.8 children, while women in the highest wealth quintile want 4.5 children. 7.5 FERTILITY PLANNING The issue of unplanned and unwanted fertility was further investigated in the 2008 NDHS by asking women with births in the five years preceding the survey whether the births were wanted at the time (planned), wanted but at a later time (mistimed), or not wanted at all (unwanted). For women who were pregnant at the time of the interview, this question was asked with reference to the current pregnancy. The procedure required respondents to recall accurately their wishes at one or more points in time over the past five years. Care should be exercised in interpreting these results because an unwanted conception may have become a cherished child, leading to the rationalisation in responses to the questions. Table 7.6 shows the percent distribution of births in the five years preceding the 2008 NDHS, by planning status of the birth. Eighty-seven percent of the births were wanted at the time they occurred, 7 percent were wanted later (mistimed), and 4 percent were unwanted. Table 7.5 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Nigeria 2008 Background characteristic Mean Number of women1 Age 15-19 5.5 5,711 20-24 5.7 5,440 25-29 5.9 5,583 30-34 6.3 4,023 35-39 6.7 3,322 40-44 6.9 2,508 45-49 7.3 2,287 Residence Urban 5.2 10,785 Rural 6.7 18,089 Zone North Central 5.7 4,005 North East 8.1 3,848 North West 8.0 5,804 South East 5.5 3,902 South South 5.2 4,994 South West 4.6 6,322 Education No education 8.0 9,298 Primary 6.3 5,714 Secondary 4.9 11,007 More than secondary 4.3 2,857 Wealth quintile Lowest 7.8 5,031 Second 7.3 5,042 Middle 6.4 5,424 Fourth 5.4 6,252 Highest 4.5 7,125 Total 6.1 28,874 1 Number of women who gave a numeric response 116 | Fertility Preferences Table 7.6 Fertility planning status Percent distribution of births among women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother's age at birth, Nigeria 2008 Planning status of birth Birth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 85.0 6.6 6.3 2.1 100.0 6,104 2 89.2 6.4 2.7 1.7 100.0 5,563 3 89.8 6.4 2.0 1.8 100.0 4,867 4+ 86.7 6.4 4.6 2.3 100.0 15,060 Mother's age at birth <20 85.8 6.1 5.7 2.3 100.0 4,603 20-24 87.3 7.2 3.3 2.2 100.0 8,059 25-29 88.7 6.7 2.6 2.0 100.0 8,456 30-34 87.9 6.6 3.6 1.8 100.0 5,588 35-39 86.4 5.5 6.4 1.7 100.0 3,187 40-44 84.1 4.0 9.3 2.6 100.0 1,350 45-49 81.7 5.7 9.2 3.5 100.0 351 Total 87.3 6.5 4.2 2.1 100.0 31,594 7.6 WANTED FERTILITY RATES The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. It is calculated in the same manner as the total fertility rate, except that only wanted births are included. A birth is considered wanted if the number of living children at the time of conception was less than the ideal number of children reported by the respondent. The gap between wanted and actual fertility shows how successful women are in achieving their reproductive intentions. A comparison of the total wanted fer- tility rate and the total fertility rate for the three years preceding the survey is presented in Table 7.7 by background characteristics. Overall, the total fertility rate (5.7 children per woman) is slightly higher than the total wanted fertility rates (5.3 children per woman). The difference between the two measures decreases with increasing level of education and wealth quintile, indicating that educated and wealthier women are better able to translate their desires into reality. Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Nigeria 2008 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 4.4 4.7 Rural 5.8 6.3 Zone North Central 5.1 5.4 North East 6.7 7.2 North West 6.8 7.3 South East 4.5 4.8 South South 4.3 4.7 South West 4.2 4.5 Education No education 6.8 7.3 Primary 6.0 6.5 Secondary 4.4 4.7 More than secondary 2.7 2.9 Wealth quintile Lowest 6.7 7.1 Second 6.5 7.0 Middle 5.4 5.9 Fourth 4.6 5.0 Highest 3.8 4.0 Total 5.3 5.7 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Infant and Child Mortality | 117 INFANT AND CHILD MORTALITY 8 Infant and child mortality rates are basic indicators of a country’s socio-economic situation and quality of life (UNDP, 2007). The rates are important for identifying population groups at risk; planning, monitoring, and evaluating population and health programmes and policies; and monitoring progress towards the Millennium Development Goal to reduce child mortality by two-thirds by the year 2015. In this chapter, results from the 2008 NDHS are presented for the levels, trends, and differentials in mortality among children under the age of five. Specifically, this chapter provides information on the levels and trends of neonatal, post-neonatal, infant, child, and under-five mortality, as well as perinatal mortality and patterns of fertility associated with high childhood mortality. Mortality differentials are shown according to socio-economic and demographic characteristics such as place of residence (rural or urban); child’s sex; birth order and birth interval; mother’s level of education; and household wealth quintiles. 8.1 BACKGROUND AND ASSESSMENT OF DATA QUALITY Childhood mortality estimates are based on information from women’s birth histories given in section 2 of the Women’s Questionnaire. All women age 15-49 were asked questions about the number of sons and daughters they had, and whether they were living with them, or elsewhere, or were dead. For each of these births, information was collected on sex, month and year of birth, survival status, and current age; and, if the child had died, the age at death was collected. Age-specific childhood mortality rates are presented as follows: Neonatal mortality: the probability of dying within the first month of life Post-neonatal mortality: the difference between infant and neonatal mortality Infant mortality: the probability of dying before the first birthday Child mortality: the probability of dying between the first and fifth birthdays Under-five mortality: the probability of dying between birth and the fifth birthday. All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. The reliability of mortality estimates depends on the sampling variability of the estimates and on non-sampling errors. Sampling variability and sampling errors are discussed in Appendix B. Non- sampling errors depend on the completeness with which child deaths are recalled and reported, and the accuracy of the date of birth information for living children, and the age at death information for deceased children provided by the mother. Serious omission of births and deaths affects mortality estimates; displacement of dates of such vital events impacts mortality trends, and misreporting of age at death distorts the age pattern of mortality. Typically, the most serious source of non-sampling errors in a survey that collects retrospective information on births and deaths is the underreporting of births and deaths for children who were not living at the time of the survey. Mothers may be reluctant to talk about their dead children either because it brings back sad memories or because their culture discourages mention of the dead. Even if a respondent is willing to talk about a dead child, she may forget events that happened in the more distant past, particularly if a child was alive only for a short time. 118 | Infant and Child Mortality When selective omission of childhood deaths occurs, it is usually most severe for deaths in early infancy. Appendix Tables D.3 to D.6 show the level of such omissions that may affect the 2008 NDHS childhood mortality estimates. Table D.3 shows that the percentage of missing information such as missing birth dates (births in past 15 years), missing age at death, missing age at first union, and mother’s education varied from below 1 percent to about 3 percent. Table D.4 shows high rates of completeness of birth dates. These rates vary from 92 to 100 percent for the years under observation (2003-2008), and are higher for living children than for dead children. Sex ratio at birth in Table D.4 shows a high level of accuracy in female-male birth reporting. Table C.5 shows the distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods preceding the survey. For all infant deaths reported in days, for the period 0-4 years preceding the survey, 78 percent were neonatal deaths occurring in the first week of life. For all t infant deaths reported in days for the 20 years preceding the survey, 74 percent were neonatal deaths. These rates are relatively high, suggesting that there has not been severe underreporting of early infant deaths in the 2008 NDHS. Another issue affecting childhood mortality estimates is the quality of reporting of age at death. If age at death is misreported, estimates may be biased, especially if the net effect of age misreporting results in the transfer of deaths from one childhood mortality category to another. To minimise this error, interviewers were instructed to record the age at death in days for deaths under one month, and in months for deaths under two years. They were also asked to probe for deaths reported at one year to determine a more precise age at death in terms of months. Table D.6 shows that there may have been death transfers or heaping of deaths at age 12 months because the number of deaths at this age is more than doubling the number of 11 months of age. Though this is consistent in infant deaths reported at 12 months for all five-year periods of birth in the 20 years preceding the survey, it is possible that some of these deaths may have occurred before one year of age but are not included in the infant mortality rate. However, the excess deaths reported at 12 months would have no effect on estimates of under-five mortality rates. Despite evidence of heaping at age of death, it should be noted that the age at death data collected in the 2008 NDHS are more accurate than the data collected in previous NDHS surveys. 8.2 INFANT AND CHILD MORTALITY LEVELS AND TRENDS Early childhood mortality rates based on data from the 2008 NDHS are presented on Table 8.1 for three five-year periods preceding the survey. The under-five mortality rate for the five years preceding the survey is 157 deaths per 1,000 live births. This translates to about one in every six children born in Nigeria dying before their fifth birthday. The child mortality rate is 88 deaths per 1,000 children surviving to 12 months of age, but not to their fifth birthday. The infant mortality rate is 75 deaths per 1,000 live births, and the neonatal mortality rate is 40 deaths per 1,000 live births. The post-neonatal mortality rate is 35 deaths per 1,000 live births. An examination of mortality levels across the three successive five-year periods shows that under-five mortality decreased from 199 deaths per 1,000 births during the middle to late 1990s (circa 1993-1998) to 157 deaths per 1,000 births in the middle part of this decade (2003-2008). Most of the decrease in mortality occurred outside of the neonatal period. The declining trend in under-five mortality rates over the 15 years preceding the survey is shown in Figure 8.1. Infant and Child Mortality | 119 Table 8.1 Early childhood mortality rates Neonatal, post-neonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Nigeria 2008 Years preceding the survey Approximate time period of estimated rates Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 2003-2008 40 35 75 88 157 5-9 1998-2003 52 47 99 97 187 10-14 1993-1998 49 48 97 113 199 Note: Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. 1 Computed as the difference between the infant and neonatal mortality rates Table 8.2 shows trends in under-five mortality for five-year periods before the 1990 NDHS, the 2003 NDHS, and the 2008 NDHS. The results indicate that there has been a decrease in neonatal mortality, although the decrease is small over the 18-year period between the 1990 and 2008 NDHS surveys, from 42 deaths per 1,000 births in the 1990 NDHS to 40 deaths per 1,000 births in the 2008 NDHS. Post-neonatal mortality shows a decrease from 45 deaths per 1,000 births in 1990 to 35 deaths per 1,000 births in 2008. Infant mortality has decreased from 87 deaths per 1,000 births in 1990 to 75 deaths per 1,000 in 2008. Child mortality has decreased by 24 percent over the 18-year period (from 115 to 88 deaths), and under-five mortality has decreased by 18 percent over the same period (from 192 to 157 deaths). 49 48 97 113 199 52 47 99 97 187 40 35 75 88 157 Neonatal Post-neonatal Infant Child Under-five 0 25 50 75 100 125 150 175 200 Deaths per 1,000 1993-1998 1998-2003 2003-2008 Figure 8.1 Mortality Trends 120 | Infant and Child Mortality Table 8.2 Trends in early childhood mortality Neonatal, post-neonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Nigeria 1990-2008 Survey Approximate time period of estimated rates Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) NDHS 2008 2003-2008 40 35 75 88 157 NDHS 2003 1998-2003 48 52 100 112 201 NDHS 1990 1986-1990 42 45 87 115 192 Note: The conclusion of the data quality assessment for the 1999 NDHS report is that the reported rates significantly underestimated the true mortality levels in the country because of underreporting of events in the survey. For this reason, the 1999 NDHS childhood mortality rates are not presented in this table. Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. 1 Computed as the difference between the infant and neonatal mortality rates 8.3 SOCIO-ECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Table 8.3 presents mortality differentials by background characteristics. The mortality estimates are calculated for the 10-year period before the survey so that the rates are based on a sufficient number of cases in each category to ensure statistically reliable estimates. Childhood mortality rates differ substantially between urban and rural areas, and are in rural areas than in urban areas for all categories. For example, the under-five mortality rate is 121 deaths per 1,000 births in the urban areas, compared with 191 deaths per 1,000 births in rural areas. Among the zones, under-five mortality ranges from 89 deaths per 1,000 births in South West to 222 deaths per 1,000 births in North East. The South West zone has the lowest rates for all five childhood mortality estimates compared with the other zones. Infant mortality is lowest in South West (59 deaths per 1,000 births) and highest in North East (109 deaths per 1,000 births). Higher levels of educational attainment are generally associated with lower mortality rates. Table 8.3 shows that children born to mothers with no education have the highest under-five mortality rate (209 deaths per 1,000 live births). Rates decline sharply as mother’s level of education increases. Under-five mortality is 68 deaths per 1,000 live births for children whose mothers have more than a secondary education. Under-five mortality rates are lowest for children in households in to the highest wealth quintile (87 deaths per 1,000 live births); the rate for children in the lowest wealth quintile is 219 deaths per 1,000 live births. Infant and Child Mortality | 121 Table 8.3 Childhood mortality rates by socio-economic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, Nigeria 2008 Background characteristic Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 38 29 67 58 121 Rural 49 46 95 106 191 Zone North Central 41 37 77 62 135 North East 53 56 109 126 222 North West 47 44 91 139 217 South East 51 44 95 64 153 South South 48 37 84 58 138 South West 37 22 59 32 89 Mother's education No education 49 49 97 124 209 Primary 48 40 89 77 159 Secondary 40 30 70 49 116 More than secondary 33 15 48 22 68 Wealth quintile Lowest 50 49 100 132 219 Second 51 52 103 121 212 Middle 45 40 86 87 165 Fourth 40 34 73 60 129 Highest 39 20 58 31 87 Total 46 41 87 92 171 Note: Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. 1 Computed as the difference between the infant and neonatal mortality rates 8.4 DEMOGRAPHIC DIFFERENTIALS IN CHILDHOOD MORTALITY The demographic characteristics of both mother and child such as sex of the child, mother’s age at birth, birth order, previous birth interval, and birth size have an impact on child survival. This section examines early childhood mortality rates by demographic differentials for the 10-year period preceding the survey. Table 8.4 shows that childhood mortality rates for male children are higher than those for female children, except for child mortality where the rates are higher for females than males. The under-five mortality rates for male and female children are 175 and 166 deaths per 1,000 live births, respectively. Childhood mortality rates are higher among younger women (less than age 20) and older women (age 40-49) than among women age 20-39. Childhood mortality rates are described as having a U-shaped relationship with birth order, with first-order births and higher-order births experiencing higher risk of death than middle-order births. This pattern is notable for neonatal and infant mortality. Studies have shown that a longer birth interval has a positive effect on a child’s chances of survival. Table 8.4 shows that childhood mortality decreases as length of the birth interval increases. The difference in the under-five mortality rate between births with intervals of less than two years and births with intervals of four or more years is large: 252 deaths per 1,000 live births compared with 92 deaths per 1,000 live births, respectively. 122 | Infant and Child Mortality Another important indicator of childhood survival is the child’s weight at birth. Mothers were asked about their infants’ weight at birth. Mothers who could not recall or refer to the exact weight from the child’s records were asked whether the infant was very large, larger than average, average, smaller than average, or small at birth. These descriptions have been used effectively as proxies for children’s weight. Table 8.4 shows that babies who were small or very small at birth have higher mortality rates than those reported to be average or larger in size. Table 8.4 Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Nigeria 2008 Demographic characteristic Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 51 42 93 91 175 Female 41 40 81 93 166 Mother's age at birth <20 61 49 110 112 209 20-29 39 39 78 85 156 30-39 45 41 86 89 167 40-49 72 41 113 118 218 Birth order 1 55 34 89 72 155 2-3 36 38 73 83 150 4-6 40 40 81 94 167 7+ 66 57 123 136 242 Previous birth interval2 <2 years 70 65 135 135 252 2 years 37 39 76 99 168 3 years 31 28 59 68 123 4+ years 23 21 44 51 92 Birth size3 Small/very small 66 40 106 na na Average or larger 32 34 65 na na Total 46 41 87 92 171 Note: Estimates are for deaths per 1,000 live births except for child mortality, which is deaths per 1,000 children age 12-59 months. na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey 8.5 PERINATAL MORTALITY Perinatal deaths include pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths within the first seven days of life (early neonatal deaths). The perinatal death rate is calculated by dividing the total number of perinatal deaths by the total number of pregnancies reaching seven months of gestation. The distinction between a stillbirth and an early neonatal death is a fine one, often depending on the observed presence or absence of some signs of life after delivery. The causes of stillbirths and early neonatal deaths overlap, and examining just one or the other can understate the true level of mortality around delivery. For these reasons, both events are usually combined and examined together. Information on stillbirths for the five years preceding the survey was derived from the calendar at the end of the Women’s Questionnaire. Infant and Child Mortality | 123 Table 8.5 presents the number of stillbirths, early neonatal deaths, and the perinatal mortality rates for the five-year period preceding the 2008 NDHS, by selected demographic and socio-economic characteristics. The perinatal mortality rate in Nigeria is 39 deaths per 1,000 pregnancies. The perinatal mortality rate is highest among teenage mothers and mothers age 40-49 (50 and 55 percent, respectively). Pregnancies that occurred at an interval less than 15 months have the highest perinatal mortality rate (76 deaths per 1,000 pregnancies). Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Nigeria 2008 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 46 164 50 4,204 20-29 102 408 34 14,801 30-39 65 231 38 7,828 40-49 15 68 55 1,495 Previous pregnancy interval in months4 First pregnancy 77 186 51 5,166 <15 17 101 76 1,551 15-26 50 272 41 7,861 27-38 41 190 32 7,301 39+ 43 121 25 6,448 Residence Urban 72 221 35 8,431 Rural 156 649 40 19,898 Zone North Central 27 99 33 3,856 North East 41 140 39 4,616 North West 83 257 38 8,863 South East 30 109 50 2,760 South South 19 136 42 3,686 South West 28 129 35 4,548 Mother's education No education 103 383 37 13,174 Primary 43 228 41 6,565 Secondary 68 218 40 7,064 More than secondary 14 41 36 1,525 Wealth quintile Lowest 55 222 42 6,580 Second 47 202 39 6,442 Middle 36 155 35 5,454 Fourth 49 141 38 5,052 Highest 40 150 40 4,800 Total 228 870 39 28,328 1 Stillbirths are foetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months' duration, expressed per 1,000. 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. 124 | Infant and Child Mortality 8.6 HIGH-RISK FERTILITY BEHAVIOUR Typically, the chances of dying in early childhood are much higher when children are born to mothers who are too young or too old, when children are born at less than a two-year birth interval, and when they are high-birth order children. Very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. Older women may also experience age- related problems during pregnancy and delivery. In this analysis, a mother is considered to be “too young” if she is less than 18 years and “too old” if she is older than 34 years at the time of delivery. A “short birth interval” is a birth occurring within 24 months of a previous birth. Table 8.6 shows the percent distribution of children born in the five- year period preceding the survey by risk category (no high risk, unavoidable risk, single high-risk, and the multiple high- risk). First births, which make up 14 percent of births, are considered “unavoid- able” and are shown as a separate risk category. Twenty-three percent of children born in the five-year period preceding the survey were born to mothers not in any of the high-risk categories. Sixty-four percent of births occurring in the five years preceding the survey were in an avoidable high-risk category: 40 percent were births to mothers in a single high-risk category and 24 percent were births to mothers in a multiple high-risk category. The risk ratio represents the increased risk of dying among births in various high-risk categories relative to births with no high-risk characteristics. The risk ratio for single high-risk categories is 1.37, while the risk ratio for multiple high-risk categories is 1.92. The highest risk is associated with mothers in the single high-risk category, age less than 18 years (1.73), followed by mothers in the multiple high-risk category, younger than 18 years, with birth intervals less than 24 months (3.88). The last column in Table 8.6 shows the distribution of currently married women by the risk category into which a birth would fall if conceived at the time of the survey. This column is based on assumptions that do not take into account family planning, postpartum infecundity, and prolonged abstinence. The data show that 13 percent of women are not in any elevated mortality risk category; however, 81 percent of currently married women have the potential for having a high-risk birth, with 32 and 49 percent in a single or multiple high-risk category, respectively. Table 8.6 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Nigeria 2008 Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women1 Not in any high-risk category 22.9 1.00 13.1a Unavoidable risk category First-order births between ages 18 and 34 years 13.6 1.07 6.0 Single high-risk category Mother's age <18 6.4 1.73 2.0 Mother's age >34 1.1 0.98 3.7 Birth interval <24 months 7.3 1.65 10.3 Birth order >3 25.1 1.21 16.2 Subtotal 39.9 1.37 32.2 Multiple high-risk category Age <18 and birth interval <24 months2 0.9 3.88 0.5 Age >34 and birth interval <24 months 0.2 (0.75) 0.2 Age >34 and birth order >3 11.6 1.35 27.7 Age >34 and birth interval <24 months and birth order >3 2.4 2.87 6.6 Birth interval <24 months and birth order >3 8.5 2.25 13.6 Subtotal 23.6 1.92 48.7 In any avoidable high-risk category 63.5 1.57 81.0 Total 100.0 na 100.0 Number of births/women 28,107 na 23,578 Notes: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Figures in parentheses are based on 25 to 49 unweighted cases. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilised women Maternal Health and Obstetric Fistula | 125 MATERNAL HEALTH AND OBSTETRIC FISTULA 9 Proper care during pregnancy and delivery is important for the health of both the mother and the baby, and is an indicator of the status of maternal and child health in the society. In the 2008 NDHS, women who had given birth in the five years preceding the survey were asked a number of questions about maternal care. Mothers were asked whether they had received tetanus toxoid injections while pregnant and whether they had obtained antenatal care during the pregnancy for their most recent live birth in the past five years. For all live births in the past five years, mothers were asked what type of assistance they received at the time of delivery. The health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child. The 2008 NDHS obtained information on the extent to which women in Nigeria receive care during pregnancy, during delivery, and in the period after the baby is born. These findings are important to policy- makers and programme implementers in designing appropriate strategies and interventions to improve maternal and child health care services.1 9.1 ANTENATAL CARE The major objective of antenatal care is to ensure optimal health outcomes for the mother and the baby. Antenatal care from a trained provider is important to monitor the pregnancy and reduce morbidity risks for the mother and child during pregnancy and delivery. Antenatal care provided by a skilled health worker enables: 1) early detection of complications and prompt treatment (e.g., detection and treatment of sexually transmitted infections); 2) prevention of diseases through immunisation and micronutrient supplementation; 3) birth preparedness and complication readiness; and 4) health promotion and disease prevention through health messages and counselling of pregnant women. In the 2008 NDHS, women who had given birth in the five years preceding the survey were asked a number of questions about maternal care. For the last live birth in that period, mothers were asked whether they had obtained antenatal care during the pregnancy. For women with two or more live births during the five-year period, data refer to the most recent birth. Table 9.1 presents information on the type of provider from whom antenatal care services were received for the most recent birth among women who had a live birth in the five years preceding the survey, by background characteristics. For women who reported more than one source for antenatal services, only the provider with the highest qualifications is presented in the table. According to the World Health Organisation (WHO), a skilled health worker is “an accredited health professional—such as a midwife, doctor, or nurse—who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate post-partum period, and in the identification, management, and referral of complications in women and newborns” (WHO, 2008). WHO further states that traditional birth attendants (TBA), trained or untrained, are excluded from the category of skilled health workers. In this context, the term TBA refers to traditional, independent (of the health system), non-formally trained and community-based providers of care during pregnancy, childbirth, and the postnatal period. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 126 | Maternal Health and Obstetric Fistula Table 9.1 shows that 58 percent of women age 15-49 received antenatal care (ANC) from a skilled provider (doctor, nurse/midwife, or auxiliary nurse/midwife) during their last pregnancy. Thirty percent of women received ANC services from a nurse or midwife, while 23 percent received ANC services from a doctor. Three percent of women received ANC services from a traditional birth attendant, and 36 percent did not receive ANC services at all. Mother’s age at birth is related to use of professional antenatal care services, increasing from 45 percent among women under age 20 at the time of the birth to 61 percent among women age 20- 34, and then declining to 55 percent among older mothers age 35-49. Child’s birth order is inversely related to the use of antenatal care. Women with higher order births are less likely to receive antenatal care from a skilled professional. Table 9.1 indicates that 64 percent of women pregnant with their first child received antenatal care from a skilled health worker, compared with 47 percent of women with births of order six or higher. Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Nigeria 2008 Background characteristic Doctor Nurse/ midwife Auxiliary nurse/ midwife Community health worker Traditional birth attendant Other No one Missing Total Percentage receiving antenatal care from a skilled provider1 Number of women Mother's age at birth <20 10.7 27.5 4.8 3.0 3.3 0.3 50.2 0.2 100.0 43.0 2,368 20-34 25.6 30.7 5.0 2.0 3.0 0.4 33.0 0.4 100.0 61.3 12,005 35-49 21.9 29.0 4.4 2.3 3.3 0.2 38.3 0.8 100.0 55.2 3,263 Birth order 1 28.9 30.3 5.0 2.6 3.4 0.3 29.5 0.1 100.0 64.2 3,053 2-3 27.1 29.8 5.2 1.9 2.9 0.5 32.3 0.4 100.0 62.1 5,632 4-5 22.9 31.4 4.8 2.1 3.2 0.4 34.8 0.4 100.0 59.1 4,264 6+ 13.9 28.7 4.5 2.3 2.9 0.2 47.0 0.6 100.0 47.0 4,687 Residence Urban 41.8 37.0 5.1 1.1 2.2 0.6 11.8 0.4 100.0 83.8 5,330 Rural 14.7 26.9 4.8 2.6 3.4 0.2 46.9 0.4 100.0 46.4 12,305 Zone North Central 23.0 34.4 7.6 3.8 4.3 0.3 26.2 0.4 100.0 65.1 2,525 North East 4.1 32.4 6.5 5.1 0.4 0.2 51.2 0.2 100.0 43.0 2,751 North West 6.6 22.1 2.4 0.7 0.3 0.1 67.1 0.7 100.0 31.1 5,372 South East 38.9 36.2 11.9 2.0 3.1 0.2 7.4 0.2 100.0 87.0 1,603 South South 33.4 32.8 3.6 1.8 9.1 0.2 18.8 0.3 100.0 69.8 2,310 South West 51.7 32.5 2.8 1.1 4.6 1.1 5.7 0.4 100.0 87.1 3,075 Mother's education No education 7.0 20.5 3.3 2.3 2.4 0.2 63.7 0.6 100.0 30.8 8,017 Primary 22.2 39.8 7.0 2.9 4.3 0.5 23.1 0.2 100.0 68.9 4,012 Secondary 41.0 38.9 6.1 1.6 3.7 0.5 7.9 0.3 100.0 86.0 4,557 More than secondary 67.9 25.7 3.7 0.4 0.5 0.1 1.2 0.4 100.0 97.4 1,050 Wealth quintile Lowest 4.9 15.5 3.1 2.7 2.2 0.2 71.0 0.3 100.0 23.5 4,074 Second 9.9 25.9 3.9 3.1 3.8 0.2 52.7 0.5 100.0 39.7 3,916 Middle 17.7 39.1 7.1 2.8 4.5 0.2 27.9 0.5 100.0 64.0 3,350 Fourth 32.2 43.0 6.7 1.2 2.7 0.5 13.1 0.5 100.0 81.9 3,204 Highest 59.0 30.8 4.1 0.4 2.0 0.6 2.9 0.2 100.0 93.8 3,091 Total 22.9 30.0 4.9 2.2 3.1 0.3 36.3 0.4 100.0 57.7 17,635 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, and auxiliary nurse/midwife Maternal Health and Obstetric Fistula | 127 The proportion who obtained ANC services from a skilled health worker is higher among women residing in urban areas (84 percent) than among women who reside in rural areas (46 percent). The percentage of women receiving antenatal care from a skilled provider varies substantially among the zones, from 31 percent of women in North West to 87 percent in South East and South West. There is also zonal variation in the type of health care professional from whom women receive ANC, with 52 percent of women in South West receiving care from a doctor, compared with only 4 percent of women in North East. Mother’s education is directly associated with increased use of a skilled health worker for ANC services. Almost all women (97 percent) with more than secondary education received ANC from a skilled health worker, compared with 31 percent of women with no education. Furthermore, women with more than secondary education are much more likely to receive ANC services from a doctor (68 percent) than their counterparts with no education (7 percent). Similarly, women in the higher wealth quintiles are more likely than women in the lower wealth quintiles to visit a skilled health provider or a doctor for ANC services. 9.2 NUMBER OF ANC VISITS AND TIMING OF FIRST VISIT The antenatal care policy in Nigeria follows the newest WHO approach to promote safe pregnancies, recommending at least four ANC visits for women without complications. This updated approach, called Focused Antenatal Care (FANC), emphasises quality of care during each visit instead of focusing on the number of visits. Early detection of problems during pregnancy leads to more timely treatment and referrals in the case of complications. This is particularly important in Nigeria, a large country where physical barriers are a challenge to the health care delivery system. In Nigeria, the provision of ANC is in transition from the traditional approach to the FANC approach. The new schedule of visits is as follows: the first visit should occur by the end of 16 weeks of pregnancy; the second visit should be between 24 and 28 weeks of pregnancy; the third visit is at 32 weeks; and the fourth visit takes place at 36 weeks. However, women with complications, special needs, or conditions beyond the scope of basic care may require additional visits. Table 9.2 presents information on the number of antenatal visits and the timing of the first antenatal visit for the most recent birth in the five years preceding the survey. Forty-five percent of women who had a live birth in the five years preceding the survey reported visiting antenatal clinics at least four times during pregnancy, and 8 percent reported two or three antenatal visits during their last pregnancy. While 2 percent of women had just one antenatal care visit, 36 percent did not receive any antenatal care. Table 9.2 shows that only 16 percent of women had their first antenatal visit in the first trimester of pregnancy; about 45 percent had their first ANC visit before six months of pregnancy, and 15 percent of women had their first antenatal visit between their sixth or seventh months of pregnancy. The median number of months of pregnancy at the first ANC visit is five months. Differentials do not vary much by urban and rural residence. There was no substantial change in the proportion of women receiving no antenatal care between the 2003 NDHS (37 percent) and the 2008 NDHS (36 percent), and the median gestational age at the first visit has remained the same at 5 months over the five-year period. 128 | Maternal Health and Obstetric Fistula Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Nigeria 2008 Residence Number and timing of ANC visits Urban Rural Total Number of ANC visits None 11.8 46.9 36.3 1 0.9 1.7 1.5 2-3 7.2 8.6 8.2 4+ 68.8 34.4 44.8 Don't know/missing 11.2 8.4 9.2 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 11.8 46.9 36.3 <4 22.2 13.7 16.2 4-5 41.7 23.5 29.0 6-7 21.2 12.5 15.1 8+ 1.7 1.5 1.6 Don't know/missing 1.5 1.9 1.8 Total 100.0 100.0 100.0 Number of women 5,330 12,305 17,635 Median months pregnant at first visit (for those with ANC) 5.0 5.1 5.0 Number of women with ANC 4,677 6,480 11,158 9.3 COMPONENTS OF ANTENATAL CARE The content of antenatal care is an essential component of the quality of services. Focused antenatal care hinges on the principle that every pregnancy is at risk of complications. Therefore, apart from receiving basic care, every pregnant woman should be monitored for complications. For that reason, ensuring that pregnant women receive information on the symptoms of complications or the danger signs of pregnancy, and screening for complications should be routinely included in all antenatal care visits. To assess ANC services, the 2008 NDHS respondents were asked a number of questions about the care they received during pregnancy for their most recent live birth. Table 9.3 presents information on the content of ANC services, including the percentage of women who took iron tablets or syrup, who took intestinal parasite drugs, who were informed of the symptoms of pregnancy complications, and who received selected routine services during ANC visits for their most recent birth in the past five years. For each of the specified components of antenatal care, women in urban areas were more likely to receive the component than women in rural areas. Looking at the specific ANC components, 54 percent of women took iron supplements during pregnancy. Mothers age 20 or older were more likely to take iron supplements than their younger counterparts. Women with six or more children were less likely to take iron supplements (45 percent) than women having five or less children. There is marked variation by urban-rural residence in the proportion of women who took iron supplements (77 percent in urban areas compared with 44 percent in rural areas). The percentage of women who took iron supplements increases with level of education and wealth quintile. Maternal Health and Obstetric Fistula | 129 As a component of antenatal care, the administration of intestinal anti-parasitic drugs is less common than the administration of iron supplements. Ten percent of women took drugs to combat intestinal parasites during their last pregnancy. There is variation in the use of de-worming mediations during pregnancy by mother’s age, birth order, residence, education, and wealth quintile. Women in urban areas (12 percent) are more likely than women in rural areas (9 percent) to have taken drugs to prevent intestinal parasites during their last pregnancy. Women with more than secondary education (15 percent) and women who are in the fourth and highest wealth quintile (about 14 percent) are more likely than other women to have taken drugs to prevent intestinal parasites. Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy for the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific ANC services, according to background characteristics, Nigeria 2008 Among women with a live birth in the past five years, the percentage who during the pregnancy for their last birth: Among women who received antenatal care for their most recent birth in the past five years, the percentage receiving selected services Background characteristic Took iron tablets or syrup Took intestinal parasite drugs Number of women with a live birth in the past five years Informed of signs of pregnancy complications Weighed Blood pressure measured Urine sample taken Blood sample taken Number of women receiving ANC for most recent birth Mother's age at birth <20 41.6 8.1 2,368 47.2 78.2 75.5 62.1 59.5 1,176 20-34 57.5 10.1 12,005 63.0 87.7 86.1 76.4 75.5 7,992 35-49 51.8 8.7 3,263 62.5 88.4 86.6 74.5 74.4 1,989 Birth order 1 59.6 11.3 3,053 61.7 86.2 84.7 75.7 75.5 2,150 2-3 58.4 10.6 5,632 64.5 87.8 86.2 76.8 75.6 3,790 4-5 55.7 9.7 4,264 62.9 87.2 86.2 75.6 74.1 2,762 6+ 44.8 7.0 4,687 54.1 85.5 82.4 68.6 68.4 2,456 Residence Urban 77.4 11.7 5,330 70.9 93.5 92.7 85.8 84.9 4,677 Rural 44.4 8.7 12,305 54.4 82.0 79.5 66.4 65.5 6,480 Zone North Central 50.3 11.7 2,525 45.7 82.8 82.1 74.7 71.8 1,854 North East 46.0 5.9 2,751 58.6 88.0 77.8 59.9 61.3 1,337 North West 30.6 3.2 5,372 40.5 90.5 80.8 67.6 62.5 1,730 South East 76.7 11.4 1,603 69.5 83.4 87.0 77.2 83.5 1,480 South South 63.8 18.2 2,310 57.8 80.3 81.2 71.3 70.9 1,869 South West 87.8 14.6 3,075 83.0 92.7 94.4 86.0 83.9 2,887 Mother's education No education 30.4 4.2 8,017 45.9 81.4 75.1 59.4 56.7 2,865 Primary 64.1 12.4 4,012 58.9 84.3 83.0 72.0 71.5 3,077 Secondary 79.6 15.3 4,557 68.1 89.7 90.4 81.8 82.1 4,184 More than secondary 89.7 14.8 1,050 83.2 97.6 97.2 94.3 92.4 1,033 Wealth quintile Lowest 24.0 4.2 4,074 42.8 76.0 68.2 52.7 52.3 1,167 Second 37.9 6.1 3,916 46.7 78.1 72.8 56.7 55.7 1,833 Middle 59.0 11.3 3,350 53.0 83.4 82.2 69.4 68.4 2,398 Fourth 75.0 14.7 3,204 67.7 89.7 90.6 81.8 81.7 2,766 Highest 88.7 13.7 3,091 78.1 96.4 96.3 91.3 89.6 2,995 Total 54.3 9.6 17,635 61.3 86.8 85.1 74.5 73.6 11,158 130 | Maternal Health and Obstetric Fistula Three in five women who received antenatal care during their last pregnancy were informed of the symptoms of pregnancy complications. Table 9.3 shows that women whose age was under 20 years at the time of the most recent birth and those with sixth- or higher-order births are less likely than other women to receive information on pregnancy complications during antenatal care. Women in urban areas are more likely to receive such information than those in rural areas (71 percent compared with 54 percent). More than eight in ten women who received antenatal care were weighed (87 percent) and had their blood pressure measured (85 percent), while about 75 percent of women had urine and blood samples taken. Blood testing is of particular importance in the screening for maternal syphilis, HIV, and anaemia. 9.4 TETANUS TOXOID INJECTIONS Neonatal tetanus is a leading cause of neonatal death in developing countries where a high proportion of deliveries take place at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) injections are given to women during pregnancy to prevent infant deaths due to neonatal tetanus; neonatal tetanus can result when sterile procedures are not followed in cutting the umbilical cord after delivery. In the 2008 NDHS, information was collected on the number of TT doses the mother received during pregnancy for her most recent birth in the five years preceding the survey. If the mother did not receive at least two TT injections during the pregnancy, additional questions were asked about the number and timing of TT injections that she may have received prior to that pregnancy. If a pregnant woman has not received any previous TT injections, she needs two doses of TT during pregnancy to be fully protected. However, if a woman was immunised before she became pregnant, she may require one or no TT injections during her pregnancy, depending on the number of injections she has received in the past, and the timing of the last injection. Five lifetime tetanus toxoid doses are required to provide protection from neonatal tetanus. Table 9.4 shows the percentage of women with a live birth in the five years preceding the survey who reported receiving TT injections during the pregnancy for the last live birth. Also shown is whether the last birth was fully protected against neonatal tetanus. An infant is considered fully protected if any of the following criteria are met: 1) the mother had two tetanus toxoid injections during the pregnancy; 2) the mother had two lifetime injections, with the last injection received within three years of the last birth; 3) the mother had three lifetime injections, with the last injection received within five years of the last birth; 4) the mother had four lifetime injections, with the last injection received within 10 years of the last birth; or 5) the mother had at least five lifetime injections. Forty-five percent of women received two or more TT injections during the pregnancy. Women younger than 20 were less likely to have received two or more TT injections than their counterparts age 20-49. The likelihood of receiving two doses of TT during pregnancy decreases with birth order. Half of women pregnant with their first child received two doses of TT during pregnancy, compared with 35 percent of those with sixth- or higher-order births. The southern zones have the highest proportion of women who received two or more injections during pregnancy (64 percent or more), while the northern zones have the lowest proportion (46 percent or less). The proportion of women who received two or more TT injections during pregnancy varies by level of education and wealth. Four in five women with more than secondary education received two or more TT injections during the last pregnancy compared with one in five women with no education. Women in the lowest wealth quintile (15 percent) were less likely to receive TT injections than those in the highest wealth quintile (80 percent). Maternal Health and Obstetric Fistula | 131 Overall, 48 percent of women’s last births were protected against neonatal tetanus. Women younger than 20 were least likely to have been protected (31 percent), compared with older women (47 percent or higher). The southern zones have the highest proportion of women protected against neonatal tetanus (ranging from 69 to 81 percent), while the northern zones have the lowest proportion (ranging from 20 to 50 percent). Uneducated women and those in the lowest wealth quintile are less likely to have their last birth protected against tetanus than other women. Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid (TT) injections during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Nigeria 2008 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother's age at birth <20 29.5 31.1 2,368 20-34 48.6 51.4 12,005 35-49 44.7 47.4 3,263 Birth order 1 49.7 51.0 3,053 2-3 49.3 52.2 5,632 4-5 47.7 50.7 4,264 6+ 35.3 38.4 4,687 Residence Urban 67.3 71.3 5,330 Rural 35.7 37.9 12,305 Zone North Central 45.7 48.9 2,525 North East 28.7 30.0 2,751 North West 17.9 20.1 5,372 South East 77.7 81.3 1,603 South South 63.6 68.7 2,310 South West 76.9 79.1 3,075 Mother's education No education 19.5 20.8 8,017 Primary 54.5 58.3 4,012 Secondary 73.8 77.2 4,557 More than secondary 82.8 88.9 1,050 Wealth quintile Lowest 14.5 15.3 4,074 Second 27.9 30.1 3,916 Middle 50.8 53.8 3,350 Fourth 66.6 70.3 3,204 Highest 79.7 84.2 3,091 Total 45.3 48.0 17,635 1 Includes mothers with two injections during the pregnancy for her last live birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth 132 | Maternal Health and Obstetric Fistula 9.5 PLACE OF DELIVERY Increasing the percentage of births delivered in health facilities is an important factor in reducing deaths arising from the complications of pregnancy. The expectation is that if a complication arises during delivery, a skilled health worker can manage the complication or refer the mother to the next level of care. Table 9.5 shows the percent distribution of all live births in the five years preceding the survey by place of delivery, and the percentage of births delivered in a health facility, according to background characteristics. Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Nigeria 2008 Health facility Background characteristic Public sector Private sector Home Other Missing Total Percentage delivered in a health facility Number of births Mother's age at birth <20 14.7 7.2 75.9 1.2 1.0 100.0 21.9 4,159 20-34 21.4 17.0 58.6 2.0 1.0 100.0 38.4 19,636 35-49 19.0 13.3 64.6 2.1 1.0 100.0 32.3 4,305 Birth order 1 24.5 20.1 51.7 2.7 1.0 100.0 44.6 5,371 2-3 21.7 18.7 56.6 2.1 0.9 100.0 40.4 9,334 4-5 19.4 14.0 63.6 1.9 1.1 100.0 33.4 6,564 6+ 14.7 6.9 76.2 1.1 1.1 100.0 21.6 6,831 Residence Urban 30.9 28.5 35.9 3.6 1.0 100.0 59.4 8,359 Rural 15.4 9.3 73.1 1.2 1.0 100.0 24.7 19,741 Zone North Central 27.0 13.9 57.3 0.5 1.3 100.0 41.0 3,830 North East 12.0 0.8 86.6 0.1 0.5 100.0 12.8 4,575 North West 7.6 0.8 90.1 0.0 1.5 100.0 8.4 8,779 South East 25.3 48.6 21.1 4.0 0.9 100.0 73.9 2,730 South South 30.0 18.1 48.5 2.9 0.5 100.0 48.1 3,667 South West 35.0 35.0 22.5 6.7 0.8 100.0 70.0 4,519 Mother's education No education 7.5 2.2 88.7 0.3 1.3 100.0 9.7 13,071 Primary 23.4 15.6 57.2 3.0 0.8 100.0 39.0 6,521 Secondary 34.8 31.9 28.3 4.0 0.9 100.0 66.7 6,997 More than secondary 45.3 44.5 8.3 1.6 0.4 100.0 89.8 1,511 Antenatal care visits1 None 2.6 0.7 95.7 0.8 0.1 100.0 3.3 6,403 1-3 18.8 10.8 69.7 0.6 0.1 100.0 29.6 1,699 4+ 34.5 25.9 36.2 3.3 0.0 100.0 60.4 7,905 Don't know/missing 32.6 25.2 37.7 2.4 2.1 100.0 57.7 1,628 Wealth quintile Lowest 4.8 2.4 91.3 0.6 0.9 100.0 7.3 6,525 Second 10.4 4.7 82.6 1.0 1.3 100.0 15.1 6,395 Middle 21.0 12.2 64.1 1.5 1.2 100.0 33.2 5,417 Fourth 34.7 21.4 40.0 3.1 0.8 100.0 56.1 5,003 Highest 37.2 42.4 15.2 4.3 0.8 100.0 79.6 4,760 Total 20.0 15.0 62.1 1.9 1.0 100.0 35.0 28,100 1 Includes only the most recent birth in the five years preceding the survey Maternal Health and Obstetric Fistula | 133 Thirty-five percent of births in Nigeria are delivered in a health facility; 20 percent of deliveries occur in public sector facilities and 15 percent occur in private sector facilities. Three in five births (62 percent) occur at home. By age, women 20-34 are most likely to deliver in a health facility (38 percent). Women having their first baby are more likely than other women to deliver in a health facility; the proportion of births occurring in a facility decreases sharply as birth order increases. Women in urban areas are more than twice as likely to deliver in a health facility as their rural counterparts (60 percent compared with 25 percent). South East has the highest proportion of institutional deliveries (74 percent), followed by South West (70 percent), while North West has the lowest proportion (8 percent). Women with higher levels of educational attainment are more likely to deliver in a health facility than women with less education or no education. For example, women with more than secondary education (90 percent) are nine times more likely to deliver in a health facility, compared with women with no education (10 percent). The proportion of births occurring in a health facility increases steadily with increasing wealth quintile, from 7 percent of births in the lowest wealth quintile to 80 percent among those in the highest quintile. Similarly, 5 percent of births to mothers in the lowest wealth quintile occur in a public health facility, compared with 37 percent among births to women in the highest wealth quintile. Women in the highest wealth quintile are the only group more likely to give birth in a private facility than in a public facility (42 percent compared with 37 percent, respectively). The majority of women who received no ANC services delivered at home (96 percent). 9.6 ASSISTANCE DURING DELIVERY In addition to place of birth, assistance during childbirth is an important variable influencing the birth outcome and the health of the mother and infant. The skills and performance of the person providing assistance during delivery determine whether complications are managed and hygienic practices are observed. Table 9.6 shows the percent distribution of live births in the five years preceding the survey by person providing assistance at delivery and the percentage of births attended by a skilled health worker, according to background characteristics. Note that in Nigeria an auxiliary Figure 9.1 Place of Delivery NDHS 2008 Other 2% Private sector 15% Public sector 20% Home 62% 134 | Maternal Health and Obstetric Fistula nurse/midwife is considered a skilled health worker. Table 9.6 also presents data on the prevalence of births by caesarean section (C-section). According to Table 9.6, 39 percent of births in the five years preceding the survey were assisted by a skilled health worker (doctor, nurse, midwife, or auxiliary nurse/midwife); 9 percent by a doctor; 25 percent by a nurse or midwife; and 5 percent by auxiliary nurse/midwife. In the absence of a skilled health worker, a traditional birth attendant was the next most common person assisting a delivery (22 percent). Nineteen percent of births were assisted by a relative or other person, and an equal proportion of births were attended by no one. Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider and percentage delivered by caesarean section, according to background characteristics, Nigeria 2008 Person providing assistance during delivery Background characteristic Doctor Nurse/ midwife Auxiliary nurse/ midwife Traditional birth attendant Relative/ other No one Don't know/ missing Total Percentage delivered by a skilled provider1 Percentage delivered by C- section Number of births Mother's age at birth <20 3.9 17.4 3.3 28.7 26.2 18.8 1.7 100.0 24.6 0.8 4,159 20-34 10.3 27.4 4.9 20.3 17.5 18.1 1.4 100.0 42.7 2.1 19,636 35-49 8.5 23.0 4.0 20.7 17.3 25.3 1.3 100.0 35.6 1.8 4,305 Birth order 1 13.6 30.5 5.0 21.4 18.5 9.7 1.2 100.0 49.1 3.3 5,371 2-3 10.9 28.8 4.7 20.1 18.4 15.7 1.4 100.0 44.4 2.1 9,334 4-5 8.1 24.3 5.0 21.9 17.9 21.2 1.6 100.0 37.5 1.4 6,564 6+ 4.0 17.3 3.5 23.5 20.2 30.0 1.4 100.0 24.8 0.7 6,831 Place of delivery Health facility 25.2 63.8 9.5 0.5 0.5 0.3 0.2 100.0 98.5 5.2 9,836 Elsewhere 0.4 4.6 1.9 33.4 29.0 29.9 0.6 100.0 6.9 0.0 17,979 Missing 0.0 1.1 0.0 1.4 0.7 3.5 93.2 100.0 1.1 0.0 286 Residence Urban 20.3 39.5 5.6 13.1 11.2 9.0 1.3 100.0 65.4 3.7 8,359 Rural 4.4 19.3 4.1 25.2 22.0 23.7 1.5 100.0 27.7 1.0 19,741 Zone North Central 9.9 26.7 6.1 9.5 36.1 10.2 1.5 100.0 42.7 2.0 3,830 North East 1.4 11.7 2.4 33.6 31.0 18.6 1.3 100.0 15.5 0.6 4,575 North West 2.3 6.6 0.9 25.9 18.5 43.8 2.0 100.0 9.8 0.4 8,779 South East 12.2 53.2 16.5 8.4 5.5 3.0 1.3 100.0 81.8 3.9 2,730 South South 12.3 38.5 5.0 32.9 7.6 3.1 0.7 100.0 55.8 3.2 3,667 South West 25.0 46.5 5.0 10.2 9.3 3.2 0.8 100.0 76.5 3.4 4,519 Mother's education No education 2.0 7.8 1.8 27.9 24.8 34.0 1.8 100.0 11.5 0.4 13,071 Primary 7.7 30.6 6.0 22.6 21.3 10.9 1.0 100.0 44.2 1.4 6,521 Secondary 17.1 48.3 8.0 12.9 8.8 3.6 1.3 100.0 73.4 3.2 6,997 More than secondary 40.0 47.2 6.8 2.8 1.8 1.2 0.4 100.0 93.9 10.0 1,511 Wealth quintile Lowest 1.1 5.8 1.4 26.2 29.7 34.5 1.4 100.0 8.3 0.3 6,525 Second 2.8 12.4 2.4 28.8 24.1 27.8 1.7 100.0 17.6 0.4 6,395 Middle 4.4 26.8 6.4 26.5 18.3 15.9 1.7 100.0 37.5 0.8 5,417 Fourth 10.9 44.7 7.7 15.9 11.8 7.9 1.2 100.0 63.3 2.7 5,003 Highest 32.0 47.3 6.4 6.0 4.5 2.9 0.9 100.0 85.7 6.1 4,760 Total 9.1 25.3 4.6 21.6 18.8 19.3 1.4 100.0 38.9 1.8 28,100 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife and auxiliary nurse/midwife Maternal Health and Obstetric Fistula | 135 Women under age 20 (25 percent) are least likely to receive assistance from a skilled provider at delivery. Older women (35-49 years) are most likely to deliver without any assistance (25 percent). The likelihood of a skilled attendant delivering a birth decreases with increasing birth order, from 49 percent for first-order births to 25 percent for births of order six or higher. One of the most striking differentials in assistance during childbirth is by urban-rural residence. About seven in ten births to urban women are attended by a skilled provider, compared with three in ten births to women in rural areas. Women in urban areas are most likely to be assisted by a nurse or midwife (40 percent), while women in rural areas are most likely to be assisted by a traditional birth attendant (25 percent). Births in North East, South South, and North West zones are more likely to be assisted by a traditional birth attendant (34, 33, and 26 percent, respectively) than births in other zones. Women in North West are much more likely to deliver without any assistance (44 percent) than are women in other zones (19 percent or lower). A mother’s level of education and wealth status have a positive association with the likelihood that her delivery will be attended by a skilled provider. Table 9.6 shows that about 2 percent of the births were delivered by C-section. Caesarean births are slightly more common among first births (3 percent) and births to women in urban areas (4 percent). Women with more than secondary education are much more likely than other women to give birth by C-section (10 percent, compared with 3 percent or less). Higher proportions of births in the southern zones are delivered by C-section than in other zones. 9.7 POSTNATAL CARE A large proportion of maternal and neonatal deaths occur during the first 24 hours after delivery. Thus, prompt postnatal care is important for both the mother and the child to treat complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. It is recommended that all women receive a health check within three days of giving birth. To assess the extent of postnatal care, women with a live birth during the five years prior to the survey were asked questions about any postnatal care they may have received related to the last birth. If they reported receiving care, they were asked about the timing of the first check-up and the type of health provider performing the postnatal check-up. This information is presented according to background characteristics in Tables 9.7 and 9.8. Table 9.7 shows that more than half (56 percent) of women did not receive any postnatal care; however, 38 percent received a postnatal check-up within two days of delivery, and 3 percent of women had a check-up 3 to 41 days after delivery. Mothers age 20-34 and mothers who gave birth to their first child are most likely to receive postnatal care within the first four hours after giving birth (20 and 33 percent, respectively). Urban women are twice as likely as rural women to receive a postnatal check-up in the first four hours after delivery (44 percent compared with 22 percent). Almost six in ten women (59 percent) in urban areas obtain postnatal care within the first two days after delivery, compared with three in ten (30 percent) women in rural areas. By zone, the highest percentage of women who receive postnatal care within the first two days after delivery is found in the South West zone (68 percent). The lowest percentage of women utilising postnatal care services is in North West zone, where only 17 percent received postnatal care within two days of delivery, and only 19 percent received postnatal care in the first 41 days. As with other health services surrounding childbirth, better educated and wealthier mothers are more likely to receive a postnatal check-up within the first two days after delivery. 136 | Maternal Health and Obstetric Fistula Table 9.7 Timing of first postnatal check-up Percent distribution of women age 15-49 with a birth in the five years preceding the survey by timing of first postnatal check-up (for the last live birth), according to background characteristics, Nigeria 2008 Timing of first postnatal check-up (time since delivery) Background characteristic Less than 4 hours 4-23 hours 2 days 3-41 days Don't know/ missing No postnatal check-up1 Total Number of women Mother's age at birth <20 22.2 3.0 4.0 2.2 1.6 67.0 100.0 2,368 20-34 30.0 5.2 5.6 3.4 2.3 53.5 100.0 12,005 35-49 26.8 4.3 4.8 3.2 1.8 59.1 100.0 3,263 Birth order 1 33.2 5.9 6.7 4.5 2.7 46.9 100.0 3,053 2-3 31.6 5.8 5.8 2.9 2.1 51.7 100.0 5,632 4-5 29.1 4.2 5.1 3.5 2.2 55.9 100.0 4,264 6+ 20.7 3.1 3.7 2.5 1.7 68.3 100.0 4,687 Residence Urban 43.9 7.4 7.2 4.2 3.2 34.2 100.0 5,330 Rural 21.7 3.6 4.4 2.8 1.7 65.9 100.0 12,305 Zone North Central 29.3 6.0 3.9 2.6 1.5 56.7 100.0 2,525 North East 22.4 2.3 2.4 2.1 0.5 70.3 100.0 2,751 North West 15.3 0.7 1.4 1.4 1.1 80.1 100.0 5,372 South East 22.3 6.7 11.0 6.2 2.6 51.1 100.0 1,603 South South 39.9 9.8 9.6 4.3 6.3 30.0 100.0 2,310 South West 50.2 8.2 9.2 5.5 2.5 24.5 100.0 3,075 Education No education 14.7 1.4 2.4 1.6 1.0 79.0 100.0 8,017 Primary 30.2 5.7 6.5 4.4 2.4 50.8 100.0 4,012 Secondary 44.2 8.3 7.9 4.7 3.6 31.3 100.0 4,557 More than secondary 57.4 11.1 10.6 4.5 3.3 13.1 100.0 1,050 Wealth quintile Lowest 11.1 1.5 2.4 1.5 0.8 82.7 100.0 4,074 Second 16.6 2.5 3.5 2.3 1.2 74.0 100.0 3,916 Middle 27.1 4.6 5.9 3.6 2.2 56.6 100.0 3,350 Fourth 40.2 7.5 6.5 4.7 3.0 38.0 100.0 3,204 Highest 55.2 9.2 9.1 4.6 4.2 17.8 100.0 3,091 Total 28.4 4.7 5.2 3.2 2.1 56.3 100.0 17,635 1 Includes women who received a check-up after 41 days Table 9.8 presents information on the type of health provider performing the first postnatal check-up. This information is important because the skills of a provider determine the ability to diagnose problems and to recommend appropriate treatment or referral. Thirty-two percent of women received a postnatal check-up from a doctor, nurse, or midwife, 3 percent from auxiliary nurse/midwife, and 7 percent from a traditional birth attendant. Urban women and those who are better educated are more likely to receive postnatal care from a doctor, nurse, or midwife after delivery. For example, 56 percent of women in urban areas received postnatal care from a doctor, nurse, or midwife, compared with 22 percent of women in rural areas. Maternal Health and Obstetric Fistula | 137 Table 9.8 Provider of first postnatal check-up Percent distribution of women age 15-49 with a birth in the five years preceding the survey by provider of mother's first postnatal check-up (for the last live birth), according to background characteristics, Nigeria 2008 Provider of mother's first postnatal check-up Background characteristic Doctor/ nurse/ midwife Auxiliary nurse/ midwife Community health worker Traditional birth attendant Other Don't know/ missing No postnatal check-up1 Total Number of women Mother's age at birth <20 19.6 2.5 0.8 9.7 0.1 0.3 67.0 100.0 2,368 20-34 34.7 3.3 0.8 7.1 0.1 0.4 53.5 100.0 12,005 35-49 30.8 2.3 0.8 6.6 0.1 0.3 59.1 100.0 3,263 Birth order 1 40.4 3.6 0.8 8.0 0.1 0.1 46.9 100.0 3,053 2-3 36.7 3.0 0.8 7.1 0.1 0.5 51.7 100.0 5,632 4-5 31.8 3.4 0.7 7.5 0.2 0.4 55.9 100.0 4,264 6+ 20.9 2.2 0.9 7.2 0.1 0.4 68.3 100.0 4,687 Residence Urban 56.0 3.8 0.4 4.7 0.2 0.7 34.2 100.0 5,330 Rural 21.5 2.7 1.0 8.6 0.1 0.2 65.9 100.0 12,305 Zone North Central 34.5 4.4 1.5 2.7 0.1 0.3 56.7 100.0 2,525 North East 13.8 2.2 1.1 12.2 0.1 0.3 70.3 100.0 2,751 North West 11.1 0.7 0.7 7.0 0.0 0.3 80.1 100.0 5,372 South East 39.8 7.5 0.1 0.7 0.4 0.4 51.1 100.0 1,603 South South 45.7 4.5 0.7 18.2 0.2 0.7 30.0 100.0 2,310 South West 68.1 3.3 0.7 3.0 0.1 0.4 24.5 100.0 3,075 Education No education 10.3 1.2 0.8 8.4 0.0 0.2 79.0 100.0 8,017 Primary 34.9 4.1 0.9 8.7 0.2 0.4 50.8 100.0 4,012 Secondary 56.4 4.9 0.8 5.9 0.2 0.5 31.3 100.0 4,557 More than secondary 80.2 4.3 0.1 1.4 0.2 0.6 13.1 100.0 1,050 Wealth quintile Lowest 6.6 0.7 0.9 8.8 0.1 0.1 82.7 100.0 4,074 Second 14.5 1.6 0.9 8.7 0.1 0.2 74.0 100.0 3,916 Middle 28.6 4.3 1.1 8.8 0.1 0.4 56.6 100.0 3,350 Fourth 48.4 5.0 0.8 6.9 0.3 0.5 38.0 100.0 3,204 Highest 73.9 4.3 0.2 2.8 0.2 0.8 17.8 100.0 3,091 Total 31.9 3.0 0.8 7.4 0.1 0.4 56.3 100.0 17,635 1 Includes women who received a check-up after 41 days 9.8 PERCEIVED PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers some women face in seeking care during pregnancy and at the time of delivery. In the 2008 NDHS, women were asked whether each of the following factors would be a big problem in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to health facility, transport cost, not wanting to go alone, concern there may not be a female provider or any health provider, and concern that drugs may not be available. Table 9.9 and Figure 9.2 present information on the extent to which women reported that each of these factors was a serious problem for them in accessing health care. 138 | Maternal Health and Obstetric Fistula Three-quarters of women reported that they have at least one serious problem in accessing health care. The leading barrier to health care for Nigerian women is getting money for treatment. Fifty-six percent of women said that getting money for treatment was a serious problem in accessing health care. Forty-one percent of women said they were concerned that there would be no drugs available at the health facility. About one in three women reported that transportation, distance to the health facility, and not having a provider to attend to them are big problems. Twenty-one percent of women were concerned that there would be no female provider to attend to them. Not wanting to go alone (17 percent), and problems getting permission to go for treatment (14 percent) were less likely to be reported as a hindrance to seeking health care. Table 9.9 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem and background characteristics, Nigeria 2008 Problems in accessing health care Background characteristic Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concerned no female provider available Concerned no provider available Concerned no drugs available At least one problem accessing health care Number of women Age 15-19 16.2 56.6 36.8 33.8 23.6 20.5 33.2 40.5 73.2 6,493 20-34 13.3 55.2 35.3 33.1 15.7 20.3 33.5 41.4 73.0 17,076 35-49 12.4 58.6 37.4 35.6 15.4 20.8 33.4 41.7 75.1 9,816 Number of living children 0 12.5 51.8 32.3 29.6 19.1 17.1 30.6 37.7 68.8 10,392 1-2 14.6 56.0 37.1 35.0 16.6 21.6 34.0 41.9 73.7 8,352 3-4 13.5 59.4 37.0 34.6 15.8 21.1 32.9 41.2 75.8 7,591 5+ 14.2 60.6 40.0 38.5 16.3 23.5 37.5 45.9 78.7 7,049 Marital status Never married 10.6 52.2 31.0 28.2 18.0 13.7 28.1 35.2 67.4 8,397 Married or living together 15.0 57.4 37.9 35.9 17.1 23.0 35.3 43.4 75.7 23,578 Divorced/separated/widowed 7.6 65.1 38.0 37.3 13.6 19.1 34.4 42.2 78.5 1,409 Employed last 12 months Not employed 15.1 55.9 36.4 34.2 20.0 21.9 35.3 43.8 73.9 12,464 Employed for cash 12.9 55.1 33.6 31.6 14.6 20.6 32.7 40.2 72.6 16,532 Employed not for cash 11.8 63.2 45.6 42.4 18.6 16.1 30.7 38.0 77.2 4,309 Residence Urban 9.8 44.1 21.1 18.9 10.4 14.1 26.0 32.4 61.4 11,934 Rural 15.7 63.3 44.6 42.4 20.9 24.1 37.6 46.2 80.5 21,451 Zone North Central 14.3 65.4 40.6 36.5 19.5 15.2 25.8 35.2 75.8 4,748 North East 20.5 63.2 47.8 47.6 31.6 26.1 47.4 58.4 87.3 4,262 North West 20.4 57.8 37.7 37.4 18.7 39.4 48.6 57.0 80.3 8,022 South East 16.0 65.0 42.3 42.6 16.3 13.0 30.2 40.1 74.5 4,091 South South 6.9 50.7 32.2 26.8 10.7 11.7 31.6 37.6 69.1 5,473 South West 4.8 43.8 23.8 20.3 10.4 10.1 15.5 19.9 59.1 6,789 Education No education 21.5 64.6 45.9 45.0 24.0 32.7 44.0 52.9 84.3 11,942 Primary 11.9 62.3 39.9 36.6 16.5 17.3 32.0 39.8 77.4 6,566 Secondary 8.6 50.3 28.8 26.0 13.1 12.9 26.4 33.6 66.2 11,904 More than secondary 5.9 35.1 18.6 16.0 7.9 9.4 22.3 28.6 52.8 2,974 Wealth quintile Lowest 21.0 71.8 59.3 57.8 29.0 32.6 45.4 54.4 89.6 6,194 Second 17.8 66.2 46.1 43.6 21.5 28.0 40.2 49.3 83.0 6,234 Middle 14.5 60.4 36.9 35.0 17.2 19.0 33.8 42.7 76.4 6,341 Fourth 10.1 51.2 25.7 23.0 12.2 14.4 28.5 35.2 68.2 6,938 Highest 6.7 37.7 18.4 16.1 8.6 11.4 22.4 28.5 55.9 7,678 Total 13.6 56.4 36.2 34.0 17.2 20.5 33.4 41.3 73.7 33,385 Note: Total includes 1 woman with information missing on marital status and 81 women with information missing on employment status Maternal Health and Obstetric Fistula | 139 9.9 OBSTETRIC FISTULA The 2008 NDHS included a series of questions on obstetric fistula to measure awareness levels, to estimate the prevalence of this condition among Nigerian women, and to examine events reported to precipitate fistula symptoms, as well as access to treatment. Obstetric fistula is a complication that arises from obstructed or prolonged labour resulting in a hole or opening in the birth canal. This condition develops when the blood supply to the tissues of the vagina, bladder, and/or rectum is cut off by prolonged obstructed labour without prompt medical care. As a result of unrelieved obstructed labour, the bladder, urethra, or rectum and the vaginal wall are compressed between the foetal head and the maternal pubis. This compression and loss of blood supply produces necrosis of the compressed tissues resulting in uncontrolled leakage of urine from the bladder through the vagina, in the case of vesico-vaginal fistula (VVF) and leakage of stool from the vagina, in the case of recto-vaginal fistula (RVF) (FMWA, 2006). The woman is left with chronic incontinence, which results in social problems such as rejection, shame, and stigma as well as economic problems. Fistula can also result from sexual violence or complications from pelvic surgery. Underdevelopment of the pelvis, arising from chronic malnutrition, is a common cause of obstructed labour that can result in fistula. Obstetric fistula is almost entirely preventable with timely and effective medical intervention. Fistula affects the most powerless members of society, occurring disproportionately among impoverished girls and women, especially those living far from medical services and emergency obstetric care. Many women do not know it can be treated, and some have lived with the condition for prolonged periods. An estimated 2 million women in sub-Sahara Africa, South Asia, and the Arab world are living with the condition, and some 50,000-100,000 new cases occur each year (UNFPA, 2008). All women interviewed in the 2008 NDHS were asked if they have heard of obstetric fistula and, if they have, whether they themselves had experienced the condition. Those who reported suffering from fistula were further asked whether the problem occurred after a normal labour and delivery, after a very difficult labour and delivery, or after another event, and if they had ever been treated for it. These women were asked if there were other women in the household who suffered from it and if so how many. 14 56 36 34 17 21 33 41 74 Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concerned no female provider available Concerned no provider available Concerned no drugs available At least one problem accessing health care 0 20 40 60 80 100 Percent Figure 9.2 Problems in Accessing Health Care NDHS 2008 140 | Maternal Health and Obstetric Fistula 9.9.1 Knowledge of Obstetric Fistula Table 9.10 presents data on the percentage of all women who have heard of obstetric fistula symptoms, and the percentage of women reporting fistula symptoms according to age group and socio-economic characteristics. The findings indicate that 31 percent of women have heard of obstetric fistula symptoms. Knowledge of obstetric fistula is higher among rural women (33 percent) than women residing in urban areas (27 percent). There is substantial variation in knowledge by age: 20 percent of women age 15-19 years have heard of obstetric fistula, compared with 37 percent of women age 40-44 years. Knowledge of obstetric fistula is highest among women living in the North West and North East (66 and 50 percent, respectively), among those with no education (47 percent), among women currently in union (36 percent), and among women in the poorest households (41 percent). A very small proportion of women (less than 1 percent) reported experiencing symptoms consistent with fistula. Table 9.10 Knowledge of fistula and experience of fistula-like symptoms Percentage of all women who have heard of fistula symptoms, and percentage reporting fistula symptoms, by age group and socio-economic characteristics, Nigeria 2008 Background characteristic Percentage who have heard of fistula symptoms Percentage who report ever experiencing symptoms consistent with fistula Number of women Age 15-19 20.1 0.3 6,493 20-24 29.6 0.3 6,133 25-29 31.7 0.4 6,309 30-34 34.6 0.4 4,634 35-39 34.1 0.7 3,912 40-44 37.2 0.4 3,032 45-49 36.4 0.5 2,872 Residence Urban 27.3 0.3 11,934 Rural 32.5 0.4 21,451 Zone North Central 21.1 0.8 4,748 North East 49.6 0.5 4,262 North West 66.2 0.3 8,022 South East 7.9 0.3 4,091 South South 17.0 0.5 5,473 South West 8.1 0.2 6,789 Education No education 46.9 0.4 11,942 Primary only 25.8 0.5 6,566 Secondary or higher 19.7 0.4 14,878 Marital status Currently in union 36.2 0.4 23,578 Never in union 16.3 0.3 9,048 Divorced/separated 28.8 0.9 759 Wealth quintile Lowest 41.4 0.5 6,194 Second 39.8 0.5 6,234 Middle 29.3 0.3 6,341 Fourth 24.0 0.4 6,938 Highest 21.7 0.4 7,678 Total 30.7 0.4 33,385 Note: Total includes 1 woman with information missing on marital status Maternal Health and Obstetric Fistula | 141 9.9.2 Characteristics of Labour Reported as Cause of Fistula Symptoms Table 9.11 shows information on the small group of women who experienced symptoms of fistula and who reported that the cause of their symptoms was labour or childbirth. Women who reported fistula symptoms are most likely to say that the symptoms started following the delivery of their first child (46 percent). Thirty percent reported that the fistula symptoms began after delivery of their second, third, or fourth child. The proportion of women reporting that their fistula symptoms started after delivering five or more children decreases to 21 percent. Table 9.11 shows the characteristics of labour and delivery that women reported were the cause of their fistula. Three-quarters of women with fistula reported that their symptoms began after a difficult labour. Forty-four percent reported that their symptoms started following a difficult labour in which the baby was born alive, while 30 percent of women reported their symptoms started following a very difficult delivery in which the baby was stillborn. Another 19 percent of women reported that their fistula symptoms began following a normal labour and delivery in which the baby was born alive. Table 9.11 also shows the percent distribution of women who have experienced symptoms of fistula following a delivery by the number of days after the delivery that symptoms began. One in four women reported that symptoms began 2-4 days after delivery, while 16 percent reported that symptoms began on the same day or the day following the delivery. Around one in five women reported the symptoms began 5-7 days or 8 days or more after delivery. Table 9.11 Characteristics of labour reported as cause of fistula symptoms Among women who reported labour as the cause of their fistula symptoms, the percent distribution by parity at time of developing fistula symptoms, by characteristics of labour and delivery, by survival status of infant, and by the number of days after the delivery that symptoms began, Nigeria 2008 Characteristic Total Parity at time of symptom development First birth 45.7 Second through fourth birth 29.8 Fifth birth or higher 21.4 Missing 3.1 Characteristics of labour and delivery Normal labour and delivery, baby born alive 19.0 Normal labour and delivery, baby stillborn 1.4 Very difficult labour and delivery, baby born alive 44.0 Very difficult labour and delivery, baby stillborn 30.2 Very difficult labour and delivery, missing outcome 2.6 Missing how was the labour and delivery 2.7 Number of days after delivery that symptoms began 0-1 16.3 2-4 24.2 5-7 21.2 8 or more days 21.7 Missing number of days 16.5 Total 100.0 Number 62 Child Health | 143 CHILD HEALTH 10 This chapter presents findings on several areas of importance to child survival. Information is presented on birth weight, child vaccinations, and treatment practices for children who have the three most common childhood diseases: acute respiratory infection (ARI), fever, and diarrhoea. Many early childhood deaths can be prevented by immunising children against preventable diseases and by ensuring that children receive prompt and appropriate treatment when they become ill. Results are presented on the prevalence of ARI and treatment of ARI with antibiotics, and the prevalence of fever and treatment of fever with anti-malarial drugs. The prevalence of treatment of diarrhoeal diseases with oral rehydration therapy (including increased fluids) is useful in assessing programmes that recommend such treatment. Information is also presented on the manner of disposing of children’s faecal matter, because appropriate sanitary practices help prevent and reduce the severity of diarrhoeal disease.1 10.1 CHILD’S WEIGHT AT BIRTH Birth weight is an important indicator for assessing child health in terms of early exposure to childhood morbidity and the risks of mortality. Children whose birth weight is less than 2.5 kilograms, or children reported to be ‘very small’ or ‘smaller than average,’ are considered to have a higher than average risk of early childhood death. In the 2008 NDHS, for births in the five years preceding the survey, birth weight was recorded in the Women’s Questionnaire based on either a written record or the mother’s report. The mother’s estimate of the infant’s size at birth was also obtained because birth weight may not be known for many infants. While the mother’s estimate is subjective it can be a useful proxy for the child’s weight. Table 10.1 shows that birth weight information was reported for 18 percent of live births that occurred in the five years preceding the survey; 8 percent of these infants had low birth weight (less than 2.5 kg). Younger mothers (less than 20 years old) are more likely to have low birth weight infants when compared with older mothers (10 percent compared with 7-9 percent, respectively). By birth order, the first birth and the sixth or higher births (9 percent each) are more likely to result in low birth weight infants than other birth orders. Among the zones, South East has the lowest proportion of low birth weight infants (6 percent) and North East and North Central zones have the highest proportions (13 and 10 percent, respectively). There is an inverse relationship between low birth weight and mother’s education and household wealth quintile. As level of education and household wealth increase, the percentage of low birth weight infants decreases. For example, the percentage of births less than 2.5 kg decreases from 11 percent among mothers with no education to 6 percent among mothers with more than a secondary education. Likewise, the percentage of births less than 2.5 kg decreases from 20 percent among mothers in the lowest wealth quintile to 7 percent among mothers in the highest wealth quintile. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 144 | Child Health Table 10.1 includes information on the mother’s estimate of the infant’s size at birth. Five percent of births were reported as very small, and 10 percent were reported as smaller than average. Seventeen percent of births to women younger than 20 and to women with sixth-order births were described as very small or smaller than average. Twenty percent and 15 percent of births described as very small or smaller than average were amongst women in the lowest and second wealth quintiles, respectively. By zone, North East has the highest proportion of very small infants (11 percent). Table 10.1 Child's weight and size at birth Percent distribution of live births in the five years preceding the survey with a reported birth weight by birth weight; percentage of all births with a reported birth weight; percent distribution of all live births in the five years preceding the survey by mother's estimate of baby's size at birth, according to background characteristics, Nigeria 2008 Distribution of births with reported birth weight1 Distribution of births by mother’s estimate of size of child at birth Background characteristic Less than 2.5 kg 2.5 kg or more Total Number of births Percentage of all births with a reported birth weight Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 9.5 90.5 100.0 277 6.7 6.2 10.3 80.7 2.7 100.0 4,159 20-34 7.3 92.7 100.0 4,108 20.9 4.1 9.3 84.2 2.4 100.0 19,636 35-49 8.8 91.2 100.0 715 16.6 5.6 9.7 82.7 1.9 100.0 4,305 Birth order 1 8.7 91.3 100.0 1,275 23.7 4.7 9.6 82.9 2.7 100.0 5,371 2-3 6.5 93.5 100.0 2,155 23.1 3.9 8.7 85.1 2.3 100.0 9,334 4-5 8.2 91.8 100.0 1,150 17.5 4.4 9.3 84.0 2.2 100.0 6,564 6+ 8.8 91.2 100.0 520 7.6 5.7 10.8 81.2 2.3 100.0 6,831 Mother's smoking status Smokes cigarettes/tobacco * * 100.0 12 8.1 6.4 13.8 77.4 2.3 100.0 149 Does not smoke 7.6 92.4 100.0 5,079 18.2 4.6 9.5 83.5 2.4 100.0 27,916 Missing * * 100.0 9 25.5 (3.8) (16.4) (72.9) (6.9) 100.0 35 Residence Urban 6.6 93.4 100.0 3,348 40.0 3.3 8.5 85.7 2.5 100.0 8,359 Rural 9.7 90.3 100.0 1,752 8.9 5.2 10.0 82.5 2.3 100.0 19,741 Zone North Central 10.0 90.0 100.0 429 11.2 3.6 12.1 81.6 2.7 100.0 3,830 North East 12.8 87.2 100.0 177 3.9 10.7 9.7 78.1 1.4 100.0 4,575 North West 8.2 91.8 100.0 269 3.1 4.4 10.6 82.3 2.8 100.0 8,779 South East 5.8 94.2 100.0 1,160 42.5 2.3 9.1 85.7 2.9 100.0 2,730 South South 6.9 93.1 100.0 868 23.7 2.6 6.2 88.7 2.4 100.0 3,667 South West 8.0 92.0 100.0 2,198 48.6 2.8 8.0 87.3 1.9 100.0 4,519 Mother's education No education 10.8 89.2 100.0 329 2.5 6.6 12.2 78.5 2.7 100.0 13,071 Primary 8.4 91.6 100.0 964 14.8 3.9 7.3 86.6 2.2 100.0 6,521 Secondary 7.6 92.4 100.0 2,683 38.3 2.2 7.1 88.5 2.1 100.0 6,997 More than secondary 6.2 93.8 100.0 1,125 74.4 1.9 6.7 89.6 1.8 100.0 1,511 Wealth quintile Lowest 19.5 80.5 100.0 58 0.9 7.6 12.3 78.4 1.8 100.0 6,525 Second 9.5 90.5 100.0 260 4.1 5.2 10.1 82.0 2.7 100.0 6,395 Middle 9.5 90.5 100.0 570 10.5 4.0 9.0 83.8 3.2 100.0 5,417 Fourth 8.1 91.9 100.0 1,333 26.6 3.0 7.6 87.1 2.2 100.0 5,003 Highest 6.6 93.4 100.0 2,879 60.5 2.2 7.5 88.3 2.0 100.0 4,760 Total 7.6 92.4 100.0 5,100 18.1 4.6 9.5 83.5 2.4 100.0 28,100 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases. 1 Based on written record or mother's report Child Health | 145 10.2 VACCINATION OF CHILDREN According to the World Health Organisation, a child is considered fully vaccinated if he or she has received a BCG vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertussis, and tetanus (DPT); at least three doses of polio vaccine; and one dose of measles vaccine. These vaccinations should be received during the first year of life. In Nigeria, BCG and Polio 0 vaccine should be given at birth, DPT and polio vaccines should be given at approximately 6, 10, and 14 weeks of age. Measles vaccine should be given at or soon after the child reaches nine months of age. It is also recommended that children receive the complete schedule of vaccinations before their first birthday and that the vaccinations be recorded on a health card given to the parents or guardians. The 2008 NDHS collected information on coverage for these vaccinations among all children born in the five years preceding the survey. During the five years prior to the survey, the immunisation programme in Nigeria introduced activities that were geared towards improving coverage of all the antigens in the immunisation schedule. In December 2004, Nigeria adopted the Reaching Every Ward approach during a National Review and Planning meeting to strengthen routine immunisation in every ward. Activities include capacity building for strengthening static services; re-establishing outreach and mobile services; supportive supervision; linking services with communities; resource management and mobilisation; monitoring and evaluation, including monitoring the impact of routine immunisation on vaccine preventable diseases. In May 2006, the Immunisation Plus Days (IPDs) strategy was introduced. The IPDs are supplementary immunisation activities with the following objectives: • Administer oral polio vaccine (OPV) to all children under five years of age, irrespective of previous doses • Reach all previously unreached eligible children, thus reducing substantially the percentage of missed children • Strengthen routine immunisation • Administer other child survival interventions (de-worming, ITN distribution, vitamin A supplementation, anti-malarial drugs, soaps) In the 2008 NDHS, information on vaccination coverage was obtained in two ways—from health cards and from mothers’ verbal reports. All mothers were asked to show the interviewer the health cards in which immunisation dates are recorded for all children born since January 2003. If a card was available, the interviewer recorded onto the questionnaire the dates of each vaccination received by the child. If a child never received a health card, or the mother was unable to show the card to the interviewer, or a particular vaccination was not recorded on the health card, the vaccination information for the child was based on the mother’s report. Questions were asked for each vaccine type. Mothers were asked to recall whether the child had received BCG, polio, DPT, and measles vaccinations. If the mother indicated that the child had received the polio or DPT vaccines, she was asked about the number of doses that the child received. The mother was then asked whether the child had received other vaccinations that were not recorded on the card, and if so, they too were noted on the questionnaire. The results presented here are based on both health card information and, for children without a card, information provided by the mother. 146 | Child Health Table 10.2 shows vaccination coverage by source of information for children age 12-23 months, the age by which they should have received all vaccinations. Overall, 23 percent of children ages 12-23 months are fully vaccinated. Vaccination coverage has nearly doubled from the estimate in the 2003 NDHS (13 percent). Fifty percent received vaccinations for BCG and 41 percent for measles. Fewer children received DPT 3 (35 percent) and polio 3 (39 percent), compared with those who received DPT 1 (52 percent) and polio 1 (68 percent). Only 19 percent of children are fully immunised by 12 months of age. Overall, 29 percent of children in Nigeria have not received any vaccinations. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Nigeria 2008 DPT Polio1 Source of information BCG 1 2 3 0 1 2 3 Measles All basic vacci- nations2 No vacci- nations Number of children Vaccinated at any time before survey Vaccination card 23.7 24.9 22.6 20.2 21.9 24.4 21.8 19.2 19.4 15.7 0.0 1,293 Mother's report 25.9 27.1 22.1 15.2 14.7 43.4 35.4 19.5 22.1 7.0 28.7 3,652 Either source 49.7 52.0 44.7 35.4 36.7 67.8 57.2 38.7 41.4 22.7 28.7 4,945 Vaccinated by 12 months of age3 47.9 49.4 41.4 32.8 35.8 64.1 53.5 36.0 33.6 19.2 32.2 4,945 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. Table 10.3 presents information on vaccine coverage among children age 12-23 months from the vaccination cards and mothers’ reports, by background characteristics. Vaccination cards were seen for 26 percent of children. Twenty-seven percent of first births are fully immunised, compared with 14 percent of children of sixth or higher birth order. Children in urban areas are more than twice as likely as rural children to be fully vaccinated; 38 percent compared with 16 percent, respectively. Among the zones, full vaccination coverage ranges from a high of 43 percent in South East and South West to a low of 6 percent in the North West. Mother’s level of education is strongly related to immunisation coverage; 61 percent of children whose mothers have more than a secondary education are fully immunised compared with 7 percent of children whose mothers have no education. Level of household wealth is also linked to whether a child is fully immunised: 53 percent of children in the highest wealth quintile are fully immunised, compared with 5 percent in the lowest wealth quintile. Child Health | 147 Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card seen, by background characteristics, Nigeria 2008 DPT Polio1 BCG 1 2 3 0 1 2 3 Measles All basic vacci- nations2 No vacci- nations Percentage with a vaccination card seen Number of children Sex Male 49.1 51.4 44.3 35.6 36.6 66.7 56.4 38.7 41.5 22.6 29.6 26.2 2,448 Female 50.2 52.7 45.1 35.3 36.7 68.9 58.0 38.7 41.4 22.8 27.8 26.1 2,497 Birth order 1 57.9 59.6 53.1 43.4 45.2 70.2 60.6 41.1 46.2 27.2 25.8 33.9 939 2-3 54.1 56.0 48.9 39.6 40.9 70.4 60.4 42.1 44.5 26.4 26.1 27.9 1,652 4-5 49.6 51.4 44.6 35.8 36.0 67.4 55.4 36.7 43.1 22.3 29.6 24.8 1,208 6+ 36.6 40.8 31.8 22.5 24.4 62.6 51.8 33.9 31.4 14.0 33.8 18.7 1,146 Residence Urban 71.4 71.3 64.5 54.8 57.2 77.6 68.4 51.6 59.1 37.5 17.9 38.8 1,498 Rural 40.2 43.7 36.1 27.0 27.8 63.5 52.3 33.0 33.7 16.2 33.3 20.6 3,447 Zone North Central 62.4 63.9 54.5 43.4 42.0 72.7 59.9 40.5 51.8 25.9 23.4 31.2 640 North East 27.2 30.5 18.9 12.4 17.7 61.4 45.6 28.6 24.8 7.6 33.3 15.1 780 North West 19.1 23.9 17.4 9.1 11.2 48.6 38.5 24.3 19.5 6.0 48.5 5.8 1,545 South East 79.1 79.3 74.8 66.9 68.1 80.6 75.4 52.5 63.9 42.9 17.2 46.1 504 South South 75.3 74.5 65.6 54.2 56.4 86.7 74.9 53.6 55.5 36.0 10.2 46.4 663 South West 80.3 81.7 77.8 66.5 63.4 83.2 76.0 53.4 65.5 42.8 12.9 42.5 814 Mother's education No education 20.2 24.4 17.6 10.7 11.7 50.0 38.4 24.0 19.0 6.5 47.2 8.6 2,248 Primary 58.2 61.0 50.1 37.7 39.9 73.5 62.5 38.7 47.4 23.1 21.5 29.8 1,107 Secondary 83.6 83.1 76.4 65.4 66.0 88.5 78.9 56.9 65.7 41.4 8.0 45.7 1,283 More than secondary 92.6 92.5 90.7 83.4 85.2 91.3 85.8 69.8 82.9 61.2 5.3 59.6 307 Wealth quintile Lowest 18.2 22.6 14.9 8.2 10.9 51.4 39.2 21.9 17.3 4.8 46.2 8.4 1,158 Second 33.6 37.9 30.2 20.8 21.4 58.7 48.3 29.7 28.1 11.9 37.6 17.3 1,092 Middle 50.3 52.8 43.8 32.9 35.4 67.7 56.2 38.2 40.5 19.7 28.2 25.5 945 Fourth 73.0 72.7 64.7 52.5 53.0 80.8 69.1 48.9 57.9 33.4 14.5 36.0 892 Highest 87.7 87.5 83.5 76.0 75.2 88.1 81.6 62.8 74.9 52.7 8.8 51.9 858 Total 49.7 52.0 44.7 35.4 36.7 67.8 57.2 38.7 41.4 22.7 28.7 26.1 4,945 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 10.2.1 Trends in Vaccination Coverage One way of measuring trends in vaccination coverage is to compare coverage among children of different ages within the same survey. Table 10.4 shows the percentage of children age 12-59 months who received vaccinations during the first year of life, by current age. The results show trends in vaccination coverage over the past five years. There have been small improvements in vaccination coverage over the past five years. The percentage of children who received no vaccinations by 12 months of age has decreased from 41 percent among children age 48-59 months to 32 percent among children age 12-23 months. The percentage of children fully immunised by age 12 months has increased from 14 to 19 percent for the same age groups. Overall, vaccination cards were seen for 18 percent of the children surveyed, compared with 14 percent of children in the 2003 NDHS. The proportion of children age 12-23 months for whom vaccination cards were seen increased from 21 to 26 percent between the two surveys. 148 | Child Health Forty-seven percent of children age 12-59 months received a BCG vaccination, while 32 percent received the third dose of DPT. Thirty-six percent of children received polio 3 and 32 percent received the measles vaccine. Overall, 17 percent of children age 12-59 months received all basic vaccinations on time, i.e., by the time they are 12 months old. Table 10.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card seen, by current age of child, Nigeria 2008 DPT Polio1 Age in months BCG 1 2 3 0 1 2 3 Measles All basic vacci- nations2 No vacci- nations Percentage with a vaccination card seen Number of children 12-23 47.9 49.4 41.4 32.8 35.8 64.1 53.5 36.0 33.6 19.2 32.2 26.1 4,945 24-35 48.4 48.3 40.6 32.1 34.3 63.9 55.8 36.9 32.0 17.2 33.0 19.9 4,633 36-47 45.1 42.7 36.0 30.3 29.8 57.3 50.3 34.0 31.3 15.9 41.2 14.0 5,013 48-59 45.7 40.3 35.7 29.3 29.4 56.6 50.5 33.4 27.8 13.6 41.1 12.4 4,653 Total 47.2 46.1 39.1 31.6 32.6 61.6 53.4 35.7 32.3 16.8 35.6 18.2 19,245 Note: Information was obtained from a vaccination card or, if there was no written record, from the mother’s report. For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) Polio can continue to circulate even if the population is highly immunised through routine immunisation, therefore supplemental immunisation activities are required. In Nigeria as in other countries, national or sub-national immunisation days (NIDs/SNIDs) are conducted to rapidly boost the immunity of children under five years of age, regardless of their immunisation status. The idea is to catch children who have not been immunised at all, or are only partially protected, and to boost immunity in those who have been immunised. This way, every child in the most susceptible age group is protected against polio. These activities deprive the virus of the opportunity to spread. The IPDs are used as an opportunity to reach children who are under 12 months who missed their routine vaccination, through the administration of routine immunisation vaccines (BCG, DPT, HepB, TT, Yellow Fever, and measles). Other child survival interventions (antihelmintics, anti-malarial, soaps, ITNs, Vitamin A supplementation) may also be delivered during the IPDs. In December 2005, Nigeria conducted the first phase of its accelerated measles campaign in the entire 19 northern states and the Federal Capital Territory (FCT), Abuja. The 17 southern states of the country had a measles campaign in October 2006. The measles campaigns targeted children age 9 months to 14 years. The campaign has as its objectives the provision of a second opportunity for children who have received their routine measles vaccination and for children who missed their routine measles vaccination. Table 10.5 presents information on children age 12-59 months who received specific vaccines during national immunisation campaigns at any time before the survey (from the vaccination card or mother’s report), by background characteristics. Mothers reported that 19 percent of children received basic vaccinations including polio, measles, and DPT in the May-July 2006 IPDs. Eighteen percent of children received polio vaccinations through polio campaigns in the February-March 2006 NIDs. Mothers also reported that 45 percent of children received vaccinations in the January 2007 IPDs and March-September SIPDs the same year. Fifty percent of children received basic vaccinations during the January-February 2008 IPDs and April SIPDs the same year. Prior to 2007, 26 percent of children or less in each zone received vaccinations through a campaign. The percentages of children who received vaccinations during the 2007 and 2008 campaigns are higher than those in the 2006 campaigns. Clearly, the efforts to increase vaccination coverage through national campaigns have been effective. Child Health | 149 10.2.2 Reasons for Not Receiving Vaccinations Table 10.6 presents information on the percentage of children age 12-59 months who did not receive any vaccines any time before the survey, by reason for not receiving any vaccines and background characteristics. Information from the mothers on the reasons their children were not vaccinated is helpful to immunisation programmes for targeting special efforts to improve vaccination coverage. Lack of information is the most commonly reported reason (27 percent) mothers gave for their children not being immunised, followed by fear of side effects (26 percent), and the post being located too far away (13 percent). Women in rural areas are more likely to report lack of information on immunisations than women in urban areas (29 percent and 20 percent, respectively). Table 10.5 Vaccinations received during national immunization day campaigns Percentage of children age 12-59 months who received specific vaccines through a national immunisation day campaign at any time before the survey (according to a vaccination card or the mother's report), by background characteristics, Nigeria 2008 National immunisation campaigns and vaccines received Background characteristic Polio 2006 (NIDs/ Feb-Mar)1 Measles 2005 and 2006 (SIA/Dec 2005, Oct 2006)2 All 2006 (IPDs/ May-Jul3 All 2007 (IPDs/Jan, SIPDs/ Mar-Sep)4 All 2008 (IPDs/ Jan-Feb, SIPDs/ Apr)5 Number of children Sex Male 18.0 12.2 18.6 45.1 49.6 6,932 Female 17.5 12.4 19.2 44.6 49.6 6,876 Birth order 1 18.0 12.7 18.2 42.2 45.8 2,694 2-3 19.0 13.5 20.8 45.1 50.3 4,850 4-5 17.6 12.9 19.9 45.3 50.3 3,324 6+ 15.6 9.5 15.4 46.4 51.1 2,940 Residence Urban 18.7 13.8 19.9 41.1 44.8 4,941 Rural 17.2 11.5 18.4 46.9 52.2 8,867 Zone North Central 21.8 15.5 22.5 46.5 43.4 1,986 North East 14.8 7.2 14.6 49.1 54.3 2,064 North West 7.8 7.3 14.0 42.7 59.8 3,097 South East 16.2 12.0 18.8 36.5 32.3 1,582 South South 22.7 12.0 17.7 44.8 41.3 2,246 South West 24.7 19.8 26.0 47.6 55.7 2,833 Mother's education No education 12.7 8.8 15.6 45.6 55.9 4,752 Primary 19.2 13.7 19.5 44.8 46.4 3,598 Secondary 21.3 14.7 21.1 44.9 46.5 4,369 More than secondary 20.3 13.9 22.6 41.3 45.4 1,088 Wealth quintile Lowest 11.5 6.8 13.0 44.1 52.5 2,324 Second 14.8 9.9 18.1 47.9 55.5 2,626 Middle 18.0 12.4 19.4 46.7 49.6 2,755 Fourth 20.8 15.1 20.2 44.0 48.5 2,930 Highest 21.5 15.7 22.3 41.9 43.6 3,173 Total 17.7 12.3 18.9 44.8 49.6 13,808 1 National immunisation days (NIDs) in February-March 2006 for polio vaccination 2 Supplemental immunisation activities (SIAs) in December 2005 and October 2006 for measles vaccination 3 Immunisation plus days (IPDs) in May-July 2006 for a range of vaccines including polio, measles, and DPT 4 Immunisation plus days (IPDs) in January 2007 and sub-national immunisation plus days (SIPDs) in March-September 2007 for a range of vaccines including polio, measles, and DPT 5 Immunisation plus days (IPDs) in January-February 2008 and sub-national immunisation plus days (SIPDs) in April 2008 for a range of vaccines including polio, measles, and DPT 150 | Child Health Table 10.6 Reasons for child not receiving any vaccines Percentage of children age 12-59 months who did not receive any vaccines at any time before the survey, by mother's reason for child not receiving any vaccinations and background characteristics, Nigeria 2008 Main reasons child has not received any vaccinations Background characteristic Lack of information Fear of side effects Fear child may get disease Vaccines do not work Religious reasons Post too far Child was absent Other Number of children Sex Male 28.0 25.5 6.4 4.0 6.9 13.5 5.1 12.6 2,762 Female 26.3 26.4 7.4 4.0 6.3 13.3 5.4 12.7 2,675 Birth order 1 28.2 24.3 8.3 4.2 7.4 13.8 6.2 12.6 997 2-3 26.9 26.2 7.1 4.0 7.6 13.6 5.1 11.9 1,690 4-5 27.9 25.7 5.3 3.8 7.3 14.0 4.6 12.6 1,295 6+ 26.3 27.0 7.1 4.1 4.2 12.3 5.4 13.6 1,455 Residence Urban 19.6 27.4 9.9 4.9 8.9 4.9 5.1 14.7 1,013 Rural 28.9 25.6 6.2 3.8 6.0 15.3 5.3 12.2 4,424 Zone North Central 45.5 24.5 7.5 6.5 11.1 17.8 6.4 6.9 666 North East 39.6 16.7 8.5 3.6 4.3 14.6 4.5 13.3 1,008 North West 18.3 29.3 6.8 4.0 7.4 10.5 5.9 13.9 2,780 South East 22.6 31.0 5.8 4.5 5.1 12.9 3.4 10.6 305 South South 35.9 19.8 5.9 1.4 2.7 26.1 4.1 14.5 278 South West 24.6 28.7 3.8 2.0 3.0 14.4 3.2 12.0 400 Mother's education No education 28.8 25.9 7.7 4.2 7.1 13.8 5.4 12.3 4,043 Primary 24.1 26.8 4.9 2.6 5.6 13.0 4.3 14.2 931 Secondary 19.4 25.3 3.8 3.7 2.2 10.8 5.3 10.9 420 More than secondary (22.9) (15.7) (2.7) (16.0) (15.5) (11.5) (7.6) (25.2) 44 Wealth quintile Lowest 36.2 22.0 6.8 4.3 5.7 18.8 4.8 9.4 2,000 Second 24.4 26.5 5.7 2.9 6.6 13.8 6.1 14.2 1,639 Middle 22.0 31.8 9.6 5.5 8.2 7.8 4.6 14.0 959 Fourth 18.9 29.2 5.6 3.7 8.4 5.2 5.0 17.5 567 Highest 13.6 23.8 7.3 3.4 3.4 7.2 5.9 12.1 273 Total 27.2 25.9 6.9 4.0 6.6 13.4 5.2 12.6 5,437 Note: Figures in parentheses are based on 25-49 unweighted cases. Among the zones, mothers in the North Central (46 percent), North East (40 percent), and South South (36 percent) report the greatest proportions of children not immunised for lack of information. Children residing in South East (31 percent), North West (29 percent), and South West (29 percent) are most likely to have received no immunisations because of fear of side effects of the vaccine. Fifteen percent of children in rural areas are not immunised because the post is too far away, while 26 percent of children in South South are not vaccinated for the same reason. These results highlight the need to improve localisation of routine and outreach immunisation programme efforts. Table 10.7 presents information on the percentage of children age 12-59 months who did not receive polio vaccines at any time before the survey, by mother’s reason and by background characteristics. The reasons mothers report for their children not receiving polio vaccinations are similar to those reported for children not receiving any vaccinations at all. Overall, 29 percent of children did not receive any polio vaccine. Lack of information is the most commonly reported reason (27 percent) mothers gave for their children not being immunised, followed by fear of side effects (25 percent), and the post being located too far away (14 percent). Child Health | 151 Table 10.7 Reasons for child not receiving any polio vaccine Percent distribution of children age 12-59 months by whether child received any polio vaccine, and for children who did not receive polio vaccine, mother’s reason for child not being immunised against polio, by background characteristics, Nigeria 2008 Distribution of children age 12-59 months by receipt of polio vaccine Mother’s reasons for child not receiving polio vaccine Background characteristic Received polio vaccine Did not receive any polio vaccine Don’t know/ missing Total Number of children Lack of informa- tion Fear of side effects Fear child may get disease Vaccines do not work Religious reasons Post too far Child was absent Other Number of children Sex Male 70.1 29.6 0.3 100.0 9,695 27.2 24.9 6.3 2.8 6.3 14.3 5.1 13.5 2,867 Female 70.8 28.9 0.3 100.0 9,550 27.0 25.0 7.1 3.2 5.9 14.0 5.6 12.3 2,757 Birth order 1 71.9 27.7 0.4 100.0 3,690 28.8 24.1 7.7 3.2 6.8 14.1 6.8 13.1 1,023 2-3 72.9 27.0 0.2 100.0 6,540 27.1 24.1 7.4 2.4 7.0 14.0 4.9 12.6 1,763 4-5 70.7 29.1 0.2 100.0 4,620 27.2 25.3 5.5 2.8 6.9 15.7 4.7 12.6 1,344 6+ 65.4 34.0 0.6 100.0 4,395 25.9 26.4 6.3 3.9 3.8 12.8 5.5 13.4 1,495 Residence Urban 81.7 17.9 0.4 100.0 5,954 18.5 26.3 8.0 3.1 8.7 5.5 5.0 16.5 1,068 Rural 65.4 34.3 0.3 100.0 13,292 29.1 24.7 6.4 3.0 5.5 16.1 5.4 12.1 4,556 Zone North Central 72.9 26.8 0.2 100.0 2,652 47.8 21.6 7.1 5.9 11.0 18.4 7.4 6.7 712 North East 64.9 35.0 0.1 100.0 3,072 36.4 14.9 8.4 2.2 3.1 13.1 3.4 13.9 1,075 North West 51.6 47.9 0.4 100.0 5,877 18.2 29.0 6.6 3.2 7.2 12.2 6.1 14.0 2,817 South East 82.9 16.7 0.4 100.0 1,887 18.5 30.2 6.7 3.5 3.7 14.6 2.2 12.9 315 South South 88.3 11.4 0.3 100.0 2,525 36.2 20.1 4.2 0.8 2.1 23.9 5.1 14.1 289 South West 86.8 12.9 0.3 100.0 3,233 28.2 29.3 3.6 0.4 2.3 15.6 4.3 12.7 417 Mother's education No education 52.9 46.8 0.3 100.0 8,795 28.7 25.0 7.7 3.5 6.9 14.6 5.4 12.6 4,119 Primary 77.4 22.1 0.5 100.0 4,529 23.8 26.7 3.8 1.6 5.0 14.2 5.1 14.5 1,001 Secondary 90.3 9.5 0.1 100.0 4,789 20.0 23.7 4.0 1.7 0.9 10.1 5.8 12.5 457 More than secondary 95.6 4.2 0.1 100.0 1,132 (23.2) (4.5) (3.4) (7.4) (11.1) (11.3) (3.9) (10.0) 48 Wealth quintile Lowest 52.7 47.0 0.3 100.0 4,324 34.9 20.6 6.9 3.3 5.4 19.2 4.2 10.4 2,033 Second 60.3 39.4 0.3 100.0 4,265 25.8 26.1 6.6 2.9 6.5 15.7 6.2 14.1 1,681 Middle 72.6 27.0 0.3 100.0 3,714 22.0 31.6 7.1 3.0 6.8 8.8 6.1 13.6 1,004 Fourth 81.8 17.8 0.4 100.0 3,497 16.7 27.3 5.8 3.2 8.1 5.7 5.2 16.2 623 Highest 91.5 8.2 0.3 100.0 3,445 19.7 21.4 6.0 1.1 1.8 6.0 6.3 14.1 284 Total 70.5 29.2 0.3 100.0 19,245 27.1 25.0 6.7 3.0 6.1 14.1 5.3 12.9 5,624 Note: Figures in parentheses are based on 25-49 unweighted cases. 10.3 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths caused by ARI. In the 2008 NDHS, ARI prevalence was estimated by asking mothers whether their children under age five had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These symptoms are compatible with ARI. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Table 10.8 shows the prevalence of ARI symptoms among children under five years during the two-week period preceding the interview, and the actions mothers took in response to their children’s illness. Overall, 3 percent of children had ARI symptoms in the two weeks preceding the survey, although the prevalence varies by age. Children age 12-23 months are most likely to show ARI symptoms (4 percent), compared with children in other age groups. Children in the North East zone are more likely to have ARI symptoms (8 percent) than those in other zones. ARI symptoms among children decreases with increasing level of mother’s education and increasing wealth quintile. 152 | Child Health Table 10.8 Prevalence and treatment of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey and among children with symptoms of ARI, the percentage for whom advice or treatment was sought from a health facility or provider and percentage who received antibiotics as treatment, according to background characteristics, Nigeria 2008 Children under age five with symptoms of ARI Children under age five Background characteristic Percentage with symptoms of ARI1 Number of children Percentage for whom advice or treatment was sought from a health facility or provider2 Percentage who received antibiotics Number of children Age in months <6 2.1 2,874 58.3 23.2 61 6-11 3.3 2,855 46.3 19.7 93 12-23 3.8 4,945 47.1 24.5 190 24-35 3.1 4,633 45.4 24.9 142 36-47 2.4 5,013 32.9 21.8 118 48-59 1.8 4,653 48.6 17.4 86 Sex Male 2.8 12,614 43.5 23.5 348 Female 2.8 12,360 47.3 21.4 342 Mother's smoking status Smokes cigarettes/tobacco 2.6 127 * * 3 Does not smoke 2.8 24,819 45.3 22.5 687 Cooking fuel Electricity or gas 0.0 275 * * 0 Kerosene 1.5 4,442 (68.1) (42.1) 67 Coal/lignite 1.1 91 * * 1 Charcoal 3.2 615 * * 20 Wood/straw3 3.1 19,481 43.4 20.4 600 Animal dung * 14 * * 2 Other fuel * 11 * * 0 No food cooked in household * 11 * * 0 Residence Urban 2.2 7,690 45.9 23.8 172 Rural 3.0 17,284 45.2 22.0 519 Zone North Central 1.4 3,434 61.0 24.2 47 North East 7.5 3,989 30.7 18.2 299 North West 1.9 7,594 52.6 8.5 143 South East 1.8 2,428 (63.7) (17.9) 43 South South 3.5 3,310 55.9 40.9 115 South West 1.0 4,221 (60.1) (51.8) 43 Mother's education No education 3.4 11,342 35.7 17.4 386 Primary 2.7 5,805 53.0 21.5 155 Secondary 2.0 6,385 62.6 35.0 131 More than secondary 1.2 1,441 * * 18 Wealth quintile Lowest 3.8 5,634 31.9 12.2 216 Second 3.6 5,566 40.3 21.3 200 Middle 2.5 4,787 55.6 27.9 118 Fourth 2.1 4,533 60.7 32.9 97 Highest 1.3 4,455 (66.3) (36.2) 59 Total 2.8 24,975 45.4 22.5 690 Note: Total includes children with information missing on mother’s smoking status and type of cooking fuel. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases. 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related) is considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 3 Includes grass, shrubs, crop residues Child Health | 153 Among children with ARI symptoms, advice or treatment was sought from a health facility or a health provider for 45 percent. There are differences in the proportions of children with ARI symptoms taken to a health facility by age of child. Children less than 6 months of age are more likely to be taken to a health facility (58 percent) than other children. Twenty-three percent of children received antibiotics. The proportion of children who received antibiotics is slightly higher in urban areas (24 percent) than rural areas (22 percent). 10.4 FEVER Fever is a symptom of malaria, but it may also accompany other childhood illnesses. Malaria and other illnesses that cause fever contribute to high levels of malnutrition, morbidity, and mortality in young children. While fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Because malaria is a major cause of death in infancy and childhood in many developing countries, the presumptive treatment of fever with anti-malarial medication is advocated in many countries where malaria is endemic. Information relating to the prevention and treatment of malaria is discussed in greater detail in Chapter 12. Table 10.9 shows the percentage of children under five with fever during the two weeks preceding the survey and the percentage receiving various treatments, by background characteristics. Sixteen percent of children under five years of age were reported to have had fever in the two weeks preceding the survey. The prevalence of fever varies with children’s age. Children age 6-11 months and 12-23 months are more likely to be sick with fever (19 and 21 percent, respectively) than other children. Slightly more children were reported to have fever in rural areas, compared with urban areas (17 and 13 percent, respectively). There is variation among zones in the prevalence of fever: in three zones (South East, North East, and South South) more than 20 percent of children had fever in the two weeks preceding the survey while just 8 percent of children in the South West had fever. Children of mothers with more than a secondary education (14 percent) have the lowest prevalence of fever as do children of mothers in the highest wealth quintile (13 percent). More than half of children (54 percent) with fever were taken to a health facility or health provider for treatment. Children in the South East zone (72 percent) are more likely to be treated at a health facility or by a health provider, compared with children in other zones. Children of mothers with a secondary education (70 percent) and mothers in the fourth wealth quintile (69 percent) are most likely to receive treatment from a health facility or provider than children of other women. Thirty-three percent of children with fever received anti-malarial drugs, while 18 percent received antibiotics. 154 | Child Health Table 10.9 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage for whom treatment was sought from a health facility or provider, the percentage who took anti-malarial drugs, and the percentage who took antibiotic drugs, by background characteristics, Nigeria 2008 Children under age five with fever Children under age five Background characteristic Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took anti-malarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 9.3 2,874 47.2 25.6 17.1 268 6-11 19.4 2,855 54.0 35.6 16.4 553 12-23 21.3 4,945 55.0 31.4 18.2 1,054 24-35 17.8 4,633 56.7 34.8 21.2 826 36-47 13.7 5,013 50.5 32.6 16.8 688 48-59 12.4 4,653 56.5 36.0 18.3 579 Sex Male 16.5 12,614 54.5 34.4 18.0 2,075 Female 15.3 12,360 53.7 31.8 18.5 1,893 Residence Urban 12.8 7,690 58.7 41.1 23.0 987 Rural 17.2 17,284 52.6 30.5 16.7 2,981 Zone North Central 9.6 3,434 60.2 47.3 19.2 331 North East 21.9 3,989 42.6 21.8 17.5 872 North West 15.7 7,594 43.9 29.2 12.3 1,189 South East 22.9 2,428 71.9 21.5 15.0 555 South South 20.6 3,310 66.3 47.1 25.1 682 South West 8.1 4,221 60.1 53.6 31.8 340 Mother's education No education 16.3 11,342 41.7 25.8 13.8 1,846 Primary 15.4 5,805 59.5 31.1 19.1 893 Secondary 16.0 6,385 70.2 44.9 24.2 1,022 More than secondary 14.4 1,441 63.0 50.0 25.5 207 Wealth quintile Lowest 17.8 5,634 37.6 21.9 12.8 1,001 Second 17.1 5,566 48.8 26.4 16.4 953 Middle 16.0 4,787 59.5 35.5 17.5 765 Fourth 14.9 4,533 68.8 40.2 22.4 674 Highest 12.9 4,455 67.5 52.7 27.0 575 Total 15.9 24,975 54.1 33.2 18.3 3,968 1 Excludes pharmacy, shop, and traditional practitioner Table 10.10 shows the percentage of children with fever who received specific anti-malarial drugs, and the percentage for whom the drug was available at home when the child became ill. As mentioned above, 33 percent of children with fever received an anti-malarial drug. Among children who took an anti-malarial drug, 29 percent had the drug available at home when the child became ill with fever. Less than one-tenth of children took SP/Fansidar/Amalar/Maloxine (6 percent), 19 percent took Chloroquine, and 5 percent took other anti-malarial drugs. Child Health | 155 Table 10.10 Availability at home of anti-malarial drugs taken by children Among children under age five who had fever in the two weeks preceding the survey, the percentage who took specific anti-malarial drugs and, among children who took specific drugs, the percentage for whom the drug was at home when the child became ill with fever, Nigeria 2008 Drug Percentage who took specific anti-malarial drugs Percentage for whom drug was at home when child became ill with fever Number of children who took a specific anti-malarial drug SP/Fansidar/Amalar/Maloxine 5.9 34.2 233 Chloroquine 19.2 30.1 761 Amodiaquine 2.0 21.9 78 Quinine 1.6 32.2 63 ACT 2.4 42.8 94 Other anti-malarial 4.5 2.4 178 Any anti-malarial drugs 33.2 29.1 1,316 Note: A total of 3,968 children had fever in the two weeks preceding the survey. 10.5 PREVALENCE OF DIARRHOEA Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children. A simple and effective response to dehydration is a prompt increase in fluid intake. Exposure to diarrhoea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. In interpreting the 2008 NDHS findings, it should be borne in mind that diarrhoea prevalence is subject to seasonal variability. The 2008 NDHS obtained information on the prevalence of diarrhoea among young children by asking mothers whether their children under age five had diarrhoea during the two weeks preceding the interview. When a child was identified as having had diarrhoea, information was collected on treatment and feeding practices during the diarrhoeal episode. The mother was also asked whether there was blood in the child’s stools. Diarrhoea with blood in the stools is indicative of cholera or other diseases that need to be treated differently from diarrhoea in which there is no blood in the stool. Mothers of children who were ill with any form of diarrhoea in the past two weeks were asked about what actions they had taken to treat the diarrhoea and about feeding practices during the diarrhoeal episode. Other information included the respondent’s knowledge of oral rehydration salt (ORS) packets or pre-packaged liquids for treatment of diarrhoea (oral rehydration therapy), and disposal of children’s stools. Table 10.11 shows that 10 percent of the children under five had a diarrhoeal episode in the two weeks preceding the survey and 2 percent had blood in the stool. The prevalence of diarrhoea varies by age of children. Young children age 6-23 months are more prone to diarrhoea than children in the other age groups. Children in this age group are being introduced to complementary foods. Diarrhoea is more prevalent among children whose households do not have an improved source of drinking water (12 percent), compared with households that have an improved source of drinking water (8 percent). The proportion of children with diarrhoea is higher in rural areas than urban areas (11 and 8 percent, respectively). The prevalence of diarrhoea varies among zones: children in North East zone are more susceptible to episodes of diarrhoea (21 percent) than children in other zones. The lowest proportion of children with diarrhoea is in South South (4 percent). Lower diarrhoea prevalence is associated with children of mothers with higher levels of education and those living in households in the highest wealth quintile (each 5 percent) 156 | Child Health Table 10.11 Prevalence of diarrhoea Percentage of children under age five who had diarrhoea in the two weeks preceding the survey, by background characteristics, Nigeria 2008 Children under five with diarrhoea in the two weeks preceding the survey Background characteristic All diarrhoea Diarrhoea with blood Number of children Age in months <6 6.8 0.5 2,874 6-11 14.9 2.2 2,855 12-23 16.3 3.3 4,945 24-35 10.1 2.3 4,633 36-47 7.6 1.9 5,013 48-59 5.5 1.3 4,653 Sex Male 10.6 1.9 12,614 Female 9.7 2.0 12,360 Source of drinking water1 Improved 8.4 1.5 13,235 Not improved 12.1 2.6 11,731 Toilet facility2 Improved, not shared 11.3 2.0 7,491 Non-improved or shared 9.6 2.0 17,271 Missing 10.8 1.1 213 Residence Urban 7.9 1.3 7,690 Rural 11.1 2.3 17,284 Zone North Central 5.6 1.1 3,434 North East 20.8 5.1 3,989 North West 13.1 2.3 7,594 South East 4.9 0.7 2,428 South South 3.8 1.6 3,310 South West 6.2 0.4 4,221 Mother's education No education 13.8 2.9 11,342 Primary 8.9 1.6 5,805 Secondary 5.9 1.1 6,385 More than secondary 4.9 0.3 1,441 Wealth quintile Lowest 14.4 3.2 5,634 Second 12.9 3.0 5,566 Middle 9.2 1.6 4,787 Fourth 7.7 1.2 4,533 Highest 4.8 0.5 4,455 Total 10.1 2.0 24,975 Note: Total includes children with information missing on source of drinking water. 1 See Table 2.7 for definition of categories. 2 See Table 2.8 for definition of categories. Child Health | 157 10.6 DIARRHOEA TREATMENT For children who had diarrhoea in the two weeks preceding the survey, mothers were asked what they did to treat the illness. Table 10.12 shows the percentage of children with diarrhoea who received specific treatments, by background characteristics. Forty-two percent of the children with diarrhoea were taken to a health care facility or provider where advice or treatment was sought. The largest proportion of children receiving treatment for diarrhoea were children age 24-35 months (47 percent). Slightly more children with bloody diarrhoea (45 percent) received treatment or advice from a health facility or provider than children with non-bloody diarrhoea (42 percent). Table 10.12 Diarrhoeal treatment Among children under age five who had diarrhoea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Nigeria 2008 Oral rehydration therapy (ORT) Other treatments Background characteristic Percentage of children with diarrhoea for whom advice or treatment was sought from a health facility or provider1 ORS packets or pre- packaged liquid Recom- mended home fluids (RHF) Either ORS or RHF In- creased fluids ORT or in- creased fluids Anti- biotic drugs Anti- motility drugs Zinc supple- ments Intra- venous solution Home remedy/ other Missing No treat- ment Number of children with diarrhoea Age in months <6 31.5 20.8 7.7 28.0 7.2 34.2 24.9 1.8 0.0 0.3 23.8 0.4 34.6 196 6-11 43.7 30.1 10.3 37.2 7.6 41.4 32.7 2.4 1.2 0.0 23.7 0.0 27.0 424 12-23 44.4 28.1 8.0 33.2 8.8 38.2 32.7 1.1 0.7 0.2 26.2 1.4 27.8 805 24-35 46.9 24.5 6.4 28.7 10.2 35.3 37.2 1.1 0.2 0.0 23.2 1.4 28.2 469 36-47 36.2 18.6 8.0 24.1 10.2 32.0 32.9 0.4 1.4 0.0 20.7 1.7 31.9 380 48-59 41.4 25.6 11.3 32.6 8.7 36.2 33.1 0.2 0.0 0.2 19.1 1.9 31.2 257 Sex Male 42.3 25.0 9.1 31.0 8.5 36.4 33.8 1.1 0.5 0.1 23.4 1.1 28.5 1,336 Female 42.1 26.1 7.6 31.5 9.4 37.1 32.1 1.3 0.8 0.1 23.6 1.3 30.1 1,194 Type of diarrhoea Non bloody 42.2 26.1 8.1 31.5 9.0 37.1 33.5 1.2 0.7 0.1 21.9 0.9 29.7 1,807 Bloody 45.2 26.5 9.4 32.1 9.2 36.7 34.1 1.0 0.7 0.1 27.8 0.6 27.1 496 Missing 37.1 19.4 8.9 28.2 8.1 35.1 27.2 1.9 0.0 0.0 25.4 4.4 29.9 215 Residence Urban 49.8 40.5 8.8 45.3 11.0 50.1 39.6 2.0 0.6 0.1 17.1 1.4 21.6 608 Rural 39.8 20.8 8.2 26.7 8.3 32.5 30.9 0.9 0.7 0.1 25.5 1.1 31.6 1,922 Zone North Central 44.3 33.5 17.5 43.2 18.4 52.3 21.5 5.5 2.3 0.4 34.6 1.7 18.8 193 North East 35.9 17.6 4.9 20.7 10.1 28.3 29.0 0.8 0.3 0.2 20.4 0.5 38.1 831 North West 38.9 25.2 4.9 28.4 5.8 32.1 37.6 1.3 0.7 0.0 24.0 1.4 30.1 998 South East 75.2 32.9 25.6 51.4 9.0 56.0 23.3 0.0 0.0 0.0 22.3 0.9 27.3 120 South South 61.4 23.7 8.6 29.3 17.1 38.1 37.5 0.4 1.5 0.4 43.3 0.7 15.5 127 South West 48.7 43.7 17.9 58.0 6.1 60.1 38.9 0.0 0.3 0.0 14.2 2.3 13.0 261 Mother's education No education 34.2 19.5 5.8 23.4 7.2 28.8 30.2 1.5 0.7 0.1 23.2 1.2 34.8 1,565 Primary 52.0 30.7 11.5 38.7 12.4 45.2 36.6 0.4 0.5 0.1 24.9 0.4 25.2 519 Secondary 59.3 38.4 13.5 47.9 11.8 52.7 38.7 1.3 1.0 0.1 23.5 2.1 15.5 376 More than secondary 56.3 52.9 15.7 61.3 6.8 65.1 38.2 0.0 0.0 0.0 18.7 1.5 9.4 71 Wealth quintile Lowest 30.5 15.3 4.6 19.4 7.3 24.9 24.1 0.6 0.3 0.1 23.9 1.3 42.1 811 Second 37.9 20.2 7.0 25.0 8.9 31.5 32.0 1.1 0.6 0.1 27.1 0.5 30.0 717 Middle 52.0 31.8 14.1 41.8 10.8 47.6 41.5 2.1 1.0 0.0 23.8 0.8 18.2 441 Fourth 54.3 35.6 10.9 41.6 9.3 46.4 36.6 1.7 1.3 0.4 20.1 2.4 23.2 348 Highest 61.1 53.0 11.5 58.3 10.8 61.1 46.9 1.2 0.8 0.0 14.8 1.9 10.6 213 Total 42.2 25.5 8.4 31.2 8.9 36.7 33.0 1.2 0.7 0.1 23.5 1.2 29.2 2,530 Note: ORT includes solution prepared from oral rehydration salts (ORS), pre-packaged ORS packets, and recommended home fluids (RHF) 1 Excludes pharmacy, shop and traditional practitioner 158 | Child Health The distribution of diarrhoea treatment by residence shows that treatment and advice are sought more often for children in urban areas (50 percent) than children in rural areas (40 percent). Seeking treatment for diarrhoea from a health provider is highest in the South East zone (75 percent) and lowest in North East zone (36 percent). Table 10.12 includes information on oral rehydration therapy. Thirty-seven percent of children with diarrhoea were treated with oral rehydration therapy (ORT) or increased fluids. Twenty- six percent were treated with ORS, a solution prepared from a packet of oral rehydration salts; 8 percent were given recommended home fluids, and 9 percent received increased fluids. Thirty-three percent of children were given antibiotic drugs and 24 percent received home remedies or other treatments. Twenty-nine percent of children with diarrhoea did not receive any treatment at all. Children age 6-11 months (41 percent), children living in South West zone (60 percent), children with mothers who have more than a secondary education (65 percent), and children in the highest wealth quintile (61 percent) are most likely to receive some kind of ORT. 10.7 FEEDING PRACTICES When a child has diarrhoea, mothers are encouraged to continue feeding their child the same amount of food as normal and to increase the child’s fluid intake. These practices help to reduce dehydration and minimise the adverse consequences of diarrhoea on the child’s nutritional status. In the 2008 NDHS, mothers were asked whether they gave their child with diarrhoea less, the same amount, or more fluids and food than usual when their child had diarrhoea. Table 10.13 shows the percent distribution of children under five who had diarrhoea in the two weeks preceding the survey by feeding practices, according to background characteristics. Thirty-four percent of children with diarrhoea were given the same amount of liquids as usual, and 9 percent were given more. It is of concern that 32 percent of the children were given somewhat less to drink than usual, and 22 percent were given much less to drink during the diarrhoea episode. Thirty-one percent of children were given the same amount of food as usual, 33 percent were given less, 23 percent were given much less food, and 4 percent were given more food. Four percent of children were not given any food during the diarrhoea episode. Overall, only 6 percent of children had increased fluid intake and continued feeding. Twenty-five percent of children were given ORT, increased fluids, and continued feeding. T ab le 1 0. 13 F ee di ng p ra ct ic es d ur in g di ar rh oe a P er ce nt d ist rib ut io n of c hi ld re n un de r ag e fiv e w ho h ad d ia rr ho ea in t he t w o w ee ks p re ce di ng t he s ur ve y by a m ou nt o f liq ui ds a nd f oo d of fe re d co m pa re d w ith n or m al p ra ct ic e, t he p er ce nt ag e of ch ild re n gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g du rin g th e di ar rh oe a ep iso de , an d th e pe rc en ta ge o f ch ild re n w ho c on tin ue d fe ed in g an d w er e gi ve n O RT a nd /o r in cr ea se d flu id s du rin g th e ep iso de o f d ia rr ho ea , b y ba ck gr ou nd c ha ra ct er ist ic s, N ig er ia 2 00 8 Am ou nt o f l iq ui ds o ffe re d Am ou nt o f f oo d gi ve n B ac kg ro un d ch ar ac te ris tic M or e Sa m e as us ua l So m e- w ha t le ss M uc h le ss N on e D on 't kn ow / m iss in g To ta l M or e Sa m e as us ua l So m e- w ha t le ss M uc h le ss N on e N ev er ga ve fo od D on 't kn ow / m iss in g To ta l Pe rc en ta ge gi ve n in - cr ea se d flu id s an d co nt in ue d fe ed in g1 ,2 Pe rc en ta ge w ho co nt in ue d fe ed in g an d w er e gi ve n O RT a nd /o r in cr ea se d flu id s3 N um be r of ch ild re n w ith di ar rh oe a A ge in m on th s < 6 7. 2 40 .6 27 .4 21 .7 2. 3 0. 8 10 0. 0 5. 3 28 .0 22 .9 16 .3 0. 9 24 .8 1. 8 10 0. 0 3. 2 21 .4 19 6 6- 11 7. 6 37 .5 29 .9 22 .3 1. 9 0. 8 10 0. 0 3. 4 32 .3 29 .9 21 .9 3. 3 9. 1 0. 2 10 0. 0 4. 1 27 .0 42 4 12 -2 3 8. 8 30 .0 34 .8 21 .9 3. 6 0. 9 10 0. 0 4. 2 27 .0 36 .7 23 .6 4. 8 2. 9 0. 9 10 0. 0 6. 4 26 .7 80 5 24 -3 5 10 .2 35 .2 26 .7 24 .1 2. 6 1. 2 10 0. 0 5. 1 34 .4 29 .5 24 .5 4. 6 0. 2 1. 7 10 0. 0 6. 3 24 .2 46 9 36 -4 7 10 .2 31 .4 35 .6 20 .7 1. 5 0. 6 10 0. 0 5. 1 35 .2 35 .8 21 .4 1. 1 0. 0 1. 5 10 0. 0 7. 2 21 .4 38 0 48 -5 9 8. 7 32 .4 36 .8 19 .7 1. 2 1. 2 10 0. 0 2. 7 28 .0 37 .9 25 .1 3. 1 0. 3 2. 9 10 0. 0 4. 8 24 .5 25 7 S ex M al e 8. 5 35 .1 31 .7 22 .1 1. 8 0. 8 10 0. 0 3. 8 31 .6 33 .0 23 .3 2. 8 4. 3 1. 2 10 0. 0 5. 1 25 .1 1, 33 6 Fe m al e 9. 4 31 .8 32 .8 21 .8 3. 2 1. 0 10 0. 0 4. 9 29 .6 33 .3 22 .1 4. 3 4. 5 1. 4 10 0. 0 6. 4 24 .6 1, 19 4 T yp e of d ia rr ho ea N on b lo od y 9. 0 36 .8 31 .0 20 .2 2. 3 0. 7 10 0. 0 4. 6 32 .9 32 .1 21 .2 3. 3 4. 7 1. 2 10 0. 0 5. 8 25 .6 1, 80 7 Bl oo dy 9. 2 23 .0 34 .6 29 .3 3. 6 0. 3 10 0. 0 4. 9 24 .4 34 .7 27 .5 5. 1 3. 1 0. 4 10 0. 0 5. 5 24 .6 49 6 M iss in g 8. 1 28 .6 37 .5 20 .4 1. 6 3. 8 10 0. 0 0. 7 25 .3 38 .8 24 .8 1. 8 5. 2 3. 4 10 0. 0 4. 9 19 .6 21 5 R es id en ce U rb an 11 .0 37 .9 26 .6 21 .0 2. 3 1. 3 10 0. 0 5. 0 33 .0 29 .5 23 .4 2. 4 4. 7 2. 0 10 0. 0 6. 6 34 .1 60 8 Ru ra l 8. 3 32 .1 34 .0 22 .3 2. 5 0. 8 10 0. 0 4. 1 29 .9 34 .3 22 .5 3. 8 4. 3 1. 1 10 0. 0 5. 4 22 .0 1, 92 2 Z on e N or th C en tra l 18 .4 32 .5 24 .8 21 .3 1. 3 1. 8 10 0. 0 5. 4 32 .8 24 .0 25 .3 4. 3 4. 7 3. 5 10 0. 0 9. 7 32 .1 19 3 N or th E as t 10 .1 39 .7 30 .3 18 .3 1. 3 0. 3 10 0. 0 3. 2 33 .4 33 .1 21 .6 1. 8 6. 5 0. 4 10 0. 0 5. 8 19 .0 83 1 N or th W es t 5. 8 24 .2 41 .2 24 .1 3. 6 1. 1 10 0. 0 3. 8 23 .7 40 .4 21 .9 5. 2 4. 1 0. 9 10 0. 0 4. 4 21 .1 99 8 So ut h Ea st 9. 0 46 .2 25 .3 15 .2 4. 4 0. 0 10 0. 0 3. 8 43 .0 29 .0 15 .6 3. 9 2. 8 1. 9 10 0. 0 7. 6 42 .3 12 0 So ut h So ut h 17 .1 22 .8 23 .0 32 .0 3. 5 1. 7 10 0. 0 8. 9 26 .0 22 .5 36 .4 2. 8 0. 9 2. 6 10 0. 0 11 .5 23 .0 12 7 So ut h W es t 6. 1 49 .6 17 .5 24 .0 1. 1 1. 8 10 0. 0 6. 8 43 .5 19 .4 24 .2 1. 8 1. 2 3. 0 10 0. 0 3. 5 45 .5 26 1 M ot he r's e du ca tio n N o ed uc at io n 7. 2 31 .8 36 .2 21 .5 2. 6 0. 7 10 0. 0 3. 3 28 .8 36 .8 21 .2 3. 7 5. 1 1. 1 10 0. 0 4. 3 18 .9 1, 56 5 Pr im ar y 12 .4 33 .0 27 .1 23 .0 3. 4 1. 1 10 0. 0 5. 8 31 .6 29 .0 25 .8 3. 4 3. 7 0. 7 10 0. 0 9. 3 32 .2 51 9 Se co nd ar y 11 .8 39 .3 23 .3 22 .9 0. 9 1. 8 10 0. 0 6. 3 35 .3 24 .1 25 .9 2. 8 2. 9 2. 7 10 0. 0 6. 5 35 .0 37 6 M or e th an s ec on da ry 6. 8 43 .4 30 .2 19 .6 0. 0 0. 0 10 0. 0 4. 4 40 .8 29 .9 18 .0 1. 6 2. 6 2. 8 10 0. 0 5. 5 50 .7 71 W ea lth q ui nt ile Lo w es t 7. 3 31 .2 37 .3 21 .6 1. 9 0. 8 10 0. 0 2. 9 29 .5 36 .7 21 .7 3. 4 4. 6 1. 2 10 0. 0 4. 7 16 .8 81 1 Se co nd 8. 9 29 .2 35 .2 22 .3 3. 8 0. 6 10 0. 0 4. 4 27 .5 35 .1 22 .5 4. 7 4. 5 1. 2 10 0. 0 5. 2 20 .8 71 7 M id dl e 10 .8 35 .2 26 .2 24 .1 3. 0 0. 7 10 0. 0 5. 5 30 .9 29 .7 24 .8 3. 4 5. 3 0. 2 10 0. 0 7. 2 31 .3 44 1 Fo ur th 9. 3 41 .3 25 .1 20 .9 1. 5 1. 8 10 0. 0 5. 0 37 .6 29 .3 20 .7 2. 0 3. 2 2. 3 10 0. 0 6. 7 34 .1 34 8 H ig he st 10 .8 40 .3 27 .2 19 .8 0. 4 1. 4 10 0. 0 5. 7 33 .7 26 .2 26 .4 2. 0 3. 7 2. 3 10 0. 0 6. 5 41 .2 21 3 To ta l 8. 9 33 .5 32 .2 22 .0 2. 5 0. 9 10 0. 0 4. 3 30 .7 33 .1 22 .7 3. 5 4. 4 1. 3 10 0. 0 5. 7 24 .9 2, 53 0 1 E qu iv al en t t o th e U N IC EF /W H O in di ca to r " H om e m an ag em en t o f d ia rr ho ea ." M IC S In di ca to r 3 4 2 C on tin ue fe ed in g pr ac tic es in cl ud es c hi ld re n w ho w er e gi ve n m or e, s am e as u su al , o r s om ew ha t l es s fo od d ur in g th e di ar rh oe a ep iso de 3 E qu iv al en t t o U N IC EF M IC S In di ca to r 3 5. Child Health | 159 160 | Child Health 10.8 KNOWLEDGE OF ORS PACKETS To ascertain respondents’ knowledge of ORS in Nigeria, women are asked whether they knew about ORS packets. Table 10.14 presents information on the percentage of mothers with a birth in the five years preceding the survey who had heard about ORS packets. Overall, 66 percent of women know about ORS packets. Knowledge is higher in urban areas (79 percent) compared with rural areas (60 percent). Among the zones, knowledge is highest among women in South East (79 percent) and lowest in North Central (58 percent). Mothers in the 35-49 age group (70 percent) had more knowledge about ORS than women in other age groups; and women age 15-19 were least knowl- edgeable (48 percent). 10.9 STOOL DISPOSAL When human faeces are left uncontained, disease can spread by direct contact or by animal contact with the faeces. Hence, proper disposal of children’s stools is extremely important in preventing the spread of disease. Table 10.15 shows stool disposal for children under five by background characteristics. Fifty-seven percent of children’s stools are disposed of safely: 50 percent are disposed of in a toilet or latrine, 5 percent of children under five use a toilet or latrine, and 3 percent of children’s stools are buried. Nine percent of children’s stools are put or rinsed into a drain or ditch, another 24 percent are thrown into the garbage, and 7 percent are left uncontained. Safe disposal generally increases with increasing age of the child. Safe disposal is higher in urban areas (73 percent), compared with rural areas (50 percent). The North Central zone (33 percent) has the lowest proportion of safe disposal of children’s stools, while the North West has the highest proportion (74 percent). The results also show that mother’s level of education is positively associated with safe stool disposal, being highest for mothers with more than a secondary education (77 percent). Safe stool disposal is also associated with increasing wealth quintile: 44 percent for the lowest wealth quintile, compared with 79 percent for the highest wealth quintile. Table 10.14 Knowledge of ORS packets or pre- packaged liquids Percentage of women age 15-49 with a birth in the five years preceding the survey who know about ORS packets or ORS pre-packaged liquids for treatment of diarrhoea, by background characteristics, Nigeria 2008 Background characteristic Percentage of women who know about ORS packets or ORS pre-packaged liquids Number of women Age 15-19 48.1 1,168 20-24 58.5 3,399 25-34 68.2 8,311 35-49 69.9 4,758 Residence Urban 78.6 5,330 Rural 59.8 12,305 Zone North Central 58.3 2,525 North East 64.0 2,751 North West 61.2 5,372 South East 79.1 1,603 South South 62.5 2,310 South West 75.0 3,075 Education No education 55.5 8,017 Primary 67.9 4,012 Secondary 75.5 4,557 More than secondary 88.6 1,050 Wealth quintile Lowest 50.4 4,074 Second 59.1 3,916 Middle 67.5 3,350 Fourth 74.1 3,204 Highest 82.2 3,091 Total 65.5 17,635 ORS = Oral rehydration salts Child Health | 161 Table 10.15 Disposal of children's stools Percent distribution of youngest children under age five living with the mother by the manner of disposal of the child's last faecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Nigeria 2008 Manner of disposal of children's stools Background characteristic Child used toilet or latrine Put/ rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Uncon- tained Other Missing Total Percentage of children whose stools are disposed of safely Number of mothers Age in months <6 1.7 46.4 2.4 12.0 26.5 6.4 2.1 2.5 100.0 50.5 2,835 6-11 2.0 51.9 2.2 8.9 26.0 5.2 1.3 2.4 100.0 56.1 2,785 12-23 2.8 52.0 3.0 8.6 23.0 7.0 0.8 2.7 100.0 57.9 4,653 24-35 4.3 53.1 3.2 7.1 22.1 6.6 0.4 3.4 100.0 60.5 3,205 36-47 11.7 45.4 3.3 6.8 22.6 6.9 0.5 2.8 100.0 60.4 1,802 48-59 20.5 38.1 3.8 5.8 18.7 8.7 0.9 3.6 100.0 62.4 1,145 Toilet facility Improved, not shared1 7.4 71.1 1.1 5.9 9.4 2.1 0.6 2.4 100.0 79.6 4,904 Non-improved or shared 3.9 40.1 3.7 9.7 29.8 8.6 1.2 3.0 100.0 47.7 11,385 Missing 6.5 59.6 2.1 5.1 19.6 4.3 0.6 2.1 100.0 68.3 134 Residence Urban 7.1 65.2 1.0 6.3 14.6 2.5 0.7 2.6 100.0 73.3 5,004 Rural 4.0 42.7 3.7 9.5 27.5 8.5 1.1 2.9 100.0 50.4 11,419 Zone North Central 4.5 24.3 4.3 14.2 36.4 12.0 0.7 3.6 100.0 33.1 2,347 North East 3.1 53.1 5.0 7.3 24.7 3.0 0.2 3.5 100.0 61.3 2,576 North West 5.3 66.4 2.0 4.4 10.3 7.0 1.3 3.2 100.0 73.7 4,996 South East 7.3 52.3 1.0 5.8 28.6 1.7 1.7 1.6 100.0 60.5 1,477 South South 6.0 33.4 3.5 18.7 28.1 7.2 0.8 2.3 100.0 42.8 2,131 South West 4.5 48.3 1.9 6.1 29.2 7.0 1.2 1.9 100.0 54.7 2,895 Education No education 3.8 50.6 3.4 7.2 21.7 8.4 1.2 3.6 100.0 57.9 7,469 Primary 5.1 41.8 3.1 10.3 30.3 6.1 0.9 2.3 100.0 50.0 3,758 Secondary 5.0 51.5 2.1 10.2 23.1 5.2 0.8 2.1 100.0 58.6 4,211 More than secondary 12.9 62.8 1.3 5.0 14.5 1.0 0.4 2.0 100.0 77.0 985 Wealth quintile Lowest 3.0 34.7 6.0 10.2 31.1 10.2 1.4 3.4 100.0 43.7 3,784 Second 3.4 45.9 2.5 9.4 26.2 8.0 1.4 3.2 100.0 51.9 3,637 Middle 4.9 46.4 2.6 8.6 25.8 8.0 0.9 2.7 100.0 53.9 3,108 Fourth 5.5 56.4 2.1 8.5 19.7 4.8 0.7 2.2 100.0 64.0 2,953 Highest 8.8 69.6 0.7 5.2 12.2 0.9 0.4 2.3 100.0 79.1 2,941 Total 5.0 49.6 2.9 8.5 23.6 6.6 1.0 2.8 100.0 57.4 16,423 1 Non-shared facilities that are the following: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; pit latrine with a slab; and a composting toilet. Nutrition of Children and Adults | 163 NUTRITION OF CHILDREN AND ADULTS 11 This chapter assesses the current nutritional status of young children in Nigeria. It presents information on a number of aspects of feeding practices that are important in ensuring adequate nutrition for infants and young children, including early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding until at least two years of age, timely introduction of complementary foods at six months of age, with increasing frequency of feeding solid/semi-solid foods, and diet diversity. The chapter also provides a summary indicator describing the quality of infant and young child (age 6-23 months) feeding practices (IYCF). The chapter also describes the current nutritional status of women in the reproductive ages. It presents findings on the diversity of food groups consumed by mothers who gave birth in the past three years, this providing important information on maternal eating patterns. The chapter examines women’s consumption of vitamin A-rich and iron-rich foods, and micronutrient supplementation for iron and vitamin A. At the household level, salt was tested for adequate levels of iodine. The chapter presents an anthropometric assessment of the nutritional status of children under five years and women age 15-49.1 11.1 NUTRITIONAL STATUS OF CHILDREN Anthropometric data on height and weight collected in the 2008 NDHS permit the measurement and evaluation of the nutritional status of young children in Nigeria. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. However, marked differences especially in regards to height-for-age, weight-for-height, and weight-for-age are often seen among different subgroups of children within the country. 11.1.1 Measurement of Nutritional Status among Young Children The 2008 NDHS collected data on the nutritional status of children by measuring the height and weight of all children under age five, regardless of whether their mother was interviewed in the survey. Data were collected with the aim of calculating three indices—namely, height-for-age, weight-for-height, and weight-for-age. Weight measurements were obtained using lightweight, SECA mother-infant scales with a digital screen, designed and manufactured under the guidance of UNICEF. Height measurements were carried out using a measuring board produced by Shorr Productions. Children younger than 24 months were measured lying down on the board (recumbent length), while standing height was measured for older children. For the 2008 NDHS, the nutritional status of children is calculated using new growth standards published by WHO in 2006. These new growth standards were generated using data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). The study, whose sample size of 8,440 children drawn from six countries across the world, was designed to provide a description of how children should grow under optimal conditions. The WHO Child Growth Standards can therefore be used to assess children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. Each of the three nutritional status indicators described below is expressed in standard deviation units from the median of the Multicentre Growth Reference Study sample. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 164 | Nutrition of Children and Adults Each of these indices—height-for-age, weight-for-height, and weight-for-age—provides different information about growth and body composition, which is used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period and is also affected by recurrent and chronic illness. Height-for age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) are considered thin (wasted) and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) are considered severely wasted. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. 11.1.2 Results of Data Collection Height and weight measurements were obtained for 19,896 children under age five who were present in NDHS households at the time of the survey. The following analysis focuses on the children for whom complete and credible anthropometric and valid age data were collected. Table 11.1 and Figure 11.1 show the percentage of children under five years classified as malnourished according to the three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight- for-age. Height-for-age Table 11.1 indicates that 41 percent of children under five are stunted and 23 percent are severely stunted. Stunting is apparent even among children less than 6 months of age (21 percent). As shown in Figure 11.1, stunting increases with the age of the child through the first two years of life before declining in the third and fourth year. The increase is especially rapid during the first two years of life, as seen in the rise from 27 percent among children age 6-8 months to 50 percent among children age 18-23 months. Male children (43 percent) are more likely to be stunted than female children (38 percent), and rural children are more likely to be stunted (45 percent) than urban children (31 percent). Similarly, zonal variation in nutritional status of children is substantial, with stunting being highest in North West (53 percent) and lowest in South East (22 percent). Education and wealth are both inversely related to stunting levels. Stunting decreases with increasing levels of mother’s education. For example, children born to mothers with primary education are more likely to be stunted (40 percent) than children born to mothers with more than secondary education (20 percent). Half of children born to mothers with no education are stunted (51 percent). Nutrition of Children and Adults | 165 Table 11.1 Nutritional status of children Percentage of children under five years considered malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Nigeria 2008 Height-for-age Weight-for-height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Number of children Age in months <6 9.9 21.3 -0.3 9.9 17.5 18.2 -0.0 5.2 13.7 6.2 -0.3 1,911 6-8 14.3 26.7 -0.8 9.2 19.5 12.6 -0.3 9.6 22.5 3.2 -0.9 1,142 9-11 16.8 30.9 -1.0 7.4 17.9 8.1 -0.4 10.1 23.2 2.4 -0.9 1,026 12-17 26.2 45.6 -1.6 8.4 17.1 7.7 -0.4 11.7 26.2 1.5 -1.1 2,160 18-23 30.0 49.6 -1.8 7.2 14.7 8.0 -0.2 10.3 25.6 2.9 -1.0 1,610 24-35 30.1 48.0 -1.8 6.5 12.8 8.3 -0.1 11.0 26.0 1.7 -1.1 3,767 36-47 23.0 42.0 -1.6 5.7 11.2 7.2 -0.1 7.8 21.6 1.4 -1.0 4,288 48-59 21.3 41.6 -1.7 5.7 11.5 6.3 -0.2 8.0 23.9 0.4 -1.2 3,992 Sex Male 24.8 43.0 -1.6 7.4 14.4 8.5 -0.2 9.9 24.5 2.0 -1.1 9,861 Female 20.9 38.4 -1.4 6.5 13.4 9.1 -0.2 8.1 21.7 2.1 -0.9 10,035 Birth interval in months2 First birth3 20.1 38.3 -1.4 6.0 12.3 8.9 -0.1 7.2 20.6 1.9 -0.9 3,458 <24 26.0 45.1 -1.7 7.3 14.3 7.4 -0.2 11.1 26.6 1.5 -1.1 3,281 24-47 23.1 40.7 -1.5 7.3 14.4 9.1 -0.2 9.2 23.6 2.2 -1.0 8,801 48+ 21.7 38.0 -1.3 7.1 14.0 9.2 -0.2 8.2 21.0 2.4 -0.9 2,746 Size at birth2 Very small 29.6 49.2 -1.8 10.1 20.0 7.7 -0.6 14.3 34.0 1.1 -1.5 761 Small 27.8 48.2 -1.8 7.9 16.7 7.3 -0.4 12.7 30.6 1.0 -1.4 1,671 Average or larger 22.0 39.4 -1.4 6.9 13.4 9.0 -0.2 8.4 21.9 2.2 -0.9 15,577 Missing 22.8 39.2 -1.6 3.6 11.8 9.6 -0.1 7.0 21.3 2.3 -1.0 277 Mother's interview status Interviewed 22.8 40.6 -1.5 7.0 13.9 8.8 -0.2 9.0 23.2 2.0 -1.0 18,286 Not interviewed but in household 20.6 39.7 -1.3 6.4 13.1 8.6 -0.1 9.5 20.1 2.3 -0.9 393 Not interviewed, and not in the household4 23.3 41.0 -1.5 6.2 13.5 8.5 -0.1 9.3 22.4 1.9 -0.9 1,216 Mother's nutritional status Thin (BMI <18.5) 33.1 53.7 -2.0 10.7 19.9 6.2 -0.7 17.8 39.4 1.3 -1.6 2,011 Normal (BMI 18.5-24.9) 23.6 42.3 -1.5 7.3 14.5 8.7 -0.2 9.1 23.8 1.7 -1.0 12,027 Overweight/obese (BMI ≥25) 15.3 29.3 -1.0 4.2 9.4 10.2 0.1 4.4 13.6 3.3 -0.5 4,166 Missing 22.1 41.4 -1.4 9.4 15.1 12.1 -0.1 7.8 21.3 3.1 -0.9 316 Residence Urban 15.6 31.3 -1.1 5.3 11.0 8.9 -0.1 5.0 15.8 2.8 -0.7 6,365 Rural 26.2 45.0 -1.7 7.8 15.3 8.7 -0.2 10.9 26.5 1.7 -1.1 13,531 Zone North Central 25.2 43.8 -1.7 5.2 9.3 10.6 0.1 6.5 19.5 2.2 -0.9 2,800 North East 29.2 48.6 -1.8 11.4 22.2 8.5 -0.5 15.2 34.5 1.6 -1.4 3,097 North West 33.5 52.6 -1.9 10.6 19.9 8.9 -0.4 14.9 35.1 2.0 -1.4 5,488 South East 9.0 21.7 -0.7 3.4 8.6 7.4 -0.0 3.3 10.0 3.0 -0.4 1,947 South South 14.2 31.1 -1.1 2.9 7.5 9.2 0.1 3.9 12.8 1.8 -0.6 2,769 South West 13.8 31.2 -1.1 4.2 9.3 7.7 -0.1 4.0 13.3 1.9 -0.7 3,795 Mother's education6 No education 31.5 51.1 -1.9 10.6 20.1 8.2 -0.4 14.8 34.3 1.8 -1.4 7,982 Primary 21.4 40.3 -1.5 5.1 11.2 9.2 -0.1 6.6 19.4 1.9 -0.9 4,578 Secondary 13.3 28.8 -1.0 4.1 8.4 9.1 0.0 3.6 12.3 2.2 -0.6 5,004 More than secondary 8.3 19.6 -0.6 2.5 5.8 9.7 0.1 1.7 7.6 3.8 -0.3 1,105 Wealth quintile Lowest 33.3 52.1 -1.9 11.0 20.5 8.7 -0.5 15.9 35.2 1.5 -1.4 4,088 Second 28.8 49.0 -1.8 8.5 17.0 8.6 -0.3 12.6 29.1 1.5 -1.2 4,354 Middle 23.2 41.8 -1.6 5.9 11.8 9.2 -0.1 7.6 22.4 1.6 -1.0 3,948 Fourth 16.2 33.6 -1.3 4.3 9.8 8.3 -0.1 4.8 16.6 2.1 -0.8 3,776 Highest 10.8 24.2 -0.8 4.5 9.3 9.2 -0.0 3.2 10.2 3.5 -0.4 3,731 Total 22.8 40.6 -1.5 7.0 13.9 8.8 -0.2 9.0 23.1 2.0 -1.0 19,896 Total 20037 22.8 42.4 -1.6 4.4 11.0 5.6 -0.2 8.7 24.3 1.2 -1.1 4,770 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Total includes 2 children with information missing on mother’s interview status and 10 children with information missing on mother’s education. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. 1 Includes children who are below -3 standard deviations (SD) from the WHO Child Growth standards population median 2 Excludes children whose mothers were not interviewed 3 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 4 Includes children whose mothers are deceased 5 Excludes children whose mothers were not weighed and measured. Mother's nutritional status in terms of BMI (Body Mass Index) is presented in Table 11.10 6 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire 7 Recalculated according to the WHO Child Growth Standards 166 | Nutrition of Children and Adults Weight-for-height Fourteen percent of children under five are wasted. Wasting varies greatly by age and peaks among children age 6-8 months (20 percent). Boys are slightly more likely to be wasted than girls (14 percent compared with 13 percent). Children reported to be very small at birth are more likely to be wasted (20 percent) than those reported to be of average size or larger (13 percent). Wasting among children born to thin mothers (BMI less than 18.5) is higher than for children born to normal mothers (BMI 18.5-24.9) and overweight or obese mothers (BMI of 25 or higher). There is a slight difference in wasting between urban (11 percent) and rural children (15 percent). At the zonal level, North East and North West reported wasting levels that are above the national average (22 and 20 percent, respectively). As seen for stunting, wasting decreases with increasing level of education and wealth quintile. For example, children whose mothers have never attended school have the highest levels of wasting (20 percent), while children whose mothers have more than secondary education have the lowest levels of wasting (6 percent). Children born to mothers in the highest wealth quintile are also less likely to be wasted (9 percent) than those in the lowest wealth quintile (21 percent). It should be noted that 9 percent of children under age five in Nigeria are overweight, with the Z-scores above two standard deviations (+2 SD) above the median. Weight-for-age Nationally, nearly one in four children is underweight (23 percent), and 9 percent are severely underweight. Table 11.1 shows that the percentage of children who are underweight almost doubles from 14 percent among children less than 6 months of age to 26 percent among children age 12-17 months. This may be explained by the fact that weaning foods are typically introduced to children in the latter group, thus increasing exposure to infections and susceptibility to illness. This, coupled with inappropriate and/or inadequate feeding practices may be contributing to faltering nutritional status among children in these age groups. As with the other two nutritional indicators, male children are more likely to be underweight (25 percent) than female children (22 percent), and smaller size at birth is associated with lower weight-for-age. Children born to thin or underweight mothers (BMI less than 18.5) are more likely to be underweight than those born to normal mothers with a normal BMI, (39 percent compared with 24 percent). The proportion of children who are underweight is higher in rural areas than in urban areas. At the zonal level, children in South East are the least likely (10 percent) to 1 Figure 11.1 Nutritional Status of Children by Age Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a five-month moving average. # # ## ## ## ###### ############# ############## ######### ### ####### ) ) )))))) ))))))))))))))))))))))))))))))))))))))))))) ))))))))) 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Age (months) 0 10 20 30 40 50 60 Percent Stunted Wasted Underweight) # NDHS 2008 Nutrition of Children and Adults | 167 be underweight, while children in the North East and North West are the most likely (35 percent each). The proportion of children who are underweight decreases with increases in mother’s level of education. Similarly, undernutrition is higher among children in the three lowest wealth quintiles than the two highest wealth quintiles. The nutritional status of children in the 2008 NDHS according to the NCHS/CDC/WHO reference population, which was used in previous NDHS reports, is shown in Appendix Table E.1. 11.1.3 Trends in Malnutrition Figure 11.2 shows trends in the nutritional status of children in Nigeria using anthropometric measurements from the 2003 NDHS and the 2008 NDHS. For this purpose, the anthropometric measures for the 2003 survey were recalculated using new WHO growth standards. The results show that for the indicators height-for-age and weight-for-age, there has been little change between the two surveys. However, wasting has increased slightly. 11.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the contraction of the uterus and reduces post-partum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 11.2 shows the percentage of all children born in the five years before the survey by breastfeeding status and the timing of initial breastfeeding, by background characteristics. It also considers the prevalence of the practice of prelacteal feeding, i.e., giving the infant other liquids during the period between the birth and when the mother’s milk is flowing freely. This practice is discouraged because it limits the frequency of breastfeeding by the infant and exposes the baby to the risk of infection. Figure 11.2 Trends in Nutritional Status of Children Under Five, 2003 NDHHS and 2008 NDHS 42 11 24 41 14 23 Stunting (height-for-age) Wasting (weight-for-height) Underweight (weight-for-age) 0 10 20 30 40 50 Percent NDHS 2003 NDHS 2008 Note: The data for both surveys are based on the WHO Child Growth standards adopted in 2006. 168 | Nutrition of Children and Adults Table 11.2 Initial breastfeeding Among children born in the five years preceding the survey, the percentage ever breastfed, and for last-born children ever breastfed, the percentage who started breastfeeding within one hour of birth and within one day of birth and the percentage who received a prelacteal feed, by background characteristics, Nigeria 2008 Breastfeeding among children born in past five years Among last-born children ever breastfed: Background characteristic Percentage ever breastfed Number of children born in past five years Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 97.3 14,289 37.9 67.4 56.4 8,767 Female 97.4 13,811 38.9 67.7 55.7 8,502 Residence Urban 97.4 8,359 40.5 75.6 45.4 5,218 Rural 97.3 19,741 37.5 64.1 60.6 12,051 Zone North Central 97.0 3,830 60.5 80.8 39.0 2,456 North East 97.9 4,575 24.7 49.2 79.1 2,696 North West 98.1 8,779 31.4 56.1 67.7 5,305 South East 95.7 2,730 38.1 79.7 52.0 1,546 South South 96.4 3,667 51.2 82.8 56.2 2,247 South West 97.3 4,519 35.5 75.8 30.7 3,018 Mother's education No education 97.8 13,071 31.7 55.4 67.5 7,885 Primary 97.0 6,521 43.8 76.7 52.1 3,924 Secondary 96.9 6,997 43.3 77.5 44.5 4,445 More than secondary 96.7 1,511 47.8 83.2 32.7 1,014 Wealth quintile Lowest 97.7 6,525 29.9 51.9 70.6 4,003 Second 97.3 6,395 37.7 63.4 61.2 3,839 Middle 97.7 5,417 42.5 72.7 55.2 3,290 Fourth 96.9 5,003 43.2 78.3 48.4 3,113 Highest 96.8 4,760 41.2 76.8 39.1 3,024 Assistance at delivery Health professional3 96.6 10,939 44.8 79.3 42.1 6,961 Traditional birth attendant 97.7 6,069 35.6 61.0 66.4 3,676 Other 98.1 5,274 35.4 61.6 65.1 3,219 No one 97.7 5,423 31.6 56.9 65.1 3,317 Missing 97.9 396 17.4 31.1 45.8 96 Place of delivery Health facility 96.6 9,836 45.0 79.5 41.3 6,254 At home 97.8 17,437 34.5 60.6 65.5 10,609 Other 96.9 542 40.2 70.6 36.4 359 Missing 98.6 286 14.4 17.1 20.5 47 Total 97.3 28,100 38.4 67.5 56.0 17,269 Note: Table is based on births in the past five years whether the child was living or dead at the time of the interview. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse/midwife, or auxiliary midwife According to the results, nearly all children (97 percent) born in the five years preceding the survey were breastfed; this occurred regardless of background characteristics. However, less than half of infants (38 percent) were put to the breast within one hour of birth and only 68 percent started breastfeeding within the first day. These proportions are marginally higher than the 2003 levels, when 32 percent of children were breastfed within the first hour and 63 percent of children were breastfed within one day of birth. Although breastfeeding is widely practiced across all subgroups of women, the timing of initial breastfeeding varies by background characteristics. The results show that the proportion of Nutrition of Children and Adults | 169 children breastfed within one hour of delivery is slightly higher in urban areas (41 percent) than in rural areas (38 percent). With respect to zone, North Central has the highest proportion (61 percent) of children breastfed within one hour of birth, while the North East has the lowest proportion (25 percent). Children born to mothers with at least primary education are more likely to be breastfed within one hour of birth than those born to mothers with no education. Assistance at delivery and place of delivery are associated with the timing of initial breastfeeding. Children whose mothers were assisted at birth by a health professional are most likely to be breastfed within one hour of birth (45 percent), while children whose mothers were not assisted by anyone are least likely (32 percent). The proportion of children breastfed within one hour of birth is higher for children born at a health facility (45 percent) than for those born at home (35 percent). Prelacteal feeding is widely practiced in Nigeria. More than half, (56 percent) of last-born children received a prelacteal feed. There are no marked differences in the proportions of children, who received a prelacteal feed by sex of the child. However, there are substantial variations by residence, assistance at delivery, and place of delivery. Prelacteal feeding is most widely practiced in North East (79 percent) and North West zones (68 percent), and is least common in South West (31 percent). Children whose mothers have more than secondary education (33 percent) are less likely to receive prelacteal feeds than children whose mothers have no education (68 percent); likewise, children born to mothers in the highest wealth quintile (39 percent) are less likely to receive a prelacteal feed than children born to mothers in the lowest wealth quintile (71 percent). As shown in Figure 11.3, water is the most common prelacteal feed. Eighty-two percent of children who received prelacteal feeding were given plain water. One in five was given other kinds of milk, and 11 percent were given sugar or salt water. Figure 11.3 Among Last Children Born in the Five Years Preceding the Survey Who Ever Received a Prelacteal Liquid, the Percentage Who Received Specific Liquids 20 82 11 3 0 0 1 0 2 5 Milk other than breast milk Plain water Sugar or glucose water Gripe water Sugar and salt water Fruit juice Infant formula Tea/ infusions Honey Other 0 20 40 60 80 100 Percent NDHS 2008 <1 <1<1 170 | Nutrition of Children and Adults 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first six months of life and that children be given solid or semi-solid complementary foods in addition to continued breastfeeding from age 6 months to 24 months (or more) when the child is fully weaned. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for several reasons. First, it exposes infants to risk of infection. Second, it decreases infants’ intake of breast milk and therefore the frequency of breastfeeding, which reduces breast milk production. Third, in low resource settings, supplementary food is often nutritionally inferior. Table 11.3 and Figure 11.4 show the percent distribution of youngest children under three years of age living with the mother by breastfeeding status, and the percentage of all children under three years who use a bottle with a nipple, according to age in months. The survey results indicate that exclusive breastfeeding for the first six months is poorly practiced in Nigeria. Only about one in ten (13 percent) infants below six months of age are exclusively breastfed. Among children under six months, younger children are more likely to be exclusively breastfed. Twenty percent of infants below two months are exclusively breastfed, compared with only 7 percent of infants age 4-5 months. After the age of six months, children need to start receiving foods in order to meet all of their nutritional requirements. As shown in Table 11.3, only three-quarters of children age 6-9 months are breastfeeding and receiving complementary foods. Guidelines regarding breast milk substitutes (adopted from the WHO International Code of Marketing Breast Milk Substitutes) in Nigeria are very strict and discourage the use of bottles with nipples. The use of a bottle with a nipple, regardless of the contents (breast milk, formula, or any other liquid), requires hygienic handling to avoid contamination that may cause infection in the infant. Table 11.3 shows that 16 percent of infants age 0-5 months are fed using a bottle with a nipple. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under three years who are living with their mother by breastfeeding status; the percentage currently breastfeeding; and the percentage of all children under three years using a bottle with a nipple, according to age in months, Nigeria 2008 Percent distribution of youngest children under three living with their mother by breastfeeding status Breastfeeding and consuming: Age in months Not breast- feeding Exclusively breastfed Plain water only Non-milk liquids/ juice Other milk Comple- mentary foods Total Percentage currently breast- feeding Number of youngest child under three years Percentage using a bottle with a nipple1 Number of children under three years 0-1 2.6 20.1 39.4 12.6 5.5 19.9 100.0 97.4 741 12.5 748 2-3 3.1 14.2 34.0 10.7 5.9 32.1 100.0 96.9 1,011 16.6 1,024 4-5 3.1 7.2 29.1 7.9 5.1 47.6 100.0 96.9 1,083 16.7 1,102 6-8 3.9 2.7 13.9 4.0 2.7 72.8 100.0 96.1 1,508 14.2 1,543 9-11 8.0 0.9 3.2 1.8 1.4 84.7 100.0 92.0 1,277 12.5 1,312 12-17 19.8 0.5 1.9 1.1 0.7 76.1 100.0 80.2 2,817 8.4 2,894 18-23 58.9 0.2 0.8 0.4 0.2 39.5 100.0 41.1 1,836 5.7 2,051 24-35 91.2 0.1 0.1 0.1 0.0 8.5 100.0 8.8 3,205 2.8 4,633 0-3 2.9 16.7 36.3 11.5 5.8 26.9 100.0 97.1 1,752 14.9 1,773 0-5 2.9 13.1 33.5 10.1 5.5 34.8 100.0 97.1 2,835 15.6 2,874 6-9 4.4 2.4 11.6 3.7 2.5 75.5 100.0 95.6 1,924 14.5 1,971 12-15 14.6 0.6 2.3 1.2 0.8 80.6 100.0 85.4 1,995 8.9 2,041 12-23 35.2 0.4 1.5 0.8 0.5 61.6 100.0 64.8 4,653 7.3 4,945 20-23 67.7 0.3 0.6 0.5 0.1 30.7 100.0 32.3 1,099 5.8 1,267 Note: Breastfeeding status refers to a 24-hour period (yesterday and the past night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids/juice, other milk, and complementary foods (solid and semi-solid) are hierarchical and mutually exclusive, so their percentages add to 100 percent. Children who receive breast milk and non-milk liquids and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years Nutrition of Children and Adults | 171 Figure 11.5 shows changes in feeding practices between the 2003 and 2008 NDHS. Compared with the results of the 2003 NDHS, there has been a small decrease in compliance with the WHO/UNICEF recommendations. The proportion of children under the age of six months that are exclusively breastfed decreased from 17 percent in the 2003 NDHS to 13 percent in the 2008 NDHS. However the proportion of those who receive plain water only in addition to breast milk has also decreased. By contrast, the proportion of children less than six months of age who receive complementary foods increased notably from 18 percent to 35 percent. Figure 11.5 also shows that there has been an increase in the proportion of children age 6-9 months who received timely introduction of complementary foods. Figure 11.4 Infant Feeding Practices by Age <2 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 0 20 40 60 80 100 Exclusively breastfed Breast milk and plain water Breast milk and non-milk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding NDHS 2008 Percent Figure 11.5 Trends in Infant Feeding Practices for Children 0-5 Months and 6-9 Months, 2003 NDHS and 2008 NDHS 2003 2008 2003 2008 0-5 MONTHS 6-9 MONTHS 0 20 40 60 80 100 Percent Exclusively breasted Breast milk and plain water only Breast milk and non-milk liquids Breast milk and other milk/formula Breast milk and complementary foods Not breastfed 172 | Nutrition of Children and Adults 11.4 DURATION AND FREQUENCY OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding by selected background characteristics. The estimates of median and mean durations of breastfeeding are based on current status information, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The median duration of any breastfeeding in Nigeria is 18.1 months (the mean duration is 17.9). The median duration does not vary much by sex of the child. Rural children are breastfed for a longer duration (19 months) than urban children (16.2 months). Children in households in the highest wealth quintile are breastfed for the shortest duration (14.6 months) while other children are breastfed for 17-21 months. At the national levels, the median duration of exclusive breastfeeding is less than one month. Table 11.4 shows the median duration of predominant breastfeeding, which is defined as exclusive breastfeeding or breastfeeding in combination with plain water, water-based liquids, or juices. The median length of predominant breastfeeding in Nigeria is three months. There is little variation by background characteristics. However, it is worth noting that the median length of predominant breastfeeding in North West is 4.6 months, the highest in the country. Table 11.4 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Nigeria 2008 Median duration (months) of breastfeeding among children born in the past three years1 Frequency of breastfeeding among children under six months2 Background characteristic Any breast- feeding Exclusive breast- feeding Predominant breast- feeding3 Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 17.7 0.5 2.9 98.5 9.3 6.0 1,333 Female 18.4 0.5 3.0 98.5 9.0 5.9 1,296 Residence Urban 16.2 0.5 3.2 99.0 9.5 6.1 814 Rural 19.0 0.4 2.8 98.3 9.0 6.0 1,815 Zone North Central 19.1 0.5 1.5 97.8 8.2 7.0 346 North East 20.7 0.4 3.6 98.6 9.5 5.5 462 North West 20.0 0.4 4.6 99.2 9.7 6.2 743 South East 14.2 0.5 2.2 98.4 9.1 6.2 260 South South 15.4 0.5 1.8 95.9 7.9 5.2 367 South West 16.0 0.6 3.3 99.8 9.6 5.9 450 Mother's education No education 20.6 0.4 3.4 99.0 9.3 6.1 1,132 Primary 18.0 0.5 2.6 98.0 9.0 5.8 588 Secondary 15.3 0.5 2.5 98.3 9.1 5.8 782 More than secondary 14.0 0.7 3.6 97.6 8.8 6.7 127 Wealth quintile Lowest 20.9 0.4 3.4 98.9 9.0 6.3 620 Second 19.5 0.4 3.1 99.1 9.5 5.8 575 Middle 18.2 0.5 2.4 97.4 8.8 5.8 488 Fourth 16.6 0.6 2.9 98.1 8.6 6.0 485 Highest 14.6 0.6 3.1 98.7 9.8 5.9 460 Total 18.1 0.5 3.0 98.5 9.1 6.0 2,629 Mean for all children 17.9 1.6 4.7 na na na na Note: Median and mean durations are based on current status. Includes children born in the specified period whether living or dead at the time of the survey. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding 2 Excludes children without a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only Nutrition of Children and Adults | 173 It is important for an infant to breastfeed frequently as this improves milk production. Almost all breastfeeding children less than six months of age (99 percent) were breastfed at least six times during the 24 hours preceding the survey, which meets the WHO/UNICEF recommendations for optimal breastfeeding. The mean number of day-time feeds is 9, while the mean number of night-time feeds is 6. These results are comparable to those of the 2003 NDHS. 11.5 TYPES OF COMPLEMENTARY FOODS UNICEF and WHO recommend the introduction of solid food to infants around the age of six months because by that age breast milk alone is no longer sufficient to maintain a child’s optimal growth. In the transition to eating the family diet, children from the age of six months should be fed small quantities of solid and semi-solid foods throughout the day. During this transition period (ages 6-23 months), the prevalence of malnutrition increases substantially in many countries because of increased infections and poor feeding practices. Table 11.5 provides information on the types of foods given on the day and night preceding the survey to youngest children under three years of age living with their mother, according to breastfeeding status. The results show that, among all breastfeeding children under three years, very few (7 percent) consume infant formula. However, a higher proportion (24 percent) receives other milk. Between age 6 and 23 months, children consume foods made from grains more often than foods from any other food group. Among breastfeeding children in this age group, 81 percent ate foods made from grains, and 42 percent ate fruits and vegetables rich in vitamin A during the day and night preceding the interview. It is also worth noting that overall, a relatively small proportion of breastfeeding children age 6-23 months consume cheese, yogurt, and other milk products (15 percent). Comparing dietary intake of children by breastfeeding status shows that, as expected, a higher proportion of non-breastfeeding children are consuming solid and semi-solid foods (97 percent) than breastfeeding children (73 percent). More non-breastfeeding children than breastfeeding children are consuming milk other than breast milk (33 percent compared with 24 percent). However, the percentage of non-breastfeeding children consuming milk other than breast milk is still quite low, considering that they are not benefiting from breast milk. 174 | Nutrition of Children and Adults Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview Percentage of youngest children under three years of age who are living with the mother by type of foods consumed in the day and night preceding the interview, breastfeeding status, and age, Nigeria 2008 Solid or semi-solid foods Liquids Age in months Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry, and eggs Cheese, yogurt, other milk products Any solid or semi- solid food Food made with oil, fat, or butter Sugary foods Number of children BREASTFEEDING CHILDREN 0-1 4.3 9.4 26.5 1.4 9.8 2.3 1.5 1.0 1.8 2.1 1.8 20.4 0.8 1.4 722 2-3 9.4 15.9 33.5 5.3 24.1 5.2 2.7 3.0 3.8 6.3 3.7 33.1 3.4 2.5 980 4-5 10.7 21.6 40.9 10.0 41.1 8.3 3.4 5.5 6.7 10.3 6.5 48.9 4.9 5.7 1,050 6-8 9.2 25.6 56.5 11.0 66.3 23.3 11.9 13.2 15.9 28.7 11.0 75.5 13.4 12.9 1,449 9-11 8.8 31.4 64.9 10.6 82.3 42.9 19.9 25.2 29.7 50.9 14.4 91.5 25.4 24.4 1,174 12-17 3.7 28.5 68.2 5.3 87.1 48.2 24.0 29.6 34.5 52.3 16.6 94.5 26.7 25.2 2,261 18-23 1.4 26.9 66.8 2.5 90.0 55.2 25.6 29.6 40.8 54.4 19.8 96.1 29.6 27.7 755 24-35 2.2 27.3 68.4 2.1 88.3 57.1 26.6 35.6 36.7 49.7 20.3 96.2 30.7 26.6 283 6-23 5.9 28.1 64.3 7.5 81.1 41.6 20.2 24.5 29.6 46.2 15.1 89.2 23.4 22.2 5,639 Total 6.6 24.4 55.0 6.9 64.1 30.7 14.9 18.2 21.8 33.8 11.8 72.5 17.3 16.4 8,673 NON-BREASTFEEDING CHILDREN 0-1 * * * * * * * * * * * * * * 19 2-3 (13.4) (37.3) (64.3) (21.7) (68.2) (18.6) (5.7) (9.4) (18.6) (14.8) (25.5) (86.8) (16.9) (9.4) 31 4-5 (12.8) (27.5) (46.7) (12.7) (62.7) (12.6) (8.3) (13.1) (19.0) (19.2) (16.8) (67.6) (10.1) (4.2) 33 6-8 13.0 34.9 63.0 10.2 63.5 24.5 21.2 14.8 19.8 36.9 9.9 78.0 9.2 13.4 59 9-11 13.2 39.9 74.0 13.9 83.8 55.6 36.8 33.7 30.3 71.3 22.4 97.6 21.4 26.0 102 12-17 9.9 46.8 74.9 12.9 91.3 62.2 39.5 37.0 38.1 78.6 17.8 97.9 36.8 40.0 557 18-23 6.1 35.9 74.8 7.1 92.1 64.6 37.7 45.1 40.6 80.4 17.2 98.4 41.4 43.3 1,081 24-35 1.9 28.7 72.0 2.6 90.6 64.9 34.0 39.5 42.8 68.4 18.1 97.8 33.7 33.7 2,922 6-23 7.9 39.4 74.4 9.3 90.5 62.0 37.7 40.9 38.6 77.9 17.5 97.5 37.8 40.3 1,799 Total 4.3 32.8 72.5 5.3 89.9 62.9 34.9 39.5 40.7 71.0 17.9 97.2 34.8 35.6 4,804 Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and the past night). Figures in parentheses are based on 25- 49 unweighted cases; an asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Other milk includes fresh, tinned, and powdered cow or other animal milk 2 Doesn't include plain water 3 Includes fortified baby food 4 Includes pumpkin, yellow squash, carrots, orange sweet potatoes, dark green leafy vegetables, mangoes, papayas, and palm nuts 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Appropriate Infant and Young Child Feeding (IYCF) practices include timely initiation of feeding solid/semi-solid foods from age 6 months, feeding small amounts and increasing the amount of foods and the frequency of feeding as the child gets older, while maintaining breastfeeding. For the average, healthy breastfed child, solid/semi-solid foods should be provided 2-3 times per day at age 6- 8 months and 3-4 times per day from age 9 to 23 months, with an additional snack being offered 1-2 times per day, as desired. The minimum feeding frequencies are based upon the energy needs from complementary foods according to age-specific total daily energy requirements plus 2 SD (to meet the needs of almost all children), minus the average energy intake from breast milk for children in developing countries. Infants with low breast milk intake would need to be fed more frequently. However, feeding frequencies greater than necessary may lead to the displacement of breast milk (PAHO/WHO, 2003). Although it is internationally recommended that infants should be breastfed for up to two years, some infants are not breastfed and therefore do not receive the benefits of breastfeeding, while others stop breastfeeding before age two. Guidelines have been developed for this group of children who may not be breastfed because of the mother’s known HIV-positive status, or the mother having died, or some other reason (WHO, 2005). It is recommended that the non-breastfed child be fed Nutrition of Children and Adults | 175 solid/semi-solid foods 4-5 times per day from age 6 to 23 months, with an additional snack being offered 1-2 times per day, as desired. Appropriate nutrition includes feeding children a variety of foods to ensure that nutrient requirements are met. Studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients (WHO/UNICEF, 1998). Therefore, it has been advised that meat, poultry, fish or eggs should be eaten daily, or as often as possible. Vegetarian diets may not meet children’s nutrient requirements unless supplements or fortified products are used. Vitamin A-rich fruits and vegetables should be consumed daily. Children’s diets should also include adequate fat content. Fat is important in the diets of infants and young children because it provides essential fatty acids, facilitates absorption of fat-soluble vitamins (such as vitamin A) and enhances dietary energy, density, and palatability. Tea and coffee contain compounds that inhibit iron absorption and are not recommended for children. Sugary drinks and excessive juice consumption should be avoided because other than energy, they contribute little to the diet and as a result decrease the child’s appetite for more nutritious foods (PAHO/WHO, 2003). The nutritional requirements of children age 6-23 months can be summarised as follows: Breastfed children age 6-23 months should receive animal-source foods and vitamin A-rich fruits and vegetables daily (PAHO/WHO, 2003). Because first foods almost universally include a grain- or tuber-based staple, it is unlikely that young children who eat foods from two or fewer food groups will receive both an animal-source food and a vitamin A-rich fruit or vegetable. Therefore, three food groups are considered the minimum appropriate number of food groups for breastfed infants (Arimond and Ruel, 2004). Breastfed infants age 6-8 months should be fed meals of complementary foods two or three times per day, with one or two snacks as desired; breastfed children age 9-23 months should be fed meals three or four times per day, with one or two snacks (PAHO/WHO, 2003). Non-breastfed children age 6-23 months should receive milk products to ensure that their calcium needs are met. In addition, they need animal-source foods and vitamin A-rich fruits and vegetables. Therefore, four food groups are considered the minimum appropriate number of food groups for non-breastfed young children. Non-breastfed children age 6-23 months should be fed meals four or five times per day, with one or two snacks as desired (WHO, 2005). Table 11.6 presents summary indicators for three IYCF practices that take into account the percentage of breastfed and non-breastfed children for whom feeding practices met minimum standards with respect to food diversity (i.e., the number of food groups consumed) and feeding frequency (i.e., the number of times the child was fed), and the consumption of breast milk or other milk or milk products. According to the results presented in Table 11.6 and Figure 11.6, only 30 percent of youngest children age 6-23 months living with their mother are fed in accordance with IYCF practices. The proportion fed according to the guidelines is much higher among breastfed children (35 percent) than among those who are not breastfed (16 percent). Nearly nine in ten children (88 percent) received breast milk or milk products during the 24-hour period before the survey, and 55 percent of children were fed according to minimum standards with respect to food diversity (three or more food groups for breastfed children and four more food groups for non-breastfed children). Among breastfed children age 6-23 months, 52 percent receive foods from at least three food groups, while 55 percent are fed the minimum number of times or more. Among non-breastfed children age 6-23 months, 48 percent receive milk or milk products, 63 percent are fed foods from at least four food groups, and 33 percent are fed four or more times per day. A substantial proportion of non-breastfed children (more than eight in ten ) are not fed in accordance with the three IYCF practices. 176 | Nutrition of Children and Adults Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF practices based breastfeeding status, number of food groups consumed, and number of times they are fed during the day and night preceding the survey, by background characteristics, Nigeria 2008 Among breastfed children age 6-23 months, percentage fed: Among all children age 6-23 months, percentage fed: Among non-breastfed children age 6-23 months, percentage fed: Background characteristic 3+ food groups1 Mini- mum times or more2 Both 3+ food groups and mini- mum times or more Number of breast- fed children age 6-23 months Milk or milk products3 4+ food groups 4+ times or more With 3 IYCF prac- tices4 Number of non- breastfed children age 6-23 months Breast milk or milk products3 3+ or 4+ food groups5 Mini- mum times or more6 With all 3 IYCF prac- tices Number of all children age 6-23 months Age 6-8 31.3 60.0 26.0 1,449 40.6 20.6 9.9 1.6 59 97.7 30.8 58.1 25.0 1,508 9-11 55.6 47.9 31.9 1,174 54.0 57.5 21.6 10.1 102 96.3 55.8 45.8 30.1 1,277 12-17 59.7 54.1 38.2 2,261 55.3 65.2 31.2 16.4 557 91.2 60.8 49.6 33.9 2,817 18-23 64.9 61.1 46.1 755 44.4 65.3 36.9 16.8 1,081 67.3 65.1 46.9 28.8 1,836 Sex Male 51.1 54.0 33.9 2,784 49.7 62.7 33.4 15.6 938 87.3 54.0 48.8 29.3 3,722 Female 53.4 56.5 35.7 2,855 46.5 64.1 33.4 15.9 861 87.6 55.8 51.2 31.1 3,715 Residence Urban 58.5 55.1 36.6 1,493 58.6 71.0 34.8 19.7 736 86.3 62.6 48.4 31.0 2,229 Rural 50.0 55.3 34.1 4,146 41.0 58.1 32.4 13.1 1,063 88.0 51.7 50.6 29.8 5,209 Zone North Central 59.9 64.5 41.3 764 47.6 65.6 27.8 16.3 218 88.4 61.2 56.3 35.8 982 North East 44.6 61.4 32.6 1,007 43.8 52.1 41.5 16.3 154 92.5 45.6 58.7 30.4 1,161 North West 40.1 49.1 27.2 2,003 39.9 44.1 33.2 16.8 354 91.0 40.7 46.8 25.7 2,357 South East 58.9 58.3 40.1 400 53.3 62.9 37.1 14.2 303 79.9 60.6 49.2 28.9 703 South South 72.1 63.4 49.7 622 51.8 70.8 29.8 14.5 359 82.4 71.6 51.1 36.8 981 South West 65.7 46.8 35.9 843 50.5 76.8 34.0 16.8 410 83.8 69.3 42.6 29.7 1,253 Mother's education No education 44.3 52.6 29.3 2,945 39.6 47.3 32.1 13.3 480 91.5 44.8 49.7 27.0 3,425 Primary 57.9 58.9 39.9 1,251 41.0 63.5 32.1 13.0 409 85.5 59.3 52.3 33.3 1,661 Secondary 61.9 56.4 40.1 1,209 51.8 69.8 33.1 15.1 702 82.3 64.8 47.9 30.9 1,911 More than secondary 72.4 63.6 49.3 234 70.0 78.1 39.9 29.2 208 85.9 75.1 52.4 39.8 441 Wealth quintile Lowest 44.2 53.6 29.8 1,521 42.7 43.5 33.1 10.6 217 92.8 44.1 51.0 27.4 1,738 Second 45.6 53.9 30.5 1,391 33.5 50.9 30.4 11.9 301 88.2 46.6 49.7 27.2 1,692 Middle 54.0 57.9 37.8 1,066 37.5 55.8 33.8 11.5 328 85.3 54.4 52.2 31.6 1,394 Fourth 63.2 57.8 41.9 927 48.7 71.5 32.6 17.7 408 84.3 65.8 50.1 34.5 1,335 Highest 65.1 54.4 39.9 734 64.6 76.5 35.5 21.1 545 84.9 70.0 46.3 31.9 1,279 Total 52.3 55.3 34.8 5,639 48.2 63.3 33.4 15.8 1,799 87.5 54.9 50.0 30.2 7,438 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge, fortified baby food from grains; c. vitamin A-rich fruits and vegetables and palm nuts; d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts; h. foods made with oil, fat, or butter. 2 At least twice a day for breastfed infants 6-8 months and at least three times a day for breastfed children 9-23 months 3 Includes commercial infant formula, fresh, tinned and powdered animal milk, and cheese, yogurt and other milk products 4 Non-breastfed children age 6-23 months are considered to be fed with a minimum standard of three Infant and Young Child Feeding practices if they receive other milk or milk products and are fed at least the minimum number of times per day with at least the minimum number of food groups 5 3+ food groups for breastfed children and 4+ food groups for non-breastfed children 6 Fed solid or semi-solid food at least twice a day for infants age 6-8 months, 3+ times for other breastfed children, and 4+ times for non-breastfed children Nutrition of Children and Adults | 177 Looking at the variation in the proportion of children fed according to the IYCF diversity standards by background characteristics, the results indicate that male and female children are equally likely to be fed according to IYCF practices. Children in urban and rural areas are equally likely to be fed in accordance with IYCF practices. Among the zones, the percentage of children fed according to IYCF practices ranges from 26 percent in North West to 37 percent in South South. Table 11.6 shows that compliance with IYCF practices increases with mother’s level of education. The proportion of children age 6-23 months who are fed according to the minimum diversity standards generally increase with the mother’s level of education. Forty percent of children whose mothers attended more than secondary school are fed according to the IYCF practices, compared with 27 percent of children whose mothers have no education. The proportion of children fed according to IYCF practices also increases with household wealth status, from 27 percent in the two lowest wealth quintiles to 32 percent or higher in the three highest wealth quintiles. 11.7 MICRONUTRIENT INTAKE AMONG CHILDREN Table 11.7 summarises information collected in the 2008 NDHS on the intake of vitamin A and iron, and on receipt of de-worming medications among children. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe Vitamin A Deficiency (VAD) can cause eye damage. VAD can also increase severity of infections such as measles and diarrhoeal diseases in children and slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Periodic dosing (usually every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD. Table 11.7 shows that more than two in three youngest children age 6-35 months living with the mother consumed foods rich in vitamin A in the 24 hours preceding the interview. The proportion of children who consumed foods rich in vitamin A increases with age, from 36 percent for children age 6-8 months to 82 percent for children age 24-35 months. Not surprisingly, non-breastfeeding 35 15 30 65 84 70 Breastfed children Non-breastfed children All children age 6-23 months 0 20 40 60 80 100 Percentage of all children 6-23 months Fed with all IYCF practices Not fed with all IYCF practices Figure 11.6 Infant and Young Child Feeding (IYCF) Practices NDHS 2008 178 | Nutrition of Children and Adults children (84 percent) are more likely to consume foods rich in vitamin A than breastfeeding children (58 percent). Urban children (76 percent) are more likely to consume foods rich in vitamin A than rural children (67 percent). With regard to zones, children living in Southern zones (81 percent to 88 percent) are more likely to consume foods rich in vitamin A than children in the Northern zones (54 percent to 77 percent). Mother’s level of education is directly related to the consumption of foods rich in vitamin A: 58 percent of children whose mothers have no education consumed foods rich in vitamin A in the 24 hours before the survey, compared with 86 percent of children of mothers with more than secondary education. Likewise, as wealth status increases the proportion of children who receive foods rich in vitamin A increases, from 56 percent among children in the lowest wealth quintile to 83 percent among children in the highest wealth quintile. The NDHS 2008 collected information on children’s intake of iron. Iron is essential for cognitive development. Low iron intake can also contribute to anaemia. Iron requirements are greatest between age 6 and 11 months, when growth is most rapid. Table 11.7 shows that 58 percent of youngest children age 6-35 months who live with their mother consumed foods rich in iron in the 24 hours preceding the interview. The proportion of children who are fed foods rich in iron increases with age, from 29 percent among children age 6-8 months to 70 percent among children age 18-23 months. As expected, breastfeeding children (46 percent) are less likely to consume iron-rich foods than those that are not breastfeeding (73 percent). Urban children (70 percent) are more likely than rural children (53 percent) to receive iron-rich foods. By zone, the proportion of children who consumed iron-rich foods ranges from 41 percent in North East to 86 percent in South South. Children whose mothers were age 15-19 at the time of their birth are less likely than children born to older mothers to consume foods rich in iron. The proportion of children who are fed foods rich in iron increases with mother’s level of education, from 39 percent among children whose mothers have no education to 84 percent among children whose mothers have more than secondary education. Similarly, the proportion of children who are fed foods rich in iron increases with wealth status, from 37 percent among children in households in the lowest wealth quintile to 81 percent among children in households in the highest wealth quintile. The 2008 NDHS collected information on vitamin A supplementation. As shown in Table 11.7, one in four children age 6-59 months received vitamin A supplements in the six months preceding the survey. One in three urban children, compared with one in five rural children received vitamin A supplements in six months preceding the survey. Mother’s level of education is closely associated with children receiving vitamin A supplements; 14 percent of children of mothers with no education received vitamin A supplements in the past six months, compared with 49 percent of children whose mothers have more than secondary education. Similarly, the proportion of children who received vitamin A supplements increases with household wealth status, from 13 percent among children in the lowest wealth quintile to 44 percent among children in the highest wealth quintile. The NDHS 2008 also collected information on the intake of iron supplements during the seven days preceding the survey among children age 6-59 months. The results show that 16 percent of the children received iron supplements in the past week. One in four urban children were likely to receive iron supplements, compared with one in ten rural children. In the zones, children in Southern zones (16 percent to 49 percent) were more likely to receive iron supplements than their Northern counterparts (3 percent to 7 percent). The likelihood that a child received iron supplements in the past seven days increases with mother’s level of education and household wealth quintile. Infection with helminths or intestinal worms has been shown to have an adverse impact on the physical development of children and is associated with high levels of iron deficiency anaemia and other nutritional deficiencies. Regular treatment with de-worming medication is a simple, cost- effective measure to address these infections. Table 11.7 shows that one in five children age 6-59 months received de-worming medication during the six months preceding the survey. Nutrition of Children and Adults | 179 Table 11.7 Micronutrient intake among children Among youngest children age 6-35 months who are living with their mother, the percentages who consumed vitamin A-rich and iron- rich foods in the day and night preceding the survey; and among all children age 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, who were given iron supplements in the past seven days, and the percentage who were given de-worming medication in the six months preceding the survey; and among all children age 6-59 months who live in households that were tested for iodised salt, the percentage with adequately iodised salt in household, by background characteristics, Nigeria 2008 Youngest children age 6-35 months living with the mother All children age 6-59 months Children age 6-59 months in households tested for iodised salt Background characteristic Percentage who consumed foods rich in vitamin A in past 24 hours1 Percentage who consumed foods rich in iron in past 24 hours2 Number of children Percentage given vitamin A supple- ments in past 6 months Percentage given iron supple- ments in past 7 days Percentage given de- worming medica- tion in past 6 months3 Number of children Percentage with adequately iodised salt in household4 Number of children Age in months 6-8 35.9 29.0 1,508 22.4 13.0 6.8 1,543 54.3 1,508 9-11 63.9 52.5 1,277 29.6 18.8 14.4 1,312 52.3 1,278 12-17 69.3 57.5 2,817 26.9 16.1 17.6 2,894 53.2 2,815 18-23 80.3 69.7 1,836 29.3 18.2 24.8 2,051 53.2 2,006 24-35 81.9 66.8 3,205 26.0 15.9 25.2 4,633 52.6 4,510 36-47 na na na 24.8 15.4 23.3 5,013 53.1 4,856 48-59 na na na 24.6 14.5 22.9 4,653 52.4 4,522 Sex Male 69.2 57.5 5,346 25.8 15.5 21.5 11,154 52.5 10,859 Female 70.0 58.0 5,296 25.9 15.9 21.1 10,946 53.3 10,637 Breastfeeding status Breastfeeding 58.4 46.4 5,922 24.2 13.7 11.2 6,066 52.9 5,915 Not breastfeeding 84.1 72.5 4,614 26.8 16.7 25.7 15,137 52.5 14,715 Missing 63.1 51.9 107 19.6 12.6 16.2 897 59.2 866 Residence Urban 76.4 69.9 3,187 35.5 25.8 33.9 6,809 54.8 6,647 Rural 66.7 52.6 7,455 21.5 11.2 15.7 15,291 52.0 14,849 Zone North Central 77.3 70.4 1,442 25.7 6.8 9.4 3,045 54.7 3,003 North East 60.1 41.0 1,679 18.6 4.1 5.7 3,488 34.1 3,414 North West 53.5 33.6 3,390 13.9 3.2 4.0 6,770 66.5 6,498 South East 81.2 73.8 955 28.5 16.4 42.5 2,152 59.7 2,059 South South 88.1 85.6 1,364 34.4 25.3 48.4 2,910 39.8 2,841 South West 82.5 79.0 1,812 46.1 48.5 43.8 3,735 51.1 3,681 Mother's education No education 57.7 39.2 4,920 14.4 4.4 5.1 10,081 52.9 9,768 Primary 76.9 68.4 2,420 27.5 16.8 24.4 5,169 53.1 5,063 Secondary 81.1 76.2 2,665 39.7 30.0 40.8 5,551 51.4 5,405 More than secondary 85.9 83.5 637 48.6 38.2 51.9 1,299 58.2 1,260 Mother's age at birth 15-19 59.1 43.3 722 15.8 9.1 8.5 1,006 49.5 974 20-29 69.5 58.0 5,169 25.1 15.5 20.2 10,526 52.0 10,240 30-39 71.9 60.7 3,776 28.6 18.0 25.2 8,240 53.9 8,035 40-49 69.0 55.7 975 24.0 11.3 18.4 2,329 54.7 2,247 Wealth quintile Lowest 56.0 37.0 2,482 13.2 3.2 4.6 4,955 45.9 4,803 Second 63.7 47.6 2,419 17.5 6.8 9.7 4,935 54.1 4,807 Middle 70.8 59.0 1,978 26.2 13.4 18.9 4,247 52.4 4,140 Fourth 80.5 74.1 1,908 33.1 22.9 32.1 4,011 56.7 3,896 Highest 83.0 80.7 1,855 44.3 37.7 48.5 3,952 56.8 3,850 Total 69.6 57.8 10,642 25.8 15.7 21.3 22,100 52.9 21,496 Note: Information on vitamin A and iron supplements and de-worming medication is based on mothers’ reports. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, yellow squash, carrots, orange sweet potatoes, dark green leafy vegetables, mango, papaya, and palm nuts 2 Includes meat (including organ meat), fish, poultry, and eggs 3 De-worming for intestinal parasites is commonly done for helminths and for schistosomiasis 4 Salt containing at least 15 parts per million (ppm) of iodine 180 | Nutrition of Children and Adults The proportion of children who received the de-worming medication increases with age, from 7 percent among children age 6-8 months to 25 percent among children age 24-35 months, before declining among children age 36 months and older. The proportion of children who received de-worming medication is much higher among non- breastfeeding children (26 percent) than among those who are breastfeeding (11 percent). The proportion of children receiving medication is higher among urban children (34 percent) than rural children (16 percent). By zone, the proportion of children who received de-worming medication is highest in South South (48 percent) and lowest in North West zone (4 percent). The likelihood that a child has received de-worming medication is positively associated with mother’s level of education and household wealth quintile. The NDHS 2008 collected information on household salt quality by testing for the level of iodine. Iodised salt prevents goitre and aids mental development, especially in children. The results of the testing of household salt indicated that half of children age 6-59 months live in households with adequately iodised salt. 11.8 PRESENCE OF IODISED SALT IN HOUSEHOLDS Salt is used for several purposes in the household. It plays a role in cooking and food preservation, but not all types of salt are fit for consumption. In line with food and drug regulation, household salt should be iodised to at least 15 parts per million (ppm). Iodised salt is essential in the prevention of goitre among children and adults. The 2008 NDHS tested the quality of household salt in 94 percent of households. Table 11.8 shows that, among these, 3 percent use salt with no iodine content (0 ppm), 45 percent have salt with inadequate iodine content, and 52 percent have salt with adequate iodine content. Households in North East are least likely to have salt with adequate iodine content (34 percent), compared with households in North West (65 percent). Table 11.8 Presence of iodised salt in household Among all households, percentage with salt tested for iodine content and percentage with no salt; and among households with salt tested, the percent distribution by level of iodine in salt (parts per million or ppm), according to background characteristics, Nigeria 2008 All households Among households with salt tested, the percent distribution by iodine content of salt Background characteristic Percentage with salt tested Percentage with no salt Number of households None (0 ppm) Inadequate (<15 ppm) Adequate (15+ ppm) Total Number of households Residence Urban 94.1 5.9 12,100 2.7 43.8 53.5 100.0 11,380 Rural 94.2 5.8 21,970 3.8 45.8 50.4 100.0 20,698 Zone North Central 94.6 5.4 4,568 3.4 40.4 56.2 100.0 4,322 North East 92.0 8.0 3,730 5.0 61.3 33.7 100.0 3,430 North West 91.5 8.5 7,178 3.7 31.5 64.7 100.0 6,566 South East 95.6 4.4 4,527 4.3 39.0 56.7 100.0 4,327 South South 94.5 5.5 5,966 3.3 56.8 39.9 100.0 5,641 South West 96.2 3.8 8,100 1.9 47.0 51.1 100.0 7,792 Wealth quintile Lowest 93.6 6.4 6,119 4.9 50.3 44.8 100.0 5,727 Second 94.0 6.0 6,219 3.4 45.0 51.5 100.0 5,845 Middle 94.2 5.8 7,065 3.7 45.4 50.9 100.0 6,657 Fourth 93.8 6.2 7,216 2.7 43.5 53.8 100.0 6,768 Highest 95.0 5.0 7,451 2.5 42.2 55.3 100.0 7,082 Total 94.2 5.8 34,070 3.4 45.1 51.5 100.0 32,079 Nutrition of Children and Adults | 181 11.9 NUTRITIONAL STATUS OF WOMEN Anthropometric measurements of height and weight were collected for women age 15-49. In this report, two indicators of nutritional status based on these data are presented: the percentage of women with very short stature (less than 145 cm) and the body mass index (BMI). The body mass index (BMI), or the Quetelet index, is used to measure thinness and obesity. BMI is defined as weight in kilograms divided by height in metres squared (kg/m2). A cut-off point of 18.5 is used to define thinness or acute undernutrition, and a BMI of 25.0 or above usually indicates overweight or obesity. The height of a woman is associated with past socio-economic status and nutrition during childhood and adolescence. Low pre-pregnancy BMI and short stature are risk factors for poor birth outcomes and obstetric complications. In developing countries, maternal underweight is the leading risk factor for preventable deaths and diseases. Table 11.9 shows the percentage of women with height under 145 cm, the mean BMI, and the proportion of women falling into high-risk categories, according to background characteristics. Respondents for whom there was no information on height or weight and for whom a BMI could not be estimated are excluded from this analysis. The data analysis on BMI is based on 28,200 women, while the height analysis is based on 32,367 women age 15-49 years. Table 11.9 shows that 3 percent of women have short stature. Short stature decreases with increasing level of education and wealth status. Two in three women have a normal BMI. Normal BMI decreases with age from 74 percent among women age 15-19 to 57 percent among women age 40-49. Normal BMI also decreases with increasing level of education and wealth status. Four percent of women are moderately or severely thin. The proportion of women moderately or severely thin decreases with age, and with increasing level of education and wealth quintile. Regarding the overweight and obese category, nearly one in four women is either overweight or obese (16 percent overweight and 6 percent obese). Overweight and obesity increases by age from 7 percent among women age 15-19 to 34 percent among women age 40-49. More urban women (31 percent) than rural women (17 percent) are overweight or obese. Overweight and obesity are higher for women in the Southern zones than the Northern zones, and increase with increasing level of education and wealth quintile. 182 | Nutrition of Children and Adults Table 11.9 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, the mean body mass index (BMI), and the percentage of women with specific BMI levels, by background characteristics, Nigeria 2008 Body Mass Index1 Normal Thin Overweight/obese Height Background characteristic Percentage below 145 cm Number of women Mean Body Mass Index (BMI) 18.5- 24.9 (total normal) <18.5 (total thin) 17.0- 18.4 (mildly thin) <17 (moder- ately or severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of women Age 15-19 6.1 6,221 20.8 73.7 19.3 13.4 5.9 7.0 6.0 1.0 5,712 20-29 2.6 12,069 22.3 70.0 11.6 8.7 2.9 18.3 14.4 3.9 9,904 30-39 1.9 8,344 23.6 60.1 9.5 6.5 3.0 30.4 20.7 9.7 7,117 40-49 1.8 5,732 23.9 57.0 9.2 6.5 2.7 33.8 23.5 10.3 5,467 Residence Urban 2.1 11,592 23.6 60.1 9.1 6.5 2.6 30.8 21.3 9.5 10,307 Rural 3.5 20,775 22.1 69.0 14.0 10.0 4.0 17.0 13.0 4.0 17,893 Zone North Central 2.8 4,646 22.8 70.4 8.5 6.5 2.0 21.1 15.8 5.3 4,043 North East 3.1 4,130 21.3 66.6 20.7 14.0 6.7 12.7 9.7 3.0 3,456 North West 5.5 7,640 21.5 66.6 18.6 12.6 6.0 14.8 11.5 3.4 6,395 South East 2.0 3,960 23.5 63.7 6.8 5.6 1.2 29.5 21.0 8.5 3,529 South South 1.8 5,313 23.3 65.7 7.7 6.0 1.7 26.7 18.8 7.9 4,779 South West 1.6 6,678 23.3 62.4 9.7 6.9 2.8 27.9 19.7 8.2 5,998 Education No education 4.1 11,467 21.6 67.5 18.1 12.4 5.8 14.4 11.2 3.2 9,698 Primary 3.0 6,427 22.9 66.0 10.3 7.6 2.7 23.8 17.1 6.7 5,510 Secondary 2.4 11,595 22.9 66.6 9.6 7.2 2.4 23.8 17.3 6.5 10,401 More than secondary 0.8 2,878 24.8 55.0 4.5 3.4 1.2 40.5 27.2 13.3 2,591 Wealth quintile Lowest 4.7 5,950 21.0 70.0 20.7 14.1 6.6 9.3 7.5 1.8 4,960 Second 3.9 6,006 21.6 71.5 15.1 10.7 4.4 13.4 11.1 2.3 5,148 Middle 2.7 6,163 22.4 69.6 11.3 8.1 3.2 19.1 14.9 4.2 5,370 Fourth 2.5 6,775 23.0 65.0 9.6 7.3 2.3 25.4 18.5 6.9 6,059 Highest 1.5 7,472 24.5 55.6 6.7 4.9 1.8 37.7 24.9 12.8 6,664 Total 3.0 32,367 22.6 65.7 12.2 8.7 3.5 22.1 16.1 6.0 28,200 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in metres (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding 2 months 11.10 FOODS CONSUMED BY MOTHERS The quality and quantity of foods consumed by mothers influences their health and that of their children, especially the health of breastfeeding children. The 2008 NDHS included questions on the types of food consumed by mothers with children under age three during the day and night preceding the interview. Table 11.10 shows that eight in ten mothers of young children in Nigeria consume foods made grain; four in ten consume foods made from roots and tubers, and an equal proportion consume legumes; seven in ten eat meat, fish, shellfish, poultry, and egg; one in five eats cheese or yogurt; two in three eat vitamin A-rich fruits and vegetables; one in three eats other fruits and vegetables, and a similar proportion eats foods made with oil, fats or butter; and one in seven women consume sugary foods. The consumption of solid or semi-solid foods varies according to background characteristics. The consumption of legumes is lowest in South East zone (26 percent) and highest in South West (57 percent). More urban women (82 percent) than rural women (63 percent) consume meat, fish, shell fish, poultry, and egg. The consumption of meat, fish, shellfish, poultry, and egg increases with level of education and wealth status. Education and wealth status also have positive relationships with the consumption of vitamin A-rich fruits and vegetables, other fruits or vegetables, and foods made with oil, fat, and butter, and sugary foods. Nutrition of Children and Adults | 183 Table 11.10 Foods consumed by mothers in the day and night preceding the interview Among mothers age 15-49 with a child under age three years living with them, the percentage who consumed specific types of foods in the day or night preceding the interview, by background characteristics, Nigeria 2008 Solid or semi-solid foods Liquids Background characteristic Milk Tea/ coffee Foods made from grains Foods made from roots/ tubers Foods made from legumes Meat/ fish/ shellfish/ poultry/ eggs Cheese/ yogurt Vitamin A-rich fruits/ vege- tables1 Other fruits/ vege- tables Foods made with oil/ fat/ butter Sugary foods Number of mothers Age 15-19 22.1 19.5 81.0 38.8 40.8 58.2 22.7 64.9 28.0 30.8 12.6 1,016 20-29 27.8 28.4 81.0 41.4 41.6 70.3 19.6 66.7 33.8 34.9 15.0 6,642 30-39 27.5 29.0 80.2 42.1 40.7 70.0 18.4 67.8 34.3 34.6 14.6 4,652 40-49 21.1 21.4 79.7 39.9 41.8 61.9 17.4 64.4 30.0 33.2 8.9 1,167 Residence Urban 35.1 43.6 81.6 41.8 43.6 82.0 17.1 67.4 41.8 41.0 18.0 4,057 Rural 23.1 20.4 80.2 41.1 40.3 62.8 20.2 66.5 29.5 31.4 12.5 9,420 Zone North Central 28.6 25.5 76.7 59.1 44.2 83.7 26.5 74.7 43.7 46.1 22.4 1,823 North East 23.6 22.7 88.6 30.8 41.4 50.6 21.0 59.8 18.9 23.9 9.7 2,175 North West 23.5 17.2 83.3 27.7 41.2 44.3 23.9 61.2 25.9 24.2 7.1 4,207 South East 28.1 33.4 74.5 59.7 25.5 82.4 13.1 71.3 41.8 28.1 16.0 1,227 South South 28.0 34.7 73.1 63.6 28.6 93.8 11.7 71.2 43.6 36.3 22.2 1,756 South West 32.2 42.9 80.3 35.2 57.1 91.4 12.5 71.5 39.3 55.3 17.5 2,287 Education No education 22.6 15.3 82.7 31.7 41.6 50.2 24.4 62.8 24.7 28.9 9.5 6,170 Primary 22.3 26.3 79.2 49.6 41.7 78.5 14.9 70.1 35.8 35.9 13.7 3,045 Secondary 32.1 42.1 77.9 50.3 39.6 87.5 14.0 69.6 42.1 39.6 20.3 3,488 More than secondary 52.5 61.0 81.9 44.5 43.9 90.6 18.8 72.0 50.6 47.4 25.0 774 Wealth quintile Lowest 24.0 12.1 80.6 34.1 38.5 46.9 25.8 62.2 21.3 28.2 8.8 3,155 Second 18.2 14.0 80.5 38.2 41.1 57.3 19.3 64.3 28.3 29.4 10.3 3,041 Middle 18.6 23.4 78.2 46.8 39.1 72.5 16.6 67.9 35.4 32.0 14.4 2,509 Fourth 31.5 40.8 82.9 49.4 44.9 84.6 16.8 72.5 40.8 39.3 19.2 2,423 Highest 45.1 55.5 80.9 40.8 43.7 91.5 15.8 68.9 45.4 46.2 20.7 2,349 Total 26.7 27.4 80.6 41.3 41.3 68.6 19.3 66.8 33.2 34.3 14.1 13,477 Note: Foods consumed in the past 24-hour period (yesterday and the past night) 1 Includes pumpkin, yellow squash, carrots, orange sweet potatoes, green leafy vegetables, mangoes, papayas, and palm nuts 11.11 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Table 11.11 includes a number of measures that are useful in assessing the extent to which women are receiving adequate intake of vitamin A and iron. Table 11.11 shows the extent to which mothers of young children are consuming foods rich in vitamin A, iron, and iodised salt. The results indicate that 84 percent of mothers with children under three years eat foods rich in vitamin A and 69 percent eat iron-rich foods. Fifty-three percent of mothers are in households with adequately iodised salt. Mothers in urban areas (90 percent) are more likely to consume foods rich in vitamin A than those in rural areas (82 percent). At the zonal level, mothers in North West are least likely to consume foods rich in vitamin A (73 percent), while those in South South and South West are the most likely to consume these foods (96 and 95 percent, respectively). Consumption of vitamin A-rich foods increases with mother’s level of education. Consumption of iron-rich foods is substantially higher among mothers in urban areas (82 percent) than those in rural areas (63 percent). Mothers in North West are least likely to consume foods that are rich in iron (44 percent), while women in South South are the most likely to consume these foods (94 percent). Consumption of iron-rich foods is more common among women with higher education and women in households in the highest wealth quintile. T ab le 1 1. 11 M ic ro nu tri en t i nt ak e am on g m ot he rs A m on g w om en a ge 1 5- 49 w ith a c hi ld u nd er a ge th re e ye ar s liv in g w ith th em , t he p er ce nt ag es w ho c on su m ed v ita m in A -r ic h an d iro n- ric h fo od s in th e 24 h ou rs p re ce di ng th e su rv ey ; a nd a m on g w om en ag e 15 -4 9 w ith a c hi ld b or n in th e pa st fi ve y ea rs , t he p er ce nt ag e w ho re ce iv ed a v ita m in A d os e in th e fir st tw o m on th s af te r th e bi rth o f t he la st c hi ld , t he p er ce nt ag e w ho d ur in g th e pr eg na nc y fo r t he la st ch ild h ad n ig ht b lin dn es s, t he p er ce nt ag e w ho t oo k iro n ta bl et s or s yr up fo r sp ec ifi c nu m be rs o f d ay s, a nd t he p er ce nt ag e w ho t oo k de -w or m in g m ed ic at io n; a nd a m on g w om en a ge 1 5- 49 w ith a c hi ld bo rn in th e pa st fi ve y ea rs , w ho li ve in h ou se ho ld s th at w er e te st ed fo r i od ise d sa lt, th e pe rc en ta ge w ith a de qu at el y io di se d sa lt in th e ho us eh ol d, b y ba ck gr ou nd c ha ra ct er ist ic s, N ig er ia 2 00 8 W om en w ith a c hi ld b or n in th e pa st fi ve y ea rs W om en w ith a c hi ld bo rn in th e pa st fi ve ye ar s in h ou se ho ld s th at w er e te st ed fo r io di se d sa lt Am on g w om en w ith a c hi ld u nd er th re e ye ar s liv in g w ith th em N um be r o f d ay s w om en to ok ir on ta bl et s or sy ru p du rin g pr eg na nc y fo r l as t b irt h Pe rc en ta ge w ho h ad ni gh t b lin dn es s du rin g pr eg na nc y fo r l as t b irt h B ac kg ro un d ch ar ac te ris tic Pe rc en ta ge co ns um ed vi ta m in A - ric h fo od s1 Pe rc en ta ge co ns um ed iro n- ric h fo od s2 N um be r o f w om en Pe rc en ta ge w ho re ce iv ed vi ta m in A do se p os t- pa rtu m 3 Re po rt ed Ad ju st ed 4 N on e < 60 60 -8 9 90 + D on 't kn ow / m iss in g Pe rc en ta ge of w om en w ho to ok d e- w or m in g m ed ic at io n du rin g pr eg na nc y fo r la st b irt h5 N um be r of w om en Pe rc en ta ge w ith ad eq ua te ly io di se d sa lt in th e ho us eh ol d6 N um be r of w om en A ge 15 -1 9 80 .5 58 .2 1, 01 6 13 .9 4. 7 0. 9 59 .0 20 .1 2. 4 7. 6 10 .9 7. 8 1, 16 8 50 .4 1, 13 0 20 -2 9 84 .4 70 .3 6, 64 2 24 .5 5. 4 1. 1 43 .5 24 .4 3. 4 13 .9 15 .0 10 .1 8, 09 3 51 .7 7, 86 9 30 -3 9 84 .9 70 .0 4, 65 2 28 .2 5. 2 1. 0 39 .7 23 .1 3. 3 17 .4 16 .4 9. 9 6, 28 8 53 .4 6, 13 4 40 -4 9 80 .0 61 .9 1, 16 7 22 .7 6. 6 1. 5 49 .2 20 .2 3. 6 12 .1 14 .9 7. 6 2, 08 6 54 .2 2, 01 7 R es id en ce U rb an 89 .5 82 .0 4, 05 7 42 .5 4. 1 0. 6 20 .8 25 .9 4. 8 29 .5 19 .0 11 .7 5, 33 0 54 .2 5, 20 4 Ru ra l 81 .5 62 .8 9, 42 0 17 .3 6. 0 1. 3 53 .8 22 .0 2. 7 8. 0 13 .5 8. 7 12 ,3 05 51 .8 11 ,9 47 Z on e N or th C en tra l 90 .8 83 .7 1, 82 3 26 .2 5. 5 0. 5 47 .2 32 .4 1. 6 6. 2 12 .6 11 .7 2, 52 5 55 .3 2, 48 8 N or th E as t 74 .0 50 .6 2, 17 5 12 .1 7. 4 1. 9 53 .3 27 .5 4. 2 11 .0 4. 0 5. 9 2, 75 1 33 .8 2, 68 7 N or th W es t 73 .1 44 .3 4, 20 7 8. 6 2. 8 0. 7 68 .3 12 .8 2. 2 4. 8 12 .0 3. 2 5, 37 2 66 .3 5, 16 1 So ut h Ea st 91 .9 82 .4 1, 22 7 37 .1 4. 4 0. 2 20 .8 36 .9 5. 9 9. 6 26 .8 11 .4 1, 60 3 59 .2 1, 53 9 So ut h So ut h 95 .8 93 .8 1, 75 6 36 .3 9. 3 2. 4 31 .4 19 .2 2. 0 14 .1 33 .4 18 .2 2, 31 0 39 .2 2, 25 0 So ut h W es t 94 .5 91 .4 2, 28 7 48 .9 5. 9 1. 1 11 .4 25 .6 5. 4 44 .2 13 .3 14 .6 3, 07 5 49 .9 3, 02 7 E du ca tio n N o ed uc at io n 75 .1 50 .2 6, 17 0 9. 3 4. 9 1. 0 68 .2 16 .7 1. 9 5. 1 8. 0 4. 2 8, 01 7 53 .3 7, 76 4 Pr im ar y 88 .8 78 .5 3, 04 5 25 .8 6. 6 1. 2 33 .8 30 .1 4. 1 14 .3 17 .8 12 .4 4, 01 2 51 .7 3, 92 5 Se co nd ar y 93 .0 87 .5 3, 48 8 44 .4 5. 7 1. 2 18 .0 28 .2 4. 7 25 .8 23 .4 15 .3 4, 55 7 50 .7 4, 43 8 M or e th an s ec on da ry 93 .7 90 .6 77 4 56 .2 3. 6 0. 8 8. 4 23 .8 4. 6 38 .0 25 .2 14 .8 1, 05 0 57 .6 1, 02 3 W ea lth q ui nt ile Lo w es t 73 .0 46 .9 3, 15 5 7. 0 6. 2 1. 3 74 .8 14 .4 1. 6 2. 9 6. 3 4. 2 4, 07 4 46 .3 3, 94 4 Se co nd 79 .2 57 .3 3, 04 1 12 .0 5. 5 0. 9 60 .3 20 .7 1. 9 6. 2 10 .9 6. 1 3, 91 6 53 .7 3, 81 6 M id dl e 86 .1 72 .5 2, 50 9 23 .2 6. 4 1. 6 39 .2 28 .5 4. 2 10 .7 17 .5 11 .3 3, 35 0 52 .2 3, 26 8 Fo ur th 92 .0 84 .6 2, 42 3 34 .5 5. 8 0. 9 22 .4 31 .0 5. 3 18 .7 22 .7 14 .7 3, 20 4 55 .7 3, 10 7 H ig he st 94 .2 91 .5 2, 34 9 56 .9 2. 8 0. 7 9. 5 23 .8 4. 3 40 .1 22 .2 13 .7 3, 09 1 56 .2 3, 01 6 To ta l 83 .9 68 .6 13 ,4 77 24 .9 5. 4 1. 1 43 .9 23 .2 3. 3 14 .5 15 .2 9. 6 17 ,6 35 52 .5 17 ,1 51 1 In cl ud es m ea t ( an d or ga n m ea t), fi sh , p ou ltr y, e gg s, p um pk in , y el lo w s qu as h, c ar ro ts , o ra ng e sw ee t p ot at oe s, m an go , p ap ay a, a nd p al m n ut s 2 I nc lu de s m ea t ( an d or ga n m ea t), fi sh , p ou ltr y, e gg s 3 I n th e fir st tw o m on th s af te r d el iv er y of la st b irt h 4 W om en w ho re po rte d ni gh t b lin dn es s bu t d id n ot re po rt di ffi cu lty w ith v isi on d ur in g th e da y 5 D e- w or m in g fo r i nt es tin al p ar as ite s is co m m on ly d on e fo r h el m in th s an d fo r s ch ist os om ia sis . 6 S al t c on ta in in g at le as t 1 5 pp m o f i od in e or m or e 184 | Nutrition of Children and Adults Nutrition of Children and Adults | 185 Breastfeeding children benefit from the micronutrient supplementation that mothers receive, especially vitamin A. Table 11.10 includes several measures of vitamin A and iron supplementation among mothers with young children and shows the proportion of mothers reporting night blindness during pregnancy, a condition associated with vitamin A deficiency (VAD). The survey results indicate that 25 percent of women with children born in the five years preceding the survey received a dose of vitamin A in the first two months after the birth of the last child. Post-partum vitamin A supplementation is highest among urban women (43 percent), those with more than secondary education (56 percent), and those in the highest wealth quintile (57 percent). By zone, the proportion of women who received post-partum vitamin A supplementation ranges from 9 percent in North West zone to 49 percent in South West zone. Five percent of women said that they had experienced night blindness while pregnant with their youngest child. After adjusting this figure for women who also reported vision problems during the day, only 1 percent of women are estimated to have experienced VAD-related night blindness during pregnancy. Regarding iron supplementation, Table 11.11 shows the percent distribution of women who gave birth during the five years preceding the survey by the number of days they took iron tablets or syrup during the pregnancy for the last child. According to the results, 15 percent of women took iron supplements for 90 days or more, 23 percent took the iron tablets for less than 60 days, and 44 percent did not take any iron supplements at all. The percentage of women who did not take any iron supplements during the pregnancy for the last birth ranged from 11 percent in South West to 68 percent in North West. Regarding treatment for worms, Table 11.11 shows the percent distribution of women who took de-worming medication while pregnant with the last child in the five years preceding the survey. According to the results, 10 percent of women took de-worming medication during their last pregnancy. The use of de-worming medication during pregnancy is highest among urban women (12 percent), those with secondary or higher levels of education (15 percent), and those in the fourth wealth quintile (15 percent). By zone, the proportion of pregnant women who received de-worming medication ranges from 3 percent in North West to 18 percent in South South. Malaria | 187 MALARIA 12 12.1 INTRODUCTION Malaria is endemic throughout Nigeria. The Sahel regions and the high mountain area of the plateau experience slightly lower rates of transmission. Malaria currently accounts for nearly 110 million clinically diagnosed cases per year, 60 percent of outpatient visits, and 30 percent hospitalisations. An estimated 300,000 children die of malaria each year. It is also believed to contribute up to 11 percent maternal mortality, 25 percent infant mortality, and 30 percent under-five mortality. In addition to the direct health impact of malaria, there are also severe social and economic burdens on communities and the country as a whole, with about 132 billion Naira lost to malaria annually in the form of treatment costs, prevention, loss of work time, etc. (FMoH and NMCP, 2009). The National Malaria Control Strategic Plan (NMCSP) addresses national health and development priorities including the Roll Back Malaria (RBM) Goals and the Millennium Development Goals (MDGs). The NMCSP includes the following priorities: to reduce malaria related mortality, to reduce malaria parasite prevalence in children under five, to increase ownership and use of insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs), to introduce and scale-up indoor residual spraying (IRS), to increase the use of diagnostic tests for fever patients, to improve appropriate and timely treatment of malaria, and to increase coverage of intermittent preventive treatment (IPT) of malaria during pregnancy. The NMCSP lays out specific targets to be achieved by 2010 and sustained through 2013 (FMoH and NMCP, 2009). 12.2 MOSQUITO NETS The use of insecticide-treated nets is currently considered the most cost-effective method of malaria prevention in highly endemic areas. The use of insecticide-treated nets (ITNs) or long-lasting insecticidal nets (LLINs) is the main method of malaria prevention employed in Nigeria. Free distribution of long-lasting insecticidal nets (LLINs) is conducted through campaigns, public health facilities, faith-based organisations (FBOs), and non-governmental organisations (NGOs) with the goal of achieving universal access for the at-risk populations of children under age five and pregnant women. Nets are distributed through stand-alone campaigns and through integration with other interventions such as measles vaccination. Nigeria implements a nationwide, routine LLIN distribution system through health facilities that is modelled on the modified ITN Massive Promotion and Awareness Campaign (IMPAC) system. Under this system, pregnant women attending antenatal clinics receive an LLIN at first attendance, and children receive an LLIN on completion of their third dose of the diphtheria, pertussis and tetanus vaccine (DPT3). 12.2.1 Ownership of Mosquito Nets All households in the 2008 NDHS were asked whether they own a mosquito net and, if so, how many. Table 12.1 shows the percentage of households with at least one mosquito net, with at least one ever-treated net, and with at least one ITN, by background characteristics. Ownership of ITNs among surveyed households measures access to effective personal protection from malaria parasite-carrying mosquitoes.1 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 188 | Malaria Table 12.1 Ownership of mosquito nets Percentage of households with at least one and with more than one mosquito net (treated or untreated), ever-treated mosquito net, and insecticide-treated net (ITN), and the average number of nets per household, by background characteristics, Nigeria 2008 Ever-treated mosquito net1 Any type of mosquito net Insecticide-treated mosquito nets (ITNs)2 Background characteristic Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ever- treated nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Number of households Residence Urban 14.1 5.2 0.2 13.6 4.8 0.2 8.6 2.5 0.1 12,100 Rural 18.5 9.0 0.3 17.8 8.4 0.3 7.6 2.8 0.1 21,970 Zone North Central 15.9 6.9 0.3 15.5 6.6 0.3 7.4 2.4 0.1 4,568 North East 27.8 15.7 0.5 27.4 15.3 0.5 7.1 3.2 0.1 3,730 North West 21.0 10.9 0.4 20.1 10.1 0.3 7.9 3.4 0.1 7,178 South East 13.4 5.0 0.2 12.8 4.7 0.2 9.8 3.4 0.1 4,527 South South 17.2 6.5 0.3 16.7 6.1 0.3 10.3 3.0 0.1 5,966 South West 10.8 3.6 0.2 10.2 3.2 0.1 6.0 1.4 0.1 8,100 Wealth quintile Lowest 18.7 10.3 0.3 18.1 9.7 0.3 4.0 1.5 0.1 6,119 Second 18.3 9.4 0.3 17.8 8.8 0.3 6.2 2.5 0.1 6,219 Middle 16.7 7.4 0.3 16.2 7.0 0.3 7.9 2.8 0.1 7,065 Fourth 15.7 5.8 0.2 15.1 5.3 0.2 9.7 2.6 0.1 7,216 Highest 15.7 5.9 0.2 15.1 5.5 0.2 11.2 3.8 0.2 7,451 Total 16.9 7.6 0.3 16.3 7.1 0.3 8.0 2.7 0.1 34,070 1 An ever-treated net is a pre-treated net or a non-pre-treated net which has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pre-treated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. The 2008 NDHS results indicate that 17 percent of households in Nigeria own a mosquito net (treated or untreated), and 8 percent of households own more than one mosquito net. Sixteen percent of households own at least one ever-treated mosquito net, and 7 percent own more than one ever- treated mosquito net. The percentage of households that own at least one ITN is 8, while 3 percent own more than one ITN. The average number of ITNs per household is less than one. By residence, more rural households (19 percent) than urban households (14 percent) own at least one mosquito net. A similar trend is seen for ownership of ever-treated mosquito nets. In contrast, urban households are more likely than rural households to own at least one ITN. There is variation in the ownership of mosquito nets by zone. The percentage of households that own any mosquito net in the Northern zones ranges from 16 percent to 28 percent, while in the Southern zones, net ownership ranges from 11 percent to 17 percent. However, ownership of ITNs is higher among households in the Southern zones. Ownership of mosquito nets and ever-treated net decreases with increasing wealth quintile whereas ownership of ITNs increases with wealth quintile. Malaria | 189 12.2.2 Use of Mosquito Nets by Children under Age Five The use of mosquito nets by vulnerable groups in highly endemic communities is one of the major malaria control and prevention strategies espoused by the Abuja Declaration and the Plan of Action (RBM, 2000). Table 12.2 shows that 12 percent of children under age five slept under a mosquito net on the night before the survey. The same proportion slept under an ever-treated net; however, only 6 percent of the children slept under an ITN. It is interesting to note that only half of children in households that own an ITN slept under an ITN on the night before the survey. The use of any net, an ever-treated net, and an ITN decreases with increasing age of the child. The percentage of children who slept under an ITN on the night before the survey increases with wealth quintile. Table 12.2 Use of mosquito nets by children Among children under five years in all households, the percentage who, on the night preceding the interview, slept under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN), and among children under five years in households with at least one ITN, the percentage who slept under an ITN the past night, by background characteristics, Nigeria 2008 Among children under five in households with an ITN2 Among children under five in all households, percentage who, the past night Background characteristic Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of children Percentage who slept under an ITN the past night2 Number of children Age in months <1 14.2 13.7 6.7 5,730 59.3 645 1 13.3 12.9 6.4 4,987 55.6 576 2 11.9 11.6 5.5 4,815 50.6 524 3 10.7 10.4 4.3 5,336 42.1 551 4 9.4 9.0 4.2 4,915 39.3 530 Sex Male 11.7 11.4 5.3 13,079 49.8 1,396 Female 12.2 11.7 5.6 12,703 49.9 1,430 Residence Urban 10.5 10.2 6.5 7,937 47.8 1,086 Rural 12.6 12.2 5.0 17,846 51.1 1,740 Zone North Central 9.7 9.4 3.8 3,607 43.3 314 North East 12.8 12.5 3.6 4,118 41.7 358 North West 11.6 11.2 4.1 7,792 48.8 661 South East 14.3 13.9 10.5 2,490 57.6 456 South South 16.3 15.8 9.4 3,399 53.4 598 South West 8.8 8.5 5.0 4,377 49.9 439 Wealth quintile Lowest 10.8 10.4 2.5 5,817 54.6 269 Second 12.6 12.1 4.3 5,770 53.0 468 Middle 13.2 12.8 6.3 4,953 51.5 607 Fourth 11.8 11.4 7.1 4,668 49.4 675 Highest 11.4 11.2 8.0 4,574 45.5 806 Total 11.9 11.6 5.5 25,783 49.8 2,825 Note: Total for children under age five in all households includes one child with information missing on sex. 1 An ever-treated net is a pre-treated net or a non-pre-treated net which has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pre-treated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. 190 | Malaria 12.2.3 Use of Mosquito Nets by All Women and Pregnant Women Age 15-49 Use of mosquito nets by pregnant women is an important strategy to prevent malaria morbidity and to reduce the negative effects of malaria on pregnancy and pregnancy outcomes. The 2008 NDHS collected information on the use of mosquito nets by women age 15-49, including women who were pregnant at the time of the survey. The results for all women and for pregnant women are presented in Tables 12.3 and 12.4, respectively. As shown in Table 12.3, less than one in ten women slept under a mosquito net on the night before the survey and only 4 percent slept under an ITN. Use of all three types of nets is slightly higher in rural areas than urban areas. Use of any net or an ever-treated net generally decreases with increasing level of education and wealth quintile, while use of an ITN generally increases with level of education and wealth quintile. Forty-one percent of women in households with at least one ITN slept under an ITN on the night before the survey. The proportion of women in households with an ITN who slept under an ITN decreases with increasing level of education and wealth quintile. Table 12.3 Use of mosquito nets by women Among all women age 15-49 in all households, the percentage who slept the past night under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide- treated net (ITN); and among all women age 15-49 in households with at least one ITN, the percentage who slept the past night under an ITN, by background characteristics, Nigeria 2008 Women age 15-49 in households with an ITN2 Among women age 15-49 in all households, percentage who, the past night: Background characteristic Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of women Percentage who slept under an ITN2 the past night Number of women Residence Urban 6.3 6.1 3.6 12,062 35.3 1,245 Rural 10.9 10.4 4.0 21,644 44.6 1,957 Zone North Central 8.7 8.5 3.4 4,793 40.1 410 North East 13.8 13.5 3.8 4,304 46.2 356 North West 11.4 10.8 4.0 8,096 45.9 708 South East 6.2 6.0 4.2 4,132 35.5 487 South South 9.6 9.2 5.3 5,525 41.5 699 South West 5.7 5.4 2.8 6,855 35.8 541 Education No education 11.4 10.8 3.0 12,049 48.7 748 Primary 10.1 9.9 4.3 6,649 47.5 595 Secondary 7.1 6.8 4.2 11,978 35.9 1,389 More than secondary 7.5 7.4 5.5 3,007 35.2 469 Wealth quintile Lowest 10.7 10.2 2.3 6,263 51.5 277 Second 12.0 11.5 3.6 6,308 50.1 452 Middle 10.6 10.2 4.4 6,375 43.4 641 Fourth 7.9 7.6 4.8 7,001 42.4 791 Highest 5.9 5.8 4.2 7,759 31.5 1,040 Total 9.2 8.9 3.9 33,705 40.9 3,202 Note: Total for women age 15-49 includes 22 women with information missing on education. 1 An ever-treated net is a pre-treated net or a non-pre-treated net which has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pre-treated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. Malaria | 191 Table 12.4 shows the percentage of pregnant women age 15-49 that slept under a mosquito net (treated or untreated) on the night before the survey. At the national level, 12 percent of pregnant women slept under any net, and the same proportion slept under an ever-treated net. Five percent of pregnant women slept under an ITN. The percentage of pregnant women living in households that own at least one ITN who slept under an ITN is 44 percent. Pregnant women in rural areas are more likely to have slept under any type of net than their urban counterparts (13 percent compared with 9 percent). By zone, the use of any mosquito net ranges from 9 percent in North Central and South West to 18 percent in North East. For use of ITNs, North Central and South West are again the lowest, however, the highest percentages are observed in South East and South South (6 percent and 7 percent, respectively). The percentage of pregnant women who slept under any net generally decreases with increasing level of education and wealth quintile, while the opposite is seen for use of an ITN. Table 12.4 Use of mosquito nets by pregnant women Among pregnant women age 15-49 in all households, the percentage who slept the past night under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide- treated net (ITN); and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept the past night under an ITN, by background characteristics, Nigeria 2008 Pregnant women age 15-49 in households with an ITN2 Among pregnant women age 15-49 in all households, percentage who, the past night Background characteristic Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of women Percentage who slept under an ITN2 the past night Number of women Residence Urban 9.2 9.2 4.6 1,049 37.4 130 Rural 13.0 12.5 4.9 2,348 48.3 237 Zone North Central 9.4 9.3 3.4 481 45.1 37 North East 17.6 17.2 5.6 527 55.7 53 North West 12.4 12.0 4.2 1,051 47.8 93 South East 10.2 9.4 6.4 342 36.2 60 South South 11.3 11.1 7.2 444 47.3 67 South West 8.9 8.6 3.4 553 (33.4) 57 Education No education 12.7 12.2 4.0 1,465 54.3 109 Primary 12.9 12.9 4.2 738 46.8 66 Secondary 10.4 10.0 6.2 953 41.5 143 More than secondary 8.9 8.3 5.8 241 (28.2) 49 Wealth quintile Lowest 11.7 11.5 2.3 804 (52.5) 35 Second 14.2 13.5 4.6 698 55.1 59 Middle 13.5 13.1 6.8 649 53.2 83 Fourth 12.1 11.6 5.9 587 41.1 85 Highest 7.7 7.7 5.0 659 31.6 105 Total 11.8 11.5 4.8 3,397 44.4 367 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 An ever-treated net is a pre-treated net or a non-pre-treated net which has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is 1) a factory-treated net that does not require any further treatment, or 2) a pre-treated net obtained within the past 12 months, or 3) a net that has been soaked with insecticide within the past 12 months. 192 | Malaria 12.2.4 Trends in Mosquito Net Ownership and Use Figure 12.1 shows the trends in ownership and use of mosquito nets and ITNs from the 2003 NDHS to the 2008 NDHS. All net coverage and use indicators have increased between the two surveys. The percentage of households that own any type of net increased from 12 percent in 2003 to 17 percent in 2008, while ownership of an ITN increased from 2 percent to 8 percent. The proportion of children under age five who slept under a mosquito net on the night before the survey doubled in the period between the two surveys from 6 percent to 12 percent. The proportion of children sleeping under ITN increased from 1 percent to 6 percent. The percentage of pregnant women who slept under any net and under an ITN on the night before the survey showed improvements similar to those observed for children under age five. 12.3 PROPHYLACTIC USE OF ANTI-MALARIAL DRUGS AND USE OF INTERMITTENT PREVENTIVE TREATMENT IN PREGNANT WOMEN Pregnant women who carry the malaria parasite may be at risk for serious problems that jeopardise their own health, compromise the health of the foetus, and increase the likelihood of adverse pregnancy outcomes such as stillbirth, spontaneous abortion, and low birth weight. As a protective measure, in 2001, the Federal Ministry of Health recommended that pregnant women receive Intermittent Preventive Treatment (IPT) of malaria during pregnancy using two doses of sulphadoxine-pyrimethamine (SP). There are many brand names of SP available in Nigeria; however, Fansidar, Amalar, and Maloxine are some of the most common. IPT is offered as a package through Focused Antenatal Care (FANC). In accordance with the national protocol, SP is given free of charge to pregnant women through ANC services at public health facilities and non-governmental organisation (NGO) facilities. Using an approach of directly observed therapy, one dose of SP is given during the second and third trimesters. A third dose is recommended for pregnant women who are HIV positive. 12 2 6 1 5 1 17 8 12 6 12 5 At least one net At least one ITN Slept under any net Slept under an ITN Slept under any net Slept under an ITN 0 5 10 15 20 Percent NDHS 2003 NDHS 2008 Figure 12.1 Trends in Net Ownership and Use NDHS 2003 AND NDHS 2008 HOUSEHOLD OWNERSHIP OF NETS NET USE BY CHILDREN UNDER FIVE NET USE BY PREGNANT WOMEN Malaria | 193 Table 12.5 presents information on malaria prevention for pregnant women through prophylactic anti-malarial drug use and IPT. According to the 2008 NDHS, 18 percent of women received an anti-malarial drug for prevention of malaria during the pregnancy for their last live birth in the two years preceding the survey. This figure is comparable to the percentage reported in the 2003 NDHS (20 percent). The proportion of women taking anti-malarial drugs during pregnancy for prevention of malaria is 26 percent in urban areas and 15 percent in rural areas. The survey also collected information on the number of doses of SP taken by pregnant women. Overall, 11 percent of pregnant women reported receiving at least one dose of SP to prevent malaria during pregnancy and 7 percent of pregnant women received two or more doses. When IPT uptake was assessed using ANC facilities as the delivery point, 8 percent of women reported receiving at least one dose of SP for malaria prevention during an ANC visit and 5 percent received the recommended two doses of SP, at least one dose during ANC. More pregnant women received the complete schedule of SP doses as IPT during an ANC visit in urban areas than in rural areas (8 percent compared with 4 percent). Pregnant women with more than secondary education and those in the highest two wealth quintiles are more likely to receive IPT during ANC than other women. Since the 2003 NDHS, there has been an increase in the coverage of SP as IPT from 1 percent to 8 percent. Table 12.5 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy Among women age 15-49 with a live birth in the two years preceding the survey, percentage who during their pregnancy received anti-malarial drugs for prevention, percentage who received SP/Fansidar/Amalar/Maloxine (any and two or more doses), and percentage who received Intermittent Preventive Treatment (IPT) (any and two or more doses), by background characteristics, Nigeria 2008 SP/Fansidar/Amalar/ Maloxine Intermittent Preventive Treatment1 Background characteristic Percentage who received any anti-malarial drug Percentage who received any SP/Fansidar/ Amalar/ Maloxine Percentage who received 2+ doses Percentage who received any SP/ Fansidar/Amalar/ Maloxine during an ANC visit Percentage who received 2+ doses, at least one during an ANC visit Number of women with a live birth in the two years preceding the survey Residence Urban 26.0 16.6 9.9 12.6 7.9 3,289 Rural 15.2 8.5 5.1 6.0 3.7 7,738 Zone North Central 21.0 12.0 9.1 9.1 6.9 1,478 North East 12.8 6.0 4.0 4.3 2.9 1,794 North West 10.6 7.5 4.9 6.0 3.9 3,410 South East 27.3 13.6 7.2 9.9 5.4 1,060 South South 27.0 17.9 9.3 12.4 6.3 1,462 South West 24.3 14.0 7.4 9.7 5.8 1,823 Education No education 8.6 4.8 3.2 3.4 2.1 5,036 Primary 19.7 10.9 6.8 8.3 5.5 2,459 Secondary 28.9 18.5 10.8 13.4 8.2 2,922 More than secondary 43.7 25.2 13.0 18.6 10.5 610 Wealth quintile Lowest 7.2 3.3 2.3 1.6 1.3 2,601 Second 10.8 5.4 3.1 3.7 2.1 2,494 Middle 19.9 11.4 6.6 8.4 4.8 2,085 Fourth 29.1 19.3 12.0 14.8 9.4 1,987 Highest 31.3 19.5 11.3 14.7 9.1 1,860 Total 18.4 10.9 6.5 8.0 4.9 11,027 1 IPT = Intermittent Preventive Treatment. SP/Fansidar is administered to pregnant women during one or more antenatal care visits as preventive treatment against malaria. 194 | Malaria 12.4 PREVALENCE AND PROMPT TREATMENT OF FEVER IN CHILDREN UNDER AGE FIVE Following a period of continuous increases in the resistance of Plasmodium falciparum to the commonly used anti-malarial medicines, the new Artemisinin-based Combination Therapy (ACT) was introduced in 2005 with Artemether-Lumefantrine (AL) as first-line treatment for uncomplicated malaria and Artesunate+Amodiaquine (co-packaged) as an alternative. As programmatic deployment of ACT will be scaled up to include persons above five years of age over the period of the strategic plan, a policy to introduce improved diagnosis of malaria cases through parasitological confirmation by microscopy or rapid diagnostic tests (RDT) has been put in place. In recent years, considerable efforts have been undertaken to increase access to malaria treatment at the community level, including training of community health workers and role model mothers (RMM) in treatment of febrile children with ACT. The prevalence of fever measures the proportion of febrile children in the population. Because fever is the main symptom of malaria, the proportion of febrile children in the population is a proxy for assessing malaria prevalence. Any reduction in the malaria disease burden should lead to a reduction in the overall prevalence of fever. In the 2008 NDHS, mothers were asked whether their children under age five had had fever in the two weeks preceding the survey. If fever was reported, the mother was asked whether treatment was sought at a health facility; whether the child was given any medication; and if so, how soon the medication was taken after the fever began. Table 12.6 shows the percentage of children under age five with fever in the two weeks preceding the survey and, among children with fever, the percentage who took anti-malarial drugs, and the percentage who took them on the same day or next day following the onset of fever, by background characteristics. The results of the 2008 NDHS indicate that 16 percent of children under age five had fever during the two weeks preceding the interview (13 percent in urban areas and 17 percent in rural areas). Children age 12-23 months were most likely to have had fever in the past two weeks (21 percent) while children age 48-59 months were least likely (12 percent). Prevalence of fever was lowest in South West (8 percent) and highest in South East (23 percent). Fever was also lowest among children of women with more than secondary education and children in households in the highest wealth quintile. Among children with fever in the two weeks preceding the survey, one in three received anti- malarial drugs. Treatment of malaria varies by residence, with urban children being more likely than rural children to receive anti-malarials (41 percent compared with 31 percent). Among the zones, more than half of children (54 percent) in South West took anti-malarial drugs, compared with 22 percent in North East and South East zones. Use of anti-malarials increases with mother’s level of education and wealth quintile. Prompt treatment of fever is one indicator used to measure the quality of case management. Fifteen percent of children with fever in the two weeks before the survey received anti-malarial drugs on the same day or day after the onset of fever. Urban children are more likely to receive prompt treatment with anti-malarials than rural children (19 percent compared with 14 percent). The percentage of children treated promptly for fever increases with mother’s level of education, from 11 percent among women with no education to 21 percent among women with secondary education. Likewise, prompt treatment of fever increases with wealth quintile. Malaria | 195 Table 12.6 Prevalence and prompt treatment of fever Percentage of children under age five with fever in the two weeks preceding the survey, and among children with fever, the percentage who received anti-malarial drugs and the percentage who received the drugs the same or next day following the onset of fever, by background characteristics, Nigeria 2008 Children under age five Children under age five with fever Background characteristic Percentage with fever in the two weeks preceding the survey Number of children Percentage who took anti-malarial drugs Percentage who took anti-malarial drugs same or next day Number of children Age (in months) <12 14.3 5,729 32.3 14.9 820 12-23 21.3 4,945 31.4 13.7 1,054 24-35 17.8 4,633 34.8 16.0 826 36-47 13.7 5,013 32.6 14.0 688 48-59 12.4 4,653 36.0 18.3 579 Residence Urban 12.8 7,690 41.1 19.1 987 Rural 17.2 17,284 30.5 13.8 2,981 Zone North Central 9.6 3,434 47.3 21.1 331 North East 21.9 3,989 21.8 11.5 872 North West 15.7 7,594 29.2 12.9 1,189 South East 22.9 2,428 21.5 10.4 555 South South 20.6 3,310 47.1 21.1 682 South West 8.1 4,221 53.6 22.3 340 Mother's education No education 16.3 11,342 25.8 11.2 1,846 Primary 15.4 5,805 31.1 15.5 893 Secondary 16.0 6,385 44.9 20.8 1,022 More than secondary 14.4 1,441 50.0 21.1 207 Wealth quintile Lowest 17.8 5,634 21.9 9.5 1,001 Second 17.1 5,566 26.4 11.2 953 Middle 16.0 4,787 35.5 16.9 765 Fourth 14.9 4,533 40.2 19.9 674 Highest 12.9 4,455 52.7 23.5 575 Total 15.9 24,975 33.2 15.2 3,968 In the 2008 NDHS, mothers with children under five who had fever in the two weeks preceding the survey and were treated with anti-malarial drugs were asked about the type of drugs used to treat the fever. Table 12.7 shows the percentage of children under five with fever who took specific anti-malarial drugs, and when the drugs were taken. Although it is no longer the recommended first line drug, chloroquine was the most common anti-malarial drug given to children with fever (19 percent). Six percent of children received SP, 2 percent received Amodiaquine, quinine, and ACT, while 5 percent received other anti-malarials. The use of SP, Amodiaquine, quinine, and ACT is higher among urban children than their rural counterparts. For children with fever who received anti-malarial drugs the same or next day, chloroquine was the most commonly administered drug (9 percent). For the other anti-malarials, 1 to 3 percent of children received them the day the fever began or the following day. Only 1 percent of children took ACT on the day of, or the day following, the onset of fever. Prompt use of ACT is slightly higher among urban children (2 percent) than rural children (1 percent). 196 | Malaria Table 12.7 Type and timing of anti-malarial drugs Among children under age five with fever in the two weeks preceding the survey, percentage who received specific anti-malarial drugs and percentage who received the drugs the same or next day after developing the fever, by background characteristics, Nigeria 2008 Percentage of children who received specific anti-malarial drugs: Percentage of children who received anti-malarial drugs the same or next day: Background characteristic SP/ Fansidar/ Amalar/ Maloxine Chloro- quine Amodia- quine Quinine ACT Other anti- malarial SP/ Fansidar/ Amalar/ Maloxine Chloro- quine Amodia- quine Quinine ACT Other anti- malarial Number of children with fever Age (in months) <12 3.6 19.2 1.6 1.5 2.9 5.7 1.7 9.0 0.6 0.4 1.3 2.6 820 12-23 5.0 19.1 1.8 1.7 2.2 3.7 2.7 8.5 0.9 0.4 1.1 0.8 1,054 24-35 8.2 19.2 2.9 1.0 2.8 3.7 3.5 8.5 1.7 0.7 1.0 1.5 826 36-47 6.3 17.9 2.0 2.3 1.2 4.7 2.5 7.8 0.7 0.9 0.8 2.2 688 48-59 7.1 20.8 1.6 1.6 2.6 4.9 2.0 11.0 0.4 1.1 1.3 2.6 579 Residence Urban 9.2 19.0 3.2 2.6 4.3 6.3 4.3 9.9 1.1 0.5 1.8 2.3 987 Rural 4.8 19.3 1.6 1.3 1.8 3.9 2.0 8.5 0.8 0.7 0.9 1.7 2,981 Zone North Central 12.2 31.1 4.6 1.0 3.3 3.5 4.0 15.2 2.0 0.2 1.1 1.3 331 North East 2.0 15.3 0.5 0.5 1.9 2.9 1.1 8.5 0.4 0.0 1.2 1.1 872 North West 3.7 21.5 1.3 0.5 2.1 1.6 1.9 8.6 0.8 0.4 0.9 0.5 1,189 South East 6.4 8.5 0.8 2.3 0.4 4.0 3.3 3.8 0.6 0.5 0.0 2.5 555 South South 10.9 20.1 2.4 4.0 3.6 9.2 4.6 9.4 0.3 2.3 1.7 3.3 682 South West 6.4 24.9 6.6 2.7 4.3 10.9 1.5 11.5 3.3 0.4 1.7 4.6 340 Mother's education No education 3.4 19.0 1.0 0.4 1.9 1.7 1.5 8.3 0.7 0.1 0.7 0.6 1,846 Primary 5.3 19.7 1.2 1.0 1.6 3.6 2.2 10.2 0.5 0.6 1.1 1.4 893 Secondary 9.2 20.0 3.6 4.1 2.4 9.4 4.1 8.9 1.4 1.6 0.9 4.4 1,022 More than secondary 14.4 14.5 5.6 2.6 9.5 8.4 5.4 7.3 2.6 0.9 5.2 2.2 207 Wealth quintile Lowest 2.7 16.1 0.3 0.5 1.3 2.0 1.2 6.6 0.0 0.3 0.9 0.7 1,001 Second 3.5 19.5 0.7 0.7 1.5 1.9 1.7 7.8 0.5 0.5 0.5 0.9 953 Middle 6.7 21.7 2.4 2.5 1.9 3.7 2.5 11.1 1.7 0.1 0.7 1.5 765 Fourth 7.5 20.9 3.1 1.6 2.4 7.7 3.3 10.7 1.4 0.6 1.3 3.8 674 Highest 12.5 18.9 5.1 3.7 6.4 10.4 5.5 9.2 1.7 2.4 2.7 3.5 575 Total 5.9 19.2 2.0 1.6 2.4 4.5 2.5 8.8 0.9 0.6 1.1 1.8 3,968 ACT = Artemisinin Combination Therapy (Artemether-Lumefantrine (AL) for uncomplicated malaria, and Artesunate+Amodiaquine as an alternate) 12.5 AVAILABILITY AT HOME OF ANTI-MALARIAL DRUGS TAKEN BY CHILDREN WITH FEVER Anti-malarial drug policy in Nigeria does not promote the storage of anti-malarial medications in the household. Instead, community-based agents called “Role Model Mothers” are trained to assist in administering drugs for fever. However, the availability of anti-malarial drugs at home is one way to ensure prompt treatment. Mothers whose children under age five had fever and received anti-malarial drugs were asked whether the drugs were at home at the time the child became ill with fever. Table 12.8 shows that for 29 percent of children who had fever and received anti- malarial drugs, the drugs were at home when they became ill. It is interesting to note that although ACT was used less commonly than other anti-malarial drugs to treat children with fever, it was the drug most likely to be in the household at the time the child became sick. For 43 percent of children who took ACT for fever, the drug was already in the household. Amodiaquine was the anti-malarial drug least likely to be in the household at the time the child became sick (22 percent). Table 12.8 Availability at home of anti-malarial drugs taken by children with fever Among children under age five who had fever in the two weeks preceding the survey and who received specific anti-malarial drugs, the percentage for whom the drug was at home when the child became ill with fever, Nigeria 2008 Drug Percentage of children for whom the anti-malarial drug was at home when child became ill with fever Number of children who received specific anti- malarial drugs SP/Fansidar/Amalar/Maloxine 34.2 233 Chloroquine 30.0 761 Amodiaquine 21.9 78 Quinine 32.2 63 ACT 42.8 94 Other anti-malarial 2.4 178 Any anti-malarial drugs 29.0 1,316 ACT = Artemisinin Combination Therapy (Artemether- Lumefantrine (AL) for uncomplicated malaria, and Artesunate+Amodiaquine as an alternate) HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 197 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 13.1 INTRODUCTION The first case of AIDS in Nigeria was identified in 1985 and reported at an International AIDS Conference in 1986. A sentinel surveillance system conducted among pregnant women age 15-49 attending antenatal care (ANC) has been used to track HIV prevalence in the country since 1991. Information obtained from the ANC surveys shows that, nationally, HIV prevalence increased from 1.8 percent in 1991 to 4.6 percent in 2008. In 2008, state HIV prevalence rates ranged from 1.0 percent in Ekiti State to 10.6 percent in Benue State (FMoH, 2008b). UNAIDS in its 2008 global report stated that although HIV prevalence is much lower in Nigeria than in many other African countries such as South Africa and Zambia, the large size of Nigeria’s population meant that by the end of 2007, there were an estimated 2,600,000 people infected with HIV in Nigeria and approximately 170,000 people died from AIDS in 2007 alone (UNAIDS, 2008). In recent years, life expectancy in Nigeria has declined partially as a result of the effects of HIV and AIDS. In 1991, the average life expectancy was 53.8 years for women and 52.6 years for men (UNFPA, 2005). The 2007 estimate had fallen to 50 for women and 48 for men (WHO, 2009). Poverty, low literacy levels, high rates of casual and transactional unprotected sex in the general population, particularly among youth between the ages of 15 and 24, low levels of male and female condom use, cultural and religious factors, as well as stigma and discrimination are major factors in the transmission of HIV in Nigeria. (NACA, 2007) In 1999, the Federal Government of Nigeria began implementing a multi-sectoral approach, followed by the establishment of the National Action Committee on AIDS (NACA) in 2000 to coordinate the national response and to ensure multi-sector and multi-level participation. In 2007 NACA was transformed from a committee to an agency—the National Agency for the Control of AIDS (NACA)—by an act of parliament, for the purpose of sustainability and improving the effectiveness and coordination of the national HIV response. There are also State and Local Government Action Committees on AIDS (SACAs and LACAs), with 12 state committees already transformed into agencies between 2003 and 2008 by acts of parliament. National efforts coupled with support from various donors and development partners have contributed to a significant scale up of prevention, care, and treatment programmes aimed at combating the disease. Similarly, efforts have been made to strengthen monitoring and evaluation systems for HIV response activities as the country seeks to continue supporting evidence-based decision-making for a more efficient and effective response. The future course of the national response to the HIV and AIDS epidemic depends on a number of factors including levels of HIV and AIDS-related knowledge among the general population; social stigmatisation; risk behaviour modification; access to quality services for sexually transmitted infections (STI); provision and uptake of HIV counselling and testing; and access to care and anti-retroviral therapy (ART), including prevention and treatment of opportunistic infections. The principal objective of this chapter is to show the prevalence of relevant HIV and AIDS-related knowledge, perceptions, and behaviours at the national level and by residence and by selected demographic and socio-economic characteristics of the population.1 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A 198 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.2 HIV AND AIDS KNOWLEDGE, TRANSMISSION AND PREVENTION METHODS 13.2.1 Awareness of HIV and AIDS The 2008 NDHS respondents were asked whether they had heard of HIV or AIDS. Those who reported having heard of HIV or AIDS were asked a number of questions about whether and how HIV can be avoided. Table 13.1 shows the percentage of women and men age 15-49 who have heard of HIV or AIDS, by background characteristics. In Nigeria, 88 percent of women and 94 percent of men have heard of HIV or AIDS. Awareness varies by background characteristics. Women and men who have never been married and have ever had sex are most likely to have heard of HIV or AIDS (97 and 98 percent, respectively), while women currently in union (86 percent) and men who have never been married and have not had sex (89 percent) are least likely to have heard of HIV or AIDS. Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Nigeria 2008 Women Men Background characteristic Has heard of HIV or AIDS Number of women Has heard of HIV or AIDS Number of men Age 15-24 87.1 12,626 91.4 4,910 15-19 85.3 6,493 88.3 2,532 20-24 89.1 6,133 94.8 2,378 25-29 89.8 6,309 94.6 2,459 30-39 89.4 8,546 94.7 3,852 40-49 87.2 5,904 94.4 2,587 Marital status Never married 92.9 8,398 93.4 6,551 Ever had sex 96.5 3,718 98.0 3,186 Never had sex 90.0 4,680 89.0 3,365 Married/living together 86.4 23,578 93.6 7,018 Divorced/separated/widowed 91.3 1,409 92.0 238 Residence Urban 95.3 11,934 97.9 5,215 Rural 84.3 21,451 90.8 8,593 Zone North Central 75.9 4,748 90.7 2,065 North East 81.4 4,262 87.8 1,645 North West 87.8 8,022 90.9 3,237 South East 97.1 4,091 96.4 1,448 South South 92.0 5,473 96.1 2,437 South West 93.4 6,789 97.8 2,977 Education No education 76.6 11,942 80.7 2,597 Primary 90.2 6,566 92.4 2,761 Secondary 96.0 11,904 97.1 6,470 More than secondary 99.3 2,974 99.7 1,979 Wealth quintile Lowest 75.5 6,194 83.5 2,275 Second 81.7 6,234 89.9 2,332 Middle 88.8 6,341 93.8 2,570 Fourth 94.5 6,938 97.0 3,163 Highest 97.6 7,678 98.9 3,468 Total 15-49 88.2 33,385 93.5 13,808 50-59 na na 91.0 1,678 Total men 15-59 na na 93.2 15,486 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 199 Among urban women and men, HIV awareness is almost universal (95 and 98 percent, respectively), while awareness among rural women and men is lower (84 and 91 percent, respectively). When comparing results among zones, awareness is lowest among women in North Central (76 percent) and men in North East (88 percent), and highest among women in South East (97 percent) and men in South West (98 percent). 13.2.2 Knowledge of HIV Prevention HIV in adults is mainly transmitted through heterosexual contact between an HIV-positive partner and an HIV-negative partner. Nigeria’s HIV prevention programme has sought to reduce sexual transmission of the virus by promoting three behaviour change models—sexual abstinence, mutually faithful monogamy between HIV-negative partners, and condom use for people not practicing abstinence. In the 2008 NDHS, men and women were asked if it is possible to reduce the risk of acquiring HIV through consistently using condoms, limiting sexual intercourse to one HIV-negative partner who has no other sex partners, and abstaining from sexual intercourse. Table 13.2 shows that about half of women and almost three-quarters of men age 15-49 (53 and 72 percent, respectively) know that consistent use of condoms is a means of preventing the spread of HIV. Sixty-eight percent of women and 83 percent of men know that limiting sexual intercourse to one HIV-negative partner can reduce the chances of contracting HIV. Forty-eight percent of women and 69 percent of men know that using condoms and limiting sexual intercourse to one HIV-negative partner can reduce the risk of HIV infection. Sixty-five percent of women and 78 percent of men know that abstaining from sexual intercourse can reduce the risk of HIV infection. Currently married women and those who are unmarried and have never had sexual intercourse are least likely to know that using condoms and limiting sexual intercourse to one HIV-negative partner reduces the risk of HIV transmission (46 percent each). Women who have never been married but have had sexual intercourse are most likely to know that using condoms and limiting sexual intercourse to one HIV-negative partner reduces the risk of HIV transmission (63 percent). A similar pattern is seen for men, with men who are unmarried and have never had sexual intercourse least likely to be aware that using condoms and limiting sexually intercourse to one HIV-negative partner reduces the risk of HIV transmission (61 percent). On the other hand, men who have never been married but have had sexual intercourse are most likely to be aware of these prevention methods (77 percent). Overall, women in urban areas are more likely to be knowledgeable about HIV prevention methods than their counterparts in rural areas. The same pattern is seen for men, with the exception of one prevention method—abstaining from sexual intercourse—for which the level of knowledge is the same for men in urban and rural areas (78 percent). Knowledge of HIV prevention varies by zone, and is highest in South South and South East. Educational attainment is positively associated with increased awareness of HIV prevention methods. 200 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting HIV by using condoms every time they have sexual intercourse, by having one sex partner who is HIV-negative and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Nigeria 2008 Women Men Background characteristic Using condoms1 Limiting sexual intercourse to one HIV- negative partner2 Using condoms and limiting sexual intercourse to one HIV- negative partner1,2 Abstaining from sexual intercourse Number of women Using condoms1 Limiting sexual intercourse to one HIV- negative partner2 Using condoms and limiting sexual intercourse to one HIV- negative partner1,2 Abstaining from sexual intercourse Number of men Age 15-24 52.0 66.3 46.6 64.4 12,626 69.7 80.2 65.9 75.1 4,910 15-19 48.3 63.2 42.9 61.6 6,493 64.6 75.5 60.6 71.9 2,532 20-24 55.9 69.5 50.6 67.3 6,133 75.0 85.3 71.5 78.5 2,378 25-29 57.1 70.2 52.2 66.0 6,309 77.3 84.7 72.9 78.9 2,459 30-39 54.9 70.3 50.0 67.0 8,546 74.5 85.2 70.8 80.0 3,852 40-49 47.9 65.4 43.5 63.6 5,904 69.5 83.5 66.2 78.8 2,587 Marital status Never married 60.1 71.5 53.9 67.6 8,398 73.2 82.0 68.9 76.8 6,551 Ever had sex 70.0 77.6 63.2 69.7 3,718 81.5 87.1 76.9 78.4 3,186 Never had sex 52.3 66.7 46.4 66.0 4,680 65.3 77.2 61.4 75.3 3,365 Married/living together 50.2 66.4 45.6 64.1 23,578 71.7 84.1 68.4 79.1 7,018 Divorced/separated/widowed 57.1 72.3 52.8 69.8 1,409 70.1 79.3 63.9 70.8 238 Residence Urban 63.2 74.5 56.9 68.8 11,934 77.7 86.9 73.3 77.9 5,215 Rural 47.3 64.3 43.1 63.2 21,451 69.1 80.7 65.7 77.8 8,593 Zone North Central 48.3 62.1 45.4 55.7 4,748 74.3 80.5 69.6 74.2 2,065 North East 38.6 62.3 34.7 70.1 4,262 71.7 82.1 68.6 82.5 1,645 North West 46.4 66.2 43.0 66.8 8,022 65.5 80.3 63.0 81.8 3,237 South East 60.9 77.8 55.1 78.7 4,091 76.0 87.6 72.4 83.0 1,448 South South 64.6 73.2 59.8 70.2 5,473 77.6 88.6 74.9 83.1 2,437 South West 58.9 67.3 50.2 54.7 6,789 72.8 81.5 66.9 66.7 2,977 Education No education 34.4 55.3 31.0 56.6 11,942 51.9 68.8 49.3 69.6 2,597 Primary 55.3 70.0 50.3 67.3 6,566 67.8 81.3 64.5 78.9 2,761 Secondary 65.4 76.1 59.1 71.1 11,904 79.0 86.9 74.6 80.1 6,470 More than secondary 72.6 81.2 66.7 71.6 2,974 83.7 91.3 80.0 79.8 1,979 Wealth quintile Lowest 31.3 53.2 27.8 55.1 6,194 57.1 72.3 54.3 71.4 2,275 Second 42.4 62.1 38.5 60.8 6,234 67.8 79.6 64.4 77.5 2,332 Middle 55.4 69.2 50.5 68.6 6,341 73.4 84.2 69.6 81.5 2,570 Fourth 64.5 75.2 58.7 71.0 6,938 79.9 87.8 76.0 81.9 3,163 Highest 66.6 76.9 60.2 69.0 7,678 77.8 87.2 73.2 75.9 3,468 Total 15-49 53.0 67.9 48.0 65.2 33,385 72.4 83.0 68.6 77.9 3,808 50-59 na na na na na 61.3 78.8 58.3 74.5 1,678 Total men 15-59 na na na na na 71.2 82.6 67.5 77.5 5,486 na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 13.2.3 Rejection of Misconceptions about HIV and AIDS As part of the effort to assess HIV and AIDS knowledge, the 2008 NDHS obtained information on common misconceptions about HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have HIV and whether they believe HIV is transmitted through mosquito bites, supernatural means, or from sharing food with a person who has HIV or AIDS. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 201 Tables 13.3.1 and 13.3.2 show the proportion of women and men age 15-49 who know that a healthy-looking person can have HIV and who reject common misconceptions about HIV transmission. Sixty-six percent of women and 78 percent of men agree that a healthy-looking person can have HIV. With respect to misconceptions about methods of HIV transmission, 56 percent of women and 61 percent of men believe HIV cannot be transmitted by mosquitoes. Fifty-three percent of women and 66 percent of men believe HIV cannot be transmitted by supernatural means. Sixty- four percent of women and 74 percent of men believe a person cannot contract HIV by sharing food with a person who has AIDS. Table 13.3.1 Comprehensive knowledge about HIV and AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have HIV and who, in response to prompted questions, correctly reject local misconceptions about HIV transmission and prevention, and the percentage with a comprehensive knowledge about HIV and AIDS, by background characteristics, Nigeria 2008 Percentage of women who say that: Background characteristic A healthy- looking person can have HIV HIV cannot be transmitted by mosquito bites HIV cannot be transmitted by supernatural means A person cannot contract HIV by sharing food with a person who has HIV Percentage who say that a healthy- looking person can have HIV and who reject the two most common local misconceptions1 Percentage with a compre- hensive knowledge about HIV and AIDS2 Number of women Age 15-24 63.5 55.1 52.1 63.5 33.4 22.2 12,626 15-19 60.2 52.8 49.6 59.7 30.8 19.7 6,493 20-24 67.1 57.5 54.7 67.5 36.2 24.8 6,133 25-29 68.6 58.8 55.3 66.7 37.9 26.6 6,309 30-39 67.8 57.7 53.3 65.1 36.0 24.6 8,546 40-49 63.0 52.5 49.8 59.4 31.3 20.7 5,904 Marital status Never married 72.8 64.9 60.5 74.4 42.2 28.2 8,398 Ever had sex 80.2 68.1 63.6 81.0 46.5 33.2 3,718 Never had sex 67.0 62.3 58.0 69.1 38.8 24.2 4,680 Married/living together 62.8 52.8 49.9 59.8 32.0 21.7 23,578 Divorced/separated/widowed 66.3 56.4 50.4 67.1 32.5 23.6 1,409 Residence Urban 79.1 70.5 66.2 77.9 49.4 33.2 11,934 Rural 57.9 47.9 45.1 56.0 26.3 17.9 21,451 Zone North Central 56.2 50.0 45.9 56.6 30.0 22.0 4,748 North East 53.8 44.4 43.8 53.8 24.4 14.4 4,262 North West 59.7 48.9 44.4 53.4 28.8 20.7 8,022 South East 69.3 70.0 63.9 81.1 42.1 30.9 4,091 South South 73.1 58.3 49.2 72.8 35.4 26.0 5,473 South West 77.7 65.6 68.4 69.8 45.9 26.5 6,789 Education No education 47.7 39.9 37.7 44.3 20.8 12.6 11,942 Primary 64.8 52.4 51.0 61.5 30.2 20.9 6,566 Secondary 77.5 66.8 62.2 77.4 43.0 29.9 11,904 More than secondary 90.3 85.3 77.6 93.0 65.5 46.3 2,974 Wealth quintile Lowest 43.0 36.2 32.8 40.8 16.3 9.5 6,194 Second 54.5 43.9 42.1 51.7 23.2 14.7 6,234 Middle 64.3 52.5 51.0 62.1 30.4 21.5 6,341 Fourth 75.9 64.6 61.4 73.5 42.2 30.5 6,938 Highest 84.2 76.9 70.5 84.9 55.1 36.8 7,678 Total 15-49 65.5 56.0 52.6 63.8 34.6 23.4 33,385 1 Two most common local misconceptions: HIV can be transmitted by mosquito bites and HIV can be transmitted by supernatural means. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV- negative and faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission and prevention. 202 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.3.2 Comprehensive knowledge about HIV and AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission and prevention, and the percentage with a comprehensive knowledge about HIV and AIDS, by background characteristics, Nigeria 2008 Percentage of men who say that: Background characteristic A healthy- looking person can have HIV HIV cannot be transmitted by mosquito bites HIV cannot be transmitted by supernatural means A person cannot contract HIV by sharing food with a person who has HIV Percentage who say that a healthy looking person can have HIV and who reject the two most common local misconceptions1 Percentage with a compre- hensive knowledge about HIV and AIDS2 Number of men Age 15-24 74.2 57.2 62.1 70.0 40.3 32.6 4,910 15-19 68.6 52.7 57.9 64.7 35.9 28.2 2,532 20-24 80.3 62.1 66.5 75.6 45.0 37.2 2,378 25-29 80.6 63.5 69.0 78.6 47.8 40.2 2,459 30-39 81.3 63.3 67.6 75.0 47.5 38.4 3,852 40-49 79.7 62.2 65.6 73.1 46.6 36.7 2,587 Marital status Never married 78.2 61.9 66.0 74.8 45.6 37.1 6,551 Ever had sex 84.7 67.1 70.9 81.2 49.9 41.0 3,186 Never had sex 72.0 57.0 61.3 68.8 41.5 33.4 3,365 Married/living together 78.6 60.4 65.3 72.4 44.4 35.9 7,018 Divorced/separated/widowed 76.0 52.3 60.5 70.1 36.8 27.3 238 Residence Urban 87.5 72.0 74.1 83.4 56.9 45.4 5,215 Rural 72.9 54.3 60.3 67.5 37.6 30.8 8,593 Zone North Central 73.3 55.4 59.2 69.2 37.6 32.5 2,065 North East 70.7 49.9 64.8 64.5 37.5 32.4 1,645 North West 76.4 59.5 66.1 69.8 45.2 37.7 3,237 South East 81.1 68.5 64.1 78.9 48.5 39.6 1,448 South South 80.1 62.8 62.0 78.3 43.6 37.0 2,437 South West 85.5 67.4 73.1 78.9 52.8 37.3 2,977 Education No education 57.8 40.5 48.4 51.6 24.9 18.4 2,597 Primary 73.8 51.2 59.3 67.4 34.5 27.5 2,761 Secondary 83.7 65.7 69.7 79.1 49.2 40.1 6,470 More than secondary 94.2 86.0 82.9 92.5 71.4 59.6 1,979 Wealth quintile Lowest 60.0 41.5 52.0 54.2 25.1 19.6 2,275 Second 71.3 50.3 58.5 64.5 34.0 27.9 2,332 Middle 78.4 58.7 62.7 72.7 42.1 35.4 2,570 Fourth 83.5 66.3 69.9 79.1 50.5 42.5 3,163 Highest 90.5 77.8 77.1 87.7 62.1 47.9 3,468 Total 15-49 78.4 61.0 65.5 73.5 44.9 36.3 13,808 50-59 72.7 54.6 59.2 66.7 39.8 29.7 1,678 Total men 15-59 77.8 60.3 64.8 72.8 44.3 35.6 15,486 1 Two most common local misconceptions: HIV can be transmitted by mosquito bites and HIV can be transmitted by supernatural means. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV-negative faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission and prevention. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 203 Two composite measures of HIV and AIDS knowledge are included in Tables 13.3.1 and 13.3.2. The first measure indicates that 35 percent of women and 45 percent of men know that the two most common misconceptions about HIV and AIDS (i.e., HIV can be transmitted by mosquito bites and by supernatural means) are incorrect, and they are also aware that a healthy-looking person can have HIV. The second measure shows that 23 percent of women and 36 percent of men have comprehensive knowledge about HIV and AIDS: 1) they know that using condoms and limiting sexual intercourse to one HIV-negative partner are HIV prevention methods; 2) they are aware that a healthy-looking person can have HIV; and 3) they reject the two most common local misconceptions about HIV and AIDS, that HIV and AIDS can be transmitted by mosquito bites and by supernatural means. Respondents in urban areas are more likely than those in rural areas to have comprehensive knowledge of HIV and AIDS. The level of comprehensive knowledge is highest in the South East (31 percent for women and 40 percent for men). The proportion with comprehensive knowledge about HIV and AIDS rises with increasing level of education and wealth quintile among both women and men. 13.3 KNOWLEDGE ABOUT MOTHER-TO-CHILD TRANSMISSION Increasing the level of knowledge about HIV transmission from mother to child and reducing the risk of transmission by using anti-retrovirals prior to delivery is critical to reducing mother-to- child transmission (MTCT). To assess MTCT knowledge, respondents were asked if HIV can be transmitted from a mother to a child through breastfeeding and whether a mother with HIV can reduce the risk of transmission to her baby by taking certain drugs during pregnancy. Table 13.4 shows that 52 percent of women and 59 percent of men know that HIV can be transmitted through breastfeeding. This is an increase from the 2003 NDHS in which 46 percent of women and 56 percent of men reported that HIV can be transmitted by breastfeeding. Although knowledge about mother-to-child transmission has increased, knowledge about how this risk can be reduced is still limited; 28 percent of women and 39 percent of men know that the risk of MTCT can be reduced by taking special drugs. Twenty-six percent of women and 33 percent of men are aware that HIV can be transmitted through breastfeeding and that the risk of MTCT can be reduced by taking special drugs. Knowledge of MTCT increases with level of education and wealth quintile, and it is higher in urban areas than in rural areas. 204 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to- child transmission (MTCT) of HIV can be reduced by mother taking special drugs during pregnancy, by background characteristics, Nigeria 2008 Women Men Background characteristic HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 47.1 25.4 23.2 12,626 55.2 34.7 29.3 4,910 15-19 41.7 21.1 19.2 6,493 48.7 29.1 24.0 2,532 20-24 52.8 30.0 27.5 6,133 62.1 40.7 34.9 2,378 25-29 56.7 32.5 30.2 6,309 60.9 42.4 36.0 2,459 30-39 56.3 31.6 28.9 8,546 61.4 40.8 34.3 3,852 40-49 51.9 24.7 22.8 5,904 61.2 39.5 33.4 2,587 Marital status Never married 55.2 30.8 28.3 8,398 58.0 38.6 32.7 6,551 Ever had sex 64.8 38.1 35.4 3,718 67.6 43.0 37.5 3,186 Never had sex 47.6 25.1 22.6 4,680 48.9 34.5 28.2 3,365 Married/living together 50.6 27.2 25.1 23,578 60.1 38.7 32.6 7,018 Divorced/separated/ widowed 58.9 28.7 26.5 1,409 61.3 39.1 32.6 238 Currently pregnant Pregnant 51.5 28.6 26.1 3,494 na na na na Not pregnant or not sure 52.2 28.2 25.9 29,891 na na na na Residence Urban 65.3 40.8 37.2 11,934 63.2 45.8 38.1 5,215 Rural 44.8 21.2 19.7 21,451 56.6 34.4 29.4 8,593 Zone North Central 50.1 30.8 29.1 4,748 66.1 36.2 33.1 2,065 North East 40.4 28.9 26.2 4,262 52.1 51.6 40.9 1,645 North West 33.6 22.0 19.1 8,022 48.3 39.9 33.3 3,237 South East 70.1 26.9 25.0 4,091 67.4 38.2 35.0 1,448 South South 58.7 35.2 32.8 5,473 67.2 36.2 30.1 2,437 South West 66.6 28.4 26.6 6,789 59.1 34.2 28.1 2,977 Education No education 29.7 15.2 13.5 11,942 36.5 23.6 19.2 2,597 Primary 56.8 24.9 22.7 6,566 57.9 30.4 26.2 2,761 Secondary 64.9 34.8 32.5 11,904 64.5 40.6 34.5 6,470 More than secondary 80.5 61.7 56.8 2,974 72.6 63.7 53.3 1,979 Wealth quintile Lowest 28.4 13.1 12.0 6,194 44.9 26.9 22.1 2,275 Second 37.5 18.4 16.9 6,234 54.2 34.0 28.6 2,332 Middle 53.4 24.3 22.4 6,341 58.8 37.4 32.0 2,570 Fourth 62.9 33.0 30.2 6,938 64.5 40.1 34.9 3,163 Highest 72.3 47.3 43.6 7,678 66.9 49.1 40.8 3,468 Total 15-49 52.1 28.2 25.9 33,385 59.1 38.7 32.7 13,808 50-59 na na na na 53.9 31.4 27.4 1,678 Total men 15-59 na na na na 58.5 37.9 32.1 15,486 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 205 13.4 ATTITUDES TOWARDS PEOPLE LIVING WITH HIV AND AIDS HIV and AIDS have generated fear, anxiety, and prejudice against people living with HIV and AIDS. There is widespread stigma and discrimination regarding people who are HIV-positive. These societal attitudes can adversely affect both people’s willingness to be tested for HIV and their adherence to anti-retroviral therapy. Reducing stigma and discrimination is therefore an important factor in prevention, management, and control of the HIV epidemic. In the 2008 NDHS, women and men who had heard of HIV and AIDS were asked a number of questions to assess the level of stigma associated with HIV and AIDS. Tables 13.5.1 and 13.5.2 present these results for women and men age 15-49, respectively. Tables 13.5.1 and 13.5.2 show that more males (74 percent) than females (60 percent) are willing to take care of a family member with HIV at home. This represents a substantial increase in the levels observed in the 2003 NDHS (44 percent of women and 40 percent of men, respectively). Slightly more than a third (37 percent) of the women and less than half (48 percent) of the men said that they would buy fresh vegetables from a shopkeeper who has HIV. In 2003, only 20 percent of women and 28 percent of men said they would buy fresh vegetables from a shopkeeper with HIV. About half (49 percent) of women and more than half of men (58 percent) think that a female teacher with HIV should be allowed to continue teaching. Sixty percent of women and two-thirds of men (66 percent) indicated that they would not want to keep secret the fact that a family member was infected with HIV. Overall, 13 percent of women and 22 percent of men expressed accepting attitudes regarding all four situations, i.e., they would care for a family member with HIV or AIDS in their own home, they would buy fresh food from a shopkeeper with HIV, they would allow an HIV-positive teacher to continue teaching, and they would not want to keep secret the HIV-positive status of a family member. Accepting attitudes are generally more common among respondents in urban areas than those in rural areas. Similarly, it is more common among respondents in the highest wealth quintile. The proportion of women expressing accepting attitudes on all four stigma indicators is highest for women in the North Central (17 percent) and highest for men in the South East (26 percent). 206 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.5.1 Accepting attitudes towards persons living with HIV or AIDS: Women Among women age 15-49 who have heard of HIV or AIDS, percentage expressing specific accepting attitudes towards people with HIV or AIDS, by background characteristics, Nigeria 2008 Percentage of women who: Background characteristic Are willing to care for a family member with HIV in the respondent's home Would buy fresh vegetables from shopkeeper who has HIV Say that a female teacher with HIV who is not sick should be allowed to continue teaching Would not want to keep secret that a family member has HIV Percentage expressing acceptance attitudes on all four indicators Number of women who have heard of HIV or AIDS Age 15-24 60.4 35.8 50.2 57.2 12.1 10,999 15-19 58.4 32.7 48.2 55.7 10.3 5,536 20-24 62.4 39.0 52.1 58.6 13.9 5,463 25-29 61.2 39.0 51.2 59.0 13.5 5,665 30-39 60.9 37.1 49.0 61.6 13.7 7,641 40-49 58.5 34.5 46.2 64.7 12.4 5,149 Marital status Never married 66.0 43.6 57.7 54.7 14.7 7,799 Ever had sex 69.5 47.5 59.6 54.1 16.0 3,588 Never had sex 63.0 40.3 56.2 55.2 13.7 4,211 Married/living together 58.1 33.9 46.1 61.9 12.0 20,367 Divorced/separated/widowed 62.6 35.2 50.3 61.9 13.1 1,287 Residence Urban 66.5 47.4 59.3 55.7 16.7 11,374 Rural 56.5 29.7 43.1 62.7 10.4 18,079 Zone North Central 78.7 37.2 59.3 60.2 17.2 3,602 North East 65.1 25.9 46.5 66.2 13.3 3,469 North West 50.7 35.2 44.9 63.5 14.0 7,040 South East 65.1 38.5 49.1 60.6 12.7 3,971 South South 63.9 45.2 56.3 47.4 11.0 5,033 South West 52.3 35.3 44.9 62.1 10.3 6,339 Education No education 49.8 24.4 37.2 64.8 8.2 9,149 Primary 58.3 28.9 43.2 62.7 10.5 5,925 Secondary 65.6 41.9 54.9 56.7 14.3 11,426 More than secondary 76.9 68.8 78.3 52.5 26.1 2,954 Wealth quintile Lowest 52.4 20.5 32.4 62.4 6.8 4,674 Second 53.5 25.7 40.8 63.4 8.6 5,095 Middle 60.0 31.5 47.7 64.8 12.5 5,633 Fourth 60.9 41.0 53.3 59.7 14.6 6,553 Highest 69.7 53.7 63.5 52.8 18.1 7,498 Total 15-49 60.4 36.5 49.4 60.0 12.8 29,453 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 207 Table 13.5.2 Accepting attitudes towards persons living with HIV or AIDS: Men Among men age 15-49 who have heard of HIV or AIDS, percentage expressing specific accepting attitudes towards people with HIV or AIDS, by background characteristics, Nigeria 2008 Percentage of men who: Background characteristic Are willing to care for a family member with HIV in the respondent's home Would buy fresh vegetables from shopkeeper who has HIV Say that a female teacher with HIV who is not sick should be allowed to continue teaching Would not want to keep secret that a family member has HIV Percentage expressing acceptance attitudes on all four indicators Number of men who have heard of HIV or AIDS Age 15-24 71.4 44.4 54.6 59.4 17.4 4,489 15-19 68.5 39.5 50.5 57.0 15.0 2,236 20-24 74.3 49.2 58.7 61.9 19.7 2,254 25-29 74.0 53.0 60.2 65.2 23.5 2,326 30-39 74.6 49.5 58.8 69.7 24.7 3,649 40-49 75.7 49.7 58.2 71.0 24.9 2,442 Marital status Never married 73.1 50.0 59.4 61.5 21.3 6,118 Ever had sex 75.1 51.6 62.2 65.5 24.3 3,122 Never had sex 71.1 48.4 56.6 57.3 18.2 2,996 Married/living together 74.2 46.8 55.7 69.2 22.4 6,568 Divorced/separated/widowed 69.8 48.9 56.6 69.3 26.7 219 Residence Urban 76.8 58.5 66.1 64.3 26.9 5,104 Rural 71.5 41.7 51.8 66.4 18.7 7,802 Zone North Central 85.8 41.3 51.7 75.3 25.0 1,872 North East 81.9 45.8 50.2 57.1 19.5 1,445 North West 70.9 52.8 62.4 62.1 19.1 2,941 South East 80.4 52.3 64.3 62.9 26.3 1,395 South South 64.8 47.5 59.6 68.2 21.9 2,342 South West 68.2 48.6 54.8 66.1 22.1 2,910 Education No education 74.0 31.4 40.7 59.8 11.0 2,097 Primary 68.6 35.3 47.6 65.8 14.9 2,552 Secondary 73.0 50.2 59.2 66.5 22.5 6,283 More than secondary 81.7 77.6 82.7 68.4 41.2 1,974 Wealth quintile Lowest 72.3 30.6 41.4 63.1 11.7 1,899 Second 75.5 38.9 48.4 64.5 15.9 2,097 Middle 72.3 47.1 55.8 66.8 21.3 2,409 Fourth 68.4 50.6 59.6 66.9 23.1 3,070 Highest 78.7 62.9 71.1 65.6 30.8 3,430 Total 15-49 73.6 48.4 57.5 65.6 22.0 12,905 50-59 73.1 43.6 53.8 74.6 21.9 1,527 Total men 15-59 73.5 47.9 57.1 66.5 22.0 14,433 13.5 ATTITUDES TOWARDS NEGOTIATING SAFER SEXUAL RELATIONS WITH HUSBANDS The high levels of HIV transmission through sexual intercourse make negotiating safer sex indispensable. This is especially the case in marital unions where women’s status is compromised by societal expectations, thereby increasing their vulnerability to HIV transmission. Table 13.6 shows that 81 percent of women and 87 percent of men in Nigeria believe that if a husband has a sexually transmitted disease, his wife is justified in refusing to have sexual intercourse with him. A lower proportion of women and men believe it would be justified for women to ask their husband or partner to use a condom (70 and 84 percent, respectively). Overall, 86 percent of women and 92 percent of men believe that a wife is justified in taking some action to protect herself from HIV either by refusing to have sexual intercourse or by requesting that her husband or partner use a condom. 208 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour People living in rural areas have less favourable attitudes towards a wife refusing to have sexual intercourse with her husband or asking him to use a condom if he has a sexually transmitted disease. Eighty-four percent of women in rural areas have a favourable attitude, compared with 89 percent in urban areas. Among men, the comparable figures are 90 percent in rural areas and 95 percent in urban areas. Regarding education, the lowest proportions in agreement that a wife can negotiate safer sex with her husband are seen among women and men who have no education (82 and 84 percent, respectively). Table 13.6 Attitudes towards negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that, if a husband has a sexually transmitted disease, his wife is justified in refusing to have sexual intercourse with him or asking that they use a condom, by background characteristics, Nigeria 2008 Percentage of women who think that a wife is justified in Percentage of men who think that a wife is justified in: Background characteristic Refusing to have sexual intercourse with husband Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Number of women Refusing to have sexual intercourse with husband Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Number of men Age 15-24 76.6 66.9 81.8 12,626 83.7 80.4 88.8 4,910 15-19 72.2 61.9 77.1 6,493 81.0 75.9 85.3 2,532 20-24 81.3 72.2 86.8 6,133 86.6 85.2 92.6 2,378 25-29 83.6 73.2 88.5 6,309 87.4 86.1 93.5 2,459 30-39 83.9 71.6 88.4 8,546 88.9 86.2 94.0 3,852 40-49 83.3 67.9 87.3 5,904 87.7 82.8 92.9 2,587 Marital status Never married 74.9 70.2 81.4 8,398 85.0 82.8 90.5 6,551 Ever had sex 82.0 81.3 89.9 3,718 88.2 88.7 95.0 3,186 Never had sex 69.3 61.4 74.7 4,680 81.9 77.2 86.3 3,365 Married/living together 82.9 69.1 87.1 23,578 88.1 84.1 93.1 7,018 Divorced/separated/widowed 84.5 71.4 89.1 1,409 84.1 83.3 92.6 238 Residence Urban 82.2 78.7 89.2 11,934 87.2 87.8 94.8 5,215 Rural 80.3 64.3 83.8 21,451 86.2 80.9 90.1 8,593 Zone North Central 79.9 68.0 83.8 4,748 89.6 81.7 92.7 2,065 North East 79.3 60.1 84.0 4,262 85.3 82.3 90.0 1,645 North West 83.8 64.6 85.6 8,022 83.9 79.7 86.8 3,237 South East 71.5 59.2 78.9 4,091 88.8 81.7 94.3 1,448 South South 80.4 75.8 86.3 5,473 91.1 89.9 96.8 2,437 South West 85.7 83.2 91.9 6,789 83.3 85.0 92.5 2,977 Education No education 79.2 57.9 82.0 11,942 79.4 71.1 83.5 2,597 Primary 82.6 70.0 86.7 6,566 86.7 81.8 92.2 2,761 Secondary 81.0 76.7 87.0 11,904 88.2 86.4 93.7 6,470 More than secondary 84.6 85.7 93.1 2,974 90.6 92.4 96.4 1,979 Wealth quintile Lowest 77.2 52.2 80.1 6,194 80.5 72.4 84.8 2,275 Second 79.8 62.0 82.9 6,234 86.2 80.5 89.9 2,332 Middle 80.6 69.6 84.6 6,341 88.3 84.0 91.7 2,570 Fourth 83.0 77.5 88.7 6,938 88.1 86.7 93.3 3,163 Highest 83.5 82.1 90.8 7,678 88.1 89.5 96.6 3,468 Total 15-49 81.0 69.5 85.7 33,385 86.6 83.5 91.9 13,808 50-59 na na na na 87.0 77.0 90.6 1,678 Total men 15-59 na na na na 86.6 82.8 91.7 15,486 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 209 13.6 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH Condom use is one of the most effective strategies for combating the spread of HIV. However, educating youth about condoms is sometimes controversial, with some people believing it promotes early sexual initiation. To gauge attitudes towards condom education for youth, the 2008 NDHS asked respondents if they thought that young people age 12-14 should be taught about using a condom to avoid HIV infection. Because the table focuses on adult opinions, results are tabulated for respondents age 18-49. Table 13.7 shows that less than a third of women (32 percent) and less than half of men (47 percent) support teaching young people age 12-14 about condoms for HIV prevention. Among women, support for condom education for youths is lowest in the North East (21 percent) and highest among women living in the South West (41 percent). Among men it is lowest in the North West (29 percent) and highest in the South South (61 percent). The proportion of men and women who support condom education for youth increases with level of education and wealth quintile. Table 13.7 Adult support of education about condom use to prevent transmission of HIV Percentage of women and men age 18-49 who agree that children age 12-14 years should be taught about using a condom to avoid HIV infection, by background characteristics, Nigeria 2008 Women age 18-49 Men age 18-49 Background characteristic Percentage who agree Number of women Percentage who agree Number of men Age 18-24 34.0 8,731 49.6 3,378 18-19 32.4 2,597 44.5 1,000 20-24 34.7 6,133 51.7 2,378 25-29 33.6 6,309 50.9 2,459 30-39 31.7 8,546 45.5 3,852 40-49 28.1 5,904 40.9 2,587 Marital status Never married 44.0 5,349 51.9 5,024 Married or living together 29.0 22,746 43.0 7,013 Divorced/separated/widowed 35.9 1,395 48.1 238 Residence Urban 37.8 10,577 50.2 4,674 Rural 28.8 18,913 44.6 7,602 Zone North Central 32.9 4,195 56.4 1,803 North East 21.1 3,749 44.8 1,475 North West 23.6 7,234 28.6 2,914 South East 34.9 3,570 50.2 1,276 South South 39.2 4,791 60.6 2,136 South West 41.2 5,951 48.5 2,671 Education No education 19.1 11,052 27.2 2,394 Primary 33.6 5,966 41.1 2,458 Secondary 41.7 9,515 54.1 5,452 More than secondary 46.6 2,957 57.2 1,972 Wealth quintile Lowest 19.9 5,505 35.8 2,034 Second 23.7 5,519 42.4 2,057 Middle 33.2 5,566 48.5 2,242 Fourth 39.3 6,105 50.6 2,800 Highest 41.2 6,794 52.0 3,142 Total 18-49 32.1 29,489 46.8 12,276 50-59 na na 35.8 1,678 Total men 18-59 na na 45.4 13,954 na = Not applicable 210 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.7 PERCEPTIONS AND BELIEFS ABOUT ABSTINENCE AND FAITHFULNESS Both male and female respondents age 15-49 were asked questions on their perceptions and beliefs about abstinence and faithfulness. Figure 13.1 shows that men and women are of the view that young people of both sexes should wait until they are married before they have sexual intercourse. A lower proportion of men (89 percent) believe that married men should only have sex with their wives, while a higher proportion of men (94 percent) think that married women should only have sex with their husbands. However, only 28 percent of women and 36 percent of men think that most married men they know only have sex with their wives. Less than half of the women (44 percent) and men (46 percent) think that married women only have sex with their husbands. 13.8 HIGHER-RISK SEX Given that most HIV in Nigeria is transmitted through heterosexual contact, information on multiple sexual partners and higher-risk sexual behaviour is important in designing and monitoring intervention programmes to control the spread of the epidemic. The 2008 NDHS included questions on respondents’ sexual partners during the past 12 months and during their lifetime. Respondents were also asked detailed questions about their sexual behaviour, including the number of partners they had in the 12 months preceding the survey, and whether they had sexual intercourse with someone who was neither a spouse nor a cohabiting partner (i.e., a higher-risk sexual partner). Women and men were also asked about condom use. The results are shown in Tables 13.8.1 and 13.8.2 for women and men age 15-49. 85 88 90 93 28 44 84 85 89 94 36 46 Young men Young women Married men Married women Most married Most married 0 20 40 60 80 100 Percent Women Men Figure 13.1 Perception and Beliefs about Abstinence and Faithfulness Young men should wait until they are married to have sexual intercourse Young women should wait until they are married to have sexual intercourse Married men should only have sex with their wives Most married men they know only have sex with their wives Married women should only have sex with their husbands Most married women they know only have sex with their husbands NDHS 2008 T ab le 1 3. 8. 1 M ul tip le s ex ua l p ar tn er s an d hi gh er -r isk s ex ua l i nt er co ur se in th e pa st 1 2 m on th s: W om en A m on g al l w om en a ge 1 5- 49 , t he p er ce nt ag e w ho h ad s ex ua l i nt er co ur se w ith m or e th an o ne s ex ua l p ar tn er a nd th e pe rc en ta ge w ho h ad h ig he r- ris k se xu al in te rc ou rs e in th e pa st 1 2 m on th s; a m on g w om en a ge 1 5- 49 w ho h ad s ex ua l in te rc ou rs e in t he p as t 12 m on th s, t he p er ce nt ag e w ho h ad s ex ua l in te rc ou rs e w ith m or e th an o ne p ar tn er a nd t he p er ce nt ag e w ho h ad h ig he r- ris k se xu al in te rc ou rs e in th e pa st 1 2 m on th s; a m on g w om en w ho h ad m or e th an o ne p ar tn er in th e pa st 1 2 m on th s, th e pe rc en ta ge w ho u se d a co nd om a t l as t s ex ua l i nt er co ur se ; an d am on g w om en w ho h ad hi gh er -r isk s ex ua l i nt er co ur se in t he p as t 12 m on th s, t he p er ce nt ag e w ho u se d a co nd om a t la st s ex ua l i nt er co ur se w ith t ha t pe rs on ; an d am on g w om en w ho e ve r ha d se xu al in te rc ou rs e, t he m ea n nu m be r o f s ex ua l p ar tn er s du rin g lif et im e, b y ba ck gr ou nd c ha ra ct er ist ic s, N ig er ia 2 00 8 Al l w om en W om en w ho h ad s ex ua l i nt er co ur se in th e pa st 1 2 m on th s W om en w ho h ad 2 + pa rtn er s in th e pa st 12 m on th s W om en w ho h ad hi gh er -r isk s ex ua l in te rc ou rs e1 in th e pa st 12 m on th s W om en w ho e ve r ha d se xu al in te rc ou rs e B ac kg ro un d ch ar ac te ris tic Pe rc en ta ge w ho h ad 2 + pa rtn er s in th e pa st 12 m on th s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 in th e pa st 12 m on th s N um be r Pe rc en ta ge w ho h ad 2 + pa rtn er s in th e pa st 12 m on th s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 in th e pa st 12 m on th s N um be r Pe rc en ta ge w ho u se d a co nd om du rin g la st se xu al in te rc ou rs e N um be r Pe rc en ta ge w ho u se d a co nd om a t la st s ex ua l in te rc ou rs e w ith th at pe rs on N um be r M ea n nu m be r o f se xu al pa rtn er s in lif et im e N um be r A ge 15 -2 4 1. 2 17 .1 12 ,6 26 2. 1 28 .8 7, 46 9 29 .0 15 6 35 .5 2, 15 4 1. 4 8, 11 0 1 5- 19 1. 0 13 .9 6, 49 3 2. 3 33 .3 2, 70 8 24 .8 63 28 .6 90 3 1. 3 2, 94 5 2 0- 24 1. 5 20 .4 6, 13 3 2. 0 26 .3 4, 76 1 31 .8 93 40 .5 1, 25 1 1. 5 5, 16 4 25 -2 9 1. 4 10 .4 6, 30 9 1. 6 11 .9 5, 50 3 27 .0 88 38 .4 65 7 1. 6 5, 89 5 30 -3 9 0. 8 4. 2 8, 54 6 0. 9 4. 7 7, 60 1 15 .5 66 25 .7 36 1 1. 7 8, 24 1 40 -4 9 0. 6 2. 9 5, 90 4 0. 7 3. 5 4, 87 6 (0 .0 ) 36 4. 5 17 2 1. 6 5, 72 8 M ar ita l s ta tu s N ev er m ar rie d 2. 1 34 .0 8, 39 7 5. 8 95 .8 2, 98 1 38 .8 17 3 36 .9 2, 85 6 1. 9 3, 61 0 M ar rie d or li vi ng to ge th er 0. 6 0. 6 23 ,5 79 0. 6 0. 6 21 ,8 86 5. 0 13 2 11 .8 13 6 1. 5 23 ,0 12 D iv or ce d/ se pa ra te d/ w id ow ed 3. 0 25 .0 1, 40 9 7. 2 60 .7 58 1 (1 4. 1) 42 13 .3 35 3 2. 1 1, 35 2 R es id en ce U rb an 1. 2 13 .2 11 ,9 34 1. 6 18 .3 8, 61 5 32 .4 13 9 43 .0 1, 57 4 1. 7 9, 41 8 Ru ra l 1. 0 8. 3 21 ,4 51 1. 2 10 .5 16 ,8 34 16 .5 20 7 24 .9 1, 77 1 1. 5 18 ,5 56 Z on e N or th C en tra l 1. 7 8. 8 4, 74 8 2. 5 12 .8 3, 28 7 7. 8 82 25 .8 42 0 1. 4 3, 84 5 N or th E as t 0. 7 3. 1 4, 26 2 0. 8 3. 7 3, 59 8 (7 .9 ) 29 19 .1 13 1 1. 4 3, 81 8 N or th W es t 0. 3 0. 7 8, 02 2 0. 3 0. 8 7, 05 4 * 22 (2 3. 8) 54 1. 2 7, 24 6 So ut h Ea st 1. 0 13 .1 4, 09 1 1. 7 21 .9 2, 44 6 (3 1. 1) 42 40 .7 53 5 1. 7 3, 01 0 So ut h So ut h 2. 2 24 .9 5, 47 3 2. 9 32 .7 4, 16 6 35 .2 12 2 30 .9 1, 36 1 2. 3 4, 58 2 So ut h W es t 0. 7 12 .4 6, 78 9 1. 0 17 .2 4, 89 7 (2 2. 8) 49 39 .5 84 4 1. 7 5, 47 3 E du ca tio n N o ed uc at io n 0. 4 1. 1 11 ,9 42 0. 5 1. 2 10 ,5 30 1. 8 54 4. 2 12 6 1. 3 11 ,3 63 Pr im ar y 1. 2 6. 2 6, 56 6 1. 5 8. 0 5, 09 7 5. 4 78 13 .0 40 6 1. 6 5, 81 3 Se co nd ar y 1. 3 18 .0 11 ,9 04 2. 0 28 .4 7, 52 8 32 .8 15 3 34 .1 2, 13 8 1. 8 8, 28 3 M or e th an s ec on da ry 2. 1 22 .7 2, 97 4 2. 7 29 .4 2, 29 4 39 .2 61 49 .0 67 5 2. 1 2, 51 7 W ea lth q ui nt ile Lo w es t 0. 9 3. 6 6, 19 4 1. 0 4. 2 5, 31 9 4. 4 55 7. 4 22 3 1. 4 5, 71 5 Se co nd 0. 8 5. 6 6, 23 4 1. 0 7. 0 5, 02 7 9. 1 49 19 .1 35 1 1. 4 5, 51 1 M id dl e 0. 9 9. 9 6, 34 1 1. 2 13 .7 4, 57 6 22 .3 56 26 .6 62 7 1. 6 5, 25 4 Fo ur th 1. 3 14 .9 6, 93 8 1. 9 20 .7 4, 99 4 27 .5 93 36 .4 1, 03 2 1. 7 5, 55 9 H ig he st 1. 2 14 .5 7, 67 8 1. 7 20 .1 5, 53 2 36 .8 93 44 .2 1, 11 2 1. 9 5, 93 5 T ot al 1 5- 49 1. 0 10 .0 33 ,3 85 1. 4 13 .1 25 ,4 48 22 .9 34 6 33 .4 3, 34 5 1. 6 27 ,9 74 N ot e: F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s su pp re ss ed 1 S ex ua l i nt er co ur se w ith a n on -m ar ita l, no n- co ha bi tin g pa rtn er HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 211 T ab le 1 3. 8. 2 M ul tip le s ex ua l p ar tn er s an d hi gh er -r isk s ex ua l i nt er co ur se in th e pa st 1 2 m on th s: M en A m on g al l m en a ge 1 5- 49 , th e pe rc en ta ge w ho h ad s ex ua l i nt er co ur se w ith m or e th an o ne s ex ua l p ar tn er a nd t he p er ce nt ag e w ho h ad h ig he r- ris k se xu al i nt er co ur se i n th e pa st 1 2 m on th s; am on g m en a ge 1 5- 49 w ho h ad s ex ua l i nt er co ur se in th e pa st 1 2 m on th s, th e pe rc en ta ge w ho h ad s ex ua l i nt er co ur se w ith m or e th an o ne p ar tn er a nd th e pe rc en ta ge w ho h ad h ig he r- ris k se xu al nt er co ur se in th e pa st 1 2 m on th s; a m on g m en w ho h ad m or e th an o ne p ar tn er in th e pa st 1 2 m on th s, th e pe rc en ta ge w ho u se d a co nd om a t l as t s ex ua l i nt er co ur se ; an d am on g m en w ho h ad hi gh er -r isk s ex ua l i nt er co ur se in th e pa st 1 2 m on th s, th e pe rc en ta ge w ho u se d a co nd om a t l as t s ex ua l i nt er co ur se w ith th at p er so n; a nd a m on g m en w ho e ve r ha d se xu al in te rc ou rs e, th e m ea n nu m be r o f s ex ua l p ar tn er s du rin g lif et im e, b y ba ck gr ou nd c ha ra ct er ist ic s, N ig er ia 2 00 8 Al l m en M en w ho h ad s ex ua l i nt er co ur se in th e pa st 1 2 m on th s M en w ho h ad 2 + pa rtn er s in th e pa st 12 m on th s M en w ho h ad h ig he r- ris k se xu al in te rc ou rs e1 in th e pa st 1 2 m on th s M en w ho e ve r h ad se xu al in te rc ou rs e B ac kg ro un d ch ar ac te ris tic Pe rc en ta ge w ho h ad 2 + pa rtn er s in th e pa st 12 m on th s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 in th e pa st 12 m on th s N um be r Pe rc en ta ge w ho h ad 2 + pa rtn er s in th e pa st 12 m on th s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 in th e pa st 12 m on th s N um be r Pe rc en ta ge w ho u se d a co nd om du rin g la st se xu al in te rc ou rs e N um be r Pe rc en ta ge w ho u se d a co nd om a t la st s ex ua l in te rc ou rs e w ith th at pe rs on N um be r M ea n nu m be r o f se xu al pa rtn er s in lif et im e N um be r A ge 15 -2 4 5. 8 27 .0 4, 91 0 17 .1 79 .2 1, 67 4 56 .4 28 6 49 .4 1, 32 6 3. 1 1, 97 3 1 5- 19 2. 4 15 .7 2, 53 2 14 .5 94 .5 42 2 61 .3 61 36 .3 39 8 2. 3 55 0 2 0- 24 9. 4 39 .0 2, 37 8 17 .9 74 .1 1, 25 2 55 .0 22 5 55 .1 92 8 3. 4 1, 42 2 25 -2 9 12 .5 34 .8 2, 45 9 16 .8 46 .7 1, 83 3 47 .8 30 8 60 .7 85 6 4. 3 1, 97 1 30 -3 9 11 .7 18 .5 3, 85 2 13 .0 20 .5 3, 48 2 24 .1 45 2 58 .5 71 2 4. 7 3, 48 6 40 -4 9 12 .6 8. 1 2, 58 7 13 .8 8. 8 2, 37 3 11 .5 32 6 46 .5 21 0 4. 7 2, 34 4 M ar ita l s ta tu s N ev er m ar rie d 8. 3 37 .2 6, 54 9 21 .6 96 .5 2, 52 2 64 .9 54 4 56 .2 2, 43 4 4. 3 3, 03 6 M ar rie d or li vi ng to ge th er 11 .3 8. 1 7, 02 1 11 .9 8. 5 6, 69 1 11 .7 79 5 49 .0 57 0 4. 2 6, 51 8 D iv or ce d/ se pa ra te d/ w id ow ed 14 .4 41 .7 23 8 23 .1 66 .7 14 9 (2 6. 0) 34 43 .8 99 5. 6 22 0 R es id en ce U rb an 9. 8 27 .4 5, 21 5 14 .7 41 .1 3, 47 9 48 .0 51 1 66 .0 1, 42 8 4. 6 3, 58 3 Ru ra l 10 .0 19 .5 8, 59 3 14 .6 28 .5 5, 88 3 24 .3 86 1 44 .6 1, 67 6 4. 1 6, 19 1 Z on e N or th C en tra l 12 .3 23 .9 2, 06 5 18 .9 36 .6 1, 34 5 18 .5 25 4 39 .7 49 3 3. 7 1, 41 5 N or th E as t 5. 6 8. 9 1, 64 5 8. 2 13 .0 1, 12 8 15 .3 93 32 .8 14 6 2. 9 1, 19 3 N or th W es t 4. 3 3. 0 3, 23 7 7. 0 5. 0 1, 97 1 6. 0 13 8 51 .6 98 1. 8 2, 04 4 So ut h Ea st 5. 0 25 .3 1, 44 8 8. 0 40 .4 90 7 53 .5 73 64 .4 36 6 3. 6 1, 01 2 So ut h So ut h 18 .4 41 .4 2, 43 7 25 .3 56 .9 1, 77 4 38 .3 44 8 50 .8 1, 00 9 8. 3 1, 82 8 So ut h W es t 12 .3 33 .3 2, 97 7 16 .4 44 .3 2, 23 7 47 .8 36 7 65 .2 99 2 4. 6 2, 28 1 E du ca tio n N o ed uc at io n 6. 4 3. 6 2, 59 7 8. 7 4. 9 1, 90 7 4. 2 16 7 13 .2 93 2. 3 1, 97 5 Pr im ar y 9. 0 15 .0 2, 76 1 12 .5 20 .9 1, 98 0 18 .1 24 8 37 .9 41 3 4. 0 2, 06 4 Se co nd ar y 10 .7 29 .9 6, 47 0 17 .7 49 .1 3, 93 2 36 .7 69 4 53 .2 1, 93 2 4. 9 4, 15 9 M or e th an s ec on da ry 13 .3 33 .6 1, 97 9 17 .1 43 .2 1, 54 2 56 .1 26 4 74 .1 66 6 5. 4 1, 57 7 W ea lth q ui nt ile Lo w es t 7. 8 10 .7 2, 27 5 10 .9 15 .0 1, 62 2 8. 9 17 7 23 .0 24 4 2. 8 1, 66 8 Se co nd 8. 4 15 .1 2, 33 2 12 .2 22 .1 1, 59 8 14 .6 19 5 33 .8 35 2 3. 4 1, 67 3 M id dl e 8. 9 19 .5 2, 57 0 14 .2 31 .1 1, 61 1 28 .0 22 8 47 .5 50 1 4. 0 1, 75 7 Fo ur th 10 .1 27 .5 3, 16 3 16 .0 43 .4 2, 00 6 37 .6 32 1 57 .7 87 0 4. 6 2, 15 3 H ig he st 13 .0 32 .8 3, 46 8 17 .9 45 .0 2, 52 6 50 .1 45 2 68 .1 1, 13 6 5. 8 2, 52 3 T ot al 1 5- 49 9. 9 22 .5 13 ,8 08 14 .7 33 .2 9, 36 2 33 .1 1, 37 3 54 .4 3, 10 4 4. 3 9, 77 4 5 0- 59 12 .9 5. 1 1, 67 8 14 .9 5. 9 1, 46 2 4. 7 21 7 29 .8 86 4. 5 1, 51 0 T ot al m en 1 5- 59 10 .3 20 .6 15 ,4 86 14 .7 29 .5 10 ,8 24 29 .3 1, 59 0 53 .8 3, 19 0 4. 3 11 ,2 84 N ot e: F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 1 S ex ua l i nt er co ur se w ith a n on -m ar ita l, no n- co ha bi tin g pa rtn er 212 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 213 A much larger proportion of men than women reported having two or more sexual partners. Ten percent of men reported having two or more partners in the 12 months preceding the survey, compared with only 1 percent of women. The proportion engaging in higher-risk sex (i.e., sexual intercourse with a non-marital, non-cohabiting partner) in the past 12 months is also higher among men than women (23 percent compared with 10 percent). Among respondents who had sexual intercourse in the 12 months preceding the survey, 15 percent of men and 1 percent of women had two or more partners, while 33 percent of men and 13 percent of women engaged in higher-risk sexual intercourse during that period. On the other hand, men were more likely than women to report using a condom at last higher-risk sexual intercourse (54 and 33 percent, respectively). On average, men have a mean of four lifetime sexual partners, compared with a mean of less than two partners for women. It is interesting to note that the mean number of lifetime sexual partners for men in the South South is eight, which is twice than the national average. Among women who had sexual intercourse in the 12 months preceding the survey, the proportion with two or more sexual partners is highest among women who are divorced, separated, or widowed (7 percent), women in urban areas (2 percent), women in South South (3 percent), women with more than secondary education (3 percent), and women in the fourth and the highest wealth quintile (2 percent each). Among women who had sexual intercourse in the 12 months preceding the survey, the proportion who engaged in higher-risk sexual intercourse is highest among those age 15-19 (33 percent), never married women (96 percent), women in urban areas (18 percent), women in South South (33 percent), women with more than a secondary education (29 percent), and women in the fourth wealth quintile (21 percent). Younger women age 15-24 are twice as likely as women age 40-49 to have had sexual intercourse with two or more sexual partners in the past 12 months. Likewise, younger women age 20-24 who engaged in higher-risk sexual intercourse are more likely to have used a condom with their last high-risk partner. Six percent of never-married women and 7 percent of divorced, separated, or widowed women reported having two or more sexual partners, while less than 1 percent of married women reported two or more sexual partners. For men, the highest percentages with two or more sexual partners are seen among men age 20-24 (18 percent), men who are divorced, separated, or widowed (23 percent), men who live in South South (25 percent), men with secondary education (18 percent); and men in the highest wealth quintile (18 percent). Among men who had sexual intercourse in the 12 months preceding the survey, the percentage of respondents engaging in higher-risk sexual intercourse is highest among those age 15-19 (95 percent), never-married men (97 percent), men living in the urban areas (41 percent), men in the South South (57 percent), men with secondary education (49 percent), and men in the highest wealth quintile (45 percent). 13.9 PAYMENT FOR SEX Transactional sex involves the exchange of money, favours, or gifts for sexual intercourse. This type of sexual intercourse is associated with greater risk of contracting HIV and other STIs because of compromised power relations between women and men and the tendency of those involved to have multiple sexual relationships. Male respondents in the 2008 NDHS who had sexual relations in the 12 months preceding the interview were asked if they paid anyone for sexual intercourse during that time. Further, respondents who had engaged in paid sexual intercourse were asked if they used a condom the last time they paid for sexual intercourse. Table 13.9 presents information on men age 15-49 who engaged in paid sexual intercourse in the 12 months preceding the survey and the prevalence of condom use during last paid sexual 214 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour intercourse. Two percent of men reported paying for sexual intercourse at least once during the past 12 months. Sixty-two percent of the men who engaged in paid sex reported that they used a condom the last time they paid for sex. Paid sex was most common among men age 20-24 and 25-29 (2 percent each); divorced, widowed, or separated men (4 percent); men in urban areas (2 percent); men in South South (4 percent); and men in the fourth and highest wealth quintile (2 percent each). Condom use by men who paid for sexual intercourse is highest among men age 25-29 (75 percent), those who have never married (64 percent), and men in urban areas (73 percent). A comparison of the 2003 and 2008 NDHS results suggests there has been a decrease in payment for sexual intercourse among men from 3 percent to 2 percent. Condom use among men who paid for sex increased from 48 percent in 2003 to 62 percent in 2008. Table 13.9 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men Percentage of men age 15-49 who paid for sexual intercourse in the past 12 months, and among them, the percentage who used a condom the last time they paid for sexual intercourse, by background characteristics, Nigeria 2008 Condom use at last paid sexual intercourse Payment for sexual intercourse in the past 12 months Background characteristic Percentage who paid for sexual intercourse Number of men Percentage who used a condom at last paid sexual intercourse Number of men who paid for sexual intercourse in the past 12 months Age 15-24 1.5 4,910 50.6 73 15-19 0.8 2,532 (37.8) 20 20-24 2.2 2,378 55.4 53 25-29 2.0 2,459 74.9 49 30-39 1.5 3,852 69.8 58 40-49 0.9 2,587 * 24 Marital status Never married 1.9 6,549 64.3 125 Married or living together 1.0 7,021 56.8 70 Divorced/separated/widowed 3.8 238 * 9 Residence Urban 1.6 5,215 72.6 85 Rural 1.4 8,593 53.8 120 Zone North Central 1.5 2,065 (53.5) 30 North East 0.9 1,645 * 15 North West 0.5 3,237 * 16 South East 1.5 1,448 * 21 South South 4.0 2,437 65.5 98 South West 0.8 2,977 * 24 Education No education 0.5 2,597 * 12 Primary 1.6 2,761 (58.3) 44 Secondary 1.8 6,470 63.3 118 More than secondary 1.6 1,979 (81.9) 31 Wealth quintile Lowest 0.9 2,275 (28.8) 20 Second 1.3 2,332 (16.4) 31 Middle 1.1 2,570 (75.0) 28 Fourth 1.9 3,163 73.1 60 Highest 1.9 3,468 (77.1) 65 Total 15-49 1.5 13,808 61.6 205 50-59 0.4 1,678 * 7 Total men 15-59 1.4 15,486 61.3 212 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has suppressed. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 215 13.10 COVERAGE OF HIV TESTING SERVICES Knowing one’s HIV status is important for helping individuals make specific decisions about adopting safer sex practices to reduce the risk of contracting or transmitting HIV. For those who are HIV positive, knowledge of their HIV status allows them to take actions to protect their sexual partners and to access treatment services for themselves. To assess the awareness of coverage of HIV testing services, respondents were asked whether they knew where to get an HIV test and whether they had ever been tested for HIV. If they said they had been tested for HIV, respondents were asked whether they had received the results of their last test. Tables 13.10.1 and 13.10.2 present the results for women and men age 15-49, respectively. Table 13.10.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who received the results of the last HIV test taken in the past 12 months, according to background characteristics, Nigeria 2008 Percent distribution of women by testing status and by whether they received the results of the last test Background characteristic Percentage who know where to get an HIV test Ever tested, and received results Ever tested, did not receive results Never tested1 Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of women Age 15-24 45.4 9.2 1.5 89.4 100.0 10.6 5.2 12,626 15-19 40.3 4.0 0.8 95.2 100.0 4.8 2.2 6,493 20-24 50.8 14.7 2.1 83.2 100.0 16.8 8.4 6,133 25-29 54.3 21.7 3.6 74.7 100.0 25.3 10.3 6,309 30-39 52.0 20.5 3.0 76.5 100.0 23.5 8.0 8,546 40-49 44.3 10.1 1.5 88.4 100.0 11.6 3.4 5,904 Marital status Never married 59.0 12.6 1.1 86.3 100.0 13.7 6.7 8,398 Ever had sex 68.6 20.9 1.8 77.2 100.0 22.8 11.1 3,718 Never had sex 51.3 6.0 0.4 93.5 100.0 6.5 3.3 4,680 Married/living together 44.5 15.3 2.7 82.1 100.0 17.9 6.5 23,578 Divorced/separated/ widowed 54.8 15.3 2.4 82.3 100.0 17.7 5.9 1,409 Residence Urban 66.2 24.7 3.6 71.8 100.0 28.2 10.9 11,934 Rural 38.8 9.0 1.5 89.5 100.0 10.5 4.1 21,451 Zone North Central 45.4 11.4 1.7 86.9 100.0 13.1 5.2 4,748 North East 28.4 4.7 1.0 94.3 100.0 5.7 2.1 4,262 North West 26.6 3.7 0.9 95.4 100.0 4.6 2.0 8,022 South East 72.2 31.9 2.8 65.3 100.0 34.7 13.8 4,091 South South 56.7 20.8 2.7 76.5 100.0 23.5 9.9 5,473 South West 68.7 20.5 4.4 75.0 100.0 25.0 8.6 6,789 Education No education 21.1 2.1 0.6 97.3 100.0 2.7 1.0 11,942 Primary 48.9 11.0 2.7 86.3 100.0 13.7 4.3 6,566 Secondary 66.3 20.7 3.3 76.0 100.0 24.0 9.6 11,904 More than secondary 87.3 48.2 3.8 48.0 100.0 52.0 21.7 2,974 Wealth quintile Lowest 20.9 1.5 0.3 98.2 100.0 1.8 0.6 6,194 Second 29.0 4.4 1.0 94.6 100.0 5.4 1.9 6,234 Middle 47.0 10.3 1.9 87.9 100.0 12.1 4.6 6,341 Fourth 61.9 18.2 3.3 78.5 100.0 21.5 8.6 6,938 Highest 76.1 33.8 4.2 62.0 100.0 38.0 14.8 7,678 Total 15-49 48.6 14.6 2.3 83.1 100.0 16.9 6.6 33,385 1 Includes 'don't know/missing' 216 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.10.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who received the results of the last HIV test taken in the past 12 months, according to background characteristics, Nigeria 2008 Percent distribution of men by testing status and by whether they received the results of the last test Background characteristic Percentage who know where to get an HIV test Ever tested, and received results Ever tested, did not receive results Never tested1 Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of men Age 15-24 59.3 7.4 1.0 91.6 100.0 8.4 3.9 4,910 15-19 52.0 3.8 0.7 95.6 100.0 4.4 2.2 2,532 20-24 67.1 11.3 1.4 87.3 100.0 12.7 5.6 2,378 25-29 69.0 16.7 1.5 81.8 100.0 18.2 7.9 2,459 30-39 69.5 19.3 1.7 79.0 100.0 21.0 9.1 3,852 40-49 65.7 16.2 1.3 82.5 100.0 17.5 6.3 2,587 Marital status Never married 65.2 11.7 1.2 87.1 100.0 12.9 5.9 6,551 Ever had sex 76.2 19.4 1.9 78.6 100.0 21.4 9.7 3,186 Never had sex 54.8 4.4 0.6 95.1 100.0 4.9 2.3 3,365 Married/living together 64.8 16.1 1.4 82.5 100.0 17.5 7.0 7,018 Divorced/separated/ widowed 67.9 17.4 3.8 78.7 100.0 21.3 8.5 238 Residence Urban 78.3 20.9 1.9 77.2 100.0 22.8 9.2 5,215 Rural 57.0 9.9 1.0 89.1 100.0 10.9 4.9 8,593 Zone North Central 66.8 13.7 1.5 84.8 100.0 15.2 7.2 2,065 North East 55.2 4.3 1.0 94.8 100.0 5.2 2.2 1,645 North West 54.0 5.1 0.7 94.2 100.0 5.8 2.5 3,237 South East 73.8 25.2 1.1 73.7 100.0 26.3 11.2 1,448 South South 71.1 20.3 1.4 78.3 100.0 21.7 10.5 2,437 South West 72.1 18.7 2.3 79.0 100.0 21.0 7.4 2,977 Education No education 38.7 1.4 0.4 98.2 100.0 1.8 0.6 2,597 Primary 56.7 9.7 1.1 89.2 100.0 10.8 4.3 2,761 Secondary 70.9 13.6 1.4 85.1 100.0 14.9 6.6 6,470 More than secondary 92.2 38.1 2.9 59.0 100.0 41.0 17.0 1,979 Wealth quintile Lowest 43.0 2.5 0.7 96.8 100.0 3.2 1.2 2,275 Second 53.0 6.3 0.7 92.9 100.0 7.1 3.8 2,332 Middle 62.4 10.2 1.3 88.6 100.0 11.4 4.7 2,570 Fourth 71.8 15.3 1.7 83.0 100.0 17.0 6.9 3,163 Highest 83.5 28.4 2.0 69.6 100.0 30.4 12.9 3,468 Total 15-49 65.1 14.0 1.4 84.6 100.0 15.4 6.5 13,808 50-59 58.1 12.6 1.1 86.3 100.0 13.7 5.1 1,678 Total men 15-59 64.3 13.9 1.3 84.8 100.0 15.2 6.4 15,486 1 Includes 'don't know/missing' Overall, 49 percent of women and 65 percent of men know a place where they can get an HIV test. Younger female and male respondents (age 15-19) are somewhat less likely to know a place where they can go to be tested for HIV (40 and 52 percent, respectively). Married women (45 percent) and unmarried men who have not yet initiated sexual activity (55 percent) are also less likely to know a place to obtain an HIV test. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 217 Knowing where to get an HIV test is more common among respondents in urban areas than those in rural areas: 66 percent of women and 78 percent of men in urban areas, compared with 39 percent of women and 57 percent of men in rural areas. Zonal patterns show that women and men in North West are the least likely to know a place to get tested for HIV (27 percent for women and 54 percent for men). Awareness of a place to obtain an HIV test increases with level of education and wealth quintile for both females and males. Tables 13.10.1 and 13.10.2 show respondents’ experience with prior HIV testing and whether respondents received their results. The majority of women (83 percent) and men (85 percent) have never been tested for HIV. Seventeen percent of women and 15 percent of men were tested for HIV at some time prior to the survey. However, among women and men who were tested for HIV in the past 12 months, only 7 percent of women and 7 percent of men received their test results. For women whose last HIV test was in the past 12 months, urban residents were more likely than rural residents to have received the test results (11 and 4 percent, respectively). The percentages for women by zone range from 2 percent in North East and North West to 14 percent in South East. For men, the percentage who were tested for HIV in the past 12 months and received the results of the test ranges from 2 percent in North East to 11 percent in South East and South South. Table 13.11 presents information on HIV screening for pregnant women. This process is a key tool in reducing HIV transmission from mother to child. Table 13.11 shows that 24 percent of women who gave birth during the two years prior to the 2008 NDHS received HIV counselling. Sixteen percent of the women were offered and accepted an HIV test during antenatal care and received the test results. Thirteen percent of the women were counselled, were offered and accepted an HIV test, and received the results of the test. Women most likely to be in the latter group were those age 25-29 (17 percent), women who live in urban areas (29 percent), women in South East (35 percent), and women who have more than a secondary education (54 percent). Three percent of women who gave birth in the two years preceding the survey were offered and accepted an HIV test during antenatal care but did not receive the results. 218 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.11 Pregnant women counselled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received HIV counselling during antenatal care for their most recent birth, the percentage who were offered and accepted an HIV test during antenatal care by whether they received their test results, and the percentage who were counselled, were offered and accepted an HIV test, and received the results, according to background characteristics, Nigeria 2008 Percentage who were offered and accepted an HIV test during antenatal care and who:2 Background characteristic Percentage who received HIV counselling during antenatal care1 Received results Did not receive results Percentage who were counselled, were offered and accepted an HIV test, and who received results2 Number of women who gave birth in the past two years3 Age 15-24 16.5 10.8 2.2 8.4 3,407 15-19 11.8 5.5 1.9 4.4 957 20-24 18.3 12.9 2.3 10.0 2,450 25-29 28.5 19.6 3.9 16.7 3,147 30-39 27.1 19.2 3.3 16.2 3,598 40-49 18.7 10.4 3.8 8.6 875 Residence Urban 44.4 32.9 5.7 28.9 3,289 Rural 14.7 8.9 2.0 6.7 7,738 Zone North Central 23.3 11.3 2.5 9.5 1,478 North East 12.1 5.3 1.3 4.5 1,794 North West 7.3 3.8 1.0 3.2 3,410 South East 47.4 44.7 4.7 35.3 1,060 South South 30.7 22.3 4.2 16.9 1,462 South West 45.8 31.6 7.7 28.4 1,823 Education No education 6.1 2.5 0.7 2.0 5,036 Primary 22.8 12.9 3.6 10.4 2,459 Secondary 44.5 32.3 6.2 26.9 2,922 More than secondary 70.5 62.3 6.9 53.8 610 Wealth quintile Lowest 4.4 1.2 0.3 0.9 2,601 Second 9.5 4.7 1.2 3.5 2,494 Middle 21.2 11.8 3.0 9.5 2,085 Fourth 34.6 22.6 5.3 18.2 1,987 Highest 60.0 49.8 7.5 42.9 1,860 Total 15-49 23.5 16.0 3.1 13.3 11,027 1 In this context, "counselled" means that someone talked with the respondent about all three of the following topics: 1) babies getting the AIDS virus from their mother, 2) preventing transmission of the virus, and 3) getting tested for the virus 2 Only women who were offered the test are included here; women who were either required or asked for the test are excluded from the numerator of this measure 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years 13.11 MALE CIRCUMCISION Circumcision is a common practice in many parts of Nigeria for traditional, health, and other reasons and often serves as a rite of passage to adulthood. Recently, male circumcision has been shown to be associated with lower STI transmission, including HIV (WHO and UNAIDS, 2007). To examine this practice at the national level, men interviewed in the 2008 NDHS were asked whether they were circumcised. The results are presented in Table 13.12. Overall, 98 percent of the men interviewed reported that they were circumcised. The practice is almost universal and shows little variation across age groups, location, ethnicity, zones, and educational levels. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 219 Table 13.12 Male circumcision Percentage of men age 15-49 who reported having been circumcised, by background characteristics, Nigeria 2008 Background characteristic Percentage circumcised Number of men Age 15-24 97.7 4,910 15-19 97.5 2,532 20-24 97.8 2,378 25-29 97.8 2,459 30-39 98.3 3,852 40-49 97.8 2,587 Residence Urban 97.4 5,215 Rural 98.2 8,593 Zone North Central 97.6 2,065 North East 98.3 1,645 North West 98.2 3,237 South East 97.4 1,448 South South 97.1 2,437 South West 98.5 2,977 Ethnicity Ekoi 99.0 205 Fulani 98.3 744 Hausa 97.4 3,107 Ibibio 98.1 340 Igala 98.1 230 Igbo 97.9 1,999 Ijaw/Izon 98.0 621 Kanuri/Beriberi 98.6 241 Tiv 99.2 362 Yoruba 98.0 2,555 Others 97.9 3,381 Education No education 97.7 2,597 Primary 97.9 2,761 Secondary 97.9 6,470 More than secondary 98.0 1,979 Wealth quintile Lowest 98.1 2,275 Second 98.2 2,332 Middle 97.9 2,570 Fourth 97.7 3,163 Highest 97.7 3,468 Total 15-49 97.9 13,808 50-59 98.0 1,678 Total men 15-59 97.9 15,486 13.12 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS In the 2008 NDHS, respondents who had ever had sexual intercourse were asked if in the past 12 months they had experienced a disease acquired through sexual contact, or if they had experienced either of two symptoms associated with STIs: a bad-smelling abnormal discharge from the vagina or penis, or a genital sore or ulcer. Table 13.13 shows the self-reported prevalence of STIs and STI symptoms in the population for both women and men. Five percent of women and 3 percent of men reported having had an STI or experiencing STI symptoms during the 12 months preceding the survey. Among women, 2 percent reported having an STI; 4 percent had a bad-smelling, abnormal discharge, and 2 percent had a genital sore or ulcer. The prevalence of STIs and STI symptoms was highest among never-married women. Women in urban areas were more likely to have had an STI or STI symptoms than those in rural areas. The prevalence of STIs or STI symptoms among women was highest in South East (8 percent) and increased with level of educational attainment. 220 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Among men, 1 percent reported having an STI in the past 12 months; 2 percent had a bad- smelling, abnormal discharge and 1 percent had a genital sore or ulcer. Men who are divorced, separated or widowed are more likely to have an STI or STI symptoms than those who are married or are never married but sexually active. Men in rural areas are more likely to have had an STI or STI symptoms than men in urban areas. Self-reported STI prevalence was highest in North Central (6 percent). Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage who reported having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Nigeria 2008 Percentage of women who reported: Percentage of men who reported: Background characteristic STI Bad- smelling/ abnormal genital discharge Genital sore/ ulcer STI/ genital discharge/ sore or ulcer Number of women who ever had sexual intercourse STI Bad- smelling/ abnormal genital discharge Genital sore/ ulcer STI/ genital discharge / sore or ulcer Number of men who ever had sexual intercourse Age 15-24 2.0 4.1 2.8 5.5 8,259 2.0 3.0 1.1 4.1 2,031 15-19 1.4 3.5 2.5 4.8 3,001 1.2 3.6 1.0 4.5 559 20-24 2.4 4.5 3.0 5.9 5,258 2.3 2.7 1.1 4.0 1,472 25-29 2.3 4.1 2.7 5.5 6,060 1.7 2.5 1.2 3.3 2,070 30-39 2.1 3.9 2.3 5.1 8,481 1.2 1.8 0.8 2.6 3,759 40-49 1.8 3.2 2.0 4.2 5,900 1.1 1.6 0.7 2.1 2,579 Marital status Never married 2.9 5.9 3.1 7.6 3,717 1.9 2.6 1.2 3.7 3,184 Married or living together 1.9 3.5 2.3 4.7 23,573 1.1 1.8 0.8 2.5 7,016 Divorced/separated/ widowed 2.5 4.8 2.7 6.0 1,409 2.7 4.2 1.1 5.2 238 Male circumcision Circumcised na na na na na 1.4 2.1 0.9 2.9 10,230 Not circumcised na na na na na 0.0 1.2 2.4 2.4 76 Don’t know/missing na na na na na 1.4 1.1 1.4 3.2 132 Residence Urban 2.7 4.3 2.6 5.8 9,709 1.4 1.8 0.6 2.7 3,894 Rural 1.8 3.6 2.3 4.7 18,990 1.4 2.3 1.1 3.1 6,544 Zone North Central 2.6 5.2 1.9 6.3 3,958 1.9 4.2 2.8 5.5 1,561 North East 1.5 4.7 3.5 6.5 3,866 1.4 2.4 1.4 3.0 1,223 North West 2.3 3.3 3.2 4.4 7,465 1.1 2.3 0.5 2.9 2,129 South East 3.9 6.2 3.3 8.1 3,128 1.4 1.3 0.3 2.2 1,095 South South 1.4 2.5 1.6 3.7 4,724 1.6 1.6 0.7 2.7 1,975 South West 1.3 3.0 1.4 3.7 5,559 1.2 1.2 0.2 1.9 2,456 Education No education 1.7 3.5 2.6 4.8 11,641 0.8 1.9 1.4 2.7 2,062 Primary 1.7 3.4 2.0 4.3 5,965 1.4 2.7 1.1 3.3 2,219 Secondary 2.5 4.1 2.4 5.5 8,496 1.6 2.3 0.8 3.2 4,437 More than secondary 3.3 5.6 2.6 6.9 2,597 1.7 1.0 0.4 2.1 1,720 Wealth quintile Lowest 1.4 3.8 2.6 4.9 5,831 1.1 2.4 1.5 3.2 1,768 Second 2.0 3.7 2.6 4.9 5,650 1.6 3.3 1.5 4.0 1,752 Middle 2.0 3.9 2.4 5.0 5,375 1.3 2.3 1.0 3.3 1,855 Fourth 2.2 3.8 2.4 5.3 5,736 1.6 1.5 0.5 2.3 2,289 Highest 2.7 4.1 2.2 5.4 6,107 1.4 1.5 0.4 2.5 2,773 Total 15-49 2.1 3.9 2.4 5.1 28,699 1.4 2.1 0.9 2.9 10,438 50-59 na na na na na 0.7 0.7 0.7 1.4 1,678 Total men 15-59 na na na na na 1.3 1.9 0.9 2.7 12,116 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 221 When women or men reported having an STI and/or STI symptoms in the past 12 months, then they were asked whether they had sought any advice or treatment. Figure 13.2 shows that 46 percent of women and 58 percent of men sought advice or treatment from a clinic, hospital, private doctor, or other health professional. However, 38 percent of women and 22 percent of men sought no advice or treatment. 13.13 PREVALENCE OF MEDICAL INJECTIONS Injection overuse in a health care setting can contribute to the transmission of blood-borne pathogens because it amplifies the effect of unsafe practices such as reuse of injection equipment. As a result, the proportion of injections given with reused injection equipment is an important indicator for programme initiatives to prevent and control the spread of HIV. To obtain information for this indicator, respondents in the 2008 NDHS were asked if they received any injections from a health worker in the 12 months preceding the survey and, if so, whether their last injection was given with a syringe from a new, unopened package. It should be noted that medical injections can also be self-administered (e.g., insulin for diabetes); these injections were not included in the calculation. Table 13.14 shows the reported prevalence of injections and safe injection practices. Twenty- five percent of women and 28 percent of men reported receiving an injection from a health worker during the 12 months preceding the survey. Generally, the average number of medical injections received over the 12-month period was one per person for both women and men. 46 4 6 38 58 4 12 22 Clinic/hospital/ private doctor/ other health faci Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment 0 20 40 60 80 Percent Women Men Figure 13.2 Women and Men Seeking Advice or Treatment for STIs NDHS 2008 facility 222 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Looking at the differentials, injection prevalence was highest among women age 25-29 (29 percent), urban residents (30 percent), women in South East (35 percent), women with more than secondary education (36 percent), and women in the highest wealth quintile (33 percent). Injection prevalence was highest among men age 30-39 (30 percent), men in South East (31 percent), and men with more than secondary education (31 percent). The likelihood of receiving at least one medical injection increases with wealth quintile among men. Table 13.14 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Nigeria 2008 Women Men Background characteristic Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the past 12 months Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of men For last injection, syringe and needle taken from a new, unopened package Number of men receiving medical injections in the past 12 months Age 15-24 22.5 0.9 12,626 95.4 2,847 25.3 1.1 4,910 97.6 1,240 15-19 18.2 0.7 6,493 95.0 1,180 25.9 1.1 2,532 97.7 655 20-24 27.2 1.2 6,133 95.7 1,667 24.6 1.1 2,378 97.6 585 25-29 29.1 1.3 6,309 95.5 1,839 28.6 1.3 2,459 97.5 704 30-39 28.2 1.3 8,546 96.6 2,406 30.1 1.6 3,852 98.5 1,159 40-49 20.7 1.0 5,904 95.8 1,220 29.1 1.6 2,587 96.8 754 Residence Urban 29.7 1.3 11,934 96.3 3,542 28.2 1.4 5,215 97.6 1,471 Rural 22.2 1.0 21,451 95.5 4,769 27.8 1.4 8,593 97.8 2,386 Zone North Central 21.3 1.1 4,748 95.2 1,012 27.9 1.5 2,065 98.1 577 North East 21.6 0.8 4,262 92.3 921 29.0 1.3 1,645 98.5 476 North West 16.5 0.6 8,022 95.6 1,325 25.0 1.1 3,237 98.6 809 South East 34.7 1.8 4,091 96.5 1,421 30.8 1.6 1,448 98.3 446 South South 29.3 1.5 5,473 96.1 1,602 29.1 1.6 2,437 96.0 710 South West 29.9 1.2 6,789 97.4 2,030 28.2 1.4 2,977 97.3 839 Education No education 15.4 0.6 11,942 94.1 1,843 19.6 0.9 2,597 96.9 510 Primary 26.8 1.2 6,566 95.8 1,760 28.7 1.5 2,761 98.2 792 Secondary 30.6 1.4 11,904 96.2 3,637 30.0 1.4 6,470 97.3 1,944 More than secondary 36.0 1.8 2,974 97.6 1,071 30.9 1.7 1,979 99.1 611 Wealth quintile Lowest 15.0 0.6 6,194 93.0 929 23.3 1.0 2,275 97.8 530 Second 18.9 0.8 6,234 95.0 1,175 27.4 1.3 2,332 97.8 638 Middle 25.1 1.1 6,341 96.3 1,590 28.6 1.4 2,570 97.1 736 Fourth 29.7 1.4 6,938 96.6 2,062 28.1 1.5 3,163 98.6 890 Highest 33.3 1.5 7,678 96.4 2,554 30.7 1.6 3,468 97.3 1,063 Total 15-49 24.9 1.1 33,385 95.9 8,311 27.9 1.4 13,808 97.7 3,857 Total men 15-59 na na na na na 27.9 1.4 15,486 97.8 4,314 Note : Medical injections are those given by a doctor, nurse, pharmacist, dentist or other health worker na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 223 13.14 HIV AND AIDS-RELATED KNOWLEDGE AND BEHAVIOUR AMONG YOUTH This section addresses HIV and AIDS-related knowledge among Nigerian youth age 15-24, and assesses the extent to which Nigerian youth are engaged in behaviours that may place them at risk of contracting HIV. 13.14.1 Knowledge about HIV and AIDS and Sources for Condoms Knowledge of how HIV is transmitted is crucial to enabling people to avoid contracting HIV, especially young people, who are often at greater risk because they may have shorter relationships with more partners or engage in other risky behaviours. Table 13.15 shows the level of comprehensive knowledge about HIV and AIDS among youth and the percentage of youth who know a source where they can obtain condoms. Comprehensive knowledge of HIV and AIDS is defined as knowing that condom use and having just one HIV-negative and faithful partner can reduce the chances of contracting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common misconceptions about HIV transmission—that HIV can be transmitted by mosquito bites and that HIV can be transmitted by supernatural means. Table 13.15 shows that only 22 percent of young women and 33 percent of young men have comprehensive knowledge about HIV. The table also shows that comprehensive knowledge is higher among youths in urban areas than those in rural areas. Among both sexes, the proportion with comprehensive knowledge tends to increase with level of education and wealth quintile. Knowledge of where to obtain a condom also tends to increase with education and wealth quintile for both young women and young men. Among young women, the level of comprehensive knowledge about HIV is highest in South East (29 percent) and lowest in North East (13 percent). Thirty-seven percent of young women know a place where they can obtain a condom. Knowledge of a source for condoms is higher among young women in urban areas than those in rural areas (54 and 27 percent, respectively). At the zonal level, young women in the South West (65 percent) are most likely to know a condom source, while those in North West (8 percent) are least likely to know where to obtain a condom. Young men in North West have the highest level of comprehensive knowledge (36 percent), while those in North East have the lowest level of comprehensive knowledge (28 percent). Sixty-eight percent of young men know a place where they can obtain a condom. Knowledge of a source for condoms is higher among young men in urban areas than those in rural areas (81 and 60 percent, respectively). At the zonal level, young men in South West (83 percent) are most likely to know a condom source while those in North East (50 percent) are least likely to know a source for condoms. 224 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.15 Comprehensive knowledge about HIV and AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about HIV and AIDS and percentage with knowledge of a source of condoms, by background characteristics, Nigeria 2008 Women age 15-24 Men age 15-24 Background characteristic Percentage with comprehensive knowledge of HIV and AIDS1 Percentage who know a condom source2 Number of women Percentage with comprehensive knowledge of HIV and AIDS1 Percentage who know a condom source2 Number of men Age 15-19 19.7 30.2 6,493 28.2 60.5 2,532 15-17 18.9 26.2 3,896 24.8 55.1 1,532 18-19 20.9 36.2 2,597 33.3 68.7 1,000 20-24 24.8 43.3 6,133 37.2 76.1 2,378 20-22 23.2 39.5 4,114 36.0 72.4 1,595 23-24 28.1 51.1 2,020 39.7 83.6 784 Marital status Never married 26.2 48.2 6,940 33.1 69.0 4,516 Ever had sex 30.7 69.3 2,579 36.0 89.6 1,639 Never had sex 23.5 35.8 4,362 31.5 57.3 2,877 Ever married 17.3 22.4 5,686 25.8 57.1 394 Residence Urban 29.8 53.8 4,529 39.7 81.0 1,847 Rural 17.9 27.0 8,097 28.2 60.2 3,064 Zone North Central 21.1 28.7 1,877 29.2 67.2 821 North East 12.8 17.5 1,612 27.5 49.6 554 North West 19.5 8.4 2,873 36.1 52.5 1,061 South East 28.9 51.9 1,626 35.0 67.7 571 South South 26.2 51.6 2,223 34.5 81.9 934 South West 24.3 64.8 2,416 31.1 83.2 969 Education No education 10.6 4.9 3,446 12.5 27.8 654 Primary 16.4 23.3 1,846 19.3 53.2 692 Secondary 27.8 51.7 6,598 36.5 77.0 3,222 More than secondary 40.9 82.7 736 60.1 90.5 342 Wealth quintile Lowest 9.4 9.3 2,192 18.3 37.8 733 Second 14.7 17.0 2,288 25.4 56.1 821 Middle 21.2 33.2 2,477 32.9 67.0 1,010 Fourth 27.5 49.0 2,869 38.4 79.5 1,284 Highest 33.7 64.2 2,801 40.5 85.3 1,063 Total 22.2 36.6 12,626 32.6 68.0 4,910 1 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one HIV-negative, faithful partner can reduce the chances of getting HIV, knowing that a healthy- looking person can have HIV, and rejecting the two most common local misconceptions about HIV transmission and prevention. The components of comprehensive knowledge are presented in Tables 13.3.1 and 13.3.2. 2 Friends, family members, and home are not considered sources for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 225 13.14.2 Age at First Sexual Intercourse Age at first sex is an important indicator of both exposure to risk of pregnancy and exposure to STIs. Young people who initiate sex at an early age are considered to be at a higher risk of becoming pregnant or contracting an STI than young people who delay initiation of sexual activity. Consistent use of condoms can also reduce these risks. Table 13.16 shows that 16 percent of young women and 6 percent of young men age 15-24 initiated sexual activity before age 15. About half of young women (49 percent) and more than a quarter of young men (26 percent) age 18-24 had first sexual intercourse before age 18. As expected, the proportion of youth initiating sexual activity early is higher among ever-married youth than among those who have not yet married. The likelihood of early sexual debut generally decreases with increasing level of education for both young women and young men. Table 13.16 Age at first sexual intercourse among youth Percentage of young women and of young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and of young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Nigeria 2008 Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Background characteristic Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 15.3 6,493 na na 6.2 2,532 na na 15-17 15.1 3,896 na na 6.1 1,532 na na 18-19 15.5 2,597 52.9 2,597 6.3 1,000 25.5 1,000 20-24 16.2 6,133 47.8 6,133 5.3 2,378 25.6 2,378 20-22 17.9 4,114 50.6 4,114 4.5 1,595 24.7 1,595 23-24 12.7 2,020 42.1 2,020 6.9 784 27.6 784 Marital status Never married 5.1 6,940 23.9 3,891 5.4 4,516 23.3 2,990 Ever married 28.7 5,687 69.8 4,839 9.5 395 42.9 388 Knows condom source1 Yes 8.5 4,620 36.5 3,599 7.1 3,342 29.5 2,497 No 19.9 8,006 58.3 5,132 2.8 1,569 14.5 881 Residence Urban 7.8 4,529 33.6 3,172 5.0 1,847 23.0 1,305 Rural 20.2 8,097 58.3 5,559 6.2 3,064 27.2 2,073 Zone North Central 11.8 1,877 41.6 1,324 8.0 821 32.4 560 North East 28.4 1,612 67.5 1,099 3.0 554 21.1 385 North West 28.4 2,873 71.5 2,086 0.9 1,061 6.4 738 South East 4.9 1,626 25.7 1,104 7.1 571 24.2 399 South South 12.0 2,223 48.2 1,540 8.1 934 38.8 633 South West 5.9 2,416 31.4 1,577 7.6 969 32.1 663 Education No education 34.7 3,446 78.4 2,556 3.3 654 16.5 451 Primary 17.3 1,846 58.8 1,246 6.4 692 26.9 389 Secondary 7.0 6,598 34.8 4,209 6.2 3,222 27.8 2,204 More than secondary 1.6 736 14.3 719 5.0 342 21.5 334 Wealth quintile Lowest 30.0 2,192 73.5 1,502 5.6 733 22.7 492 Second 24.5 2,288 67.4 1,573 4.2 821 25.3 546 Middle 14.6 2,477 50.4 1,703 6.6 1,010 25.8 682 Fourth 9.7 2,869 39.2 2,036 5.7 1,284 28.7 921 Highest 4.5 2,801 25.4 1,917 6.2 1,063 23.7 737 Total 15.7 12,626 49.3 8,731 5.7 4,910 25.6 3,378 na = Not applicable 1 Friends, family members, and home are not considered a source for condoms. 226 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Young women in rural areas are more likely to have initiated sex before age 15 and age 18 than their urban counterparts: 20 percent for rural women versus 8 percent for urban women before age 15, and 58 percent for rural women versus 34 for urban women before age 18. Analysis by zone indicates that women in the North East and North West have the highest proportion of young women who had first sexual intercourse before age 15 (28 percent each). South East has the lowest proportion of women age 18-24 who initiated sex by age 18 (26 percent) while North West has the highest proportion (72 percent). Young men in rural areas are more likely to have initiated sex before age 15 and before age 18: 6 percent for rural men versus 5 percent for urban men before age 15 and 27 percent for rural men versus 23 percent for urban men before age 18. As with young women, the proportion of young men initiating sexual intercourse by age 15 is highest in North Central and South South (8 percent each). North West has the lowest proportion of men age 15-24 who initiated sex by age 15 (1 percent) as well as the lowest proportion of men age 18-24 who initiated sex by age 18 (6 percent). 13.14.3 Trends in Age at First Sexual Intercourse Figure 13.3 shows trends in the age at first sexual intercourse between the 2003 and 2008 NDHS surveys. It shows that early sexual activity has generally decreased in Nigeria. For example, among women age 15-19, only 20 percent had first sexual intercourse by age 15 in the 2003 NDHS, compared with 15 percent in the 2008 NDHS. The proportion of men age 15-19 who initiated sexual activity before age 15 decreased from 8 to 6 percent. Likewise, the proportion of men age 18-19 who had sexual intercourse before age 18 declined from 29 to 26 percent over the same period. In contrast, the proportion of women age 18-19 who had first sexual intercourse before age 18 increased slightly from 52 to 53 percent. 20 52 8 29 15 53 6 26 Women 15-19 who had sex before exact age 15 Women 18-19 who had sex before exact age 18 Men 15-19 who had sex before exact age 15 Men age 18-19 who had sex before exact age 18 0 20 40 60 80 Percent 2003 2008 Figure 13.3 Trends in Age at First Sexual Intercourse HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 227 13.14.4 Condom Use at First Sex To assess the extent of condom use at the beginning of sexual exposure, sexually active youth age 15-24 were asked whether they had used a condom the first time they had sexual intercourse. Table 13.17 shows that young men were twice as likely (22 percent) to have used a condom during the first sexual intercourse as young women (11 percent). Young women and men in urban areas were much more likely than their counterparts in rural areas to have used a condom the first time they had sexual intercourse. The likelihood that a condom was used the first time a young person had sexual intercourse increases with level of education and household wealth quintile. Table 13.17 Condom use at first sexual intercourse among youth Among young women and young men age 15-24 who have ever had sexual intercourse, percentage who used a condom the first time they had sexual intercourse, by background characteristics, Nigeria 2008 Women age 15-24 Men age 15-24 Background characteristic Percentage who used a condom at first sexual intercourse Number of women who have ever had sexual intercourse Percentage who used a condom at first sexual intercourse Number of men who have ever had sexual intercourse Age 15-19 9.5 3,001 19.5 559 15-17 7.9 1,341 14.7 226 18-19 10.8 1,660 22.7 333 20-24 11.0 5,258 23.3 1,472 20-22 10.4 3,418 23.0 896 23-24 12.3 1,840 23.8 576 Marital status Never married 23.7 2,578 25.8 1,638 Ever married 4.5 5,681 7.2 393 Knows condom source1 Yes 21.8 3,060 25.4 1,693 No 3.8 5,198 6.2 338 Residence Urban 17.7 2,493 30.3 754 Rural 7.4 5,766 17.5 1,277 Zone North Central 8.0 1,130 14.9 378 North East 2.9 1,232 11.0 205 North West 2.7 2,346 6.4 172 South East 21.6 776 36.8 259 South South 16.2 1,509 22.1 521 South West 20.9 1,267 30.5 495 Education No education 1.9 3,159 2.6 210 Primary 5.8 1,273 13.1 224 Secondary 16.8 3,324 24.7 1,375 More than secondary 34.3 503 34.7 222 Wealth quintile Lowest 2.2 1,837 5.2 282 Second 5.5 1,722 15.2 301 Middle 9.8 1,574 21.9 402 Fourth 14.4 1,761 22.8 559 Highest 23.6 1,365 36.1 486 Total 10.5 8,259 22.2 2,031 1 Friends, family members, and home are not considered sources for condoms. 228 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Never-married women young women were about five times as likely (24 percent) as ever- married young women (5 percent) to have used a condom the first time they had sexual intercourse. At the zonal level, young women in South East (22 percent) were most likely to have used a condom at first sex while those in North West and North East were least likely (3 percent each). About a quarter of never-married young men (26 percent) and 7 percent of ever-married young men reported using a condom at first sexual intercourse. Young men in South East were most likely to use a condom at first sex (37 percent) while those in North West were least likely (6 percent). 13.14.5 Premarital Sex The period between initiation of sexual intercourse and marriage is often a time of sexual experimentation. Table 13.18 presents information on premarital sexual intercourse and condom use among never-married youth age 15-24 in Nigeria. Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Nigeria 2008 Never-married women age 15-24 Never-married men age 15-24 Among women who had sexual intercourse in the past 12 months Among men who had sexual intercourse in the past 12 months Background characteristic Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married women Percentage who used condom at last sexual intercourse Number of women Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married men Percentage who used condom at last sexual intercourse Number of men Age 15-19 76.0 19.8 4,586 28.2 906 78.6 16.0 2,508 36.2 400 15-17 83.6 13.4 3,048 21.3 410 85.6 10.4 1,525 30.6 159 18-19 61.0 32.3 1,538 33.8 497 67.6 24.6 982 39.8 242 20-24 37.1 52.8 2,354 40.9 1,242 45.2 44.3 2,008 56.3 889 20-22 42.7 48.0 1,628 39.5 782 50.0 39.6 1,398 52.9 553 23-24 24.8 63.4 726 43.4 461 34.1 55.0 610 61.9 336 Knows condom source1 Yes 46.6 46.1 3,346 44.4 1,543 52.9 38.2 3,116 53.6 1,189 No 78.0 16.8 3,594 13.0 606 87.8 7.2 1,400 7.8 101 Residence Urban 63.5 30.9 3,205 46.3 991 61.8 30.6 1,768 62.9 542 Rural 62.3 31.0 3,735 26.3 1,157 64.9 27.2 2,748 40.7 748 Zone North Central 71.0 23.1 1,051 29.4 243 60.3 31.4 733 39.2 230 North East 78.6 17.7 484 17.4 85 74.6 17.9 468 23.5 84 North West 92.2 6.6 568 (22.4) 37 94.1 3.7 943 39.7 34 South East 65.0 24.1 1,306 40.6 315 56.0 29.1 556 66.7 162 South South 42.3 51.7 1,689 33.2 873 46.7 43.8 886 44.5 388 South West 62.4 32.3 1,842 42.1 595 50.9 42.1 930 61.6 392 Education No education 88.9 8.4 319 (1.4) 27 89.1 7.4 497 (8.2) 37 Primary 71.3 21.5 803 17.7 173 75.7 17.1 619 30.3 105 Secondary 62.8 30.9 5,208 34.7 1,610 60.1 31.6 3,071 49.5 969 More than secondary 38.2 55.5 610 51.1 338 36.5 54.1 330 73.2 178 Wealth quintile Lowest 67.4 25.4 520 10.7 132 76.1 18.2 589 18.0 107 Second 66.6 28.0 849 22.7 237 71.7 22.4 725 37.0 162 Middle 63.9 29.1 1,412 27.1 410 64.8 27.0 938 44.0 253 Fourth 57.4 35.8 1,930 37.9 691 59.0 32.0 1,229 55.6 394 Highest 64.4 30.4 2,228 47.5 678 55.7 36.1 1,035 63.2 373 Total 62.9 31.0 6,940 35.5 2,148 63.7 28.6 4,516 50.1 1,289 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Friends, family members, and home are not considered sources for condoms. . HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 229 Sixty-three percent of never-married young women age 15-24 have never had sexual intercourse. Abstinence is most common among those age 15-17 (84 percent). Thirty-one percent of never-married young women age 15-24 had sexual intercourse during the 12 months preceding the survey. Among never-married, sexually active young women, condom use at last sexual intercourse was 36 percent. At the zonal level, condom use was highest in South West (42 percent) and lowest in North East (17 percent). Similar to their female counterparts, 64 percent of never-married young men age 15-24 have never had sexual intercourse. Abstinence is most common among those age 15-17 (86 percent). Twenty-nine percent of never-married young men age 15-24 had sexual intercourse during the 12 months preceding the survey. Among never-married, sexually active young men, condom use at last sexual intercourse was 50 percent. Condom use is highest in South-East (67 percent) and lowest in North East (24 percent). Condom use increases with level of education and wealth quintile. For example, 73 percent of sexually active, never-married young men who have more than secondary education used a condom the last time they had sexual intercourse, compared with 30 percent of those with primary education. 13.14.6 Higher-Risk Sexual Intercourse Tables 13.19.1 and 13.19.2 present information on young people age 15-24 who engaged in higher-risk sexual intercourse (i.e., sexual intercourse with a non-marital, non-cohabiting partner) during the 12 months preceding the survey, and condom use during last higher-risk sexual encounters. Twenty-nine percent of young women age 15-24 reported having higher-risk sexual intercourse in the 12 months preceding the survey. Among ever-married young women, only 2 percent reported having higher-risk sexual intercourse. Higher-risk sexual intercourse is most prevalent among young women in South South (64 percent) and least prevalent among those in North West (2 percent). Thirty-six percent of young women who had higher-risk sexual intercourse used a condom the last time they had higher-risk sexual intercourse. Young men were much more likely than young women to report having higher-risk sexual intercourse in the past 12 months (79 percent). Among ever-married young men, 17 percent reported having higher-risk sexual intercourse. Higher-risk sexual intercourse is most prevalent among young men in South West and South East (93 percent each). Young men Male youth in North West are least likely to engage in higher-risk sexual intercourse (25 percent). Forty-nine percent of young men who had higher-risk sexual intercourse used a condom the last time they had higher-risk sexual intercourse. In general, young women and men who have never married, who know a condom source, who live in urban areas, who have more than a secondary education, and who are in the highest wealth quintile are more likely to have had higher-risk sexual intercourse than other young women and men. 230 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Women Among young women age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse, and among those who had higher- risk sexual intercourse in the past 12 months, the percentage who used a condom at last higher-risk sexual intercourse, by background characteristics, Nigeria 2008 Women age 15-24 who had sexual intercourse in the past 12 months Women age 15-24 who had higher-risk sexual intercourse in the past 12 months: Background characteristic Percentage who had higher-risk intercourse in the past 12 months1 Number of women Percentage who reported using a condom at last higher-risk sexual intercourse1 Number of women Age 15-19 33.3 2,708 28.6 903 15-17 33.0 1,212 21.9 400 18-19 33.6 1,496 33.9 503 20-24 26.3 4,761 40.5 1,251 20-22 25.4 3,097 39.0 786 23-24 28.0 1,665 42.8 466 Marital status Never married 96.5 2,148 36.0 2,074 Ever married 1.5 5,321 22.9 80 Knows condom source2 Yes 56.4 2,751 44.1 1,550 No 12.8 4,718 13.4 604 Residence Urban 43.9 2,250 46.1 989 Rural 22.3 5,219 26.5 1,166 Zone North Central 25.9 955 28.7 248 North East 7.8 1,166 19.2 91 North West 1.6 2,251 (23.1) 36 South East 52.6 614 41.1 323 South South 64.2 1,379 32.6 886 South West 51.8 1,104 43.0 572 Education No education 1.0 2,949 (1.3) 29 Primary 16.1 1,145 17.3 184 Secondary 55.2 2,917 34.7 1,610 More than secondary 72.1 458 52.3 330 Wealth quintile Lowest 7.6 1,701 11.0 129 Second 15.4 1,574 21.0 243 Middle 29.8 1,389 27.8 415 Fourth 44.0 1,575 38.2 692 Highest 54.9 1,231 47.4 675 Total 15-24 28.8 7,469 35.5 2,154 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 231 Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Men Among young men age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse, and among those who had higher- risk sexual intercourse in the past 12 months, the percentage who used a condom at last higher-risk sexual intercourse, by background characteristics, Nigeria 2008 Men age 15-24 who had sexual intercourse in the past 12 months Men age 15-24 who had higher-risk sexual intercourse in the past 12 months: Background characteristic Percentage who had higher-risk intercourse in the past 12 months1 Number of men Percentage who reported using a condom at last higher-risk sexual intercourse1 Number of men Age 15-19 94.5 422 36.3 398 15-17 94.6 165 30.9 156 18-19 94.4 256 39.8 242 20-24 74.1 1,252 55.1 928 20-22 75.6 747 51.8 565 23-24 71.8 505 60.2 363 Marital status Never married 97.7 1,289 50.4 1,260 Ever married 17.1 384 30.9 66 Knows condom source2 Yes 86.1 1,410 53.3 1,214 No 42.4 264 7.5 112 Residence Urban 88.3 619 62.4 546 Rural 73.9 1,055 40.4 780 Zone North Central 78.2 313 36.8 245 North East 47.1 169 24.2 80 North West 25.2 150 (36.3) 38 South East 92.7 176 66.2 163 South South 91.8 436 45.7 400 South West 93.3 430 60.3 401 Education No education 22.1 190 7.1 42 Primary 66.7 177 31.5 118 Secondary 88.2 1,118 49.2 987 More than secondary 95.1 189 72.4 180 Wealth quintile Lowest 47.6 247 18.7 118 Second 69.0 255 34.8 176 Middle 80.1 324 44.9 259 Fourth 89.8 448 55.7 402 Highest 92.7 400 62.6 371 Total 15-24 79.2 1,674 49.4 1,326 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. 232 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.14.7 Age-mixing in Sexual Relationships In many societies, young women have sexual relationships with men who are considerably older than them. This practice can contribute to the spread of HIV and other STIs because older men re more likely to have been exposed to these diseases. Using preventative methods such as negotiating safer sex is more difficult when the age differences are large. To examine age-mixing in the 2008 NDHS, young women age 15-19 who had sex with a non-marital, non-cohabiting partner in the 12 months preceding the survey were asked whether the man was younger, about the same age, or older than they were. If older, they were asked if they thought he was less than ten years older or ten or more years older. The results presented in Table 13.20 show that, among women age 15-19 who had higher-risk sexual intercourse in the 12 months preceding the survey, 11 percent had higher-risk sex with a man ten or more years older than them. Age mixing in sexual relationships is more common among young women who do not know a condom source, women in rural areas, women in North East, and women in the lowest wealth quintile than among other women. 13.14.8 Drunkenness during Sexual Intercourse Sexual intercourse when one or both partners are under the influence of alcohol is more likely to be unplanned and couples are therefore less likely to use condoms. Respondents who had sexual intercourse in the past 12 months were asked if they or their partner drank alcohol the last time they had sexual intercourse and, if so, whether they or their partner were drunk. Table 13.21 shows the prevalence of sexual intercourse while drunk for young women and men age 15-24 in the 12 months preceding the survey. Less than 1 percent of young women and only 1 percent of young men reported being drunk at least once when they had sexual intercourse during the past 12 months. One percent each of young women and young men reported that they or their partner had been drunk when they had sexual intercourse in the 12 months preceding the survey. Table 13.20 Age-mixing in sexual relationships among women age 15-19 Percentage of young women age 15-19 who had higher-risk sexual intercourse in the past 12 months with a man who was 10 or more years older than them, by background characteristics, Nigeria 2008 Background characteristic Percentage of women age 15-19 who had higher-risk sexual intercourse with a man 10+ years older1 Number of women age 15-19 who had higher-risk sexual intercourse in the past 12 months1 Age 15-17 12.9 400 18-19 8.6 503 Marital status Never married 10.4 881 Ever married * 21 Knows condom source2 Yes 8.6 563 No 13.7 340 Residence Urban 10.1 330 Rural 10.8 573 Zone North Central 15.4 104 North East 26.8 38 North West * 13 South East 14.5 109 South South 9.5 420 South West 5.5 218 Education No education * 13 Primary 20.2 102 Secondary 9.0 765 More than secondary * 23 Wealth quintile Lowest 23.7 72 Second 9.8 140 Middle 9.8 216 Fourth 8.1 267 Highest 10.4 207 Total 15-19 10.5 903 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has suppressed. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour | 233 Table 13.21 Drunkenness during sexual intercourse among youth Among all young women and young men age 15-24, the percentage who had sexual intercourse in the past 12 months while being drunk and percentage who had sexual intercourse in the past 12 months while drunk or with a partner who was drunk, by background characteristics, Nigeria 2008 Women age 15-24 Men age 15-24 Background characteristic Percentage who had sexual intercourse in the past 12 months while drunk Percentage who had sexual intercourse in the past 12 months while drunk or with a partner who was drunk Number of women Percentage who had sexual intercourse in the past 12 months while drunk Percentage who had sexual intercourse in the past 12 months while drunk or with a partner who was drunk Number of men Age 15-19 0.3 0.7 6,493 0.2 0.2 2,532 15-17 0.1 0.4 3,896 0.2 0.2 1,532 18-19 0.6 1.2 2,597 0.2 0.2 1,000 20-24 0.4 1.6 6,133 2.0 2.1 2,378 20-22 0.5 1.8 4,114 2.0 2.2 1,595 23-24 0.1 1.2 2,020 2.0 2.1 784 Marital status Never married 0.6 1.3 6,940 1.1 1.2 4,516 Ever married 0.1 1.0 5,687 0.8 0.8 395 Knows condom source1 Yes 0.9 2.1 4,620 1.6 1.7 3,342 No 0.1 0.6 8,006 0.0 0.0 1,569 Residence Urban 0.5 1.3 4,529 1.3 1.4 1,847 Rural 0.3 1.0 8,097 0.9 1.0 3,064 Zone North Central 0.1 1.0 1,877 1.2 1.2 821 North East 0.1 0.4 1,612 0.4 0.4 554 North West 0.0 0.2 2,873 0.0 0.0 1,061 South East 0.3 1.0 1,626 3.7 3.8 571 South South 1.7 3.6 2,223 1.5 1.8 934 South West 0.0 0.6 2,416 0.6 0.6 969 Education No education 0.1 0.4 3,446 0.1 0.1 654 Primary 0.3 1.7 1,846 1.3 1.5 692 Secondary 0.5 1.3 6,598 1.0 1.0 3,222 More than secondary 0.9 2.0 736 3.1 3.5 342 Wealth quintile Lowest 0.1 1.0 2,192 0.3 0.4 733 Second 0.2 0.7 2,288 1.0 1.0 821 Middle 0.5 1.4 2,477 0.7 0.8 1,010 Fourth 0.5 1.4 2,869 1.6 1.6 1,284 Highest 0.4 1.1 2,801 1.3 1.5 1,063 Total 15-24 0.4 1.1 12,626 1.1 1.1 4,910 1 Friends, family members, and home are not considered sources for condoms. 13.14.9 HIV Testing Obtaining an HIV test can be more difficult for youth than for adults because many youth lack experience in accessing health services for themselves and because barriers often exist for youth trying to obtain services. Table 13.22 presents information on sexually active youth who were tested for HIV and received the results in the 12 months preceding the survey. Overall, 7 percent each of young women and young men were tested for HIV in the past 12 months and received the results. 234 | HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.22 Recent HIV tests among youth Among young women and young men age 15-24 who had sexual intercourse in the past 12 months, the percentage who were tested for HIV in the past 12 months and received the results, by background characteristics, Nigeria 2008 Women age 15-24 who had sexual intercourse in the past 12 months Men age 15-24 who had sexual intercourse in the past 12 months Background characteristic Percentage who were tested for HIV in the past 12 months and received the results Number of women Percentage who were tested for HIV in the past 12 months and received the results Number of men Age 15-19 3.0 2,708 6.5 422 15-17 2.0 1,212 2.6 165 18-19 3.8 1,496 9.0 256 20-24 9.0 4,761 7.3 1,252 20-22 6.7 3,097 5.9 747 23-24 13.2 1,665 9.4 505 Marital status Never married 9.8 2,148 7.7 1,289 Ever married 5.6 5,321 5.2 384 Knows condom source1 Yes 13.8 2,751 8.2 1,410 No 2.7 4,718 1.1 264 Residence Urban 12.3 2,250 8.7 619 Rural 4.4 5,219 6.2 1,055 Zone North Central 4.8 955 7.9 313 North East 2.7 1,166 2.7 169 North West 1.6 2,251 3.0 150 South East 23.0 614 10.0 176 South South 10.8 1,379 9.4 436 South West 9.4 1,104 6.1 430 Education No education 1.0 2,949 0.5 190 Primary 4.1 1,145 4.1 177 Secondary 10.5 2,917 6.9 1,118 More than secondary 27.2 458 17.5 189 Wealth quintile Lowest 0.5 1,701 0.9 247 Second 2.6 1,574 6.7 255 Middle 6.2 1,389 6.2 324 Fourth 10.1 1,575 7.7 448 Highest 17.3 1,231 11.2 400 Total 15-24 6.8 7,469 7.1 1,674 1 Friends, family members, and home are not considered sources for condoms. Young women and men age 23-24 are more likely to have been tested for HIV and to have received the results than their younger counterparts age 15-17. In urban areas, both young women and young men are more likely to have been tested for HIV and received the results than their rural counterparts. Among young women, South East has the highest proportion tested for HIV who also received the results of the test (23 percent), while North-West has the lowest proportion (2 percent). Among young men, South East also has the highest proportion tested for HIV who also and received the results of the test (10 percent), while the lowest proportion is in North East (3 percent). The prevalence of HIV testing and receipt of test results increases among both young women and young men with level of education and wealth quintile. Adult and Maternal Mortality | 235 ADULT AND MATERNAL MORTALITY 14 In the 2008 NDHS, data were collected on the survivorship of respondents’ siblings. These data allow for the estimation of adult mortality. The inclusion of questions to determine if female sibling deaths were maternity-related permits the estimation of the level of maternal mortality, a major indicator of maternal health and well-being. In Chapter 8 of this report, survey findings relating to child mortality were presented and discussed. While early childhood mortality is high and varies substantially with social and economic development, death rates are much lower at adult ages, and estimates for particular subgroups can be distorted by small sample sizes. Maternal mortality is an aspect of adult mortality dynamics that is of particular interest in the Nigerian context. Maternal mortality is an important indicator for women’s programmes and reproductive health programmes in the country. 14.1 DATA To obtain the sibling history, each respondent was first asked to give the total number of her mother’s live births. The respondent was next asked to provide a list of all of the children born to her mother starting with the first-born. Then, the respondent was asked whether each of these siblings was still alive at the survey date. For living siblings, the current age was collected. For deceased siblings, the age at death and number of years since the person’s death were collected. Interviewers were instructed that, when a respondent could not provide precise information on age at death or years since death, approximate but quantitative answers were acceptable. For sisters who died at age 12 or above, three questions were used to determine whether the death was maternity-related: “Was [NAME OF SISTER] pregnant when she died?” and if negative, “Did she die during childbirth?” and if negative, “Did she die within two months after the end of a pregnancy or childbirth?” The estimation of adult and maternal mortality by either direct or indirect means requires reasonably accurate reporting of the number of sisters and brothers the respondent ever had, the number who have died, and (for maternal mortality) the number of sisters who died of maternity-related causes. Table 14.1 shows the number of siblings reported by the respondents and the completeness of the data reported on current age, age at death, and years since death. Table 14.1 Completeness of reporting on siblings Number of siblings reported by female survey respondents and completeness of reported data on sibling age, age at death (AD) and years since death (YSD), Nigeria 2008 Sisters Brothers All siblings Number Percent Number Percent Number Percent Total siblings reported 86,223 100.0 92,541 100.0 178,764 100.0 Surviving 72,300 83.9 75,958 82.1 148,258 82.9 Deceased 13,743 15.9 16,355 17.7 30,098 16.8 Missing information 180 0.2 228 0.2 408 0.2 Surviving siblings 72,300 100.0 75,958 100.0 148,258 100.0 Age reported 71,537 98.9 75,111 98.9 146,647 98.9 Age missing 763 1.1 847 1.1 1,610 1.1 Deceased siblings 13,743 100.0 16,355 100.0 30,098 100.0 AD and YSD reported 13,085 95.2 15,461 94.5 28,546 94.8 Missing only AD 297 2.2 406 2.5 703 2.3 Missing only YSD 114 0.8 168 1.0 281 0.9 Missing both 247 1.8 320 2.0 567 1.9 236 | Adult and Maternal Mortality Of the 178,764 siblings reported in the sibling histories of 2008 NDHS respondents, survival status was not reported for 408 siblings (0.2 percent). Among surviving siblings, current age (used to estimate exposure to death) was not reported for 1,610 siblings (1.1 percent). For 95 percent of deceased siblings, both age at death and years since death (or year of death) were reported. In 2 percent of cases, both age at death and the years since death (or year of death) were missing. 14.2 DIRECT ESTIMATES OF ADULT MORTALITY One way to assess the quality of the data used to estimate maternal mortality is to evaluate the plausibility and stability of overall adult mortality. It is reasoned that if estimated rates of overall adult mortality are implausible, rates based on a subset of deaths—i.e., maternal deaths in particular—are unlikely to be free of serious problems. The direct estimation of adult mortality uses the reported ages at death and years since death of respondents’ brothers and sisters. Because of the differentials in exposure to the risk of dying, age and sex- specific death rates are presented in this report. Table 14.2 and Figure 14.1 present the age-specific rates for female and male mortality (15-49 years) for the period zero to six years before the 2008 NDHS. This seven-year period is taken as a compromise between the desire for the most recent data and the need to minimise the level of sampling errors. The results in Table 14.2 indicate that the age- adjusted adult mortality rate for women and men over the age range 15-49 years was 4.6 deaths per 1,000 years of exposure for the period zero to six years preceding the 2008 NDHS. The rate is almost the same for women (4.7 deaths per 1,000 years of exposure) and men (4.6 deaths per 1,000 years of exposure). Mortality levels rise rapidly with age among both women and men. For women, rates rise steadily from 3.3 per 1,000 years of exposure for age group 15-19 to 6.2 per 1,000 years of exposure for age group 30-34, before decreasing in age group 35-39 and increasing thereafter. For men, mortality levels increase steadily up to age group 35-39 (5.4 deaths per 1,000 years of exposure). Then for men age group 40-44 mortality jumps to 8.7 deaths per 1,000 years of exposure, and decreases to 8.2 deaths per 1,000 years of exposure for men age 44-49. Table 14.2 Adult mortality rates and trends Direct estimates of age-specific mortality rates for women and men age 15-49 for the period 0-6 years preceding the 2008 NDHS Age Deaths Exposure (person- years) Mortality rates1 WOMEN 15-19 256 76,631 3.3 20-24 286 84,488 3.4 25-29 325 75,950 4.3 30-34 363 58,928 6.2 35-39 214 40,952 5.2 40-44 161 25,578 6.3 45-49 94 14,936 6.3 15-49 1,699 377,463 4.7a MEN 15-19 221 77,951 2.8 20-24 260 88,967 2.9 25-29 291 80,087 3.6 30-34 318 63,228 5.0 35-39 242 44,601 5.4 40-44 236 27,216 8.7 45-49 132 16,080 8.2 15-49 1,700 398,130 4.6a TOTAL 15-19 477 154,581 3.1 20-24 546 173,455 3.1 25-29 616 156,037 3.9 30-34 681 122,156 5.6 35-39 457 85,553 5.3 40-44 397 52,794 7.5 45-49 226 31,016 7.3 15-49 3,399 775,592 4.6a 1 Expressed per 1,000 person-years of exposure a Age-adjusted rate Adult and Maternal Mortality | 237 14.3 DIRECT ESTIMATES OF MATERNAL MORTALITY Maternal deaths are a subset of all female deaths and are associated with pregnancy and childbearing. Two survey methods are generally used to estimate maternal mortality in developing countries: the indirect sisterhood method (Graham et al., 1989) and a direct variant of the sisterhood method (Rutenberg and Sullivan, 1991). In this report, the direct estimation procedure is applied. Age-specific estimates of maternal mortality from the reported survivorship of sisters are shown in Table 14.3 for the six-year period before the 2008 survey. These rates were calculated by dividing the number of maternal deaths by woman-years of exposure. To remove the effect of truncation bias—the upper boundary of eligibility for women interviewed in the survey is 49 years—the overall rate for women age 15-49 was standardised by the age distribution of survey respondents. Maternal deaths were defined as any death that was reported as occurring during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy. Estimates of maternal mortality are therefore based solely on the timing of the death in relationship to the pregnancy. The results in Table 14.3 indicate that the rate of mortality associated with pregnancy and childbearing is 1.0 maternal deaths per 1,000 woman-years of exposure. Table 14.3 Direct estimates of maternal mortality Direct estimates of maternal mortality for the period 0-6 years preceding the survey, Nigeria 2008 Age Deaths Exposure (woman- years) Mortality rates1 15-19 63 76,631 0.822 20-24 88 84,488 1.042 25-29 75 75,950 0.987 30-34 94 58,928 1.595 35-39 47 40,952 1.148 40-44 25 25,578 0.977 45-49 5 14,936 0.335 15-49 398 377,463 1.000a General fertility rate (GFR) 0.186a Maternal mortality ratio (MMR)2 545 1 Expressed per 1,000 woman-years of exposure 2 Expressed per 100,000 live births; calculated as the maternal mortality rate divided by the general fertility rate a Age-adjusted rate ( ( ( ( ( ( ( ) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 2 4 6 8 10 Women Men) ( NDHS 2008 Figure 14.1 Adult Mortality Rates among Women and Men Age 15-49 238 | Adult and Maternal Mortality The estimated age-specific mortality rates display a plausible pattern, being generally higher during the peak childbearing ages than at the younger and older age groups. However, the age-specific pattern should be interpreted with caution because of the small number of events—only 398 maternal deaths for women of all ages. The maternal mortality rate can be converted to a maternal mortality ratio and expressed per 100,000 live births by dividing the rate by the general fertility rate of 0.186, which prevailed during the same period. Thus, the obstetrical risk of pregnancy and childbearing is emphasised. Using this procedure, the maternal mortality ratio during the seven-year period preceding the 2008 NDHS is estimated as 545 maternal deaths per 100,000 live births. The confidence interval for the estimate ranges from 475 to 615 maternal deaths per 100,000 live births. Women’s Empowerment and Health Outcomes | 239 WOMEN’S EMPOWERMENT AND HEALTH OUTCOMES 15 Gender equality and women’s empowerment are important indicators in development strategies that focus on poverty reduction, improved standard of living, and good governance. In June 2007, the Federal Republic of Nigeria launched the National Gender Policy to promote gender equity and sustainable development. The policy derives essentially from the Constitution of the Federal Republic of Nigeria, 1999 which guarantees the fundamental human rights of all its citizens and incorporates the principles of global and regional frameworks that support gender equity and women’s empowerment. This chapter presents information on factors affecting women’s status such as employment, type of earnings, women’s control over cash earnings, and the magnitude of their earnings relative to those of their partner’s. This chapter also defines three summary indices of women’s empowerment derived from women’s responses. The indices are based on the number of household decisions in which the respondent participates, her opinion on the number of circumstances in which a woman is justified in refusing to have sexual intercourse with her husband, and her opinion on the number of reasons wife beating is justified. The ranking of women on these three indices is then related to select demographic and health outcomes, including contraceptive use and the receipt of health care services during pregnancy, at delivery, and in the postnatal period.1 15.1 WOMEN’S AND MEN’S EMPLOYMENT The 2008 NDHS collected information relating to women’s and men’s employment. In measuring women’s employment it is important to take extra care because some of the activities that women do are often not perceived by women themselves as employment and hence are not reported as such. These activities include work on family farms, in family businesses and other aspects of the informal sector. To avoid underestimating women’s employment, the 2008 NDHS asked female respondents several questions to ascertain their employment status. First they were asked, “Aside from your own housework, are you currently working?” Women who answered “no” to this question were then asked, “As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business, or work on the family farm or in the family business. Are you currently doing any of these things or any other work? Do you have any job or business from which you were on leave, illness, vacation, maternity leave, or any other such reason? Have you done any work in the last 12 months? What is your occupation, that is, what kind of work do you mainly do?” It should be recognised however, that there are several obstacles standing in the way of women gaining access to employment, the ‘most significant being inequality with respect to access to education, discrimination in employment and occupation, which leads to categorisation of jobs according to gender, national laws and regulations, inequality with respect to access to factors of production, the low level of women’s participation in decision-making and social control bodies and finally, social attitudes’ (ILO, 1995). 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 240 | Women’s Empowerment and Health Outcomes 15.1.1 Employment Status Table 15.1 shows the percent distribution of women and men age 15-49, by employment status and form of payment according to age. Overall, 71 percent of currently married women and nearly all currently married men (99 percent) were employed in the 12 months preceding the survey. The proportion of employed women increases steadily with age from 43 percent among women age 15-19 to 82 percent among women age 45-49. A higher proportion of married women than married men were paid in cash only (71 versus 56 percent, respectively). Married men are almost twice as likely as married women to receive no pay for their employment; 30 percent for married men compared with 17 percent for married women. Table 15.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Nigeria 2008 Currently married respondents Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Age Percentage employed Number of respondents Cash only Cash and in-kind In-kind only Not paid Missing Total Number of respondents WOMEN 15-19 43.4 1,863 70.9 10.7 3.9 14.1 0.4 100.0 810 20-24 58.2 3,659 69.5 10.4 2.7 17.2 0.3 100.0 2,130 25-29 69.3 5,112 70.6 10.1 1.8 17.2 0.3 100.0 3,544 30-34 76.8 4,173 73.4 10.1 0.9 15.4 0.2 100.0 3,205 35-39 80.1 3,575 71.1 10.9 1.2 16.6 0.2 100.0 2,863 40-44 80.4 2,711 69.2 11.9 0.9 17.7 0.4 100.0 2,180 45-49 81.6 2,484 68.4 11.8 1.2 18.2 0.4 100.0 2,026 Total 15-49 71.1 23,578 70.6 10.7 1.6 16.8 0.3 100.0 16,758 MEN 15-19 (96.9) 23 (18.7) (8.0) (4.4) (68.9) (0.0) (100.0) 23 20-24 96.0 354 38.1 14.0 2.8 45.1 0.0 100.0 340 25-29 98.5 1,076 54.1 11.9 1.9 32.0 0.2 100.0 1,060 30-34 98.9 1,504 55.8 12.3 1.5 30.2 0.2 100.0 1,488 35-39 99.2 1,618 60.2 11.1 0.7 28.0 0.1 100.0 1,605 40-44 99.0 1,316 57.1 13.3 0.9 28.7 0.1 100.0 1,303 45-49 98.7 1,127 58.0 13.7 1.2 26.9 0.2 100.0 1,112 Total 15-49 98.8 7,018 56.2 12.4 1.3 30.0 0.1 100.0 6,931 50-59 97.7 1,599 53.4 14.2 0.8 31.3 0.3 100.0 1,563 Total 15-59 98.6 8,618 55.6 12.8 1.2 30.2 0.1 100.0 8,494 Note: Numbers in parentheses are based on 25-49 unweighted cases. 15.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS As a means of assessing women’s autonomy, currently married women who earned cash for their work in the 12 months preceding the survey were asked who usually decides how their earnings are spent. This information assesses women’s control over their own earnings. Women who earned cash for their work were asked the relative magnitude of their earnings compared with those of their husband or partner. It is expected that employment and earnings are more likely to empower women if women themselves control their own earnings and perceive them as significant relative to those of their husband or partner. Women’s Empowerment and Health Outcomes | 241 Table 15.2.1 shows the percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by the person who decides how their cash earnings are used, and by the relative magnitude of their earnings compared with those of their husband or partner, according to background characteristics. Two-thirds of women (66 percent) decide for themselves how their earnings are used. On the other hand, 19 percent of women make joint decisions with their husbands, while 13 percent report that decisions regarding their earnings are mainly made by their husbands. The percentage of women who make independent decisions on their earnings does not vary widely by age or number of living children. Independent decision-making on earnings by women is also not dependent on urban-rural residence (65 percent compared with 67 percent). Independent decision-making on earnings varies by zone. Eighty-six percent of currently married women in the North West decide independently what to do with their earnings compared with 27 percent in South East. South East has the highest proportion of women (39 percent) who report joint decision-making with their husbands regarding their earnings. On the other hand, women in South East also report the highest proportion for their husbands mainly deciding on how their earning should be used (33 percent). Table 15.2.1 Control over women's cash earnings and relative magnitude of women's earnings: Women Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife's cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Nigeria 2008 Person who decides how the wife's cash earnings are used: Women's cash earnings compared with husband's cash earnings: Background characteristic Mainly wife Wife and husband jointly Mainly husband Other Missing Total More Less About the same Husband/ partner has no earnings Don't know/ missing Total Number of women Age 15-19 71.4 10.0 15.8 1.3 1.6 100.0 2.2 85.2 1.1 1.1 10.3 100.0 660 20-24 69.5 14.7 14.5 0.4 0.8 100.0 2.8 86.4 2.9 0.3 7.5 100.0 1,702 25-29 65.1 19.7 14.3 0.0 0.9 100.0 2.9 84.6 5.0 1.0 6.4 100.0 2,859 30-34 65.1 20.8 13.2 0.0 0.9 100.0 4.2 83.2 5.1 0.9 6.7 100.0 2,676 35-39 64.1 22.1 12.8 0.1 1.0 100.0 4.8 81.7 5.3 0.8 7.4 100.0 2,348 40-44 66.9 20.8 11.4 0.2 0.7 100.0 5.8 79.0 6.3 1.0 7.9 100.0 1,766 45-49 67.9 19.1 11.8 0.2 1.0 100.0 7.9 74.9 7.1 1.5 8.5 100.0 1,625 Number of living children 0 61.5 21.5 14.6 0.8 1.6 100.0 4.8 81.9 4.1 1.0 8.2 100.0 1,089 1-2 66.2 18.4 14.4 0.2 0.8 100.0 4.1 82.5 4.8 0.8 7.8 100.0 4,007 3-4 67.3 19.5 12.4 0.1 0.7 100.0 4.3 83.3 5.1 0.8 6.4 100.0 4,458 5+ 66.9 19.3 12.6 0.1 1.1 100.0 4.7 80.7 5.5 1.1 7.9 100.0 4,083 Residence Urban 64.9 21.2 12.9 0.0 0.9 100.0 5.3 81.1 5.6 1.3 6.8 100.0 4,824 Rural 67.2 18.2 13.4 0.3 0.9 100.0 3.9 82.8 4.8 0.7 7.8 100.0 8,812 Zone North Central 46.1 32.9 19.2 0.1 1.7 100.0 5.1 80.7 8.5 1.2 4.6 100.0 1,753 North East 71.9 9.9 16.2 1.1 1.0 100.0 2.8 89.3 3.3 1.4 3.3 100.0 1,678 North West 86.3 3.3 9.2 0.0 1.1 100.0 1.7 84.4 1.7 0.1 12.0 100.0 3,741 South East 26.7 38.8 33.1 0.4 0.9 100.0 9.3 74.3 9.8 1.2 5.5 100.0 1,244 South South 59.1 28.6 11.4 0.0 0.9 100.0 7.8 77.4 7.0 1.4 6.3 100.0 1,679 South West 70.1 22.5 7.0 0.0 0.4 100.0 4.4 82.3 5.1 1.1 7.2 100.0 3,541 Education No education 76.1 8.7 13.7 0.2 1.3 100.0 2.4 85.3 3.3 0.8 8.2 100.0 5,750 Primary 62.7 22.4 13.8 0.3 0.7 100.0 5.0 80.4 6.1 1.2 7.3 100.0 3,163 Secondary 58.8 27.6 12.9 0.1 0.7 100.0 5.3 81.2 6.0 0.8 6.6 100.0 3,450 More than secondary 51.9 36.8 10.5 0.0 0.8 100.0 9.5 75.5 7.4 1.2 6.5 100.0 1,274 Wealth quintile Lowest 70.6 9.6 18.4 0.4 1.0 100.0 2.7 85.8 3.0 0.8 7.7 100.0 2,505 Second 75.8 11.1 11.7 0.3 1.1 100.0 3.0 83.6 3.6 0.9 8.8 100.0 2,776 Middle 64.1 21.0 13.8 0.1 0.9 100.0 5.0 80.5 6.4 0.9 7.2 100.0 2,343 Fourth 60.0 26.1 13.0 0.2 0.8 100.0 5.2 80.0 6.7 0.8 7.3 100.0 2,675 Highest 62.0 26.6 10.5 0.0 0.9 100.0 5.8 81.4 5.5 1.1 6.2 100.0 3,339 Total 66.4 19.3 13.2 0.2 0.9 100.0 4.4 82.2 5.0 0.9 7.4 100.0 13,637 242 | Women’s Empowerment and Health Outcomes Table 15.2.1 also shows the relative magnitude of women’s earnings with respect to their husbands’ earnings during the 12 months preceding the survey. While 82 percent of women report that they earn less than their husband, 4 percent of women report that they earn more than their husbands and 5 percent earn about the same as their husbands. The proportion of women who earn more than their husbands generally increases with age. The South East zone has the highest proportion (9 percent) of women reporting that they earn more than their husbands, while the North West has the lowest proportion (2 percent). Regarding education, women with more than a secondary education are most likely (10 percent) to report that they earn more than their husbands. Table 15.2.2 shows the percent distributions of currently married men age 15-49 who receive cash earnings, and of currently married women age 15-49 whose husbands receive cash earnings, by the person who decides how men's cash earnings are used and according to background characteristics. Table 15.2.2 Control over men's cash earnings Percent distribution of currently married men age 15-49 who receive cash earnings and percent distribution of currently married women age 15-49 whose husbands receive cash earnings, by person who decides how men's cash earnings are used, according to background characteristics, Nigeria 2008 Men Women Person who decides how husband’s cash earnings are used: Person who decides how husband’s cash earnings are used: Background characteristic Mainly wife Husband and wife jointly Mainly husband Other Missing Total Number of men Mainly wife Husband and wife jointly Mainly husband Other Missing Total Number of women Age 15-19 * * * * * * 6 4.2 14.1 80.9 0.3 0.4 100.0 1,826 20-24 3.9 23.4 71.5 1.2 0.0 100.0 177 4.6 21.0 73.6 0.2 0.6 100.0 3,608 25-29 1.2 15.7 81.8 0.6 0.7 100.0 699 4.9 25.9 68.9 0.1 0.2 100.0 5,025 30-34 1.1 17.3 80.6 0.4 0.5 100.0 1,014 6.5 26.1 67.1 0.0 0.3 100.0 4,111 35-39 1.0 18.7 79.9 0.2 0.2 100.0 1,144 6.7 26.1 66.7 0.1 0.4 100.0 3,526 40-44 1.0 19.7 78.7 0.3 0.4 100.0 917 6.8 26.1 66.6 0.0 0.6 100.0 2,666 45-49 1.6 18.8 78.9 0.0 0.7 100.0 797 6.9 24.5 68.2 0.1 0.3 100.0 2,421 Number of living children 0 1.8 21.7 74.6 1.1 0.8 100.0 475 4.9 23.7 70.6 0.3 0.6 100.0 2,355 1-2 1.2 19.0 79.3 0.3 0.2 100.0 1,627 5.7 23.6 70.2 0.2 0.3 100.0 7,296 3-4 1.2 17.7 80.3 0.2 0.6 100.0 1,422 5.6 24.8 69.3 0.0 0.3 100.0 7,068 5+ 1.2 16.9 81.2 0.2 0.5 100.0 1,231 6.3 24.3 68.9 0.1 0.4 100.0 6,462 Residence Urban 1.6 18.6 79.3 0.0 0.5 100.0 2,009 6.1 28.2 65.1 0.1 0.5 100.0 7,280 Rural 1.1 18.1 79.8 0.6 0.4 100.0 2,745 5.6 22.3 71.7 0.1 0.3 100.0 15,902 Zone North Central 2.1 23.0 74.5 0.2 0.3 100.0 662 4.9 41.9 52.7 0.1 0.4 100.0 3,272 North East 1.1 5.4 92.6 0.0 0.9 100.0 337 7.5 12.6 79.3 0.3 0.4 100.0 3,455 North West 0.5 4.0 93.8 1.1 0.6 100.0 1,089 4.6 10.8 84.1 0.0 0.4 100.0 7,097 South East 3.1 29.4 66.4 0.0 1.1 100.0 550 3.3 45.9 50.1 0.2 0.5 100.0 2,118 South South 1.2 40.2 58.1 0.2 0.2 100.0 792 5.2 30.6 63.6 0.1 0.5 100.0 2,927 South West 0.8 13.4 85.5 0.0 0.2 100.0 1,325 8.7 26.8 64.3 0.1 0.2 100.0 4,313 Education No education 1.7 4.5 92.0 1.1 0.7 100.0 823 5.7 13.7 80.1 0.1 0.4 100.0 10,905 Primary 1.5 17.7 79.8 0.6 0.4 100.0 1,224 5.7 28.3 65.6 0.1 0.3 100.0 5,053 Secondary 1.1 20.3 78.2 0.0 0.3 100.0 1,838 5.7 35.0 58.7 0.1 0.4 100.0 5,552 More than secondary 0.8 28.1 70.6 0.0 0.5 100.0 870 6.5 43.6 49.6 0.1 0.2 100.0 1,672 Wealth quintile Lowest 2.0 8.6 87.8 1.4 0.2 100.0 573 5.3 14.3 79.9 0.2 0.3 100.0 5,262 Second 1.0 13.8 84.2 0.7 0.3 100.0 695 5.7 18.1 75.7 0.1 0.4 100.0 4,956 Middle 1.3 18.2 79.8 0.1 0.6 100.0 877 5.7 26.9 66.9 0.1 0.4 100.0 4,255 Fourth 0.7 20.7 78.1 0.2 0.4 100.0 1,124 5.4 30.8 63.4 0.1 0.4 100.0 4,173 Highest 1.5 22.5 75.4 0.0 0.5 100.0 1,486 6.8 33.5 59.2 0.1 0.5 100.0 4,535 Total 15-49 1.3 18.3 79.6 0.3 0.5 100.0 4,755 5.8 24.1 69.6 0.1 0.4 100.0 23,182 50-59 1.0 17.1 80.9 0.4 0.6 100.0 1,057 na na na na na na na Total 15-59 1.2 18.1 79.8 0.3 0.5 100.0 5,811 na na na na na na na Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable Women’s Empowerment and Health Outcomes | 243 According to men, 80 percent report that most decisions about who decides how their cash earnings are used are made mainly by the husband, with 18 percent stating that decisions are jointly decided and only one percent stating that these decisions are mainly made by their wives. According to women, 70 percent report that their husbands mainly decide how their cash earnings are used, 24 percent report that the decisions are jointly decided, and 6 percent report that they mainly decide how to use their husband’s earnings. 15.3 WOMEN’S PARTICIPATION IN DECISION-MAKING Decision-making can be a complex process; the ability of women to make decisions that affect their personal circumstances is essential for their empowerment. To assess women’s decision- making autonomy, the 2008 NDHS collected information on women’s participation in four types of household decisions: respondent’s own health care; making major household purchases; making household purchases for daily needs; and visits to family or relatives. Women are considered to participate in decision-making if they make decisions alone or jointly with their husband or someone else. Table 15.3 shows that the majority of currently married women who earn more than their husbands are more likely to decide mainly by themselves and jointly with their husbands on how their earnings are spent (86 percent), that is, they are a part of the decision-making process. Likewise, about half of the same group of women (49 percent) are a part of the decision-making process when it comes to deciding how their husbands’ earnings are spent. The data show that a woman is more likely to be a part of the decision-making process on how her earnings and her husband’s earnings are spent if she makes more than or the same amount of money as her husband. Table 15.3 Women's control over their own earnings and the earnings of their husband Percent distributions of currently married women age 15-49 with cash earnings in the past 12 months by person who decides how the woman's cash earnings are used and of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband's cash earnings are used, according to the relation between woman's and husband's cash earnings, Nigeria 2008 Person who decides how the wife's cash earnings are used: Person who decides how husband's cash earnings are used: Women's earnings relative to husband's earnings Mainly wife Wife and husband jointly Mainly husband Other Missing Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing Total Number of women More than husband/partner 58.1 28.1 13.3 0.2 0.4 100.0 603 13.3 35.2 51.0 0.3 0.2 100.0 592 Less than husband/ partner 68.6 17.4 13.8 0.2 0.0 100.0 11,209 5.6 21.5 72.8 0.1 0.1 100.0 11,172 Same as husband partner 32.7 55.5 11.8 0.0 0.0 100.0 687 3.0 60.0 36.6 0.0 0.3 100.0 687 Husband partner has no cash earnings/did not work 57.7 32.4 9.9 0.0 0.0 100.0 125 na na na na na na na Woman has no cash earnings na na na na na na na 8.0 35.7 55.8 0.1 0.4 100.0 3,039 Woman did not work in past 12 months na na na na na na na 3.5 20.3 75.3 0.2 0.7 100.0 6,685 Don't know/missing 70.0 9.1 8.5 0.1 12.3 100.0 1,013 13.7 13.4 71.5 0.0 1.4 100.0 1,007 Total1 66.4 19.3 13.2 0.2 0.9 100.0 13,637 5.8 24.1 69.6 0.1 0.4 100.0 23,182 na = Not applicable 1 Excludes cases where a woman or her husband/partner has no earnings and includes cases where a woman does not know whether she earned more or less than her husband/partner Table 15.4.1 shows the percent distribution of currently married women by the person who usually makes decisions, according to women. Half or more of married women report that their husbands mainly make the decisions for their own health care (56 percent), major household purchases (62 percent), and purchases for daily household needs (50 percent). The data show that three in ten women report that they jointly make each of these decisions with their husbands. Less than half of women report that their husbands alone make the decision about visits to their family or relatives, and the same proportion report that this decision is made jointly with their husbands (44 percent). 244 | Women’s Empowerment and Health Outcomes Table 15.4.1 Women's participation in decision-making Percent distribution of currently married women by person who usually makes decisions about four kinds of issues, Nigeria 2008 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 9.8 33.8 55.7 0.3 0.1 0.3 100.0 23,578 Major household purchases 5.7 31.9 61.6 0.3 0.1 0.4 100.0 23,578 Purchases of daily household needs 16.7 32.9 49.7 0.3 0.1 0.4 100.0 23,578 Visits to her family or relatives 11.2 43.6 44.4 0.2 0.1 0.3 100.0 23,578 Table 15.4.2 shows the percent distribution of currently married men by the person whom they think should have a greater say in making decisions in five areas: major household purchases, purchases of daily household needs, visits to the wife’s family or relatives, how the money his wife earns is spent, and how many children to have. The majority of men believe they should have the greater say in decisions concerning major household purchases (84 percent), purchases of daily household needs (54 percent), and visits to their wives’ family or relatives (52 percent). Twenty-nine percent of men think that decisions about how to spend the wife’s cash earnings should be made mainly by the husband, while 32 percent think that husbands and wives should decide jointly how to spend money that the wife earns. Forty-seven percent of men think that decisions on the number of children to have should be made jointly by the husband and wife. However, 43 percent of men think that the husband alone should make the decision on the number of children to have. Table 15.4.2 Women's participation in decision-making according to men Percent distribution of currently married men 15-49 by person who they think should have a greater say in making decisions about five kinds of issues, Nigeria 2008 Decision Wife Wife and husband equally Husband Don't know/ depends Missing Total Number of men Major household purchases 2.1 14.1 83.5 0.3 0.0 100.0 7,018 Purchases of daily household needs 30.7 14.9 54.0 0.4 0.0 100.0 7,018 Visits to wife's family or relatives 4.9 42.5 51.8 0.6 0.3 100.0 7,018 What to do with the money wife earns 36.7 32.0 29.2 2.0 0.1 100.0 7,018 How many children to have 1.7 47.3 42.5 8.2 0.2 100.0 7,018 Table 15.5.1 shows how women’s participation in decision-making varies by background characteristics. The table presents results on four specific topics in which a married woman usually makes decisions either by herself or jointly with her husband: her own health care, making major household purchases, making purchases for daily household needs, and visits to her family or relatives. In addition, the table includes two summary indicators: the proportion of women involved in making decisions in all four areas, and the proportion of women not involved in making any of the decisions. Table 15.5.1 shows that almost three in ten married women (31 percent) report taking part in all four decisions, while almost four in ten women (38 percent) have no say in any of the four decisions. The percentage of women participating in all four decisions increases with higher levels of education; 53 percent of women with more than a secondary education participate in all four decisions compared with 19 percent of women with no education. Participation in all four decisions also increases with wealth quintile. Women’s Empowerment and Health Outcomes | 245 When observing data on specific decisions, married women are most likely to be involved in decisions regarding visits to her family or relatives (55 percent) and purchases for daily household needs (50 percent). Women are least likely to be involved in decisions regarding major household purchases (38 percent). The table indicates that women’s participation in household decision-making increases with age. It also shows that women who are employed, but not for cash (43 percent), and women in urban areas (39 percent) are more likely to participate in all four decisions when compared with their counterparts. The South West zone has the highest percentage of women who participate in all four decisions (50 percent), followed by North Central (45 percent). Table 15.5.1 Women's participation in decision-making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Nigeria 2008 Specific decisions Background characteristic Own health care Making major household purchases Making purchases for daily household needs Visits to her family or relatives Percentage who participate in all four decisions Percentage who participate in none of the four decisions Number of women Age 15-19 23.7 19.9 26.1 35.0 15.6 58.9 1,863 20-24 35.1 29.9 41.3 47.6 23.9 45.2 3,659 25-29 44.4 37.5 50.1 55.9 31.5 37.4 5,112 30-34 46.8 41.8 53.6 57.7 34.7 35.5 4,173 35-39 49.0 42.6 55.8 60.2 36.0 32.9 3,575 40-44 49.6 43.4 56.6 59.7 36.5 33.3 2,711 45-49 49.6 42.1 54.8 60.8 36.1 33.3 2,484 Employment (past 12 months) Not employed 29.8 26.6 32.4 39.6 22.0 54.4 6,771 Employed for cash 47.5 39.5 54.3 59.3 33.4 34.0 13,637 Employed not for cash 57.1 53.9 66.9 69.3 43.3 21.9 3,072 Missing 31.9 27.1 29.7 31.7 19.7 59.8 98 Number of living children 0 36.4 31.5 40.8 47.0 25.6 45.7 2,402 1-2 42.6 36.0 47.9 53.7 30.1 39.4 7,414 3-4 46.1 40.0 52.6 57.8 33.5 35.7 7,181 5+ 44.6 39.1 51.3 55.8 32.6 37.4 6,581 Residence Urban 54.4 45.1 59.7 63.4 38.6 28.9 7,375 Rural 38.7 34.2 45.0 51.0 28.1 42.7 16,203 Zone North Central 54.4 54.0 65.2 67.2 45.3 24.7 3,320 North East 26.7 21.9 28.2 37.7 15.8 55.8 3,585 North West 18.8 17.3 21.2 29.8 13.6 65.0 7,189 South East 58.2 52.5 68.1 65.5 43.4 24.6 2,139 South South 64.0 52.9 80.0 77.2 42.5 11.8 2,978 South West 68.9 53.8 71.9 80.3 49.5 15.4 4,366 Education No education 26.5 23.2 30.2 38.9 18.5 55.8 11,120 Primary 52.8 45.9 61.4 64.4 38.3 27.7 5,143 Secondary 61.1 51.7 68.9 70.7 44.1 20.9 5,621 More than secondary 69.9 60.2 76.7 78.4 52.9 14.5 1,693 Wealth quintile Lowest 25.7 23.3 30.2 37.4 18.3 57.1 5,408 Second 33.8 30.1 38.6 46.5 24.3 47.3 5,052 Middle 45.1 40.4 52.2 58.2 33.4 35.1 4,311 Fourth 55.8 46.3 62.2 66.3 39.2 26.3 4,216 Highest 62.8 52.2 70.3 71.1 45.5 20.6 4,590 Total 43.6 37.6 49.6 54.9 31.4 38.4 23,578 The 2008 NDHS also collected information on men’s opinions concerning women’s participation in decision-making in five specified areas. Table 15.5.2 shows the percent distribution of married men age 15-49 who think that a wife should have greater or equal say (either alone or jointly with her husband) as her husband in specific household decisions. 246 | Women’s Empowerment and Health Outcomes Table 15.5.2 shows that almost half of the married men (46 percent) think that their wives should participate in decisions about purchases for daily household needs. This proportion is similar to the proportion of women in Table 15.5.1 who say that they do participate in decisions on purchases for daily needs (50 percent). Sixty-nine percent of men think that a wife should participate in decisions about how to spend the money she earns. Similarly, almost half the men (49 percent) think that a wife should have a say in deciding the number of children to have. Table 15.5.2 Men's attitude towards wives' participation in decision-making Percentage of currently married men age 15-49 who think a wife should have the greater say alone or equal say with her husband on five specific kinds of decisions, by background characteristics, Nigeria 2008 Specific decision Background characteristic Making major household purchases Making purchases for daily household needs Visits to her family or relatives What to do with the money the wife earns How many children to have All five decisions None of the five decisions Number of men Age 15-19 (8.4) (25.6) (39.7) (44.2) (28.4) (0.0) (20.6) 23 20-24 14.5 38.0 41.3 60.7 43.7 6.3 21.1 354 25-29 13.9 41.3 43.6 64.5 46.2 8.0 19.6 1,076 30-34 15.9 44.2 46.7 66.9 50.1 8.5 16.9 1,504 35-39 17.1 46.5 47.9 70.6 48.9 9.3 15.4 1,618 40-44 14.9 47.6 49.3 71.4 48.6 8.9 14.8 1,316 45-49 19.5 50.9 51.1 72.2 53.5 11.8 13.9 1,127 Employment (past 12 months) Not employed 30.9 70.7 62.6 74.2 64.0 22.2 7.2 83 Employed for cash 17.5 55.0 49.7 74.0 53.1 10.1 12.7 4,755 Employed not for cash 12.7 24.1 41.8 56.9 39.7 6.3 24.7 2,168 Missing * * * * * * * 13 Number of living children 0 17.4 44.0 49.5 63.4 49.9 9.5 18.9 747 1-2 16.6 48.1 46.4 69.5 49.3 9.2 16.2 2,308 3-4 16.4 47.9 49.7 71.3 53.2 9.9 14.3 1,996 5+ 15.0 41.1 45.4 67.1 44.3 8.0 17.6 1,968 Residence Urban 17.8 57.5 52.2 78.5 55.6 9.7 10.1 2,309 Rural 15.4 39.8 45.0 63.9 45.9 8.8 19.4 4,709 Zone North Central 21.7 52.5 48.7 72.2 50.7 11.6 13.8 1,040 North East 4.0 9.4 31.6 50.5 32.3 2.1 34.0 1,002 North West 5.9 20.4 48.1 63.9 38.3 3.7 22.6 1,951 South East 33.1 84.6 64.7 81.6 74.4 17.1 3.9 607 South South 38.5 81.4 56.2 69.0 61.5 24.4 6.0 989 South West 12.2 59.2 43.1 79.7 55.0 5.6 9.6 1,430 Education No education 7.4 20.2 41.2 56.4 35.2 4.2 29.3 1,917 Primary 16.6 47.9 46.1 68.1 48.8 8.9 15.6 1,806 Secondary 19.8 58.8 48.8 74.4 54.8 10.2 9.6 2,323 More than secondary 24.2 60.0 58.7 80.3 63.4 16.4 8.1 973 Wealth quintile Lowest 8.2 21.4 39.6 53.1 37.1 4.8 29.3 1,512 Second 12.2 31.5 43.5 62.7 42.0 5.2 20.9 1,378 Middle 18.8 47.6 47.8 69.0 47.7 10.3 15.5 1,244 Fourth 20.9 61.5 49.8 75.2 52.7 13.5 10.1 1,284 Highest 21.3 66.5 55.8 83.0 64.7 12.1 5.7 1,600 Total 15-49 16.2 45.6 47.4 68.7 49.1 9.1 16.3 7,018 50-59 18.6 47.4 48.0 70.5 46.9 11.4 16.9 1,599 Total 15-59 16.6 46.0 47.5 69.0 48.7 9.5 16.4 8,618 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Women’s Empowerment and Health Outcomes | 247 Nine percent of married men are of the opinion that wives, alone or jointly with their husband or partner, should participate in all five of the specified decisions. Among the zones, the highest proportion of men who think that wives should participate in all the specified decisions is in South South (24 percent), while men in the North East zone are least likely to have this opinion (2 percent). Men’s support of wives’ participation in decision-making increases with the man’s age and level of education. For instance, only 4 percent of men with no education believe that a wife should participate in all five decisions, compared with 16 percent of men with education beyond the secondary level. 15.4 ATTITUDES TOWARDS WIFE BEATING The 2008 NDHS collected information on the degree of acceptance of wife beating by asking whether a husband is justified in beating his wife in each of five situations: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sex with him. Tables 15.6.1 and 15.6.2 show the percentage of women and men who agree that a husband would be justified in hitting or beating his wife for these specific reasons. The last column on each table shows the percentages (of women or men) who feel that wife beating is justified for at least one of the specified reasons. A high proportion of women agreeing that wife beating is acceptable is an indication that women generally accept the right of a man to control his wife’s behaviour by means of violence. A low proportion agreeing that wife beating is acceptable indicates that the majority of women reject conduct and beliefs that places them at a low status relative to men. Table 15.6.1 shows that 43 percent of women find wife beating justified in certain circumstances; that is, they agree that at least one of the specified reasons justifies wife beating. The least likely reason women agreed to that justifies wife beating is burning the food (16 per cent). In contrast, a third of women (32 percent) report that a husband is justified in beating his wife if she goes out without telling him. Women who have never married are least likely to agree that wife beating is justified (32 percent) for any of the reasons. Women in urban areas are less likely to agree with at least one of the specified reasons than those in rural areas (31 and 50 percent, respectively). The North East zone has the highest proportion of women who say that wife beating is justified for at least one of the reasons (54 percent), while the South West zone has the lowest proportion (24 percent). Except for the South West zone, 40 percent or more of women agree that wife beating is justified for at least one of the specified reasons. Women with no education or with a primary education are almost three times as likely as women with more than a secondary education to agree that wife beating is justified for at least one reason (55 and 20 percent, respectively). Women in the highest wealth quintile (23 percent) are less likely than women in the other wealth quintiles to agree with at least one of the specified reasons for wife beating. 248 | Women’s Empowerment and Health Outcomes Table 15.6.1 Attitudes towards wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Nigeria 2008 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason Number of women Age 15-19 16.6 25.6 30.7 29.6 20.9 40.3 6,493 20-24 16.7 28.8 33.3 31.3 26.2 44.3 6,133 25-29 15.5 26.6 31.6 29.5 26.0 42.8 6,309 30-34 15.1 27.2 32.5 29.9 26.9 43.8 4,634 35-39 16.5 29.3 33.1 31.4 26.8 45.0 3,912 40-44 16.7 28.5 31.3 30.8 25.7 42.7 3,032 45-49 16.3 29.3 33.3 32.1 26.8 43.7 2,872 Employment (past 12 months) Not employed 16.7 26.2 31.3 28.7 24.2 40.4 12,408 Employed for cash 14.9 28.0 31.8 30.2 25.1 43.1 16,532 Employed not for cash 19.6 29.8 35.9 36.5 28.9 50.4 4,309 Missing 20.8 34.7 34.0 36.3 32.4 50.9 136 Marital status Never married 11.6 19.1 22.7 23.8 12.8 31.9 8,397 Married or living together 17.8 30.6 35.5 32.8 29.9 46.9 23,578 Divorced/separated/ widowed 16.1 28.4 32.4 31.8 23.9 44.2 1,409 Number of living children 0 13.2 22.0 25.8 25.3 17.0 35.2 10,392 1-2 16.9 28.5 33.7 31.5 27.4 45.1 8,352 3-4 16.4 29.1 33.8 31.3 28.3 45.1 7,591 5+ 19.4 33.2 38.0 35.9 31.9 49.9 7,049 Residence Urban 10.3 18.5 21.0 22.5 15.9 30.9 11,934 Rural 19.5 32.7 38.4 34.9 30.6 49.8 21,451 Zone North Central 20.5 29.8 38.8 39.4 31.4 47.1 4,748 North East 29.2 32.6 39.9 37.4 41.3 53.5 4,262 North West 18.2 37.0 40.5 32.4 39.8 53.3 8,022 South East 13.4 24.8 31.4 27.4 13.9 40.1 4,091 South South 11.6 25.0 30.9 31.7 16.4 42.0 5,473 South West 8.0 15.7 14.3 18.4 8.0 24.1 6,789 Education No education 21.9 37.0 42.5 36.8 39.9 54.9 11,942 Primary 19.4 31.8 36.4 36.0 26.3 48.0 6,566 Secondary 11.3 20.2 24.7 25.2 14.3 34.2 11,904 More than secondary 5.7 10.2 11.3 13.9 8.3 19.8 2,974 Wealth quintile Lowest 23.4 37.5 42.5 37.9 39.3 55.8 6,194 Second 21.3 35.1 41.2 36.9 35.8 53.3 6,234 Middle 19.8 32.1 39.8 36.4 28.4 49.4 6,341 Fourth 12.9 24.3 28.4 28.8 18.7 39.3 6,938 Highest 6.2 12.9 13.6 16.0 8.9 22.6 7,678 Total 16.2 27.6 32.2 30.5 25.3 43.0 33,385 Note: Total includes 1 woman with information missing on marital status Table 15.6.2 shows that fewer men than women aged 15-49 agree that wife beating is justified for at least one of the specified reasons (30 and 43 percent, respectively). There is an inverse relationship between men’s age and the proportion of men who agree that wife beating is justified for at least one reason; 35 percent of men age 15-19, compared with 24 percent of men age 45-49. Rural men are more likely to agree with wife beating for one of the specified reasons than their urban counterparts (33 versus 25 percent, respectively). By zones, North East has the highest proportion of men who say wife beating is justified for at least one of the reasons specified (44 percent), while North West has the lowest proportion (22 percent). Men with more than a secondary education are half as likely as men with a primary education to accept wife beating (17 percent compared with 34 percent, respectively). Women’s Empowerment and Health Outcomes | 249 Table 15.6.2 Attitudes towards wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Nigeria 2008 Husband is justified in hitting or beating his wife if she: Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason Number of men Age 15-19 10.7 20.1 21.5 22.2 11.8 34.7 2,532 20-24 10.2 19.7 21.7 21.7 13.0 34.0 2,378 25-29 8.3 17.0 19.1 20.6 11.7 31.1 2,459 30-34 8.1 14.5 17.4 18.2 10.3 27.3 2,058 35-39 7.4 14.9 17.5 18.6 9.5 26.7 1,794 40-44 6.6 14.4 16.3 17.1 10.9 26.9 1,413 45-49 7.1 11.9 14.3 15.2 9.8 24.1 1,174 Employment (past 12 months) Not employed 7.2 14.9 15.9 16.4 7.3 26.7 2,485 Employed for cash 6.3 13.8 15.5 17.7 8.4 26.4 7,465 Employed not for cash 14.1 23.5 27.1 25.7 19.2 39.5 3,832 Missing * * * * * * 26 Marital status Never married 9.2 18.2 19.4 20.5 10.8 31.6 6,548 Married or living together 8.1 15.0 18.1 18.7 11.4 28.4 7,018 Divorced/separated/ widowed 10.7 25.0 24.6 26.6 17.0 40.7 238 Number of living children 0 9.0 18.0 19.4 20.1 11.1 31.4 7,272 1-2 8.2 15.2 18.4 19.3 10.8 29.3 2,505 3-4 7.6 15.2 17.7 18.9 11.1 27.3 2,043 5+ 8.8 15.2 18.4 19.1 12.4 29.1 1,989 Residence Urban 5.8 13.5 13.4 16.5 7.8 24.6 5,215 Rural 10.4 18.7 22.1 21.6 13.3 33.4 8,593 Zone North Central 12.5 20.3 20.7 22.3 14.1 32.4 2,065 North East 17.1 29.3 28.2 27.4 29.6 44.0 1,645 North West 6.9 10.7 17.7 14.0 10.8 22.3 3,237 South East 7.9 17.6 23.5 20.5 6.7 37.2 1,448 South South 5.7 16.1 18.0 20.9 6.3 33.1 2,437 South West 5.9 13.8 11.9 18.3 5.7 23.4 2,977 Education No education 11.6 18.5 23.0 19.6 19.2 32.2 2,597 Primary 10.1 19.5 22.6 23.4 11.4 34.4 2,761 Secondary 8.3 17.6 18.4 20.9 10.0 31.6 6,470 More than secondary 3.7 7.3 9.2 10.3 4.5 16.5 1,979 Wealth quintile Lowest 14.5 23.5 26.1 24.1 20.6 38.6 2,275 Second 12.0 19.6 23.8 22.8 15.8 33.8 2,332 Middle 9.8 19.1 21.9 22.7 12.0 34.7 2,570 Fourth 6.9 15.1 18.2 19.0 8.0 28.6 3,163 Highest 3.3 9.9 9.0 12.9 4.4 20.0 3,468 Total 15-49 8.6 16.7 18.8 19.7 11.2 30.1 13,808 50-59 6.0 12.6 16.5 15.6 9.1 25.1 1,678 Total 15-59 8.4 16.3 18.6 19.2 11.0 29.6 15,486 Note: Total includes 3 men with information missing on marital status. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 250 | Women’s Empowerment and Health Outcomes 15.5 ATTITUDES TOWARDS REFUSING SEX WITH HUSBAND The extent of control women have over when and with whom they have sex has important implications for demographic and health outcomes such as the transmission of HIV and other sexually transmitted infections. It is also an indicator of women’s autonomy and status. To measure women’s agreement with the idea that a woman has the right to refuse to have sex with her husband, respondents were asked whether a wife is justified in refusing to have sex with her husband under three circumstances: she knows her husband has a sexually transmitted disease, she knows her husband has had sex with other women, and she is tired or not in the mood. Table 15.7.1 shows that almost half (47 percent) of women believe wives are justified in refusing sexual intercourse with their husband or partner for all of the specified reasons, while about one in ten women (12 percent) believe that a woman may not refuse to have sexual intercourse with her husband for any of the specified reasons. Knowledge that a husband has a sexually transmitted disease is the most widely accepted reason for refusing sexual relations (81 percent). Although knowing that a husband is having sexual intercourse with other women and a wife being tired or not in the mood for sexual intercourse are less accepted reasons, the majority of women still agree that these are justified reasons for refusing sex with their husbands (62 and 64 percent, respectively). There is little difference between women in urban and rural areas regarding a woman’s right to refuse sex with her husband or partner. For instance, 49 per cent of women in urban areas agreed with all the specified reasons, compared with 45 percent of women in rural areas who agree with all the specified reasons for a woman to refuse sex with her husband. However, zonal variations are pronounced. Women from the North East zone are least likely to agree with all of the reasons (38 percent), while those from the South West zone are most likely to agree (58 percent). Furthermore, the belief that wives are justified in refusing to have sexual intercourse for all of the specified reasons increases in a linear trend with education level from 39 percent among women with no education to 53 percent of women with more than secondary education. Table 15.7.2 shows the percentage of men who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by background characteristics. Men are more likely than women to agree that a wife is justified in refusing sex for all three of the specified reasons, 52 percent for men compared with 47 percent for women. Knowledge that a husband has a sexually transmitted disease is the reason most frequently given by men to justify a woman refusing sexual intercourse with her husband (87 percent), whereas knowing that the husband or partner is having intercourse with other women is the least cited reason (68 percent). Men who are divorced, separated, or widowed are least likely to agree with all the specified reasons for a wife to refuse sex (48 percent). By zone, men in South West are least likely to agree with all of the reasons that a wife is justified in refusing sex (44 percent), while those from South East are most likely to agree (68 percent). Men with no education are less likely to agree with all the specified reasons for a wife refusing intercourse with her husband (43 per cent) compared with men who have been educated. There is no clear pattern by wealth quintile among men who believe that wives are justified in refusing sex with their husbands for all three reasons. Men in the middle and fourth wealth quintiles are most likely to agree with all the specified reasons for a wife refusing intercourse with her husband (55 percent for both quintiles). Women’s Empowerment and Health Outcomes | 251 Table 15.7.1 Attitudes towards refusing sexual intercourse with husband: Women Percentage of all women age 15-49 who think that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Nigeria 2008 Wife is justified in refusing intercourse with her husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of women Age 15-19 72.2 58.9 57.3 43.3 19.6 6,493 20-24 81.3 63.4 63.9 47.0 10.8 6,133 25-29 83.6 63.0 64.9 47.5 9.4 6,309 30-34 83.5 62.8 66.6 48.1 10.3 4,634 35-39 84.3 61.6 65.4 46.8 9.7 3,912 40-44 83.0 61.6 65.9 47.6 10.4 3,032 45-49 83.7 61.6 65.7 48.7 10.9 2,872 Employment (past 12 months) Not employed 77.5 60.3 59.1 44.1 15.3 12,408 Employed for cash 84.4 63.5 66.9 48.9 9.4 16,532 Employed not for cash 78.4 59.7 64.8 46.0 13.0 4,309 Missing 71.4 60.2 54.6 38.5 16.7 136 Marital status Never married 75.0 60.5 66.4 48.0 16.4 8,397 Married or living together 82.9 62.1 62.4 45.9 10.7 23,578 Divorced/separated/ widowed 84.5 64.7 70.3 51.5 8.9 1,409 Number of living children 0 75.7 59.9 63.5 45.7 15.8 10,392 1-2 83.5 63.0 64.4 47.8 10.0 8,352 3-4 83.4 62.6 64.3 47.4 10.6 7,591 5+ 83.3 62.5 62.5 46.2 10.5 7,049 Residence Urban 82.2 63.6 68.6 49.0 9.5 11,934 Rural 80.3 60.8 61.0 45.4 13.5 21,451 Zone North Central 79.9 59.9 68.9 50.3 12.9 4,748 North East 79.3 60.0 48.8 38.1 13.7 4,262 North West 83.8 64.9 47.5 40.1 12.7 8,022 South East 71.5 60.2 68.4 45.4 15.9 4,091 South South 80.4 57.1 70.6 47.2 12.0 5,473 South West 85.7 65.6 80.1 57.9 7.4 6,789 Education No education 79.2 59.1 50.4 39.1 15.3 11,942 Primary 82.6 62.2 67.3 48.4 10.4 6,566 Secondary 81.0 63.7 71.7 51.8 10.9 11,904 More than secondary 84.6 64.6 77.4 53.4 7.3 2,974 Wealth quintile Lowest 77.2 57.6 50.3 38.4 16.8 6,194 Second 79.8 60.4 55.7 42.4 14.2 6,234 Middle 80.6 63.6 65.0 49.1 12.7 6,341 Fourth 83.0 63.8 71.5 50.8 9.2 6,938 Highest 83.5 63.2 72.8 51.1 8.5 7,678 Total 81.0 61.8 63.7 46.7 12.1 33,385 Note: Total includes 1 woman with information missing on marital status 252 | Women’s Empowerment and Health Outcomes Table 15.7.2 Attitudes towards refusing sexual intercourse with husband: Men Percentage of all men age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Nigeria 2008 Wife is justified in refusing intercourse with her husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of men Age 15-19 81.0 66.0 71.3 49.4 8.7 2,532 20-24 86.6 67.9 77.5 53.1 5.1 2,378 25-29 87.4 68.0 76.3 51.2 4.0 2,459 30-34 88.0 67.4 77.6 50.8 3.5 2,058 35-39 89.9 69.3 78.2 54.7 3.4 1,794 40-44 88.0 68.4 76.9 53.5 3.8 1,413 45-49 87.4 70.2 77.2 52.6 2.9 1,174 Employment (past 12 months) Not employed 87.1 65.2 78.1 53.9 6.1 2,485 Employed for cash 88.1 65.9 79.0 51.5 3.7 7,465 Employed not for cash 83.5 73.6 69.6 51.6 6.0 3,832 Missing * * * * * 26 Marital status Never married 85.0 65.9 75.9 50.9 6.0 6,548 Married or living together 88.1 70.2 76.5 53.1 3.5 7,018 Divorced/separated/ widowed 84.1 58.7 74.0 48.2 6.5 238 Number of living children 0 84.9 66.7 75.8 51.2 5.9 7,272 1-2 87.7 67.0 77.3 51.9 4.4 2,505 3-4 89.3 69.6 78.9 54.7 3.2 2,043 5+ 88.3 71.8 73.4 51.9 2.9 1,989 Residence Urban 87.2 66.0 81.3 53.2 4.1 5,215 Rural 86.2 69.1 73.1 51.2 5.1 8,593 Zone North Central 89.6 62.0 76.7 51.8 4.9 2,065 North East 85.3 84.7 72.3 58.5 2.8 1,645 North West 83.9 73.3 62.3 45.9 7.4 3,237 South East 88.8 77.8 87.9 68.2 2.9 1,448 South South 91.1 62.9 81.9 56.1 3.2 2,437 South West 83.3 56.3 82.7 43.7 5.0 2,977 Education No education 79.4 70.9 62.0 43.3 8.2 2,597 Primary 86.7 69.2 75.4 53.0 5.0 2,761 Secondary 88.2 66.3 79.8 53.9 4.1 6,470 More than secondary 90.6 67.6 84.1 55.3 2.1 1,979 Wealth quintile Lowest 80.5 71.1 65.1 46.3 7.6 2,275 Second 86.2 73.5 71.9 51.7 4.2 2,332 Middle 88.3 70.6 76.3 55.2 4.2 2,570 Fourth 88.1 66.7 78.5 54.8 5.1 3,163 Highest 88.1 61.2 84.2 50.8 3.5 3,468 Total 15-49 86.6 67.9 76.2 51.9 4.8 13,808 50-59 87.0 70.1 76.9 52.8 4.1 1,678 Total 15-59 86.6 68.2 76.3 52.0 4.7 15,486 Note: Total includes 3 men with information missing on marital status. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Table 15.7.3 shows the percentage of men who believe that a husband has the right to certain behaviours when his wife refuses to have sex with him when he wants her to. These behaviours include getting angry and reprimanding her, refusing her financial support, forcing her to have sex, and having sex with another woman. Almost half of men (47 percent) think that a man has no right to carry out any of the specified behaviours when his wife or partner refuses to have sexual intercourse with him. On the other hand, 2 percent of men think that a man has the right to engage in all of the specified behaviours when denied sex by his wife or partner. Women’s Empowerment and Health Outcomes | 253 Table 15.7.3 Men's attitudes towards a husband's rights when his wife refuses to have sexual intercourse Percentage of men age 15-49 who consider that a husband has the right to certain behaviours when his wife refuses to have sex with him when he wants her to, by background characteristics, Nigeria 2008 When a wife refuses to have sex with her husband, he has the right to: Background characteristic Get angry and reprimand her Refuse her financial support Use force to have sex Have sex with another woman Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of men Age 15-19 45.2 17.4 6.5 8.0 1.7 50.0 2,532 20-24 48.4 16.3 6.9 10.3 1.9 46.0 2,378 25-29 49.0 14.3 5.7 10.7 1.6 45.7 2,459 30-34 48.0 14.7 5.8 7.8 1.5 47.8 2,058 35-39 46.8 14.0 4.8 7.0 1.5 48.8 1,794 40-44 50.8 15.9 5.5 7.8 1.6 45.0 1,413 45-49 47.7 15.2 5.3 8.0 1.6 46.8 1,174 Employment (past 12 months) Not employed 36.5 11.1 3.4 8.2 0.9 58.8 2,485 Employed for cash 45.1 12.1 3.9 8.7 1.0 49.9 7,465 Employed not for cash 60.5 24.9 11.4 9.1 3.3 34.7 3,832 Missing * * * * * * 26 Marital status Never married 44.9 14.8 5.7 9.5 1.6 49.9 6,548 Married or living together 50.5 16.0 6.1 7.7 1.7 45.0 7,018 Divorced/separated/ widowed 51.6 17.4 7.3 17.4 1.3 39.1 238 Number of living children 0 45.6 15.1 5.9 9.2 1.6 49.3 7,272 1-2 48.3 15.2 5.7 8.7 1.5 47.0 2,505 3-4 48.1 14.2 5.2 8.0 1.4 47.3 2,043 5+ 55.3 18.4 7.0 7.7 2.1 40.1 1,989 Residence Urban 43.2 13.2 3.9 8.0 1.0 52.1 5,215 Rural 50.7 16.8 7.1 9.1 2.0 44.3 8,593 Zone North Central 38.7 14.7 5.8 10.5 1.6 54.2 2,065 North East 75.7 34.2 21.5 11.6 8.4 21.9 1,645 North West 68.6 22.2 5.5 2.7 1.0 29.8 3,237 South East 45.6 6.7 3.6 5.4 0.7 50.1 1,448 South South 35.0 5.8 3.2 11.9 0.3 58.6 2,437 South West 27.8 10.5 1.1 11.4 0.1 64.7 2,977 Education No education 62.9 25.4 11.6 7.5 4.1 34.3 2,597 Primary 53.2 15.2 6.9 8.8 1.4 41.7 2,761 Secondary 42.1 13.4 4.3 9.8 1.1 51.8 6,470 More than secondary 39.3 9.5 2.3 6.6 0.7 57.0 1,979 Wealth quintile Lowest 59.8 24.6 12.5 9.9 4.0 35.4 2,275 Second 58.0 21.2 8.7 10.0 2.5 36.4 2,332 Middle 49.9 15.4 5.3 7.8 1.5 46.2 2,570 Fourth 43.8 11.6 3.8 8.4 0.9 51.1 3,163 Highest 35.3 9.2 2.1 7.9 0.3 59.6 3,468 Total 15-49 47.8 15.5 5.9 8.7 1.6 47.3 13,808 50-59 48.5 14.6 4.6 7.4 1.9 47.7 1,678 Total 15-59 47.9 15.4 5.8 8.6 1.7 47.3 15,486 Note: Total includes 3 men with information missing on marital status. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 254 | Women’s Empowerment and Health Outcomes Getting angry and reprimanding the wife is thought of as the most accepted behaviour by a husband when a wife refuses to have sex with him (48 percent). Fifteen percent of men think that a husband has the right to deny his wife financial support, 9 percent believe that he has the right to have sex with another woman if his wife refuses to have sex with him, and 6 percent believe he has the right to force his wife or partner to have sex with him. Among zones, the highest percentage of men who think a man has no right to behave in any of the specified manners when his wife or partner refuses to have sexual intercourse reside in South West (65 percent). North East has the lowest percentage of men who agree with all of the specified behaviour (22 percent). Men with more than a secondary education (57 percent) and those in the highest wealth quintile (60 percent) are more likely than other men to believe that a man is not justified in carrying out any of the specified behaviours if his wife or partner refuses to have sex with him. 15.6 WOMEN’S EMPOWERMENT INDICATORS The three sets of empowerment indicators, namely women’s participation in making household decisions, their attitude towards wife beating, and their attitude towards a wife’s right to refuse sexual intercourse with her husband or partner can be summarised in three separate indices. The first index shows the number of decisions (see Table 15.5.1 for the list of decisions) in which women participate either alone or jointly with their husband or partner. This index ranges from 0 to 4 and is positively related to women’s empowerment. It reflects the degree of decision-making control that women are able to exercise in areas that affect their own lives. The second index, which ranges from 0 to 5, is the number of reasons (see Table 15.6.1 for a list of reasons) for which a woman thinks that a husband is justified in beating his wife. A lower score on this indicator is interpreted as reflecting a greater sense of entitlement and self esteem, and higher status of women. The final index, which ranges in value from 0 to 3, is the number of circumstances (see Table 15.7.1 for the list of circumstances) in which the respondent feels that a woman is justified in refusing sexual intercourse with her husband or partner. This indicator reflects perceptions of sexual roles and women’s right over their bodies and relates positively to women’s sense of self and empowerment. Table 15.8 shows how these indices relate to each other. Some associations are observed between the indices. More participation in decision-making is associated with agreeing on a woman’s right to refuse sexual intercourse with her husband or partner. Women with more say in decision- making are more likely to agree that a woman is justified in refusing sexual relations with her husband for all the specified reasons than women with no say at all (56 and 36 percent, respectively). Disapproval of wife beating is also associated with participation in all household decision-making and agreement that a woman has a right to refuse sex with her husband. Women who think there is no justifiable reason to beat a wife are more likely to participate in all household decisions than women who think that a husband is justified in beating his wife for any or all of the specified reasons (36 and 22 percent, respectively). In addition, women who do not agree with any of the five reasons for justifying wife beating are more likely to agree that a woman has a right to refuse sex with her husband than women who agree with all five justifications for wife beating (63 and 58 percent, respectively). Women’s Empowerment and Health Outcomes | 255 Table 15.8 Indicators of women's empowerment Percentage of women age 15-49 who participate in all decision-making, percentage who disagree with all reasons for justifying wife-beating, and percentage who agree with all reasons for refusing sexual intercourse with husband, by value on each of the indicators of women's empowerment, Nigeria 2008 Currently married women Empowerment indicator Percentage who participate in all decision- making1 Number of women Percentage who disagree with all the reasons justifying wife beating Percentage who agree with all the reasons for refusing sexual intercourse with husband Number of women Number of decisions in which women participate1 0 na na 48.6 36.4 9,047 1-2 na na 45.6 43.0 4,680 3-4 na na 60.8 56.1 9,851 Number of reasons for which wife beating is justified2 0 36.2 12,514 na 47.2 19,016 1-2 29.9 4,244 na 49.6 5,767 3-4 24.5 3,867 na 44.6 4,998 5 22.1 2,953 na 42.4 3,605 Number of reasons given for refusing to have sexual intercourse with husband3 0 23.0 2,523 63.4 na 4,025 1-2 25.0 10,223 54.4 na 13,768 3 39.4 10,832 57.5 na 15,592 na = Not applicable 1 Restricted to currently married women. See Table 15.5.1 for specific decisions. 2 See Table 15.6.1 for reasons justifying wife beating. 3 See Table 15.7.1 for reasons justifying wife refusing to have sexual intercourse with husband. 15.7 CURRENT USE OF CONTRACEPTION BY WOMAN’S EMPOWERMENT STATUS A woman’s desire and ability to control her fertility and her choice of contraceptive methods are in part affected by her status in the household and her own sense of empowerment. A woman who is unable to control other aspects of her life may be less able to make decisions regarding her fertility. She may also feel the need to choose contraceptive methods that are less obvious or do not need the approval of her husband. Table 15.9 shows the relationship of each of the three empowerment indicators with current use of contraceptive methods by married women. The expected relationships are observed between contraceptive use and both disagreement with reasons for wife beating and agreement with reasons for refusing sexual intercourse with the husband. Use of any contraceptive method and use of any modern method increases as the number of reasons for which wife beating is justified decreases. Twenty-three percent of women who participate in 3-4 household decisions use a method of family planning, and 15 percent use a modern method. Eighteen percent of women who do not agree with any of the reasons for justifying wife beating are currently using a contraceptive method, compared with 6 percent of women who agree with all five reasons justifying wife beating. 256 | Women’s Empowerment and Health Outcomes Use of any method and use of any modern method of contraception increase with the number of reasons the respondent thinks a woman is justified in refusing sex with her husband. For example, the percentage of women using any method of contraception increases from 8 percent among women who do not agree with any of the reasons for which a woman can refuse sex with her husband to 17 percent among women who agree with all three reasons for refusing sex. Table 15.9 Current use of contraception by women's status Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women's status, Nigeria 2008 Modern methods Empowerment indicator Any method Any modern method Female sterilisation Temporary modern female methods1 Male condom Any traditional method Not currently using Total Number of women Number of decisions in which women participate2 0 6.2 4.5 0.2 3.1 1.2 1.7 93.8 100.0 9,047 1-2 13.2 8.8 0.2 6.5 2.0 4.5 86.8 100.0 4,680 3-4 23.0 14.9 0.6 10.5 3.8 8.1 77.0 100.0 9,851 Number of reasons for which wife beating is justified3 0 18.3 11.8 0.4 8.3 3.1 6.5 81.7 100.0 12,514 1-2 13.5 9.4 0.5 6.7 2.2 4.1 86.5 100.0 4,244 3-4 9.9 7.0 0.3 5.0 1.7 2.9 90.1 100.0 3,867 5 6.4 4.6 0.4 3.3 0.9 1.8 93.6 100.0 2,953 Number of reasons given for refusing to have sexual intercourse with husband4 0 7.9 5.8 0.1 4.0 1.7 2.2 92.1 100.0 2,523 1-2 13.8 9.0 0.4 6.4 2.2 4.8 86.2 100.0 10,223 3 16.9 11.3 0.5 7.9 2.9 5.6 83.1 100.0 10,832 Total 14.6 9.7 0.4 6.9 2.4 4.9 85.4 100.0 23,578 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly, and lactational amenorrhoea method 2 Restricted to currently married women. See Table 15.5.1 for specific decisions. 3 See Table 15.6.1 for reasons justifying wife beating. 4 See Table 15.7.1 for reasons justifying wife refusing to have sexual intercourse with husband. 15.8 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS Women’s fertility preferences (e.g., ideal number of children) are typically lower than those of their husband or partner. As a woman becomes more empowered to negotiate fertility decision- making, she has more control over contraceptive use and, thus, over her chances of becoming pregnant and giving birth. Women who have a desire to space or limit their births, but are not using family planning, are defined as having unmet need for family planning. Table 15.10 shows how women’s ideal family size and their unmet need for family planning vary by the three indicators of women’s status. The results show that women who participate in 3-4 decisions have the lowest desired family size (5.9 children) and a relatively higher unmet need for family planning for purposes of limiting births (7 percent), compared with women who do not participate in any decisions. However, they have a lower unmet need for spacing their children (13 percent) than other women. Conversely, women who do not participate in any decision-making have a lower unmet need for limiting, but a higher unmet need for spacing. Interestingly, women who participate in one or two decisions have a higher unmet need for family planning services (16 percent for spacing and 6 percent for limiting). Women’s Empowerment and Health Outcomes | 257 Desired family size increases with the number of reasons a woman thinks that wife beating is justified, from 5.6 children among women who do not agree with any of the reasons justifying wife beating to 7.6 children among women who agree with all five reasons justifying wife beating. Total unmet need for family planning is about the same (20 percent) for women who think that wife beating is not justified for any reason and for those who agree with all five reasons justifying wife beating. The number of reasons for which a respondent thinks that women can refuse sexual intercourse with their husband is not strongly associated with desired family size or unmet need. Table 15.10 Women's empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women's empowerment, Nigeria 2008 Percentage of currently married women with an unmet need for family planning2 Empowerment indicator Mean ideal number of children1 Number of women For spacing For limiting Total Number of currently married women Number of decisions in which women participate3 0 7.8 6,935 16.9 3.0 19.9 9,047 1-2 6.7 4,136 15.7 5.8 21.5 4,680 3-4 5.9 8,823 13.0 6.9 19.9 9,851 Number of reasons for which wife beating is justified4 0 5.6 16,728 14.1 5.4 19.5 12,514 1-2 6.4 5,036 16.6 5.4 21.9 4,244 3-4 6.8 4,293 15.5 5.3 20.9 3,867 5 7.6 2,817 16.1 3.8 19.9 2,953 Number of reasons given for refusing to have sexual intercourse with husband5 0 6.1 3,171 17.3 4.2 21.6 2,523 1-2 6.4 11,757 14.8 4.6 19.4 10,223 3 5.9 13,947 14.7 6.0 20.7 10,832 Total 6.1 28,874 15.0 5.2 20.2 23,578 1 Mean excludes respondents who gave non-numeric responses. 2 See table 7.3.1 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 15.5.1 specific decisions. 4 See Table 15.6.1 for reasons justifying wife beating. 5 See Table 15.7.1 for reasons justifying wife refusing sexual intercourse with husband. 15.9 WOMEN’S STATUS AND REPRODUCTIVE HEALTH CARE In countries where health care is widespread, women’s empowerment may not affect their access to reproductive health services. However, in other countries, increased empowerment of women is likely to increase their ability to seek out and use health services to better meet their reproductive health goals, including safe motherhood. Table 15.11 shows women’s use of antenatal, delivery, and postnatal care services from health care workers by level of empowerment as measured by the three indicators of women’s status 258 | Women’s Empowerment and Health Outcomes Table 15.11 Reproductive health care by women's empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance and postnatal care from health personnel for the most recent birth, by indicators of women's empowerment, Nigeria 2008 Empowerment indicator Received antenatal care from health personnel Received delivery assistance from health personnel Received postnatal care from health personnel within the first two days since delivery1 Number of women with a child born in the last five years Number of decisions in which women participate2 0 42.0 23.3 17.4 6,677 1-2 55.8 38.7 29.1 3,357 3-4 73.4 57.6 43.9 6,642 Number of reasons for which wife beating is justified3 0 64.9 48.9 38.3 9,121 1-2 52.7 37.0 26.5 3,237 3-4 48.9 31.5 22.2 2,995 5 47.6 24.3 16.8 2,282 Number of reasons given for refusing to have sexual intercourse with husband4 0 42.9 26.8 17.9 1,829 1-2 54.5 35.9 26.2 7,597 3 64.0 48.0 37.5 8,209 Total 57.7 40.6 30.6 17,635 Note: Health personnel includes doctor, nurse, midwife, or auxiliary nurse, or auxiliary midwife. 1 Includes deliveries in a health facility and not in a health facility 2 Restricted to currently married women. See Table 15.5.1 specific decisions. 3 See Table 15.6.1 for reasons justifying wife beating. 4 See Table 15.7.1 for reasons justifying wife refusing sexual intercourse with husband. The results show the expected association between women’s empowerment and use of services for delivery and postnatal care. The more decisions a woman participates in, the more likely she is to have received assistance during delivery and postnatal care; for example, 42 percent of women who do not participate in household decisions received delivery assistance from health personnel, compared with 73 percent of women who participated in all four decisions. The lower the number of reasons for which a woman thinks that wife beating is justified, the more likely she is to receive care from health personnel during delivery. Similarly, the higher the number of reasons for which a respondent believes a woman can refuse to have sex with her husband, the more likely she is to receive health care from health personnel during delivery. The same relationships are observed for the likelihood of receiving postnatal care. 15.10 WOMEN’S STATUS AND EARLY CHILDHOOD MORTALITY As women become more empowered, they are more likely to participate in key decisions regarding their well-being and the well-being of their children. Table 15.12 shows child mortality rates by the three indicators of women’s status. Women’s Empowerment and Health Outcomes | 259 The results show that children of women who participate in 3-4 decisions have the lowest infant mortality (77 deaths per 1,000 live births), child mortality (122 deaths per 1,000 live births), and under-five mortality (203 deaths per 1,000) rates. The trend is the same for agreement with the number of reasons a woman thinks wife beating is justified. However, the differentials in child mortality rates by the number of reasons given by women for refusing to have sexual intercourse with their husband are smaller than for the other two indexes. Table 15.12 Early childhood mortality rates by women's status Infant, child, and under-five mortality rates for the 10-year period preceding the survey, by indicators of women's status, Nigeria 2008 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which women participate1 0 92 122 203 1-2 94 96 181 3-4 77 60 133 Number of reasons for which wife beating is justified2 0 82 78 154 1-2 96 95 182 3-4 89 106 186 5 86 122 198 Number of reasons given for refusing to have sexual intercourse with husband3 0 83 98 173 1-2 93 103 186 3 81 80 155 1 Restricted to currently married women. See Table 15.5.1 for specific decisions. 2 See Table 15.6.1 for reasons justifying wife beating. 3 See Table 15.7.1 for reasons justifying wife refusing sexual intercourse with husband. Domestic Violence | 261 DOMESTIC VIOLENCE 16 Domestic violence is a confrontation between family or household members that typically involves physical harm, sexual assault, or fear of physical harm. Family or household members include spouses, former spouses, those in (or formerly in) a dating relationship, adults related by blood or marriage, and those who have a biological or legal parent-child relationship. Domestic violence can include physical and sexual abuse, emotional abuse, economic abuse, coercion and threats, intimidation, isolation, jealousy, and blame. Violence against women has been acknowledged worldwide as a violation of basic human rights. An increasing amount of research highlights the health burdens, intergenerational effects, and demographic consequences of such violence (United National General Assembly, 1991; Heise et al., 1994, 1998; Jejeebhoy, 1998). Gender-based violence is defined as any act of violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivations of liberty, occurring in public or private life (United Nations, 1993 and 1995). Despite ongoing efforts to protect women and vulnerable populations against violence, there is still much to be done to protect victims and to further inform and educate the population about the problem. Nigeria is a signatory to the United Nation’s Convention on the Elimination of all Forms of Discrimination against Women (CEDAW). However, CEDAW has not yet been adopted into Nigeria’s legal code. In order for this to happen, the National Assembly and State Houses of Assembly are required to pass legislation and put the convention into effect within the national laws. After the law is passed at the federal level, for it to become a nationally binding legislation across the country, it must be passed by at least two-thirds of the 36 State Houses of Assembly. Gender activists, civil society organisations, and women-focused NGOs have formed a coalition known as the National Coalition on Affirmative Action (NCAA) with representation from all over the country. The NCAA has begun active lobbying and sensitisation of legislators in the National and State Assemblies across the nation in preparation for the consideration of the bill. This initiative aims to expedite the passage of the CEDAW Bill at the state level and secure the requisite assent by a two-thirds majority of the State Houses of Assembly. The 2008 NDHS included a special module designed to obtain information on the extent to which women in Nigeria experience domestic violence. These findings may provide evidence that can be used in advocating for improved legislation on domestic violence, such as the CEDAW bill, expansion of domestic violence prevention efforts, and improved services for women who experience domestic violence. The domestic violence module was administered to one eligible woman randomly selected in each household using the Kish Grid technique (Kish, 1965). Although the module focused on the extent of marital violence, information was also obtained on any physical violence involving perpetrators other than the woman’s current husband (or the last husband for separated or divorced women) that a woman might have experienced since her fifteenth birthday. Women were also asked about lifetime experience of sexual violence. Women who reported recent marital violence were asked about assistance they have received, whether they ever told anyone about the violence, and whether they ever sought help. The collection of information on domestic violence is challenging because women may not disclose these experiences out of shame or fear. Collection of such sensitive information requires the establishment of rapport between the interviewer and the respondent. The interviewers received special training on gender-based violence, focusing on domestic violence, to prepare them to collect information on domestic violence. Interviewers were instructed that interviews can only proceed when 262 | Domestic Violence maximum privacy had been secured. If privacy was not assured, the questions in the domestic violence module were not to be asked. The selection of one respondent per household for domestic violence questions is an additional ethical protection for the respondent which strengthens the confidentiality of the information discussed with the interviewer. 16.1 WOMEN EXPERIENCING PHYSICAL VIOLENCE A total of 21,468 women were asked questions on domestic violence in the 2008 NDHS. In Nigeria, domestic violence cuts across all socio-economic and cultural backgrounds. Table 16.1 shows the percentage of women age 15-49 who have ever experienced physical violence since age 15, and the percentage who have experienced physical violence during the 12 months preceding the survey, by background characteristics. The results show that 28 percent of all women experienced physical violence since the age of 15, and 15 percent of women experienced physical violence in the 12 months preceding the survey. The experience of physical violence varies substantially by background characteristics. The trend by age group indicates an increase in physical violence from the 15-19 age group through the 25-29 age group, and a decrease thereafter. Thirty percent of women age 25-29 have experienced physical violence at some time since age 15, while 16 percent experienced violence during the 12 months preceding the survey. Women who are employed but are not paid in cash are more likely than other women to have ever experienced physical violence since age 15 and during the 12 months preceding the survey (38 and 23 percent, respectively). It is interesting to note that unemployed women are the least likely to experience physical violence, with 23 percent having experienced violence since age 15 and 13 percent experiencing physical violence during the 12 months preceding the survey. By marital status, women who are divorced, separated or widowed are far more likely to have experienced physical violence than other women. Forty-four percent of divorced, separated or widowed women reported experiencing violence since age 15, compared with 25 percent of women who are married or living together, and 33 percent of never-married women. Differentials in experience of physical violence by number of living children are small; however, women with no children (30 percent) are more likely to have experienced physical violence since age 15 than other women. Experience of physical violence in the past 12 months tends to increase with number of living children. Women in urban areas are more likely than their rural counterparts to report having experienced physical violence since age 15 (30 percent as compared with 26 percent). There is notable variation in experience of physical violence by zone. Experience of physical violence since age 15 is reported by the highest proportion of women in South South (52 percent) compared with only 13 percent of women in North West. The proportion of women experiencing physical violence in the past 12 months is again highest in the South South (24 percent) and lowest in North West (6 percent). Women with primary and secondary levels of schooling are more likely than other women to have experienced physical violence since age 15. Women who never attended school are the least likely to have experienced physical violence since age 15 (15 percent). A similar pattern is observed for physical violence in the past 12 months. Experience of physical violence generally increases with wealth quintile. A slight decrease is observed in physical violence in the past 12 months between the fourth and highest quintiles. Domestic Violence | 263 Table 16.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced physical violence during the 12 months preceding the survey, by background characteristics Nigeria 2008 Percentage who have experienced physical violence in the past 12 months Background characteristic Percentage who have ever experienced physical violence since age 151 Often Sometimes Often or sometimes Number of women Current age 15-19 26.7 1.8 14.4 16.2 3,865 20-24 28.2 1.7 12.7 14.4 3,881 25-29 30.0 1.9 14.1 16.0 4,201 30-39 27.4 1.9 13.0 14.9 5,718 40-49 25.9 1.8 11.5 13.4 3,802 Employed past 12 months Not employed 23.2 1.3 11.6 12.9 7,726 Employed for cash 28.1 1.9 12.6 14.4 10,938 Employed not for cash 38.4 3.2 19.8 23.0 2,752 Missing 26.4 3.8 13.1 16.9 52 Marital status Never married 33.2 1.5 14.0 15.5 4,705 Married or living together 25.1 1.7 13.0 14.7 15,852 Divorced/separated/widowed 44.0 5.7 11.7 17.3 910 Number of living children 0 30.0 1.5 13.0 14.5 6,094 1-2 27.3 2.0 12.7 14.7 5,665 3-4 26.1 2.1 13.2 15.3 5,110 5+ 26.8 1.9 13.7 15.6 4,598 Residence Urban 30.2 2.0 12.7 14.7 7,592 Rural 26.3 1.7 13.4 15.1 13,875 Zone North Central 31.0 2.5 17.5 20.0 3,176 North East 19.7 2.1 12.5 14.6 2,859 North West 13.1 0.5 5.9 6.4 5,446 South East 29.6 2.2 13.4 15.6 2,501 South South 52.1 3.0 20.9 23.9 3,342 South West 28.9 1.8 13.4 15.1 4,146 Education No education 14.9 1.3 8.6 9.9 8,033 Primary 35.6 2.8 17.4 20.2 4,308 Secondary 36.5 2.2 16.6 18.8 7,268 More than secondary 30.1 0.7 9.5 10.2 1,858 Wealth quintile Lowest 18.8 1.4 11.3 12.7 4,177 Second 21.3 1.8 10.9 12.7 4,123 Middle 29.3 2.0 14.0 16.0 4,075 Fourth 34.1 2.2 15.7 17.9 4,361 Highest 33.7 1.8 13.6 15.4 4,732 Total 27.7 1.8 13.1 15.0 21,468 1 Includes in the past 12 months 264 | Domestic Violence 16.2 PERPETRATORS OF PHYSICAL VIOLENCE Table 16.2 shows for women who experienced physical violence since age 15, the percentage who reported that specific persons committed the violence, according to marital status. The most commonly reported perpetrator of physical violence is the current husband or partner. A total of 45 percent of women who experienced violence since age 15 experienced violence from their current husband or partner, while 7 percent reported that violence was committed against them by their former husband or partner. Among ever-married women, 61 percent reported their current husband or partner committed physical violence against them, and 9 percent reported their former husband or partner did so. Among all women who experienced physical violence, the next most commonly mentioned perpetrator is mother or stepmother (30 percent), followed by father or stepfather (22 percent), and sister or brother (19 percent). Among never-married women, mother or stepmother was mentioned as the most common perpetrator of physical violence (43 percent). 16.3 EXPERIENCE OF SEXUAL VIOLENCE The 2008 NDHS asked women whether they had ever experience sexual violence in their lifetime. As shown in Table 16.3, 7 percent of women age 15-49 reported that they had experienced sexual violence at some time. There is no pronounced difference among the age groups. The experience of sexual violence ranges from 6 percent among women age 30-49 to 9 percent among women age 20-24. Women who are employed but not paid in cash are the most likely to have experienced sexual violence (11 percent), while unemployed women are least likely (6 percent). In examining marital status, women who are divorced, separated or widowed women are most likely to have experienced sexual violence (11 percent), and women who are currently married are least likely (6 percent). Nine percent of never-married women have experienced sexual violence. There is no difference in the experience of sexual violence by urban-rural residence; however, the differentials by zone are notable. By zone, the experience of sexual violence ranges from 3 percent in North West and South West to 12 percent in South East and 13 percent in South South. The experience of sexual violence is lower among women with no education (4 percent) than among women who have been to school (8-9 percent). Women in the three highest wealth quintiles are more likely to have experienced sexual violence than women in the two lowest wealth quintiles. Table 16.2 Persons committing physical violence Among women age 15-49 who have experienced physical violence since age 15, percentage who report specific persons who committed the violence, according to the respondent's marital status, Nigeria 2008 Marital status Person Ever married Never married Total Current husband/partner 60.6 na 44.7 Former husband/partner 9.0 na 6.6 Current boyfriend 0.2 0.9 0.4 Former boyfriend 1.2 3.1 1.7 Father/step-father 18.7 31.0 21.9 Mother/step-mother 25.7 42.5 30.1 Sister/brother 14.1 31.7 18.7 Daughter/son 0.2 0.3 0.2 Other relative 5.7 11.3 7.1 Mother-in-law 0.4 na 0.3 Father-in-law 0.1 na 0.1 Other in-law 1.9 na 1.6 Teacher 11.4 29.5 16.2 Employer/someone at work 0.5 1.6 0.8 Police/soldier 0.1 0.2 0.2 Other 2.1 5.0 2.8 Number of women 4,377 1,564 5,941 na = Not applicable Domestic Violence | 265 Table 16.3 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence, by background characteristics, Nigeria 2008 Background characteristic Percentage who have ever experienced sexual violence1 Number of women Current age 15-19 6.6 3,865 20-24 8.7 3,881 25-29 7.8 4,201 30-39 6.4 5,718 40-49 5.9 3,802 Employed past 12 months Not employed 5.8 7,726 Employed for cash 7.0 10,938 Employed not for cash 10.5 2,752 Missing 8.1 52 Marital status Never married 9.4 4,705 Married or living together 6.2 15,852 Divorced/separated/widowed 10.7 910 Residence Urban 6.9 7,592 Rural 7.1 13,875 Zone North Central 7.7 3,176 North East 8.6 2,859 North West 2.7 5,446 South East 11.8 2,501 South South 13.4 3,342 South West 3.2 4,146 Education No education 4.1 8,033 Primary 8.9 4,308 Secondary 8.9 7,268 More than secondary 8.1 1,858 Wealth quintile Lowest 5.8 4,177 Second 5.3 4,123 Middle 8.3 4,075 Fourth 8.4 4,361 Highest 7.2 4,732 Total 7.0 21,468 1 Includes those whose sexual initiation was forced against their will 16.4 AGE AT FIRST EXPERIENCE OF SEXUAL VIOLENCE Table 16.4 shows the distribution of women age 15-49 years who have experienced sexual violence by age at first experience of sexual violence, according to current age. The results show that 14 percent of women age 15-49 experienced sexual violence for the first time between the ages of 10 and 14, while 26 percent experienced sexual violence for the first time between the ages of 15 and 19. 266 | Domestic Violence Table 16.4 Age at first experience of sexual violence Percent distribution of women age 15-49 who have experienced sexual violence by age at first experience of sexual violence, according to current age, Nigeria 2008 Age at first experience of sexual violence Current age Less than 10 years 10-14 years 15-19 years 20-49 years Don't know1 Missing Total Number of women 15-19 5.1 22.9 44.8 na 26.6 0.6 100.0 256 20-24 0.9 15.0 34.3 14.7 33.6 1.7 100.0 339 25-29 0.8 12.0 22.6 16.4 47.4 0.8 100.0 329 30-39 3.1 12.8 13.9 11.7 57.3 1.2 100.0 365 40-49 3.3 9.8 14.1 10.8 61.8 0.2 100.0 224 Total 2.5 14.4 25.6 11.3 45.3 1.0 100.0 1,513 na = Not applicable 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed and whose sexual initiation was not forced against their will. For these women, the age at first experience of sexual violence is not known. 16.5 PERSONS COMMITTING SEXUAL VIOLENCE Table 16.5 shows for women who have ever experienced sexual violence, the percentage who reported that specific persons committed the sexual violence against them by age at first experience of sexual violence and current marital status. Overall, current husband or partner is the most commonly reported perpetrator of sexual violence, reported by 36 percent of women. Among ever-married women who have ever experienced sexual violence, the proportion who says that their current husband or partner committed sexual violence against them increases to 50 percent. Among never- married women, strangers are the most commonly reported perpetrators of sexual violence (23 percent), followed by a friend or acquaintance (18 percent) and current or former boyfriend (17 percent). The type of perpetrator does not vary much by age at first experience of sexual violence. Table 16.5 Persons committing sexual violence Among women age 15-49 who have experienced sexual violence, percentage who report specific persons committing sexual violence according to age at first experience of sexual violence and current marital status, Nigeria 2008 Age at first experience of sexual violence Marital status Person committing sexual violence <15 years 15 years or higher Don't know1 Ever married Never married Total Current husband/partner 2.7 6.9 71.6 50.3 na 35.7 Former husband/partner 1.2 1.4 7.2 5.6 na 4.0 Current/former boyfriend 10.3 22.6 1.1 7.9 17.3 10.6 Father 0.3 0.0 0.1 0.1 0.0 0.1 Step father 0.5 0.0 0.0 0.1 0.0 0.1 Other relative 11.1 5.5 0.5 3.3 6.4 4.2 In-law 1.5 1.0 0.0 0.7 0.5 0.6 Own friend/acquaintance 12.4 19.3 1.8 6.9 17.6 10.0 Family friend 7.2 9.5 0.6 3.2 9.4 5.0 Teacher 1.5 2.6 0.0 0.7 2.4 1.2 Employer/someone at work 0.2 0.3 0.0 0.1 0.3 0.1 Police/soldier 0.7 0.3 0.0 0.2 0.4 0.2 Priest/religious leader 1.1 0.2 0.0 0.1 0.7 0.3 Stranger 27.8 21.8 2.3 10.2 23.3 14.0 Other 4.0 2.5 0.3 1.7 2.0 1.8 Number of women 255 558 685 1,073 440 1,513 Note: Total includes 19 unweighted cases for which age at first experience of sexual violence is missing. na = Not applicable 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed and whose sexual initiation was not forced against their will. For these women, the age of first experience of sexual violence is not known. Domestic Violence | 267 16.6 EXPERIENCE OF DIFFERENT FORMS OF VIOLENCE Table 16.6 presents information on women age 15-49 who reported experiencing various combinations of physical and sexual violence, by current age. Overall, 30 percent of women reported that they had experienced either physical or sexual violence. About one in five women experienced only physical violence, 2 percent experienced only sexual violence, and 5 percent experienced both physical and sexual violence. There is not much variation in the experience of different forms of violence by age. Table 16.6 Experience of different forms of violence Percentage of women age 15-49 who have experienced different forms of violence by current age, Nigeria 2008 Age Physical violence only Sexual violence only1 Physical and sexual violence1 Physical or sexual violence1 Number of women 15-19 21.9 1.8 4.8 28.5 3,865 15-17 21.2 1.7 4.4 27.3 2,249 18-19 22.8 2.0 5.3 30.2 1,616 20-24 22.0 2.5 6.2 30.7 3,881 25-29 23.8 1.6 6.2 31.7 4,201 30-39 22.6 1.5 4.8 29.0 5,718 40-49 21.5 1.5 4.4 27.4 3,802 Total 22.4 1.8 5.3 29.5 21,468 1 Includes forced sexual initiation 16.7 VIOLENCE DURING PREGNANCY Respondents to the Domestic Violence module who had ever been pregnant (whether the pregnancy resulted in a live birth or not) were asked specifically whether they have ever experience physical violence while pregnant and, if so, who the perpetrators of the violence were. As shown in Table 16.7, 5 percent of women who have ever been pregnant reported that they experienced violence while pregnant. Women who are divorced, separated, or widowed are more likely than other women to have experienced violence during pregnancy (12 percent). Five percent of currently married women have experienced violence during pregnancy. The proportion of never- married women who had a pregnancy and who reported that they ever experienced violence while pregnant was negligible. Women with living children are more likely than women with no living children to have experienced violence during pregnancy. In urban and rural areas, women were roughly equally likely to have experienced physical violence during pregnancy. By zone, women in South South (9 percent), South East (8 percent), and North Central (7 percent) are more likely to experience violence during pregnancy than other women. By contrast only 2 percent of women in North West experienced violence during pregnancy. Looking at education and wealth, women with primary education and women in the middle and fourth wealth quintiles are more likely than other women to experience violence during pregnancy. Women with no education (3 percent) are less likely to experience physical violence during pregnancy, compared with other women (5 to 8 percent). 268 | Domestic Violence Table 16.7 Violence during pregnancy Among women age 15-49 who have ever been pregnant, percentage who have ever experienced physical violence during pregnancy, by background characteristics, Nigeria 2008 Background characteristic Percentage who have ever experienced physical violence during pregnancy Number of women who have ever been pregnant Current age 15-19 3.9 1,065 20-24 5.4 2,627 25-29 5.5 3,585 30-39 5.1 5,428 40-49 4.8 3,691 Marital status Never married 0.0 496 Married or living together 4.9 15,028 Divorced/separated/widowed 11.7 872 Number of living children 0 3.5 1,023 1-2 5.0 5,665 3-4 5.3 5,110 5+ 5.3 4,598 Residence Urban 4.7 5,237 Rural 5.3 11,159 Zone North Central 6.5 2,360 North East 4.5 2,385 North West 2.3 4,719 South East 8.4 1,562 South South 9.3 2,375 South West 3.9 2,995 Education No education 3.2 7,351 Primary 7.7 3,738 Secondary 6.0 4,127 More than secondary 5.4 1,180 Wealth quintile Lowest 3.9 3,642 Second 4.3 3,433 Middle 6.6 3,122 Fourth 6.5 3,034 Highest 4.4 3,164 Total 5.1 16,396 16.8 MARITAL CONTROL BY HUSBAND OR PARTNER Marital violence is violence perpetuated by a partner or spouse within the marital union. A series of questions were asked in the 2008 NDHS to determine the degree of marital control exercised by the husband or partner over the respondent. Attempts by a husband or partner to closely control and monitor the activities of their female partner or spouse have been found to be among the most important early warning signs of violence in a relationship. Controlling behaviours most often manifest themselves in terms of extreme possessiveness, jealousy, and attempts to isolate the woman from her family and friends. Domestic Violence | 269 To determine the degree of marital control by husbands over their wives, women were asked whether they experienced any of a list of specific acts of controlling behaviours by their husbands, such as the husband is jealous or gets angry if she talks to other men, accuses her of being unfaithful, does not permit meetings with female friends, tries to limit her contact with her family, insists on knowing where she is at all times, and does not trust her with any money. Table 16.8 shows the percentage of ever-married women whose husband or partner displays each of the listed behaviours by selected background characteristics. Since the accumulation of such behaviours is more significant than the display of any single behaviour, the proportion of women whose husbands display at least three of the specified behaviours is highlighted. The results show that overall, 38 percent of ever-married women say that their husband or partner exhibits none of the controlling behaviours. The main controlling behaviours women experienced from their husbands were being jealous or angry if she talks to other men (49 percent) and his insistence on knowing where she is at all times (34 percent). Eighteen percent of ever-married women said that their husband does not trust them with any money, while 14 percent reported that their husband frequently accuses them of being unfaithful, and 13 percent said their husband does not permit them to meet their female friends. Furthermore, 8 percent of women reported that their husband tries to limit their contact with their families. About one-fifth of women reported that their spouse displays three or more of these behaviours. Younger women are more likely than women age 30 and older to report that their husband or partner displays at least three of the controlling behaviours. Women who are employed but not for cash and women with fewer living children are more likely than other women to say that their husband engages in at least three controlling behaviours. Women who are divorced, separated, or widowed are more likely than currently married women to say that their husband engages in at least three controlling behaviours (31 percent compared with 20 percent). Husband’s controlling behaviours decrease with increasing marital duration. By zone, women in South South are most likely to report that their husband or partner participates in at least three controlling behaviours (28 percent), closely followed by women in North Central and North East (27 percent each). On the other hand, only 11 percent of women in North West say that their husband participates in at least three of the behaviours. Women with no education and with more than secondary education are less likely than women with primary or secondary education to report that their husband participates in at least three controlling behaviours. By wealth quintile, women in the middle and fourth quintiles report the highest percentages of husbands who exhibit at least three controlling behaviours. 270 | Domestic Violence Table 16.8 Degree of marital control exercised by husbands Percentage of ever-married women age 15-49 whose husband/partners ever demonstrated specific types of controlling behaviours, according to background characteristics, Nigeria 2008 Percentage of women whose husband: Background characteristic Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Does not trust her with any money Displays 3 or more of the specific behaviours Displays none of the specific behaviours Number of women Current age 15-19 56.4 13.6 13.5 8.4 34.2 16.6 20.7 33.4 1,322 20-24 54.4 14.9 15.1 8.6 36.7 17.2 23.7 35.4 2,601 25-29 51.7 14.2 15.1 8.1 35.9 19.4 21.3 35.3 3,608 30-39 48.3 12.7 12.7 6.9 33.3 18.9 18.8 38.5 5,472 40-49 42.2 13.4 11.3 6.8 29.6 17.1 18.0 45.1 3,759 Employed past 12 months1 Not employed 51.7 12.3 12.4 8.5 31.7 18.7 19.2 36.2 4,744 Employed for cash 48.3 12.8 13.1 6.9 33.7 16.9 19.2 39.7 9,775 Employed not for cash 48.1 20.0 16.6 8.5 37.6 22.7 25.9 37.5 2,202 Number of living children 0 51.8 14.1 15.6 8.6 35.1 17.6 22.1 36.4 1,713 1-2 50.8 13.4 14.3 8.1 35.7 18.7 21.4 36.9 5,358 3-4 48.7 12.7 13.2 6.9 33.2 17.8 19.0 38.6 5,097 5+ 47.1 14.7 11.5 7.2 31.2 18.1 18.9 40.7 4,594 Marital status and duration Currently married woman 49.3 12.9 12.9 7.2 33.3 17.8 19.5 38.5 15,852 Married only once 48.9 12.8 12.6 7.1 33.0 17.6 19.1 38.8 13,720 0-4 years 51.2 12.9 15.3 7.9 36.3 18.1 21.9 36.3 3,459 5-9 years 50.0 13.3 13.2 6.9 34.9 17.5 19.4 36.2 3,074 10+ years 47.3 12.5 11.0 6.9 30.6 17.4 17.6 41.0 7,186 Married more than once 51.8 14.1 15.1 7.5 34.8 18.8 21.9 36.9 2,132 Divorced/separated/widowed 48.7 25.1 21.1 13.5 40.0 25.2 30.8 36.2 910 Residence Urban 47.7 12.0 13.8 7.5 36.7 19.7 20.2 37.3 5,289 Rural 50.0 14.4 13.2 7.6 32.2 17.5 20.0 38.9 11,473 Zone North Central 50.9 24.5 13.1 5.9 35.8 19.3 26.9 39.7 2,429 North East 54.3 15.5 14.1 10.4 42.5 21.7 26.5 34.7 2,505 North West 53.6 7.9 9.4 6.4 24.1 10.6 11.3 38.0 5,071 South East 42.5 13.4 15.0 11.6 31.2 17.1 19.5 44.9 1,551 South South 39.7 16.1 23.0 10.2 38.2 29.7 28.4 39.4 2,205 South West 46.7 11.1 11.6 4.3 38.6 19.2 18.3 37.1 3,001 Education No education 52.0 12.8 10.5 7.0 29.9 15.7 17.7 38.9 7,830 Primary 47.5 17.0 14.4 8.2 34.0 19.1 22.1 39.6 3,775 Secondary 48.3 13.7 18.1 8.2 39.6 21.8 23.8 35.4 3,950 More than secondary 40.0 7.7 13.0 6.4 37.1 19.5 16.6 41.0 1,207 Wealth quintile Lowest 51.5 13.8 11.7 7.3 30.3 16.4 19.0 39.6 3,842 Second 52.7 14.2 11.8 7.2 31.3 15.4 18.3 37.3 3,584 Middle 49.3 15.6 13.7 8.2 33.8 18.6 21.2 38.2 3,111 Fourth 47.3 14.7 15.5 8.4 35.5 19.6 23.1 39.3 3,035 Highest 44.4 9.7 14.7 6.7 38.3 21.6 19.5 37.5 3,190 Total 49.2 13.6 13.4 7.5 33.6 18.2 20.1 38.4 16,762 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. 1 Includes 44 unweighted cases (not shown in the table) for which employment status is missing. Domestic Violence | 271 16.9 FORMS OF SPOUSAL VIOLENCE To measure spousal violence, information was obtained in the 2008 NDHS from ever-married women on whether they had ever experienced violent acts committed by their husband or partner. In the survey, spousal violence was measured using a shortened and modified Conflict Tactics Scale (CTS) (Straus, 1990). Women were asked the following eight questions: (Does/did) your (last) husband ever do any of the following things to you? a) Push you, shake you, or throw something at you? b) Slap you? c) Twist your arm or pull your hair? d) Punch you with his fist or with something that could hurt you? e) Kick you, drag you or beat you up? f) Try to choke you or burn you on purpose? g) Threaten or attack you with a knife, gun, or any other weapon? h) Physically force you to have sexual intercourse with him even when you did not want to? These clearly worded questions were asked to estimate the prevalence of physical (a-g) and sexual violence (h). For women who were currently married, the questions were asked with reference to the current husband and for women who were formerly but not currently married, they were asked with reference to women’s most recent husband. Women could respond ‘yes’ or ‘no’ to each item. A ‘yes’ response to one or more items (a) to (g) above constitutes evidence of physical violence, while a ‘yes’ response to item (h) constitutes evidence of sexual violence. In each case of a ‘yes’ response, if the woman was currently married, she was asked about the frequency of the act in the 12 months preceding the survey (often, sometimes, or not at all). Note that widowed women were asked about the experience of spousal violence by their most recent husband or partner, but they were not asked about their experience of violence in the past 12 months. Table 16.9 shows the percentage of ever-married women who experienced physical, sexual, and emotional violence from their husband or partner. It should be noted that different types of violence are not mutually exclusive and women may report multiple forms of violence. Research suggests that physical violence in intimate relationships is often accompanied by psychological abuse and, in one-third to over half of cases, by sexual abuse (Krug et al., 2002). The results from the 2008 NDHS shows that 18 percent of ever-married women reported having ever experienced physical violence from their current or most recent husband, 4 percent reported sexual violence, and 24 percent reported emotional violence. Figure 16.1 shows the proportion of ever-married women who ever experienced different forms of violence committed by their current or most recent husband, and violence experienced during the 12 months preceding the survey. Table 16.9 shows that the most common form of spousal physical violence is slapping (16 percent), followed by kicking, dragging or beating her up (6 percent), and pushing, shaking or throwing something at her (5 percent). Fourteen percent of women reported that they had experienced at least one form of these violent acts from their husband or partner in the 12 months preceding the survey. Three percent of women said that their husband or partner had forced them to have sex against their will, and 2 percent reported that they had been forced to perform sexual acts they did not want to do. The proportions of women who reported experiencing these acts of sexual violence by their husband or partner in the past 12 months were similar. 272 | Domestic Violence Table 16.9 Forms of spousal violence Percentage of ever-married women age 15-49 who experienced various forms of violence committed by their husband/partner ever and in the 12 months preceding the survey, Nigeria 2008 In the past 12 months1 Ever Often Sometimes Often or sometimes Physical violence Any 17.5 1.9 12.4 14.2 Pushed her, shook her, or threw something at her 5.4 0.6 3.8 4.4 Slapped her 16.0 1.4 11.4 12.8 Twisted her arm or pulled her hair 4.0 0.5 2.6 3.2 Punched her with his fist or with something that could hurt her 4.2 0.5 2.6 3.1 Kicked her, dragged her, or beat her up 6.0 0.7 3.9 4.6 Tried to choke her or burn her on purpose 1.0 0.2 0.5 0.6 Threatened her or attacked her with a knife, gun, or any other weapon 1.4 0.2 0.7 0.9 Sexual violence Any 3.9 0.6 2.6 3.2 Physically forced her to have sexual intercourse with him even when she did not want to 3.4 0.5 2.2 2.7 Forced her to perform any sexual acts she did not want to 2.3 0.3 1.5 1.8 Emotional violence Any 23.6 2.8 18.2 21.0 Said or did something to humiliate her in front of others 14.9 1.7 11.6 13.3 Threatened to hurt or harm her or someone close to her 6.4 1.0 4.3 5.3 Insulted her or made her feel bad about herself 16.6 1.9 12.7 14.6 Any form of physical and/or sexual violence 18.3 2.2 13.0 15.2 Any form of physical and sexual violence 3.0 0.3 1.8 2.1 Any form of emotional, physical and/or sexual violence 30.5 3.9 23.1 27.0 Any form of emotional, physical and sexual violence 2.5 0.2 1.4 1.6 Number of ever married women 16,762 16,262 16,262 16,262 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. na = Not applicable 1 Excludes widows The most common form of emotional spousal violence is a spouse insulting or making his wife feel bad about herself (17 percent), followed by humiliating her in front of others (15 percent), and threatening to harm her or someone close to her (6 percent). The percentages of women experiencing these forms of emotional violence during the 12 months preceding the survey were similar to those of women who ever experienced them. Overall, 31 percent of ever-married women have ever experienced emotional, physical, or sexual violence by their husbands or partners, and 27 percent have done so in the past 12 months. Eighteen percent of ever-married women have experienced either physical or sexual violence, and 15 percent have experienced physical or sexual violence in the 12 months preceding the survey. Domestic Violence | 273 16.10 SPOUSAL VIOLENCE BY BACKGROUND CHARACTERISTICS Table 16.10 shows the percentage of ever-married women who have experienced emotional, physical, or sexual spousal violence by selected background characteristics. Twenty-four percent of ever-married women reported emotional spousal violence, 18 percent reported physical spousal violence, and 4 percent reported sexual spousal violence. Overall, 31 percent of ever-married women have ever experienced emotional, physical, or sexual violence committed by their husband or partner. Women age 15-19 are least likely to have experienced each of the three types of spousal violence. Women in the 25-29 age group are more likely than women of other ages to have experienced each of the three types of violence. Women who are employed and not paid for cash are the most likely to report that they have ever experienced spousal emotional, physical, or sexual violence, while women who are unemployed are least likely to have experienced these types of violence (38 percent compared with 26 percent, respectively). The likelihood of having experienced each of the three types of violence increases with the number of living children from 23 percent among women with no children to 34 percent among women with five or more children. By marital status, women who are divorced, separated, or widowed were the most likely to report spousal abuse (44 percent). Rural women are more likely than their urban counterparts to have ever experienced all three types of spousal abuse (32 percent compared with 28 percent, respectively). Among the zones, women in South South reported the highest proportion of spousal abuse (46 percent), while women in South West reported the lowest proportion (18 percent). There was no clear pattern by level of education or wealth status. A family history of domestic violence is strongly associated with a respondent’s own experience of domestic violence. Among women whose fathers beat their mothers, 53 percent have themselves experience emotional, physical, or sexual violence, compared with 26 percent of women whose fathers did not beat their mothers. Figure 16.1 Forms of Spousal Violence 5 16 4 4 6 1 1 3 2 18 4 13 3 3 5 1 1 3 2 15 Pushed her, shook her, or threw something at her Slapped her Twisted her arm or pulled her hair Kicked her, dragged her, or beat her up Tried to choke her or burn her on purpose At least one of these acts 0 5 10 15 20 Percent Ever Past 12 months NDHS 2008-09 Punched her with his fist or with something that could hurt her Physically forced her to have sexual intercourse with him even when she did not want to Forced her to perform any sexual acts she did not want to Threatened her or attacked her with a knife, gun, or any other weapon 274 | Domestic Violence Table 16.10 Spousal violence by background characteristics Percentage of ever-married women age 15-49 who ever experienced emotional, physical, or sexual violence committed by their husband/partner, by background characteristics, Nigeria 2008 Background characteristic Emotional violence Physical violence Sexual violence Physical or sexual violence Emotional, physical or sexual violence Number of women Current age 15-19 18.7 9.1 3.3 10.3 22.4 1,322 20-24 24.0 16.2 4.3 17.2 30.7 2,601 25-29 24.6 19.7 4.6 20.6 32.4 3,608 30-39 23.6 18.7 3.6 19.4 30.8 5,472 40-49 24.2 17.4 3.5 18.1 31.0 3,759 Employed past 12 months1 Not employed 20.5 12.1 3.2 12.9 25.6 4,744 Employed for cash 24.8 17.7 3.7 18.5 31.2 9,775 Employed not for cash 25.3 28.1 5.8 29.1 38.0 2,202 Number of living children 0 17.7 11.0 2.8 12.4 22.7 1,713 1-2 22.5 16.9 3.6 17.6 29.4 5,358 3-4 23.6 18.1 4.1 18.9 30.9 5,097 5+ 27.2 19.8 4.4 20.6 34.4 4,594 Marital status and duration Currently married woman 22.9 16.6 3.7 17.4 29.8 15,852 Married only once 22.4 16.8 3.6 17.5 29.5 13,720 0-4 years 18.2 13.6 3.4 14.6 24.4 3,459 5-9 years 23.5 18.1 3.9 18.8 30.7 3,074 10+ years 24.0 17.7 3.5 18.4 31.4 7,186 Married more than once 26.0 15.3 4.6 16.7 31.9 2,132 Divorced/separated/widowed 36.3 33.2 6.9 34.0 43.5 910 Residence Urban 20.6 16.9 3.4 17.7 27.5 5,289 Rural 25.0 17.7 4.1 18.6 31.9 11,473 Zone North Central 29.3 25.4 4.1 26.0 37.7 2,429 North East 22.2 14.8 5.7 16.6 28.0 2,505 North West 25.6 6.5 1.6 6.9 27.8 5,071 South East 28.8 23.0 5.9 23.9 35.4 1,551 South South 28.7 37.6 8.8 39.4 45.8 2,205 South West 10.6 14.2 1.3 14.4 17.6 3,001 Education No education 23.3 10.9 2.8 11.7 27.0 7,830 Primary 27.6 26.1 5.5 26.9 38.1 3,775 Secondary 22.9 23.8 4.8 24.7 33.1 3,950 More than secondary 15.9 12.4 2.9 13.8 21.0 1,207 Wealth quintile Lowest 24.1 13.3 3.3 14.2 29.0 3,842 Second 24.7 14.3 3.2 15.0 30.0 3,584 Middle 27.4 21.6 5.6 22.4 35.2 3,111 Fourth 23.2 22.4 4.8 23.2 32.7 3,035 Highest 18.6 17.4 3.0 18.3 26.3 3,190 Respondent's father beat her mother Yes 37.9 43.0 9.6 44.5 53.3 1,714 No 20.8 13.4 3.1 14.2 26.3 13,580 Don’t know 33.9 26.5 5.2 27.0 43.3 1,361 Missing 31.7 15.3 0.5 15.8 37.6 107 Total 23.6 17.5 3.9 18.3 30.5 16,762 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. 1 Includes 44 unweighted cases (not shown in the table) for which employment status is missing. Domestic Violence | 275 16.11 VIOLENCE BY SPOUSAL CHARACTERISTICS AND WOMEN’S INDICATORS The section examines husbands’ characteristics that will help to understand some of the underlying contributing factors to spousal violence. Table 16.11 presents information on ever-married women age 15-49 who have ever experienced emotional, physical or sexual violence committed by their husband or partner, by selected characteristics and empowerment indicators. Women whose husbands have no education are less likely than husbands of other women to have experienced any of the three types of spousal violence. For example, 27 percent of women with uneducated husbands have experienced emotional, physical, or sexual violence, compared with 36 percent of women whose husbands have primary education. Women who say their husband or partner gets drunk often were more likely to report emotional, physical, or sexual violence (68 percent) than women whose husbands drinks but does not get drunk (44 percent) and women whose husband does not drink (26 percent). There are no clear patterns between spousal violence and spousal age difference or education difference; however, women who are older than their husband and who have less education than their husband are slightly more likely than other women to experience emotional, physical or sexual violence. Controlling behaviours are strongly associated with spousal violence. For example, 19 percent of women whose husbands exhibit none of the controlling behaviours have experienced emotional, physical, or sexual violence, compared with 55 percent of women whose husbands exhibit five to six of the controlling behaviours. Each of the three types of spousal violence increases as the number of controlling behaviours practiced by the husband increases. The three empowerment indicators do not appear to have a consistently protective relationship with spousal violence. Decision-making does not have the expected association with spousal violence: women who participate in the smallest number of decisions are least likely to experience spousal violence. On the other hand, as expected, women who agree with none of the five reasons justifying wife beating are less likely to experience each of the three types of spousal violence than other women. 276 | Domestic Violence Table 16.11 Spousal violence by husband's characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have ever experienced emotional, physical or sexual violence committed by their husband/partner, by selected characteristics and empowerment indicators, Nigeria 2008 Characteristic and empowerment indicator Emotional violence Physical violence Sexual violence Physical or sexual violence Emotional, physical or sexual violence Number of women Husband/partner's education No education 22.9 10.9 2.8 11.7 26.5 6,413 Primary 26.7 22.5 5.5 23.5 35.5 3,532 Secondary+ 22.6 21.3 4.1 22.1 31.7 6,558 Don’t know/missing 26.9 14.6 1.8 15.7 33.6 260 Husband/partner's alcohol consumption Does not drink 20.4 11.9 2.7 12.6 25.5 13,589 Drinks/never gets drunk 26.8 33.6 7.8 35.4 43.7 710 Gets drunk sometimes 38.3 41.3 7.6 42.8 52.8 1,868 Gets drunk very often 54.0 58.8 16.5 60.2 68.4 488 Don’t know/missing 14.5 13.6 4.0 14.3 20.1 107 Spousal age difference1 Wife older 24.4 20.2 4.2 20.6 33.9 196 Wife is same age 22.1 15.3 5.5 18.3 29.7 201 Wife's 1-4 years younger 21.9 20.8 3.6 21.5 31.3 2,462 Wife's 5-9 years younger 22.7 18.2 4.2 19.0 30.2 5,265 Wife's 10+ years younger 23.4 14.0 3.3 14.8 28.9 7,447 Missing 22.0 16.2 3.5 16.7 29.6 282 Spousal education difference Husband better educated 25.3 21.2 4.4 22.1 34.2 5,756 Wife better educated 24.3 21.9 5.2 22.8 33.0 2,271 Both equally educated 22.0 22.3 4.5 23.3 31.5 2,667 Neither educated 22.3 9.7 2.5 10.4 25.2 5,692 Don’t know/missing 26.5 17.1 4.0 18.4 33.4 377 Number of marital-control behaviours displayed by husband/partner 0 13.8 9.6 1.5 10.1 18.7 6,436 1-2 24.1 15.9 3.2 16.6 31.0 6,962 3-4 40.4 33.5 8.8 35.2 51.4 2,586 5-6 45.5 43.0 14.3 45.1 55.2 779 Number of decisions in which women participate1 0 23.6 10.0 2.3 10.6 27.6 6,106 1-2 26.8 20.3 5.9 21.5 35.3 3,151 3-4 20.4 20.8 4.0 21.7 29.2 6,595 Number of reasons given for refusing to have sexual intercourse with husband 0 14.9 10.4 2.0 10.7 19.4 1,759 1-2 27.3 16.7 4.1 17.6 33.6 7,310 3 22.2 19.9 4.2 20.7 30.1 7,693 Number of reasons for which wife beating is justified 0 19.9 14.6 2.9 15.3 26.0 8,895 1-2 25.1 21.4 4.7 22.2 32.6 2,989 3-4 32.3 23.3 5.6 24.1 41.0 2,765 5 26.0 16.6 4.7 18.0 33.0 2,114 Total 23.6 17.5 3.9 18.3 30.5 16,762 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. 1 Includes only currently married women Domestic Violence | 277 16.12 FREQUENCY OF SPOUSAL VIOLENCE Table 16.12 shows the percent distribution of ever-married women who have ever experienced emotional violence and physical or sexual violence perpetrated by their husband or partner by how often it occurred in the 12 months prior to the survey, according to background characteristics. Table 16.12 Frequency of spousal violence among those who report violence Percent distribution of ever-married women age 15-49 (excluding widows) who have ever experienced emotional violence committed by their current or most recent husband/partner by frequency of violence in the 12 months preceding the survey, and percent distribution of ever-married women age 15-49 who have ever experienced physical or sexual violence committed by their current or most recent husband/partner by frequency of violence in the 12 months preceding the survey, according to background characteristics, Nigeria 2008 Frequency of emotional violence in the past 12 months Frequency of physical or sexual violence in the past 12 months Background characteristic Often Sometimes Not at all Total Number of women Often Sometimes Not at all Total Number of women Current age 15-19 12.0 82.9 5.1 100.0 243 16.7 74.5 8.7 100.0 133 20-24 11.0 82.0 7.0 100.0 597 14.4 75.6 10.0 100.0 439 25-29 11.6 80.2 8.2 100.0 854 11.6 74.0 14.4 100.0 717 30-39 12.2 77.6 10.2 100.0 1,222 11.5 70.7 17.8 100.0 1,014 40-49 14.2 76.2 9.7 100.0 825 11.1 70.3 18.5 100.0 614 Employed past 12 months1 Not employed 11.0 80.5 8.5 100.0 935 13.6 73.2 13.2 100.0 586 Employed for cash 12.6 78.8 8.6 100.0 2,269 11.3 72.0 16.7 100.0 1,710 Employed not for cash 13.4 76.8 9.9 100.0 524 13.0 72.6 14.4 100.0 615 Number of living children 0 10.2 81.5 8.3 100.0 290 13.0 75.4 11.5 100.0 202 1-2 14.0 78.2 7.8 100.0 1,151 12.7 73.9 13.4 100.0 905 3-4 11.9 79.0 9.2 100.0 1,132 12.6 71.7 15.7 100.0 925 5+ 11.5 78.9 9.6 100.0 1,167 10.8 70.7 18.5 100.0 885 Marital status and duration Currently married woman 11.1 81.0 7.8 100.0 3,529 11.2 74.2 14.6 100.0 2,717 Married only once 10.3 81.8 7.9 100.0 3,000 11.1 74.1 14.8 100.0 2,371 0-4 years 11.6 80.3 8.1 100.0 613 13.3 73.6 13.1 100.0 497 5-9 years 8.6 84.5 7.0 100.0 704 10.9 76.2 12.9 100.0 570 10+ years 10.6 81.2 8.2 100.0 1,684 10.3 73.4 16.3 100.0 1,304 Married more than once 15.6 77.0 7.4 100.0 530 12.4 74.7 12.9 100.0 346 Divorced/separated 31.6 43.3 25.1 100.0 211 24.3 47.5 28.2 100.0 201 Residence Urban 13.1 77.0 9.9 100.0 1,022 13.3 69.7 17.0 100.0 895 Rural 12.0 79.6 8.4 100.0 2,719 11.6 73.5 14.9 100.0 2,023 Zone North Central 11.3 77.8 10.9 100.0 675 11.0 73.1 15.9 100.0 595 North East 12.3 85.6 2.1 100.0 525 15.1 81.1 3.8 100.0 406 North West 9.5 83.9 6.7 100.0 1,227 9.3 78.1 12.6 100.0 321 South East 16.0 75.8 8.2 100.0 418 16.0 63.9 20.2 100.0 352 South South 12.8 67.4 19.8 100.0 601 10.2 64.1 25.7 100.0 830 South West 19.6 76.9 3.5 100.0 294 13.6 81.8 4.6 100.0 415 Education No education 11.2 82.2 6.7 100.0 1,723 12.8 77.4 9.8 100.0 867 Primary 13.6 75.3 11.1 100.0 976 12.5 68.5 19.1 100.0 955 Secondary 13.9 75.7 10.4 100.0 859 11.7 72.0 16.2 100.0 939 More than secondary 8.0 82.6 9.4 100.0 183 9.0 69.8 21.2 100.0 156 Wealth quintile Lowest 10.2 82.6 7.2 100.0 878 11.5 79.0 9.5 100.0 510 Second 10.7 82.9 6.4 100.0 829 13.6 73.6 12.9 100.0 512 Middle 15.1 75.2 9.7 100.0 804 13.1 69.5 17.4 100.0 656 Fourth 14.0 75.4 10.6 100.0 667 11.0 69.7 19.3 100.0 683 Highest 11.7 76.8 11.5 100.0 562 11.7 71.7 16.7 100.0 557 Total 12.3 78.9 8.8 100.0 3,740 12.1 72.3 15.5 100.0 2,918 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. 1 Includes 8 unweighted cases (not shown in the table) for which employment status is missing. 278 | Domestic Violence The results show that 79 percent of ever-married women who have ever experienced emotional violence from their husbands or partners experienced emotional violence ‘sometimes’ in the past 12 months, and 12 percent experienced it ‘often.’ Among ever-married women who have ever experienced physical or sexual violence from their husbands or partners, 72 percent reported that it occurred sometimes in the past 12 months, and 12 percent reported that physical or sexual violence occurred often during the past year. Women in urban and rural areas experienced almost the same level of emotional violence from their husband or partner ‘often’ during the 12 months preceding the survey (13 and 12 percent, respectively). An analysis of the zones shows that South West has the highest percentage (20 percent) of women who reported experiencing emotional violence often in the 12 months preceding the survey and North West has the lowest percentage (10 percent). However, for physical or sexual violence, women in South East (16 percent) and North East (15 percent) are most likely to experience these forms of spousal violence often in the 12 months preceding the survey. 16.13 ONSET OF SPOUSAL VIOLENCE To obtain information on the timing of the onset of marital violence, the 2008 NDHS asked ever-married women who experienced physical or sexual spousal violence when the first episode of violence took place. Table 16.13 shows the interval between marriage and the first episode of spousal physical or sexual violence. The results show that the majority of ever-married women have not experienced physical or sexual violence by their husbands or partners (82 percent). However, 6 percent of all ever-married women reported that physical or sexual violence began to occur during the first two years after marriage. Two percent of women reported that violence was initiated less than a year into the marriage, and 5 percent said that violence was initiated three to five years after marriage. Less than 1 percent reported that violence began prior to marriage. Table 16.13 Onset of marital violence Percent distribution of ever-married women by number of years between marriage and first experience of physical or sexual violence by their husband/partner, if ever, according to marital status and duration, Nigeria 2008 Years between marriage and first experience of violence1 Marital status and duration Experienced no violence Before marriage <1 year 1-2 years 3-5 years 6-9 years 10+ years Don't know/ missing2 Total Number of women Currently married 82.6 0.9 2.2 5.8 4.4 1.6 1.6 0.9 100.0 15,852 Married only once 82.5 1.0 2.1 5.9 4.5 1.6 1.6 0.9 100.0 13,720 <1 year 90.4 2.6 5.7 na na na na 1.3 100.0 690 1-2 years 86.1 1.3 4.2 6.9 na na na 1.5 100.0 1,452 3-5 years 80.9 1.5 2.9 9.4 4.1 na na 1.2 100.0 1,995 6-9 years 81.8 0.7 1.5 7.4 5.3 2.3 na 0.9 100.0 2,397 10+ years 81.6 0.7 1.3 4.7 5.6 2.3 3.1 0.6 100.0 7,186 Married more than once 83.3 0.6 2.6 5.5 4.2 1.5 1.4 0.9 100.0 2,132 Divorced/separated/widowed 66.0 1.2 2.8 12.8 8.9 3.8 3.5 1.1 100.0 910 Total 81.7 0.9 2.2 6.2 4.7 1.7 1.7 0.9 100.0 16,762 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. 1 For couples who are not married but are living together as if married, the time of marriage refers to the time when the respondent first started living together with her partner. 2 Includes women for whom the timing of the first experience of violence and duration of marriage are inconsistent. na = Not applicable Domestic Violence | 279 16.14 TYPES OF INJURIES TO WOMEN BECAUSE OF SPOUSAL VIOLENCE Table 16.14 presents information on the types of injuries received by ever-married women as a result of spousal violence by whether they ever experienced spousal violence and their experience of spousal violence in the 12 months preceding the survey. The results shows very little difference in the prevalence of injuries by whether the violence was experienced ever or within the past 12 months. For all the specified types of violence, the injuries most commonly resulting from spousal violence are cuts, bruises or aches. These are followed by eye injuries, sprains, dislocations, or burns. Among women who have ever experienced physical violence, 30 percent received an injury— 27 percent had cuts, bruises, or aches while 12 percent had eye injuries, sprains, dislocations, or burns. Among women who have ever experienced sexual violence, 38 percent received injuries—35 percent had cuts, bruises, or aches, 18 percent had eye injuries, sprains, dislocations, or burns, and 12 percent had deep wounds, broken bones, broken teeth, or other serious injury. Table 16.14 Injuries to women due to spousal violence Percentage of ever-married women age 15-49 who have experienced specific types of spousal violence by type of injury received from husband/partner and whether they experienced the violence ever and in the 12 months preceding the survey, Nigeria 2008 Type of violence Cuts, bruises, or aches Severe burns Eye injuries, sprains, dislocations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of ever- married women Experienced physical violence1 Ever2 27.1 6.2 12.4 6.6 30.4 2,929 In the past 12 months3 28.2 6.9 13.4 6.7 32.1 2,317 Experienced sexual violence4 Ever2 34.5 8.1 18.0 11.6 37.6 652 In the past 12 months3 37.1 9.4 19.6 11.8 40.4 514 Experienced physical or sexual violence4 Ever2 26.3 5.9 12.0 6.3 29.5 3,070 In the past 12 months3 27.4 6.6 12.8 6.4 31.1 2,465 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. 1 Excludes women who experienced physical violence only during pregnancy 2 Includes in the past 12 months 3 Excludes widows 4 Excludes women whose sexual initiation was forced but who have not experienced any other form of physical or sexual violence 16.15 VIOLENCE BY WOMEN AGAINST THEIR SPOUSE In cases of domestic violence either the man or the woman can be the instigator of violent behaviour. Ever-married women were asked about instances when they said or did something to physically harm their husband or partner at times when he was not already physically hurting them. Table 16.15 shows the percentage of ever-married women who committed physical violence against their husband or partner when he was not already harming them, by selected characteristics. Overall, 2 percent of ever-married women reported that they had initiated physical violence against their husband or partner when he was not already beating or physically hurting them. 280 | Domestic Violence Table 16.15 Violence by women against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their husband/partner when he was not already beating or physically hurting them, ever and in the past 12 months, by women's own experience of spousal violence and their own and husband/partner's characteristics, Nigeria 2008 Percentage of ever-married women who have committed physical violence against their current or most recent husband/partner In the past 12 months Characteristic Ever Number of women Often Sometimes Any Number of women1 Woman's experience of spousal physical violence Ever 11.0 2,929 0.5 5.1 5.6 2,827 In the past 12 months 11.5 2,317 0.6 6.0 6.6 2,317 Not past 12 months/widow /missing 9.0 612 0.2 0.7 0.9 510 Never 0.3 13,833 0.0 0.1 0.1 13,435 Current age 15-19 0.9 1,322 0.1 0.4 0.4 1,319 20-24 1.7 2,601 0.1 1.0 1.1 2,586 25-29 2.2 3,608 0.1 1.0 1.1 3,580 30-39 2.5 5,472 0.1 1.2 1.3 5,336 40-49 2.4 3,759 0.1 0.8 0.9 3,442 Employed past 12 months2 Not employed 1.3 4,744 0.1 0.6 0.7 4,695 Employed for cash 2.5 9,775 0.1 1.1 1.2 9,434 Employed not for cash 2.6 2,202 0.1 1.4 1.5 2,097 Number of living children 0 1.7 1,713 0.0 1.1 1.1 1,698 1-2 2.0 5,358 0.1 0.8 0.9 5,262 3-4 2.3 5,097 0.0 1.1 1.1 4,950 5+ 2.3 4,594 0.2 1.1 1.3 4,352 Residence Urban 2.6 5,289 0.1 1.0 1.1 5,117 Rural 2.0 11,473 0.1 1.0 1.0 11,146 Zone North Central 2.3 2,429 0.1 1.5 1.6 2,322 North East 1.3 2,505 0.1 0.9 0.9 2,467 North West 0.5 5,071 0.0 0.1 0.1 5,006 South East 2.8 1,551 0.2 0.9 1.0 1,434 South South 6.0 2,205 0.2 2.8 3.0 2,097 South West 2.4 3,001 0.1 0.9 1.0 2,936 Wealth quintile Lowest 0.9 3,842 0.0 0.6 0.6 3,765 Second 1.6 3,584 0.1 0.8 0.9 3,481 Middle 2.3 3,111 0.1 1.0 1.1 2,977 Fourth 3.0 3,035 0.2 1.4 1.6 2,918 Highest 3.4 3,190 0.0 1.3 1.3 3,120 Continued. . Domestic Violence | 281 Table 16.15—Continued Percentage of ever-married women who have committed physical violence against their current or most recent husband/partner In the past 12 months Characteristic Ever Number of women Often Sometimes Any Number of women1 Marital status and duration Currently married woman 1.9 15,852 0.1 1.0 1.0 15,852 Married only once 1.9 13,720 0.1 1.0 1.1 13,720 0-4 years 1.6 3,459 0.1 0.8 1.0 3,459 5-9 years 2.1 3,074 0.0 1.1 1.1 3,074 10+ years 1.9 7,186 0.1 1.0 1.1 7,186 Married more than once 1.9 2,132 0.1 0.8 1.0 2,132 Divorced/separated/widowed 6.7 910 0.2 2.0 2.2 410 Education No education 1.0 7,830 0.1 0.5 0.6 7,658 Primary 2.9 3,775 0.1 1.4 1.5 3,575 Secondary 3.5 3,950 0.1 1.4 1.5 3,861 More than secondary 2.8 1,207 0.0 1.3 1.3 1,169 Husband/partner's education No education 1.1 6,413 0.0 0.6 0.6 6,228 Primary 2.9 3,532 0.2 1.5 1.6 3,391 Secondary+ 2.9 6,558 0.1 1.2 1.3 6,393 Don’t know/missing 0.0 260 0.0 0.0 0.0 250 Husband/partner's alcohol consumption Does not drink 1.0 13,589 0.0 0.4 0.5 13,250 Drinks/never gets drunk 4.4 710 0.0 1.2 1.2 680 Gets drunk sometimes 7.2 1,868 0.1 4.0 4.1 1,771 Gets drunk very often 10.9 488 1.3 5.2 6.5 456 Don’t know/missing 1.3 107 0.0 0.7 0.7 105 Spousal age difference3 Wife older 5.1 196 0.9 2.0 2.9 196 Wife is same age 2.2 201 0.3 0.8 1.1 201 Wife's 1-4 years younger 2.6 2,462 0.1 1.3 1.4 2,462 Wife's 5-9 years younger 2.1 5,265 0.1 1.0 1.1 5,265 Wife's 10+ years younger 1.5 7,447 0.1 0.8 0.8 7,447 Missing 1.2 282 0.0 0.5 0.5 282 Spousal education difference Husband better educated 2.3 5,756 0.1 1.0 1.1 5,595 Wife better educated 3.5 2,271 0.0 1.6 1.7 2,174 Both equally educated 3.4 2,667 0.1 1.6 1.7 2,570 Neither educated 0.9 5,692 0.0 0.5 0.5 5,561 Don’t know/missing 2.3 377 0.0 1.4 1.4 362 Total 2.2 16,762 0.1 1.0 1.1 16,262 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated. or widowed women. 1 Excludes widows 2 Includes 44 unweighted cases (not shown in the table) for which employment status is missing 3 Currently married women 282 | Domestic Violence Among women who have experienced physical violence by their husband or partner, 11 percent committed the physical violence against their husband or partner when he was not already beating or physically hurting them. Women age 30 and older are slightly more likely than younger women to have initiated physical violence against their current or most recent husband or partner. Women age 15-19 were the least likely to have initiated marital violence (less than 1 percent). Women who are employed, whether for cash or not, are more likely to initiate physical violence against their husband or partner than unemployed women (3 percent each compared with 1 percent) The analysis by residence shows that women who live in urban areas are slightly more likely than women in rural areas to have ever initiated physical violence against their husband or partner (3 percent compared with 2 percent). By zones, South South has the highest percentage of women who ever initiated physical violence against their husband or partner (6 percent), while North West has the lowest percentage (less than 1 percent). The likelihood of women initiating physical violence against their husband or partner increases with the household wealth quintile, from less than 1 percent among women in the lowest wealth quintile to 3 percent among women in the highest wealth quintile. Table 16.15 indicates that women who are divorced, separated, or widowed are more likely to have initiated physical violence against their husband or partner than other women (7 percent). Women with no education are less likely to initiate physical violence against their spouse than other women—less than 1 percent, compared with 4 percent among women with secondary education and 3 percent among women with more than secondary education. Women whose husband or partner gets drunk often are more likely to initiate physical violence than women whose husband does not drink (11 and 1 percent, respectively). Women who are older than their husband or have more education than their husband are more likely than other women to initiate physical violence against their husband or partner. 16.16 HELP-SEEKING BEHAVIOUR BY WOMEN WHO EXPERIENCE VIOLENCE The section describes help-seeking behaviour of women age 15-49 who have ever experienced physical or sexual violence. Table 16.16 the percent distribution of women who have ever experienced physical or sexual violence by whether they sought help to stop the violence, and for those who did not seek help, whether or not they told anyone. According to the 2008 NDHS, nearly half (45 percent) of women who experienced physical or sexual violence never told anyone. An additional 8 percent told someone about the violence but did not seek help. One in three women (34 percent) who experienced physical or sexual violence sought help to stop the violence. Women who have experienced both physical and sexual violence are more likely to have sought help (51 percent) than women who experienced only physical violence (29 percent) or only sexual violence (38 percent). Women who are unemployed are less likely to seek help (28 percent), compared with women who are either employed for cash (35 percent), or who are employed but are not paid in cash (37 percent). Divorced, separated, and widowed women are more likely to have sought help to end the violence (46 percent) than women who are currently married (33 percent) or women who are never-married (31 percent). Women in rural areas reported a higher percentage of help seeking behaviour to stop violence than their counterparts in urban areas (36 percent compared with 30 percent). There is notable variation in help-seeking by zone. Women in South East are most likely to have ever sought assistance to end violence against them (43 percent) while women in North West are least likely to have done so (24 percent). Domestic Violence | 283 Table 16.16 Help seeking to stop violence Percent distribution of women age 15-49 who have ever experienced physical or sexual violence by whether sought help from any source, and for those who did not seek help the percentage who never told anyone and the percentage who told someone, according to type of violence and background characteristics, Nigeria 2008 Never sought help to stop violence Type of violence/ background characteristic Percentage who never told anyone Percentage who told someone Sought help from any source Missing/ don’t know Total Number of women Type of violence Physical only 47.5 8.2 29.2 15.0 100.0 4,811 Sexual only 46.8 6.4 37.7 9.1 100.0 383 Both physical and sexual 32.7 7.7 50.6 9.0 100.0 1,130 Current age 15-19 48.5 10.0 28.9 12.6 100.0 1,102 20-24 46.6 9.9 32.1 11.5 100.0 1,193 25-29 41.3 7.6 35.9 15.2 100.0 1,331 30-39 44.6 7.0 35.7 12.7 100.0 1,657 40-49 43.8 5.9 33.9 16.4 100.0 1,042 Employed past 12 months1 Not employed 49.6 8.5 28.2 13.7 100.0 1,921 Employed for cash 43.6 8.0 35.4 13.0 100.0 3,266 Employed not for cash 40.4 7.2 37.4 15.1 100.0 1,123 Number of living children 0 48.0 10.2 30.3 11.5 100.0 1,983 1-2 43.5 7.8 35.5 13.2 100.0 1,649 3-4 42.2 6.4 34.7 16.6 100.0 1,397 5+ 44.5 6.6 34.9 14.1 100.0 1,294 Marital status and duration Never married 47.8 11.3 31.0 9.9 100.0 1,703 Currently married women 44.5 6.8 33.4 15.2 100.0 4,212 Married only once 45.3 6.7 33.0 14.9 100.0 3,657 0-4 years 46.9 6.7 32.2 14.3 100.0 935 5-9 years 43.9 7.9 34.8 13.4 100.0 879 10+ years 45.2 6.2 32.6 15.9 100.0 1,843 Married more than once 39.2 7.6 35.9 17.3 100.0 555 Divorced/separated/widowed 35.6 6.5 46.0 12.0 100.0 409 Residence Urban 47.4 8.9 30.3 13.4 100.0 2,417 Rural 43.2 7.5 35.6 13.7 100.0 3,907 Zone North Central 44.4 9.9 32.9 12.9 100.0 1,048 North East 44.0 7.6 28.0 20.4 100.0 647 North West 44.2 7.9 23.8 24.1 100.0 752 South East 38.8 5.6 42.9 12.7 100.0 838 South South 43.5 7.8 40.5 8.1 100.0 1,813 South West 52.0 8.7 26.4 12.9 100.0 1,226 Education No education 43.6 8.1 28.8 19.4 100.0 1,298 Primary 43.3 6.0 37.2 13.5 100.0 1,607 Secondary 46.0 8.8 34.9 10.2 100.0 2,819 More than secondary 45.9 9.2 27.6 17.3 100.0 600 Wealth quintile Lowest 41.2 8.3 32.2 18.2 100.0 857 Second 43.4 7.0 33.4 16.2 100.0 937 Middle 44.8 7.3 36.3 11.6 100.0 1,291 Fourth 45.0 7.2 36.3 11.5 100.0 1,579 Highest 47.3 9.7 29.7 13.3 100.0 1,660 Total 44.8 8.0 33.6 13.6 100.0 6,324 Note: Excludes women whose sexual initiation was forced but who have not experienced any other form of physical or sexual violence 1 Includes 16 unweighted cases (not shown in the table) for which employment status is missing 284 | Domestic Violence Uneducated women and those who have more than secondary education are less likely to have sought help, compared with women with primary and secondary education. There is little variation in help-seeking behaviour by wealth quintile; however, women in the middle and fourth wealth quintiles are slightly more likely than women in the highest wealth quintile to have sought help to stop the violence. 16.17 SOURCES OF HELP In the 2008 NDHS, information was collected on women age 15-49 who ever experienced physical or sexual violence and sought help to stop the violence. Table 16.17 shows the sources of help sought by type of violence committed. The majority of women who ever experienced physical or sexual violence sought help from their family (65 percent), while 31 percent sought help from in-laws, and 17 percent sought help from a friend or neighbour. Three percent sought help from a religious leader and 2 percent from the police. Less than 1 percent of women sought help from a social service organisation. Table 16.17 Sources from where help was sought Percentage of women age 15-49 who have ever experienced physical or sexual violence and sought help, and source from which help was sought, by type of violence experienced, Nigeria 2008 Type of violence Source of help Physical only Sexual only Both physical and sexual Total Own family 66.0 60.5 64.0 65.1 In-laws 35.9 5.2 25.5 31.0 Husband/partner boyfriend 3.0 7.2 4.1 3.6 Friend/neighbour 13.0 23.6 24.8 16.9 Religious leader 2.8 0.5 3.4 2.8 Doctor/medical personnel 0.5 0.0 0.3 0.4 Police 2.1 1.2 2.4 2.1 Lawyer 0.2 0.0 0.2 0.2 Social service organisation 0.3 0.0 0.3 0.3 Other 6.0 12.6 7.4 6.8 Number of women 1,407 144 572 2,123 Orphans and Vulnerable Children | 285 ORPHANS AND VULNERABLE CHILDREN 17 One of the outcomes of the HIV epidemic has been an increased number of children who have been orphaned or whose social and economic vulnerability has increased due to the serious illness of a parent or other adult member of the household. The response to the crisis in Nigeria was initially driven by the community, with the extended family providing protection and care and support to family members in need. The Federal Government of Nigeria has initiated a number of policy frameworks directed at improving the situation of orphans and vulnerable children (OVCs). These include the passage of the Child Rights Act (2003), which incorporates the UN Convention on the Rights of the Child, and the development of a five-year National Action Plan on Orphans and Vulnerable Children (FMWA&SD, 2006e). The Plan and the National Standard of Practice (FMWA&SD, 2006b) prioritise key areas of intervention including protection, care and support, and education for orphans and vulnerable children. This chapter looks first at the prevalence of orphaned and vulnerable children in Nigeria. It examines the extent to which children who are orphaned and vulnerable are disadvantaged in comparison to other children on several key measures of children’s welfare, including school attendance. The chapter then reviews information on the care and support given to households in which there are orphaned and vulnerable children.1 In reviewing the 2008 NDHS results, it is important to remember that the survey includes only orphans and vulnerable children living in households. Children who are living in institutions or other non-household settings, including children living on the street, are not included in the 2008 NDHS OVC results. Thus, the 2008 NDHS results should be considered as a minimum estimate of the problem of OVCs in Nigeria 17.1 ORPHANED AND VULNERABLE CHILDREN In the 2008 NDHS, an orphan is defined as a child under age 18 with one or both parents deceased. A vulnerable child is defined as a child under age 18 who has a chronically ill parent (sick for three or more consecutive months during the past 12 months) or who lives in a household where an adult was chronically ill or died during the 12 months preceding the survey. 17.1.1 Children’s Living Arrangements and Orphanhood The Household Questionnaire collected information on the living arrangements for all children under age 18 in the households included in the 2008 NDHS sample. Information was also collected of the survival status of the children’s parents. The results are presented in Table 17.1. In the households sampled, 71 percent of children under age 18 were living with both of their parents. Twelve percent of children were not living with a biological parent. The percentage of children who do not live with either of their biological parents increases with age, from about 4 percent among children age 0-4 years to 30 percent among children age 15-17. Girls are more likely to live in households with neither biological parent present than boys (13 and 10 percent, respectively). Children in South South and South East (15 percent) are more likely to live in households without a biological parent present than children in other zones. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by zone. State-level results are available in Appendix A. 286 | Orphans and Vulnerable Children The 2003 NDHS obtained information on orphanhood only for children under age 15. However, for the purposes of comparing the results of the 2003 and 2008 NDHS surveys, Table 17.1 includes the totals regarding living arrangements for children under age 15. A comparison of the results from the 2003 and 2008 NDHS surveys for this age group indicates similar proportions of children are orphaned, i.e., with one or both parents deceased (6 and 5 percent, respectively). Table 17.1 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by children's living arrangements and survival status of parents, and the percentage of children not living with a biological parent, according to background characteristics, Nigeria 2008 Not living with either parent Living with mother but not father Living with father but not mother Background characteristic Living with both parents Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Information missing on father/ mother Total Percentage not living with a biological parent Number of children Age 0-4 81.3 10.8 1.1 2.5 0.3 3.1 0.3 0.2 0.1 0.3 100.0 3.9 25,726 <2 84.1 12.6 0.7 1.0 0.1 0.8 0.1 0.1 0.0 0.4 100.0 1.5 10,434 2-4 79.4 9.5 1.4 3.6 0.5 4.6 0.3 0.3 0.1 0.3 100.0 5.6 15,292 5-9 72.0 7.9 2.4 6.1 1.0 8.5 0.5 1.0 0.3 0.3 100.0 10.5 23,118 10-14 63.3 7.2 4.4 7.9 1.8 11.3 0.8 1.9 0.7 0.6 100.0 15.4 18,042 15-17 47.7 7.3 6.2 6.6 2.1 20.5 1.4 3.1 1.4 3.8 100.0 30.2 7,901 Sex Male 71.4 8.6 2.8 6.1 1.3 7.2 0.6 1.1 0.4 0.5 100.0 9.8 38,072 Female 69.7 8.7 2.8 4.6 0.9 10.0 0.6 1.3 0.5 1.0 100.0 13.3 36,716 Residence Urban 69.7 9.1 3.2 5.2 1.0 9.0 0.7 1.1 0.5 0.6 100.0 11.9 23,206 Rural 70.9 8.5 2.7 5.4 1.1 8.4 0.6 1.2 0.4 0.8 100.0 11.3 51,582 Zone North Central 68.4 7.5 3.4 5.8 1.4 10.2 0.7 1.4 0.5 0.6 100.0 13.5 11,279 North East 77.9 4.9 1.3 5.9 1.0 6.7 0.4 1.0 0.2 0.7 100.0 9.0 11,407 North West 79.5 4.9 1.4 5.9 1.0 4.9 0.4 0.6 0.2 1.1 100.0 7.3 21,374 South East 61.9 12.4 6.6 3.1 1.0 10.7 0.7 2.3 0.7 0.5 100.0 15.0 7,529 South South 57.4 16.4 4.5 5.1 1.2 11.2 0.8 1.8 1.1 0.5 100.0 15.4 10,059 South West 66.5 10.9 2.7 5.1 1.0 11.4 0.7 0.9 0.3 0.6 100.0 13.8 13,141 Wealth quintile Lowest 76.4 5.3 2.1 5.3 1.2 7.0 0.5 0.9 0.3 0.9 100.0 9.6 16,266 Second 72.6 8.2 2.7 5.1 1.2 7.7 0.4 0.9 0.4 0.8 100.0 10.3 16,180 Middle 65.9 10.3 3.9 5.8 1.2 9.7 0.7 1.5 0.5 0.6 100.0 13.0 15,054 Fourth 66.9 10.6 3.2 5.7 0.8 9.5 0.8 1.3 0.5 0.7 100.0 12.8 14,016 Highest 69.9 9.6 2.4 4.8 0.9 9.3 0.7 1.2 0.5 0.7 100.0 12.3 13,272 Total <15 73.2 8.8 2.5 5.2 1.0 7.2 0.5 0.9 0.3 0.4 100.0 9.3 66,887 Total <18 70.5 8.7 2.8 5.3 1.1 8.6 0.6 1.2 0.4 0.7 100.0 11.5 74,788 Note: Table is based on children who usually live in the household. 17.1.2 Orphaned and Vulnerable Children Children whose parents are ill for an extended period or who li