Nigeria - Demographic and Health Survey - 2014

Publication date: 2014

Nigeria Demographic and Health Survey 2013 N igeria 2013 D em ographic and H ealth Survey NIGERIA DEMOGRAPHIC AND HEALTH SURVEY 2013 National Population Commission Federal Republic of Nigeria Abuja, Nigeria ICF International Rockville, Maryland, USA June 2014 This report summarises the findings of the 2013 Nigeria Demographic and Health Survey (NDHS), implemented by the National Population Commission (NPC). ICF International provided financial and technical assistance for the survey through the USAID-funded MEASURE DHS program, which is designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. Financial support for the survey was provided by USAID, the United Kingdom Department for International Development (DFID) through PATHS2, and the United Nations Population Fund (UNFPA). The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID, the government of Nigeria, or donor organisations. Additional information about the 2013 NDHS may be obtained from the headquarters of the National Population Commission (NPC), Plot 2031, Olusegun Obasanjo Way, Zone 7 Wuse, PMB 0281, Abuja, Nigeria (telephone: 234-09-523-9173; Fax: 243-09-523-1024; e-mail: info@populationgov.ng; Internet: www.population.gov.ng). Information about the MEASURE DHS program may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA (telephone: 301-407-6500; Fax: 301-407-6501; e-mail: info@dhsprogram.com; Internet: www.dhsprogram.com). Suggested citation: National Population Commission (NPC) [Nigeria] and ICF International. 2014. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International. Contents • iii CONTENTS TABLES AND FIGURES . ix FOREWORD . xvii STEERING COMMITTEE . xix CONTRIBUTORS TO THE REPORT . xxi ABBREVIATIONS . xxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxv MAP OF NIGERIA . xxvi 1 INTRODUCTION . 1 1.1 Geography, History, and Economy . 1 1.1.1 Geography . 1 1.1.2 History . 1 1.1.3 Economy . 2 1.2 Population . 2 1.3 Population and Health Policies . 3 1.3.1 National Population Policy . 3 1.3.2 Health Policy . 4 1.4 Organisation of the 2013 Nigeria Demographic and Health Survey . 6 1.4.1 Sample Design . 7 1.4.2 Questionnaires . 7 1.4.3 Recruitment and Training of Field Staff . 9 1.4.4 Fieldwork . 9 1.4.5 Data Processing . 10 1.5 Response Rates . 10 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS . 11 2.1 Household Environment . 11 2.1.1 Drinking Water . 11 2.1.2 Household Sanitation Facilities . 13 2.1.3 Housing Characteristics . 14 2.1.4 Household Possessions . 15 2.2 Wealth Index . 15 2.3 Hand Washing . 16 2.4 Household Population by Age, Sex, and Residence . 18 2.5 Household Composition . 19 2.6 Birth Registration . 20 2.7 Education of the Household Population . 23 2.7.1 Educational Attainment . 23 2.7.2 School Attendance Ratios . 26 3 CHARACTERISTICS OF RESPONDENTS . 31 3.1 Characteristics of Survey Respondents . 31 3.2 Educational Attainment by Background Characteristics . 33 3.3 Literacy . 36 3.4 Exposure to Mass Media . 39 3.5 Employment . 42 3.6 Occupation . 46 iv • Contents 3.7 Type of Employment . 49 3.8 Health Insurance Coverage . 50 3.9 Use of Tobacco . 52 4 MARRIAGE AND SEXUAL ACTIVITY . 53 4.1 Marital Status . 53 4.2 Polygyny . 54 4.3 Age at First Marriage . 57 4.4 Age at First Sexual Intercourse . 58 4.5 Recent Sexual Activity . 61 5 FERTILITY . 65 5.1 Current Fertility . 65 5.2 Fertility Differentials . 67 5.3 Fertility Trends . 70 5.4 Children Ever Born and Living . 71 5.5 Birth Intervals . 72 5.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 74 5.7 Menopause . 77 5.8 Age at First Birth . 77 5.9 Teenage Pregnancy and Motherhood . 78 6 FERTILITY PREFERENCES . 81 6.1 Desire for More Children . 81 6.2 Desire to Limit Childbearing by Background Characteristics . 83 6.3 Ideal Family Size . 85 6.4 Fertility Planning Status . 86 6.5 Wanted Fertility Rates . 87 7 FAMILY PLANNING . 89 7.1 Knowledge of Contraceptive Methods . 89 7.2 Knowledge of Contraceptive Methods by Background Characteristics . 91 7.3 Current Use of Contraception . 92 7.4 Current Use of Contraception by Background Characteristics . 94 7.5 Trends in Contraceptive Use . 97 7.6 Source of Modern Contraceptive Methods . 98 7.7 Use of Social Marketing Brand Pills . 98 7.8 Use of Social Marketing Brand Condoms . 99 7.9 Informed Choice . 101 7.10 Rates of Discontinuing Contraceptive Methods . 102 7.11 Reasons for Discontinuing Contraceptive Methods . 103 7.12 Knowledge of the Fertile Period . 104 7.13 Need and Demand for Family Planning . 104 7.14 Future Use of Contraception . 110 7.15 Exposure to Family Planning Messages in the Media . 110 7.16 Exposure to Specific Family Planning Messages . 112 7.17 Contact of Nonusers with Family Planning Providers . 114 8 INFANT AND CHILD MORTALITY . 117 8.1 Data Quality . 118 8.2 Levels and Trends in Infant and Child Mortality . 118 8.2.1 Early Childhood Mortality Rates . 118 8.2.2 Trends in Early Childhood Mortality . 119 Contents • v 8.3 Early Childhood Mortality Rates by Socioeconomic Characteristics . 120 8.4 Demographic Differentials in Early Childhood Mortality Rates . 121 8.5 Perinatal Mortality . 122 8.6 High-Risk Fertility Behaviour . 123 9 REPRODUCTIVE HEALTH . 127 9.1 Antenatal Care . 128 9.1.1 Number and Timing of Antenatal Visits . 130 9.1.2 Components of Antenatal Care . 131 9.1.3 Tetanus Toxoid Injections . 133 9.2 Delivery . 135 9.2.1 Place of Delivery. 135 9.2.2 Reasons for Not Delivering in a Health Facility . 137 9.2.3 Assistance during Delivery . 139 9.3 Postnatal Care . 141 9.3.1 Timing of First Postnatal Checkup for Mother . 141 9.3.2 Provider of First Postnatal Checkup for Mother . 143 9.4 Newborn Care . 145 9.4.1 Timing of First Postnatal Checkup for Newborn . 145 9.4.2 Provider of First Postnatal Checkup for Newborn . 147 9.4.3 Use of Clean Home Delivery Kits . 149 9.4.4 Newborn Care Practices . 151 9.5 Problems in Accessing Health Care . 153 10 CHILD HEALTH . 155 10.1 Child’s Size and Weight at Birth . 156 10.2 Vaccination Coverage. 158 10.2.1 Vaccination Coverage by Background Characteristics . 159 10.2.2 Trends in Vaccination Coverage . 161 10.3 Acute Respiratory Infection . 161 10.4 Fever . 163 10.5 Diarrhoeal Disease . 165 10.5.1 Prevalence of Diarrhoea . 166 10.5.2 Treatment of Diarrhoea . 167 10.5.3 Feeding Practices during Diarrhoea . 169 10.6 Knowledge of ORS Packets . 171 10.7 Stool Disposal . 171 11 NUTRITION OF CHILDREN AND WOMEN . 175 11.1 Nutritional Status of Children . 175 11.1.1 Measurement of Nutritional Status among Young Children . 176 11.1.2 Data Collection . 177 11.1.3 Measures of Child Nutritional Status . 177 11.1.4 Trends in Children’s Nutritional Status . 180 11.2 Breastfeeding and Complementary Feeding . 181 11.2.1 Initiation of Breastfeeding . 181 11.2.2 Breastfeeding Status by Age . 184 11.2.3 Duration of Breastfeeding . 186 11.2.4 Types of Complementary Foods . 187 11.3 Infant and Young Child Feeding (IYCF) Practices . 188 11.4 Micronutrient Intake among Children . 192 11.5 Nutritional Status of Women . 195 11.6 Micronutrient Intake among Mothers . 197 vi • Contents 12 MALARIA . 201 12.1 Mosquito Nets . 202 12.2 Indoor Residual Spraying . 204 12.3 Access to an Insecticide-Treated Net (ITN) . 206 12.4 Use of Mosquito Nets by Persons in the Household . 208 12.5 Use of Existing ITNs . 210 12.6 Use of Mosquito Nets by Children under Age 5 . 212 12.7 Use of Mosquito Nets by All Women and Pregnant Women Age 15-49 . 213 12.8 Prophylactic Use of Antimalarial Drugs and Use of Intermittent Preventive Treatment in Pregnant Women . 215 12.9 Prevalence and Prompt Treatment of Fever in Children under Age 5 . 217 12.10 Source of Advice or Treatment for Children with Fever . 220 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR . 223 13.1 HIV and AIDS Knowledge, Transmission, and Prevention Methods . 224 13.1.1 Awareness of HIV and AIDS. 224 13.1.2 Knowledge of HIV Prevention Methods . 226 13.1.3 Rejection of Misconceptions about HIV/AIDS . 228 13.2 Knowledge of Mother-to-Child Transmission of HIV . 231 13.3 Accepting Attitudes Toward Those Living with HIV and AIDS . 233 13.4 Attitudes Towards Negotiating Safer Sex . 236 13.5 Attitudes Toward Condom Education for Youth . 238 13.6 Higher-Risk Sex . 240 13.6.1 Multiple Sexual Partners . 240 13.6.2 Point Prevalence and Cumulative Prevalence of Concurrent Sexual Partners . 243 13.7 Transactional Sex . 245 13.8 Testing for HIV . 246 13.8.1 General HIV Testing . 246 13.8.2 HIV Counselling and Testing during Pregnancy . 250 13.9 Male Circumcision . 252 13.10 Self-Reporting of Sexually Transmitted Infections . 256 13.11 Prevalence of Medical Injections. 258 13.12 HIV- and AIDS-Related Knowledge and Behaviour among Youth . 260 13.12.1 Knowledge about HIV and AIDS and of Sources for Condoms . 260 13.12.2 Age at First Sexual Intercourse among Youth . 262 13.12.3 Trends in Age at First Sexual Intercourse among Youth . 264 13.12.4 Abstinence and Premarital Sex . 264 13.12.5 Multiple Partnerships among Young People. 266 13.12.6 Age Mixing in Sexual Relationships among Young Women Age 15-19 . 268 13.12.7 Recent HIV Tests among Youth . 270 14 ADULT AND MATERNAL MORTALITY . 273 14.1 Data . 274 14.2 Direct Estimates of Adult Mortality . 275 14.2.1 Trends in Adult Mortality . 276 14.3 Direct Estimates of Maternal Mortality . 277 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 279 15.1 Employment and Form of Earnings . 280 15.2 Control Over and Relative Magnitude of Women’s and Husbands’ Earnings . 280 15.2.1 Control Over Wife’s Earnings . 280 15.2.2 Control Over Husband’s Earnings . 282 Contents • vii 15.3 Control Over Women’s Earnings and Relative Size of Husband’s and Wife’s Earnings . 284 15.4 Ownership of Assets . 285 15.5 Women’s Participation in Decision Making . 288 15.6 Attitudes Toward Wife Beating . 292 15.7 Women’s Empowerment Indices . 296 15.8 Current Use of Contraception by Women’s Status . 297 15.9 Ideal Family Size and Unmet Need by Women’s Status . 298 15.10 Women’s Status and Reproductive Health Care . 299 15.11 Differentials in Infant and Child Mortality by Women’s Status . 300 16 DOMESTIC VIOLENCE . 301 16.1 Measurement of Violence . 302 16.1.1 Use of Valid Measures of Violence . 302 16.1.2 Ethical Considerations . 303 16.1.3 Subsample for the Violence Module . 303 16.2 Women Experiencing Physical Violence . 303 16.3 Perpetrators of Physical Violence . 306 16.4 Experience of Sexual Violence . 307 16.5 Persons Committing Sexual Violence . 309 16.6 Age at First Experience of Sexual Violence . 309 16.7 Experience of Different Forms of Violence . 309 16.8 Violence during Pregnancy . 310 16.9 Marital Control by Husband or Partner . 311 16.10 Forms of Spousal Violence . 313 16.11 Spousal Violence by Background Characteristics . 315 16.12 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 317 16.13 Recent Spousal Violence . 319 16.14 Onset of Spousal Violence . 321 16.15 Types of Injuries Caused by Spousal Violence . 321 16.16 Violence by Women Against Their Spouse . 322 16.17 Help-seeking Behaviour by Women who Experience Violence . 325 16.18 Sources of Help . 327 16.19 Domestic Violence Faced by Widowed Women . 328 17 ORPHANS AND VULNERABLE CHILDREN . 329 17.1 Orphans and Vulnerable Children . 330 17.1.1 Children’s Living Arrangements and Orphanhood . 330 17.1.2 Orphaned and Vulnerable Children . 331 17.2 Social and Economic Situation of Orphaned and Vulnerable Children. 333 17.2.1 School Attendance . 333 17.2.2 Basic Material Needs . 334 17.2.3 Orphans Living with Siblings . 336 17.2.4 Nutritional Status . 337 17.2.5 Sex Before Age 15 . 338 17.3 Care and Support for Orphaned and Vulnerable Children. 339 17.3.1 Widows Dispossessed of Property . 339 17.3.2 External Support for Households with OVCs . 341 18 FEMALE GENITAL CUTTING . 345 18.1 Knowledge of Female Circumcision . 346 18.2 Prevalence of Female Circumcision . 348 18.3 Age at Circumcision . 351 viii • Contents 18.4 Circumcision of Daughters . 353 18.5 Person Who Performed Circumcision . 357 18.6 Attitudes Toward Female Circumcision . 358 REFERENCES . 363 APPENDIX A ADDITIONAL TABLES . 369 APPENDIX B SAMPLE DESIGN AND IMPLEMENTATION . 377 APPENDIX C ESTIMATES OF SAMPLING ERRORS . 385 APPENDIX D DATA QUALITY TABLES . 397 APPENDIX E PERSONS INVOLVED IN THE SURVEY . 401 APPENDIX F QUESTIONNAIRES . 411 Tables and Figures • ix TABLES AND FIGURES 1 INTRODUCTION . 1 Table 1.1 Basic demographic indicators . 3 Table 1.2 Results of the household and individual interviews . 10 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS . 11 Table 2.1 Household drinking water . 12 Table 2.2 Household sanitation facilities . 13 Table 2.3 Household characteristics . 14 Table 2.4 Household possessions . 15 Table 2.5 Wealth quintiles . 16 Table 2.6 Hand washing . 17 Table 2.7 Household population by age, sex, and residence . 18 Table 2.8 Household composition . 19 Table 2.9 Birth registration of children under age 5 . 20 Table 2.10 Birth registration of children under age 5 by authority . 22 Table 2.11.1 Educational attainment of the female household population . 23 Table 2.11.2 Educational attainment of the male household population . 24 Figure 2.1 Population pyramid . 19 Figure 2.2 Age-specific attendance rates . 29 3 CHARACTERISTICS OF RESPONDENTS . 31 Table 3.1 Background characteristics of respondents . 32 Table 3.2.1 Educational attainment: Women . 34 Table 3.2.2 Educational attainment: Men . 35 Table 3.3.1 Literacy: Women . 37 Table 3.3.2 Literacy: Men . 38 Table 3.4.1 Exposure to mass media: Women . 40 Table 3.4.2 Exposure to mass media: Men . 41 Table 3.5.1 Employment status: Women . 42 Table 3.5.2 Employment status: Men . 45 Table 3.6.1 Occupation: Women . 46 Table 3.6.2 Occupation: Men . 48 Table 3.7.1 Type of employment: Women . 49 Table 3.7.2 Type of employment: Men . 50 Table 3.8.1 Health insurance coverage: Women . 51 Table 3.8.2 Health insurance coverage: Men . 51 Table 3.9 Use of tobacco: Men . 52 Figure 3.1 Literacy status of women and men age 15-49 by regions . 39 Figure 3.2 Women’s employment status in the past 12 months . 44 4 MARRIAGE AND SEXUAL ACTIVITY . 53 Table 4.1 Current marital status . 53 Table 4.2.1 Number of women’s co-wives . 54 Table 4.2.2 Number of men’s wives . 56 Table 4.3 Age at first marriage . 57 x • Tables and Figures Table 4.4 Median age at first marriage by background characteristics . 58 Table 4.5 Age at first sexual intercourse . 59 Table 4.6 Median age at first sexual intercourse by background characteristics . 60 Table 4.7.1 Recent sexual activity: Women . 62 Table 4.7.2 Recent sexual activity: Men . 63 5 FERTILITY . 65 Table 5.1 Current fertility . 66 Table 5.2 Fertility by background characteristics . 68 Table 5.3.1 Trends in age-specific fertility rates . 70 Table 5.3.2 Trends in age-specific and total fertility rates . 70 Table 5.4 Children ever born and living . 72 Table 5.5 Birth intervals . 73 Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility . 75 Table 5.7 Median duration of amenorrhoea, postpartum abstinence, and postpartum insusceptibility . 76 Table 5.8 Menopause . 77 Table 5.9 Age at first birth . 77 Table 5.10 Median age at first birth . 78 Table 5.11 Teenage pregnancy and motherhood . 79 Figure 5.1 Trends in age-specific fertility rates by urban-rural residence . 67 Figure 5.2 Total fertility rates of selected ECOWAS countries . 67 Figure 5.3 Fertility differentials by zone . 69 Figure 5.4 Trends in age-specific fertility rates, 2003-2013 . 71 Figure 5.5 Percentage of teenagers who have begun childbearing and who are pregnant with their first child by age . 80 6 FERTILITY PREFERENCES . 81 Table 6.1 Fertility preferences by number of living children . 82 Table 6.2.1 Desire to limit childbearing: Women . 84 Table 6.2.2 Desire to limit childbearing: Men . 84 Table 6.3 Ideal number of children by number of living children . 85 Table 6.4 Mean ideal number of children . 86 Table 6.5 Fertility planning status . 87 Table 6.6 Wanted fertility rates . 88 Figure 6.1 Percentage of currently married women and men who want no more children, by number of living children . 83 7 FAMILY PLANNING . 89 Table 7.1 Knowledge of contraceptive methods . 90 Table 7.2 Knowledge of contraceptive methods by background characteristics . 91 Table 7.3 Current use of contraception by age . 93 Table 7.4 Current use of contraception by background characteristics . 95 Table 7.5 Trends in current use of contraception . 97 Table 7.6 Source of modern contraception methods . 98 Table 7.7 Use of social marketing brand pills and injectables . 99 Table 7.8.1 Use of social marketing brand condoms: Women . 100 Table 7.8.2 Use of social marketing brand condoms: Men . 101 Table 7.9 Informed choice . 102 Table 7.10 Twelve-month contraceptive discontinuation rates . 103 Table 7.11 Reasons for discontinuation . 104 Tables and Figures • xi Table 7.12 Knowledge of fertile period . 104 Table 7.13.1 Need and demand for family planning among currently married women . 106 Table 7.13.2 Need and demand for family planning for all women . 108 Table 7.13.3 Need and demand for family planning for sexually active unmarried women . 109 Table 7.14 Future use of contraception . 110 Table 7.15 Exposure to family planning messages . 111 Table 7.16 Exposure to specific family planning messages . 113 Table 7.17 Contact of nonusers with family planning providers . 115 Figure 7.1 Differentials in contraceptive use, Nigeria. 97 Figure 7.2 Trends in unmet need for family planning . 110 8 INFANT AND CHILD MORTALITY . 117 Table 8.1 Early childhood mortality rates . 119 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 120 Table 8.3 Early childhood mortality rates by demographic characteristics . 121 Table 8.4 Perinatal mortality . 123 Table 8.5 High-risk fertility behaviour . 124 Figure 8.1 Trends in childhood mortality, 1999-2013 . 119 Figure 8.2 Under-5 mortality in the 10 years preceding the survey by socioeconomic characteristics . 121 Figure 8.3 Infant mortality rate in the 10 years preceding the survey by selected demographic characteristics . 122 9 REPRODUCTIVE HEALTH . 127 Table 9.1 Antenatal care . 128 Table 9.2 Number of antenatal care visits and timing of first visit . 130 Table 9.3 Components of antenatal care . 131 Table 9.4 Tetanus toxoid injections . 133 Table 9.5 Place of delivery . 135 Table 9.6 Reasons for not delivering in a health facility . 138 Table 9.7 Assistance during delivery . 139 Table 9.8 Timing of first postnatal checkup . 142 Table 9.9 Type of provider of first postnatal checkup for the mother . 144 Table 9.10 Timing of first postnatal checkup for the newborn . 146 Table 9.11 Type of provider of first postnatal checkup for the newborn . 147 Table 9.12 Use of clean home delivery kits and other instruments to cut the umbilical cord . 149 Table 9.13 Newborn care practices . 152 Table 9.14 Problems in accessing health care . 153 Figure 9.1 Source of antenatal care . 130 Figure 9.2 Trends in place of delivery . 137 Figure 9.3 Mother’s duration of stay in the health facility after giving birth . 141 Figure 9.4 Type of substance applied on the umbilical stump . 151 10 CHILD HEALTH . 155 Table 10.1 Child’s size and weight at birth. 156 Table 10.2 Vaccinations by source of information . 159 Table 10.3 Vaccinations by background characteristics . 160 Table 10.4 Trends in vaccination coverage . 161 Table 10.5 Prevalence and treatment of symptoms of ARI . 162 xii • Tables and Figures Table 10.6 Prevalence and treatment of fever . 164 Table 10.7 Prevalence of diarrhoea . 166 Table 10.8 Diarrhoea treatment . 168 Table 10.9 Feeding practices during diarrhoea . 170 Table 10.10 Knowledge of ORS packets or pre-packaged liquids. 171 Table 10.11 Disposal of children’s stools . 172 Figure 10.1 Percentage of children age 12-23 months with specific vaccinations . 159 Figure 10.2 Trends in vaccination coverage among children age 12-23 months, 2003-2013 . 161 Figure 10.3 Percentage of children with symptoms of ARI, fever, and diarrhoea for whom treatment was sought from a health facility or provider . 165 11 NUTRITION OF CHILDREN AND WOMEN . 175 Table 11.1 Nutritional status of children . 178 Table 11.2 Initial breastfeeding . 182 Table 11.3 Breastfeeding status by age . 185 Table 11.4 Median duration of breastfeeding . 187 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 188 Table 11.6 Infant and young child feeding (IYCF) practices . 190 Table 11.7 Micronutrient intake among children . 192 Table 11.8 Nutritional status of women . 196 Table 11.9 Micronutrient intake among mothers . 198 Figure 11.1 Nutritional status of children by age . 180 Figure 11.2 Trends in nutritional status of children under age 5, 2003-2013 . 181 Figure 11.3 Infant feeding practices by age . 185 Figure 11.4 IYCF indicators on breastfeeding status . 186 Figure 11.5 IYCF indicators on minimum acceptable diet . 192 Figure 11.6 Trends in nutritional status of women . 197 12 MALARIA . 201 Table 12.1 Household possession of mosquito nets . 203 Table 12.2 Indoor residual spraying against mosquitoes . 205 Table 12.3 Source of IRS . 206 Table 12.4 Access to an insecticide-treated net (ITN) . 207 Table 12.5 Use of mosquito nets by persons in the household . 208 Table 12.6 Use of existing ITNs . 211 Table 12.7 Use of mosquito nets by children . 212 Table 12.8 Use of mosquito nets by pregnant women . 214 Table 12.9 Use of intermittent preventive treatment by women during pregnancy . 216 Table 12.10 Prevalence, diagnosis, and prompt treatment of children with fever . 218 Table 12.11 Source of advice or treatment for children with fever . 220 Table 12.12 Type of antimalarial drugs used . 221 Figure 12.1 Percentage of the de facto population with access to an ITN in the household, by background characteristics, 2013 . 207 Figure 12.2 Ownership of, access to, and use of ITNs . 210 Figure 12.3 Trends in the percentage of women taking 2+ doses of SP and at least one dose during ANC . 217 Tables and Figures • xiii 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR . 223 Table 13.1 Knowledge of AIDS . 225 Table 13.2 Knowledge of HIV prevention methods . 226 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 228 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 230 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 232 Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 234 Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 235 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 237 Table 13.7 Adult support of education about condom use to prevent AIDS . 239 Table 13.8.1 Multiple sexual partners: Women . 241 Table 13.8.2 Multiple sexual partners: Men . 242 Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners . 244 Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse . 245 Table 13.11.1 Coverage of prior HIV testing: Women . 248 Table 13.11.2 Coverage of prior HIV testing: Men . 249 Table 13.12 Pregnant women counselled and tested for HIV . 251 Table 13.13 Male circumcision . 252 Table 13.14 Place and provider for male circumcision . 254 Table 13.15 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 256 Table 13.16 Prevalence of medical injections . 259 Table 13.17 Comprehensive knowledge about AIDS and of a source of condoms among youth . 261 Table 13.18 Age at first sexual intercourse among young people . 263 Table 13.19 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 265 Table 13.20.1 Multiple sexual partners in the past 12 months among young people: Women . 267 Table 13.20.2 Multiple sexual partners in the past 12 months among young people: Men . 268 Table 13.21 Age mixing in sexual relationships among women age 15-19 . 269 Table 13.22 Recent HIV tests among youth . 270 Figure 13.1 Women and men seeking treatment for STIs . 258 Figure 13.2 Trends in age of first sexual intercourse . 264 14 ADULT AND MATERNAL MORTALITY . 273 Table 14.1 Completeness of information on siblings . 274 Table 14.2 Adult mortality rates and trends . 275 Table 14.3 Adult mortality probabilities . 276 Table 14.4 Maternal mortality . 277 Figure 14.1 Mortality rates among women and men age 15-49 . 276 Figure 14.2 Maternal mortality ratios with confidence intervals for the seven years preceding the 2008 NDHS and the 2013 NDHS . 278 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 279 Table 15.1 Employment and cash earnings of currently married women and men . 280 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 281 Table 15.2.2 Control over men’s cash earnings . 283 Table 15.3 Women’s control over their own earnings and over those of their husbands . 285 Table 15.4.1 Ownership of assets: Women . 285 xiv • Tables and Figures Table 15.4.2 Ownership of assets: Men . 287 Table 15.5 Participation in decision making . 288 Table 15.6.1 Women’s participation in decision making by background characteristics . 289 Table 15.6.2 Men’s participation in decision making by background characteristics . 291 Table 15.7.1 Attitudes toward wife beating: Women . 293 Table 15.7.2 Attitudes toward wife beating: Men . 295 Table 15.8 Indicators of women’s empowerment . 297 Table 15.9 Current use of contraception by women’s empowerment . 298 Table 15.10 Ideal number of children and unmet need for family planning by women’s empowerment . 299 Table 15.11 Reproductive health care by women’s empowerment . 299 Table 15.12 Early childhood mortality rates by women’s status . 300 Figure 15.1 Number of decisions in which currently married women participate . 291 16 DOMESTIC VIOLENCE . 301 Table 16.1 Experience of physical violence . 305 Table 16.2 Persons committing physical violence . 306 Table 16.3 Experience of sexual violence. 307 Table 16.4 Persons committing sexual violence . 309 Table 16.5 Age at first experience of sexual violence . 309 Table 16.6 Experience of different forms of violence . 310 Table 16.7 Experience of violence during pregnancy . 310 Table 16.8 Marital control exercised by husbands . 312 Table 16.9 Forms of spousal violence . 314 Table 16.10 Spousal violence by background characteristics . 316 Table 16.11 Spousal violence by husband’s characteristics and empowerment indicators . 318 Table 16.12 Physical or sexual violence in the past 12 months by any husband/partner . 319 Table 16.13 Experience of spousal violence by duration of marriage . 321 Table 16.14 Injuries to women due to spousal violence . 321 Table 16.15 Women’s violence against their spouse . 322 Table 16.16 Women’s violence against their spouse by husband’s characteristics . 324 Table 16.17 Help seeking to stop violence . 326 Table 16.18 Sources for help to stop violence . 327 Table 16.19 Domestic violence faced by women after the death of their husbands . 328 Figure 16.1 Specific forms of physical and sexual violence committed by spouse . 315 17 ORPHANS AND VULNERABLE CHILDREN . 329 Table 17.1 Children’s living arrangements and orphanhood . 330 Table 17.2 Orphans and vulnerable children . 332 Table 17.3 School attendance by survivorship of parents and by OVC status. 334 Table 17.4 Possession of basic material needs by orphans and vulnerable children . 335 Table 17.5 Orphans not living with siblings . 336 Table 17.6 Underweight orphans and vulnerable children . 337 Table 17.7 Sexual intercourse before age 15 among orphans and vulnerable children . 339 Table 17.8 Widows dispossessed of property . 340 Table 17.9 External support for very sick persons . 342 18 FEMALE GENITAL CUTTING . 345 Table 18.1 Knowledge of female circumcision . 347 Table 18.2 Prevalence of female circumcision . 349 Table 18.3 Unclassified types of female circumcision . 351 Tables and Figures • xv Table 18.4 Age at circumcision . 352 Table 18.5 Prevalence of circumcision and age at circumcision: Girls age 0-14 . 353 Table 18.6 Circumcision of girls age 0-14 by mother’s background characteristics . 354 Table 18.7 Infibulation among circumcised girls age 0-14 . 356 Table 18.8 Aspects of circumcision among circumcised girls age 0-14 and women age 15-49 . 357 Table 18.9 Opinions of women and men about whether circumcision is required by their religion . 359 Table 18.10 Opinions of women and men about whether the practice of circumcision should continue . 361 Figure 18.1 Percentage of women age 15-49 circumcised by selected ethnic groups . 350 Figure 18.2 Percentage of women age 15-49 and girls age 0-14 circumcised by age . 354 APPENDIX A ADDITIONAL TABLES . 369 Table A.2.1 Household drinking water: States . 369 Table A.2.2 Household sanitation facilities: States . 370 Table A.2.3 Household characteristics: Electricity . 371 Table A.3.7.1 Type of earnings: Women by state . 372 Table A.3.7.2 Type of earnings: Men by state . 373 Table A.3.7.3 Type of employer: Women by state . 374 Table A.3.7.4 Continuity of employment: Women by state . 375 Table A.3.7.5 Continuity of employment: Men by state . 376 APPENDIX B SAMPLE DESIGN AND IMPLEMENTATION . 377 Table B.1 Distribution of population and EAs by states . 378 Table B.2 Sample allocation of clusters and households by state and by residence . 379 Table B.3 Expected number of female and male interviews by state and by residence . 380 Table B.4 Sample implementation: Women . 382 Table B.5 Sample implementation: Men . 383 APPENDIX C ESTIMATES OF SAMPLING ERRORS . 385 Table C.1 List of indicators for sampling errors, Nigeria 2013 . 387 Table C.2 Sampling errors for national sample, Nigeria 2013 . 388 Table C.3 Sampling errors for urban areas, Nigeria 2013 . 389 Table C.4 Sampling errors for rural areas, Nigeria 2013 . 390 Table C.5 Sampling errors for North Central zone, Nigeria 2013 . 391 Table C.6 Sampling errors for North East zone, Nigeria 2013 . 392 Table C.7 Sampling errors for North West zone, Nigeria 2013 . 393 Table C.8 Sampling errors for South East zone, Nigeria 2013 . 394 Table C.9 Sampling errors for South South zone, Nigeria 2013 . 395 Table C.10 Sampling errors for South West zone, Nigeria 2013 . 396 APPENDIX D DATA QUALITY TABLES . 397 Table D.1 Household age distribution . 397 Table D.2.1 Age distribution of eligible and interviewed women . 397 Table D.2.2 Age distribution of eligible and interviewed men . 398 Table D.3 Completeness of reporting . 398 Table D.4 Births by calendar years . 399 Table D.5 Reporting of age at death in days . 399 Table D.6 Reporting of age at death in months . 400 Table D.8 Sibship size and sex ratio of siblings . 400 Foreword • xvii FOREWORD igeria Demographic and Health Survey (NDHS) 2013 is the fourth survey of its kind to be implemented by the National Population Commission (NPC). As the agency charged with the responsibility of collecting, collating, and analysing demographic data, the Commission has been unrelenting in its efforts to provide reliable, accurate, and up-to-date data for the country. We hope that information contained in this report will assist policymakers and programme managers in monitoring and designing programmes and strategies for improving health and family planning services in Nigeria. This report presents comprehensive, detailed, final outcomes of the findings of the survey. Users will find the available information useful for programme planning and evaluation. The 2013 NDHS is a national sample survey that provides up-to-date information on background characteristics of the respondents. Specifically, information is collected on fertility levels, marriage, fertility preferences, awareness and the use of family planning methods, child feeding practices, nutritional status of women and children, adult and childhood mortality, awareness and attitudes regarding HIV/AIDS, female genital mutilation, and domestic violence. The target groups were women and men age 15-49 in randomly selected households across Nigeria. Information was also collected on the height and weight of women and children age 0-5. In addition to presenting national estimates, the report provides estimates of key indicators for both the rural and urban areas in Nigeria, the six geo-political zones, the 36 states, and the Federal Capital Territory (FCT). The success of the 2013 NDHS was made possible by a number of organizations and individuals. In this regard, I appreciate the support of the United States Agency for International Development in Nigeria (USAID/Nigeria) and the Department for International Development through PATHS2 for funding the survey, and also thank the United Nations Population Fund (UNFPA). I wish to also acknowledge Akintola Williams Deloitte (AWD) for providing accounting and disbursement services that allowed for the timely and efficient transfer of project funds throughout all the components of the survey. Furthermore, the support and collaboration witnessed by the 2013 NDHS from national, state, and local government, nongovernmental and international development organisations, and other major stakeholders is acknowledged. Special thanks go to the Federal Ministry of Health and its allies. I would like to extend our gratitude to the United Nations Children’s Fund (UNICEF) for providing technical support on height and weight measurement of women and children during the training. On behalf of the Commission, I wish to appreciate the 2013 NDHS technical team, the Project Director, Ms. Nwamaka Ezenwa, and the Project Coordinator, Inuwa Bakari Jalingo, for the management of all the technical, administrative, and logistical phases of the survey. I would also like to put on record my sincere appreciation to the Survey Steering Committee members, field staff, data processing team, and, in particular, survey respondents. Similarly, I wish to express appreciation to ICF International for its technical assistance in all stages of the survey. I greatly appreciate Ms. Anjushree Pradhan (ICF DHS Country Manager) for the commitment and great expertise with which she managed all the components of this survey. I am also thankful to Ms. Claudia Marchena (Data Processing Specialist), who handled the data processing. I wish to commend the efforts of Dr. Alfredo Aliaga and Dr. Ruilin Ren (Sampling Specialists), who provided technical support for sampling. Dr. Pav Govindasamy (Regional Coordinator) also deserves our deep appreciation for her contributions. N xviii • Foreword Finally, I would like to thank the former NPC Chairman, Eze Festus Odimegwu, CON, and the Honourable Federal Commissioners for their support during the implementation period and for providing excellent leadership and advocacy support. The support by the Director, Planning and Research, Dr. Emma Enu Attah, and all NPC staff is hereby acknowledged. Steering Committee • xix STEERING COMMITTEE Eze Festus Odimegwu, CON, National Population Commission Chairman Mr. A. A. Taiwo, National Planning Commission Member Dr. Aderemi Azeez, Federal Ministry Of Health Member Dr. Ibrahim Yisa, PATHS2 Member Dr. Mai Yakubu, OSSAP-MDG Member Mr. Gambo L. Louis, National Bureau Of Statistics Member Dr. Joseph Monehin, USAID Member Dr. Dashe Dasogot, UNFPA Member Ms. Lisa Demoor, CIDA Member Representative, UNICEF Member Representative, WHO Member Representative, World Bank Member Ms. Anjushree Pradhan, ICF International Member Secretariat Ms. Ezenwa Loveth Nwamaka, National Population Commission Mr. Inuwa B. Jalingo, National Population Commission Contributors to the Report • xxi CONTRIBUTORS TO THE REPORT Ms. Ezenwa Nwamaka L., Project Director, NDHS, National Population Commission Mr. Inuwa B. Jalingo, Project Coordinator, NDHS, National Population Commission Mr. Datsu Kalep Harris, National Population Commission Mr. Arukwe Chidimma Ben, National Population Commission Mr. Makinwa Martin, National Population Commission Mr. Basiru Dele Wasiu, Federal Ministry of Women Affairs and Social Development Mr. Onuorah Innocent, National Population Commission Mr. Fasiku A. David, National Population Commission Mr. Akinsulie Bolaji, National Population Commission Dr. Okpani Arnold Ikedichi, National Primary Health Care Development Agency Ms. Winifred Ittah, National Population Commission Ms. Raliya M. Sambo, National Population Commission Dr. Ortonga I. Gabriel, Federal Ministry of Health Mr. Bello Solomon, National Population Commission Mr. Monday Y. Yanet, National Agency for the Control of AIDS Ms. Bintu Ibrahim, National Population Commission Mr. Nasir I. Ohiani, National Population Commission Mr. Akilah J.D., National Malaria Control Programme Dr. Uche Isiugo-Abanihe, University of Ibadan Dr. Chike Nwangwu, Saving One Million Lives (SOML) Initiatives Dr. Joseph Monehin, USAID/Nigeria Ms. Anjushree Pradhan, ICF International Abbreviations • xxiii ABBREVIATIONS ACT Artemisinin-based combination therapy AIDS Acquired immune deficiency syndrome ANC Antenatal care ARI Acute respiratory infection ART Anti-retroviral therapy ASCON Administrative Staff College of Nigeria ASAR Age-specific attendance rate ASFR Age-specific fertility rate BCG Bacille-Calmette-Guerin vaccine against tuberculosis BMI Body mass index CBR Crude birth rate CDC Centers for Disease Control and Prevention CEDAW Convention on the Elimination of All Forms of Discrimination against Women CHEW Community Health Extension Workers CTS Conflict Tactics Scale DFID Department for International Development DHS Demographic and Health Survey DPT Diphtheria, pertussis, and tetanus vaccine EA Enumeration area ECOWAS Economic Community of West African States FCT Federal Capital Territory FGC Female Genital Cutting FMoH Federal Ministry of Health GAR Gross attendance ratio GDP Gross domestic product GFR General fertility rate GPI Gender parity index GPS Global Positioning System HIV Human immunodeficiency virus ICD International Classification of Diseases IMPAC ITN Massive Promotion and Awareness Campaign IPT Intermittent Preventive Therapy IRS Indoor residual spraying ITN Insecticide-treated net IUD Intrauterine device IYCF Infant and young child feeding LAM Lactational amenorrhea method LGA Local government area LLIN Long-lasting insecticide-treated bed net LPG Liquid petroleum gas xxiv • Abbreviations MDGs Millennium Development Goals MMR Maternal mortality ratio MSI Marie Stopes International MSS Midwives Service Scheme MTCT Mother-to-child transmission NAR Net attendance ratio NCHS National Center for Health Statistics NDHS Nigeria Demographic and Health Survey NDSS National Demographic Sample Survey NFS Nigeria Fertility Survey NGO Nongovernmental organization NMCSP National Malaria Control Strategic Plan NN Neonatal mortality NPC National Population Commission NPHCDA National Primary Health Care Development Agency OPV Oral polio vaccine ORS Oral rehydration salts ORT Oral rehydration therapy OVC Orphan and Vulnerable Children PATHS2 Partnership for Transforming Health Systems Phase II PAHO Pan American Health Organization PHC Primary Health Care PMS Patent Medicine Stores PMTCT Prevention of mother-to-child transmission PNN Postneonatal mortality PSU Primary sampling unit RHF Recommended home fluid SDM Standard days method SHS Second-hand smoke SP Sulphadoxine-pyrimethamine STI Sexually transmitted infection SURE-P MCH Subsidy Reinvestment and Empowerment Program, Maternal and Child Health TFR Total fertility rate TT Tetanus toxoid UNAIDS Joint United Nations Programme on HIV/AIDS UNECA United Nations Economic Commission for Africa UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development VAD Vitamin A deficiency VIP Ventilated improved pit WHO World Health Organization WHS Ward Health System Millennium Development Goal Indicators • xxv MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators Nigeria 2013 Indicator Sex Total Male Female 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under 5 years of age 30.2 27.3 28.7 2. Achieve universal primary education 2.1 Net attendance ratio in primary education1 61.6 56.7 59.1 2.3 Literacy rate of 15- to 24-year-olds2 80.2a 62.8 71.5b 3. Promote gender equality and empower women 3.1 Ratio of girls to boys in primary, secondary, and tertiary education 3.1a Ratio of girls to boys in primary education3 na na 0.9 3.1b Ratio of girls to boys in secondary education3 na na 0.9 3.1c Ratio of girls to boys in tertiary education3 na na 0.7 4. Reduce child mortality 4.1 Under-five mortality rate4 151 137 128 4.2 Infant mortality rate4 84 70 69 4.3 Percentage of 1-year-old children immunized against measles 43.1 41.0 42.1 5. Improve maternal health 5.1 Maternal mortality ratio5 na na 576 (CI:500-652) 5.2 Percentage of births attended by skilled health personnel6 na na 38.1 5.3 Contraceptive prevalence rate7 na 15.1 na 5.4 Adolescent birth rate8 na 122 na 5.5 Antenatal care coverage 5.5a At least one visit9 na 60.6 na 5.5b Four or more visits10 na 51.1 na 5.6 Unmet need for family planning na 16.1 na 6. Combat HIV/AIDS, malaria, and other diseases 6.3 Percentage of the population age 15-24 years with comprehensive correct knowledge of HIV/AIDS11 33.5a 24.2 28.9b 6.4 Ratio of school attendance of orphans to school attendance of non- orphans age 10-14 years 1.18 1.28 1.23 6.7 Percentage of children under 5 sleeping under insecticide-treated bednets 16.3 16.8 16.6 6.8 Percentage of children under 5 with fever who are treated with appropriate antimalarial drugs12 33.2 32.3 32.7 Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved water source13 77.6 47.7 59.6 7.9 Percentage of population using an improved sanitation facility14 42.7 28.2 34.0 na = Not applicable 1 The ratio is based on reported attendance, not enrollment, in primary education among primary school age children (5- to 9-year-olds). The rate also includes children of primary school age enrolled in secondary education. This is a proxy for MDG indicator 2.1, net enrollment ratio. 2 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence 3 Based on reported net attendance, not gross enrollment, among 6- to 12-year-olds for primary, 13- to 18-year-olds for secondary, and 19- to 22- year-olds for tertiary education 4 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the 5-year period preceding the survey. 5 Expressed in terms of maternal deaths per 100,000 live births in the 7-year period preceding the survey. 6 Among births in the 5 years preceding the survey 7 Percentage of currently married women age 15-49 using any method of contraception 8 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19 9 With a skilled provider 10 With any health care provider 11 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance 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 transmission or prevention of the AIDS virus. 12 Measured as the percentage of children age 0-59 months who were ill with a fever in the 2 weeks preceding the interview and received any antimalarial drug 13 Percentage of de jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, protected spring, rainwater collection, or bottled water. 14 Percentage of de jure population whose household has a flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share this facility with other households a Restricted to men in the subsample of households selected for the male interview b The total is calculated as the simple arithmetic mean of the percentages in the columns for males and females. xxvi • Map of Nigeria Introduction • 1 INTRODUCTION 1 1.1 GEOGRAPHY, HISTORY, AND ECONOMY 1.1.1 Geography igeria lies on the west coast of Africa between latitudes 4º16' and 13º53' north and longitudes 2º40' and 14º41' east. It occupies approximately 923,768 square kilometres of land stretching from the Gulf of Guinea on the Atlantic coast in the south to the fringes of the Sahara Desert in the north. The territorial boundaries are defined by the republics of Niger and Chad in the north, the Republic of Cameroon on the east, and the Republic of Benin on the west. Nigeria is the most populous country in Africa and the 14th largest in land mass. The country’s 2006 Population and Housing Census placed the country’s population at 140,431,790. Nigeria has great geographical diversity, with its topography characterised by two main land forms: lowlands and highlands. The uplands stretch from 600 to 1,300 metres in the North Central and the east highlands, with 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 the Oban Hills in the southeast. Other topographic features include the Niger-Benue Trough and the Chad Basin. Nigeria has a tropical climate with wet and dry seasons associated with the movement of the inter- tropical convergence zone north and south of the equator. Its climate is influenced by the rain-bearing southwesterly winds and the cold, dry, and dusty northeasterly 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°C 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 these climatic differences consists of mangrove swamp forest in the Niger Delta and Sahel grassland in the north. With its variety of climatic, vegetation, and soil conditions, Nigeria possesses the potential for growing a wide range of agricultural produce. 1.1.2 History Nigeria marked its centenary in 2014, having begun its existence as a nation-state in 1914 through the amalgamation of the northern and southern protectorates. Before this time, there were various cultural, ethnic, and linguistic groups, such as the Oyo, Benin, Nupe, Jukun, Kanem-Bornu, and Hausa-Fulani empires. These groups lived in kingdoms and emirates with sophisticated systems of government. There were also other strong ethnic groups such as the Igbos, Ibibios, Ijaws, and Tivs. The establishment and expansion of British influence in both northern and southern Nigeria and the imposition of British rule resulted in the amalgamation of the protectorates of southern and northern Nigeria in 1914. The British established a crown colony type of government after the amalgamation. By this arrangement, the affairs of the colonial administration were conducted by the British; however, in 1942, 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 (FCT). N 2 • Introduction Nigeria became a republic on October 1, 1963, with different administrative structures. Within the boundaries of Nigeria are many social groups with distinct cultural traits; there are about 374 identifiable ethnic groups, with the Hausa, Yoruba, and Igbo as the major groups. Presently, Nigeria is made up of 36 states and a Federal Capital Territory, grouped into six geopolitical zones: North Central, North East, North West, South East, South South, and South West. There are 774 constitutionally recognised local government areas (LGAs) in the country. 1.1.3 Economy Agriculture was the mainstay of Nigeria’s economy before the discovery of oil in January 1953. Until that point, the country had 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 in 1960, agriculture provided gainful employment and a satisfactory livelihood to more than 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. Today the country’s economic strength is derived largely from its oil and gas reserves. As of 2013, Nigeria’s gross domestic product (GDP) stood at $262.6 billion (World Bank, 2013). A sectoral analysis showed that the contribution of agriculture to the total GDP stood at 39 percent, as compared with 40 percent in 2011. Similarly, the 18 percent and 14 percent contributions of industry and crude oil to the GDP were lower than the 2011 contributions of 19 percent and 15 percent, respectively. The contributions of two other industrial sector components, solid minerals and manufacturing, stood at 0.4 percent and 4 percent, respectively. The services sector as a percentage of GDP was 20 percent, higher than the 19 percent recorded in 2011 (with the finance and insurance, communications, transportation, and utilities components contributing 3.4, 7.1, 2.7, and 2.9 percent, respectively) (Central Bank of Nigeria, 2013). Since 1999, successive democratic governments have tried to create an enabling environment that would boost investment through economic policies. Appreciable 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, measured at 1990 constant basic prices, indicated a growth rate of 6.6 percent in 2012. However, this figure was lower than the 7.4 percent rate recorded in the previous year. The reduced growth in GDP relative to 2011 was attributed to the contraction in oil’s contribution to the GDP. Previous growth rates were estimated at 2.7 percent in 1999, 2.8 percent in 2000, 3.8 percent in 2001, and 6.0 percent in 2006 (Central Bank of Nigeria, 2013). The government of Nigeria, having recognised the importance of privatisation in restructuring its economy, recently liberalised, deregulated, and privatised the power sector of the economy. This is in addition to the already long privatised telecommunications and downstream petroleum sectors. While it may be too early to determine the impact of privatisation 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, will translate into a high rate of self-sustaining, long-term economic growth. 1.2 POPULATION Over the years, Nigeria has collected data on demographic statistics through censuses, vital registration systems, and sample surveys. The censuses of 1866, 1871, and 1896 were restricted to specific parts of the country. The censuses of 1911 and 1921 included more of the urban towns in the then colony. In 1931, the procedure for the conduct of the census in the southern protectorate was different from that for the northern part of the country. Because of the Second World War, there were no attempts to conduct a census in 1941. Introduction • 3 The first elaborate and near-scientific census conducted in Nigeria was the 1952-1953 census. However, it lacked simultaneity and probably underenumerated the country’s population. The results of the 1962 census were disregarded, and another census was carried out in 1963. This census was officially accepted (Table 1.1). The population census of 1973 was not acceptable and was, therefore, cancelled. Since then, there have been considerable improvements in the data collection process. The next census took place in 1991 and counted a total of 88,992,220 Nigerians. The 2006 Population and Housing Census reported Nigeria’s population to be 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, as noted, and the seventh most populous in the world (Population Reference Bureau, 2013). Nigeria’s population is unevenly distributed across the country. Large areas in the Chad Basin, the middle Niger Valley, and 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 (Table 1.1). The most densely populated states are Lagos (2,607 people per square kilometre), Anambra (868 people per square kilometre), and Imo (758 people per square kilometre). Most of the densely populated states are found in the southern part of the country. Kano, with an average density of 442 people per square kilometre, is the most densely populated state in the north (National Population Commission [NPC], 2010). 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 by the National Population Commission 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 in 2000 and the 2003 NDHS. Another sentinel survey was conducted in 2007 to further assess the implementation of the objectives of the population policy. The most recent NDHS was conducted in 2008. 1.3 POPULATION AND HEALTH POLICIES 1.3.1 National Population Policy On February 4, 1988, the federal government of Nigeria approved the National Policy on Population for Development in response to the pattern of population growth rate and its adverse effects on national development. Emerging issues such as HIV/AIDS, poverty, and gender inequality gained wider recognition. This necessitated a review of the 1988 National Population Policy, giving way to the National Policy on Population for Sustainable Development, which was signed in January 2004 by Chief Olusegun Obasanjo, then president and commander-in-chief of the armed forces of the Federal Republic of Nigeria. The policy recognises that population factors, social and economic development, and environmental issues are irrevocably interrelated and are therefore critical to the achievement of sustainable development in Nigeria. Table 1.1 Basic demographic indicators Demographic indicators from selected sources for Nigeria, 1963-2006 Indicators 1963 census 1991 census 2006 census Population (millions) 55.7 88.9 140.4 Density (population/km2) 60 96 150 Percent urban 19 36.3 u Life expectancy (years) Male u 52.6 u Female u 53.8 u Sources: Federal Office of Statistics, 1963; National Population Commission, 1998; National Population Commission, 2009 u = No information 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 of 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 among the rate of population growth, available resources, and the social and economic development of the country • Progress toward 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 Policy Nigeria formulated a national health policy targeted at achieving quality health for all Nigerians in 1988. As a result 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 and launched in September 2004, outlined the goals, structure, strategy, and policy direction of the health care delivery system in Nigeria (Federal Ministry of Health, 2004). Roles and responsibilities of different tiers of Introduction • 5 government, including nongovernmental organisations, were clearly defined. The policy’s overall 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. The underlying principles and values of the Revised National Health Policy are as follows: • Social justice, equity, and the ideals of freedom and opportunity affirmed in the 1999 Constitution of the Federal Republic of Nigeria are basic rights. • Health and access to quality and affordable health care are human rights. • Equity in health care for all Nigerians will be pursued as a goal. • Primary health care (PHC) will remain the basic philosophy and strategy for national health development. • Good-quality health care will be assured through cost-effective interventions that are targeted at priority health problems. • A high level of efficiency and accountability will be maintained in the development and management of the national health system. • Effective partnerships and collaborations between various health sectors will be pursued while safeguarding the identity of each. 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 achievement of the health-related Millennium Development Goals (MDGs). The main health policy targets are the following: • Reduce the under-5 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 identifies primary health care as the framework to achieve improved health for the population. PHC services include health education; adequate nutrition; safe water and sanitation; reproductive health, including family planning; immunisation against five major infectious diseases; provision of essential drugs; and disease control. According to the policy, a comprehensive health care system delivered through PHC centres must incorporate maternal and child health care, including family planning services. Nigeria’s health sector is characterised by wide regional disparities in status, service delivery, and resource availability. In view of this situation, the government of Nigeria initiated several interventions including the Midwives Service Scheme (MSS); the Subsidy Reinvestment and Empowerment Program, Maternal and Child Health (SURE-P-MCH); and systematic PHC infrastructure upgrades through the Ward Health System. Under the MSS, retired and newly qualified midwives provide services at PHC facilities in underserved communities around the country. The scheme, funded through MDG debt relief gains on a cost-sharing basis among the three tiers of government, has trained and deployed approximately 4,000 midwives and 1,000 community health extension workers (CHEWs) in 1,000 PHC facilities. This has improved access to skilled birth attendants in 375 LGAs across the country. In addition, attention is 6 • Introduction continuously geared toward full childhood immunisation and HIV/AIDS prevention (National Primary Health Care Development Agency [NPHCDA], 2012). The SURE-P-MCH programme, funded through savings derived from the partial removal of the petroleum subsidy, is intended to build and expand on the gains of the MSS. The programme aims to improve both demand and supply components of maternal and child health. As of January 2013, the programme had engaged 1,168 midwives and 2,188 community health extension workers in 500 PHC facilities. A total of 3,072 village health workers were also recruited and deployed. In addition, the programme is implementing a conditional cash transfer scheme as well as pursuing PHC facility upgrades and community engagement. The Ward Health System (WHS) was initiated in 2000 to improve equitable access to essential health services. The system is premised on the synchronisation of PHC services across electoral wards with the construction of model PHC facilities in underserved areas. As of January 2012, the NPHCDA had built 1,156 PHC facilities across the country. This is in addition to 228 maternal health care centres and 10 health training institutions built by the MDG office (Federal Republic of Nigeria, 2010a; NPHCDA, 2012). 1.4 ORGANISATION OF THE 2013 NIGERIA DEMOGRAPHIC AND HEALTH SURVEY The 2013 Nigeria Demographic and Health Survey (NDHS) was implemented by the National Population Commission. It is the fifth in the series of Demographic and Health Surveys conducted so far in Nigeria; previous surveys were conducted in 1990, 1999, 2003, and 2008. The resources for the conduct of the survey were provided by the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA), the United Kingdom Department for International Development (DFID) (through the Partnership for Transforming Health Systems Phase II [PATHS2]), and the government of Nigeria (through the NPC). ICF International provided technical support throughout the duration of the survey. A steering committee composed of major stakeholders from the government and international organisations was formed. The steering committee was responsible for coordination, oversight, advice, and decision making on all major aspects of the survey. The steering committee’s membership included representatives from organisations such as the NPC, the Federal Ministry of Health, the National Planning Commission, and the National Bureau of Statistics, as well as USAID, UNFPA, the United Nations Children’s Fund (UNICEF), the World Health Organization, and the World Bank. The technical/quality assurance team was responsible for the entire technical management of the survey. The team was headed by a project director with the assistance of a project coordinator. Other members of the team included 18 state coordinators who were in charge of all of the different components of the survey (i.e., recruiting and training the field staff, monitoring the fieldwork, and assisting in any other project-related activities). Although significantly expanded in content, the 2013 NDHS, as a follow-up to the previous DHS surveys, provides updated estimates of some of the basic demographic and health indicators covered in the earlier surveys. In addition, as with the 2008 NDHS, information was gathered on violence against women. Although most of the previous surveys collected data at the national and zonal levels, the 2013 NDHS, similar to the 2008 survey, collected data representative of the 36 states and the Federal Capital Territory. The 2013 NDHS was designed to provide data to monitor the population and health situation in Nigeria with an explicit goal of providing reliable information about maternal and child health and family planning services. The primary objective of the 2013 NDHS was to provide up-to-date information on fertility levels, marriage, fertility preferences, awareness and use of family planning methods, child feeding practices, nutritional status of women and children, adult and childhood mortality, awareness and attitudes regarding HIV/AIDS, and domestic violence. This information is intended to assist policymakers and Introduction • 7 programme managers in evaluating and designing programmes and strategies for improving health and family planning services in the country. 1.4.1 Sample Design The sample for the 2013 NDHS was nationally representative and covered the entire population residing in non-institutional dwelling units in the country. The survey used as a sampling frame the list of enumeration areas (EAs) prepared for the 2006 Population Census of the Federal Republic of Nigeria, provided by the National Population Commission. The sample was designed to provide population and health indicator estimates at the national, zonal, and state levels. The sample design allowed for specific indicators to be calculated for each of the six zones, 36 states, and the Federal Capital Territory, Abuja. 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 census enumeration areas. The primary sampling unit (PSU), referred to as a cluster in the 2013 NDHS, is defined on the basis of EAs from the 2006 EA census frame. The 2013 NDHS sample was selected using a stratified three-stage cluster design consisting of 904 clusters, 372 in urban areas and 532 in rural areas. A representative sample of 40,680 households was selected for the survey, with a minimum target of 943 completed interviews per state (for further details on sample size and design, see Appendix B). A complete listing of households and a mapping exercise were carried out for each cluster from December 2012 to January 2013, with the resulting lists of households serving as the sampling frame for the selection of households. All regular households were listed. The NPC listing enumerators were trained to use Global Positioning System (GPS) receivers to calculate the coordinates of the 2013 NDHS sample clusters. A fixed sample take of 45 households were selected per cluster. All women age 15-49 who were either permanent residents of the households in the 2013 NDHS sample or visitors present in the households on the night before the survey were eligible to be interviewed. In a subsample of half of the households, all men age 15-49 who were either permanent residents of the households in the sample or visitors present in the households on the night before the survey were eligible to be interviewed. Also, a subsample of one eligible woman in each household was randomly selected to be asked additional questions regarding domestic violence. 1.4.2 Questionnaires Three questionnaires were used in the 2013 NDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. The content of these questionnaires was based on model questionnaires developed by the MEASURE DHS programme. The model questionnaires were modified according to the country’s requirements, in consultation with a broad spectrum of government ministries and agencies, nongovernmental organisations, and international donors, to reflect relevant issues such as family planning, domestic violence, HIV/AIDS, and maternal and child health. A stakeholders’ meeting organised by NPC in Abuja on March 26, 2012, provided a platform for experts to discuss the questionnaires extensively, and the input from this was used to finalise the survey questionnaires. The questionnaires were then translated into three major Nigerian languages—Hausa, Igbo, and Yoruba—and were pretested, refined, and finalised for the survey. The Household Questionnaire was used to list all of the usual members of and visitors to the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, marital status, education, and relationship to the head of the household. Information on other characteristics of household members was collected as well, including current school attendance and survivorship of parents among those under age 18. 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, 8 • Introduction additional questions related to support for orphans and vulnerable children were asked. Furthermore, 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 had died, questions were asked relating to support for sick people or people in households where a member had died. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as source of water; type of toilet facilities; materials used for the floor of the house; ownership of various durable goods; ownership of agricultural land; ownership of livestock, farm animals, or poultry; and ownership and use of mosquito nets and long-lasting insecticidal nets. The Household Questionnaire was further used to record height and weight measurements for children age 0-59 months and women age 15-49. In addition, data on the age and sex of household members in the Household Questionnaire were used to identify women and men who were eligible for individual interviews. The Woman’s Questionnaire was used to collect information from all women age 15-49. These women were asked questions on the following main topics: • Background characteristics (age, religion, education, literacy, media exposure, etc.) • Reproductive history and childhood mortality • Knowledge, source, and use of family planning methods • Fertility preferences • Antenatal, delivery, and postnatal care • Breastfeeding and infant feeding practices • Child immunisation and childhood illnesses • Marriage and sexual activity • Women’s work and husbands’ background characteristics • Malaria prevention and treatment • Women’s decision making • Awareness of AIDS and other sexually transmitted infections • Maternal mortality • Domestic violence The Man’s Questionnaire was administered to all men age 15-49 in every second household in the 2013 NDHS sample. The Man’s Questionnaire collected much of the same information found in the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health or nutrition. All aspects of the NDHS data collection procedures were pretested in November 2012 (e.g., pretesting of survey instruments and training of trainers). Twenty members of the technical team, who also served as trainers/quality assurance personnel, participated in the training of trainers and reviewed the questionnaires thoroughly before finally conducting the pretest fieldwork as interviewers. They were all trained to administer the questionnaires and take anthropometric measurements. The training of trainers consisted of an overview of the project and the objectives of the survey; detailed descriptions of interviewing techniques, field procedures, and all sections of the household and individual questionnaires; and two days of field practice. The trainers included the technical team members, who also doubled as state coordinators, and the ICF DHS country manager. Representatives of the Federal Ministry of Health, the NPHCDA, USAID, UNICEF, UN Women, and UNFPA attended as resource persons and provided technical sessions on relevant topics. The Household, Woman’s, and Man’s Questionnaires were pretested in four locations in Makurdi (Benue), where the residents are predominantly Hausa, Yoruba, English, and Igbo speaking. The teams were divided according to languages. The supervisors and editors were drawn from among the trainees. The questionnaires were pretested in 120 households. A debriefing session was held in November 2012 at the end of the pretest fieldwork. Based on observations from the field and suggestions made by the pretest Introduction • 9 teams, revisions were made in the wording and translations of the questionnaires. Logistical arrangements for the survey were also discussed. 1.4.3 Recruitment and Training of Field Staff The NDHS technical team was involved in recruiting field staff who had the requisite skill and experience to work as enumerators. The recruitment process was decentralised and, after screening of the candidates, selections were made on the basis of a written test and an interview focusing on the major languages used in the survey interviews. Almost all of those recruited had ordinary national diplomas, national certificates of education, or higher national diplomas or were university graduates; a few had master’s degrees. A substantial number of the field staff members had experience working in previous NDHS surveys. They came from the country’s 36 states and the Federal Capital Territory. The NPC organised a four-week-long training course in January and February 2013 for the 316 participants at the Administrative Staff College of Nigeria (ASCON) in Topo Badagry (Lagos). The training was carried out simultaneously in six classrooms at ASCON, with approximately 50 participants in each classroom. Technical team members, who were trained during the pretest and the training of trainers, were assigned to the six classrooms. The training, conducted according to the standard DHS training procedures, included class presentations, daily reviews, mock interviews, class exercises, and a written test at the end of every module. It also included lectures on how to complete the questionnaires and field practice. Remedial classes were set up for those who did not perform well on the tests. The trainers included the ICF DHS country manager and members of the technical team. Special training was conducted for field editors and supervisors. Efforts were made to maintain uniformity in the training sessions. Different measures were adopted: trainers were moved from one classroom to another; field staff from a specific state were spread across different classrooms; the DHS interview manual adapted for Nigeria and PowerPoint presentations were used as guidelines; and the trainers met every evening to discuss the issues raised in each class so that they could be addressed uniformly. 1.4.4 Fieldwork Unlike the previous DHS surveys, fieldwork was launched in the six zones (rather than all of the states); the teams in each zone remained together, and the first clusters were assigned in the vicinity. This enabled close supervision of the teams, as three to four trainers were available in each zone. Interviewers had ample opportunities to build their confidence before they were finally dispatched to their respective states. Fieldwork for the 2013 NDHS was carried out by 37 interviewing teams, one for each of the 36 states of the country and Federal Capital Territory. Each team consisted of a supervisor, a field editor, four female interviewers, two male interviewers, and two drivers. Fieldwork was conducted from February 15, 2013, to the end of May (with the exception of the two teams in Kano and Lagos, who completed fieldwork in June). The technical team and trainers, who also functioned as the quality controllers, were responsible for ensuring data quality. Data quality was also monitored through field check tables generated concurrently with data processing operations. This was an advantage since the technical team and trainers were able to advise and alert field teams of problems detected during data entry. The technical team and trainers met in Abuja occasionally to discuss fieldwork issues and travelled to states where immediate attention was required. Fieldwork was also monitored by representatives from ICF, USAID, UNFPA, PATHS2, and the NPC. A number of challenges were faced by the field teams (e.g., restricted working hours, lack of clearance to enter the clusters on a regular basis, and potential threats), especially in the North East and North West due to the security situation in those zones. In some areas, measurement of height and weight became difficult. However, the teams made the utmost effort to accomplish the task. Because of the 10 • Introduction security situation, the survey could not be accomplished in eight clusters (four in Borno, two in Yobe, one in Nasarawa, and one in Plateau). 1.4.5 Data Processing The processing of the 2013 NDHS data began simultaneously with the fieldwork. Completed questionnaires were edited in the field immediately by the field editors and checked by the supervisors before being dispatched to the data processing centre in Abuja. The questionnaires were then edited and entered by 26 data processing personnel specially trained for this task. Data were entered using the CSPro computer package, and all data were entered twice to allow 100 percent verification. The concurrent processing of the data offered a distinct advantage because of the assurance that the data were error free and authentic. Moreover, the double entry of data enabled easy comparisons and identification of errors and inconsistencies. Inconsistencies were resolved by tallying results with the paper questionnaire entries. Secondary editing of the data was completed in the last week of July 2013. The final cleaning of the data set was carried out by the ICF data processing specialist and completed in August. 1.5 RESPONSE RATES The household and individual response rates for the 2013 NDHS are shown in Table 1.2. A total of 40,320 households were selected from 896 sample points, of which 38,904 were found to be occupied at the time of the fieldwork. Of the occupied households, 38,522 were successfully interviewed, yielding a household response rate of 99 percent. In view of the security challenges in the country, this response rate is highly encouraging and appears to be the result of a well-coordinated team effort. In the interviewed households, a total of 39,902 women age 15-49 were identified as eligible for individual interviews, and 98 percent of them were successfully interviewed. Among men, 18,229 were identified as eligible for interviews, and 95 percent were successfully interviewed. As expected, response rates were slightly lower in urban areas than in rural areas. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Nigeria 2013 Residence Total Result Urban Rural Household interviews Households selected 16,695 23,625 40,320 Households occupied 16,070 22,834 38,904 Households interviewed 15,859 22,663 38,522 Household response rate1 98.7 99.3 99.0 Interviews with women age 15-49 Number of eligible women 15,972 23,930 39,902 Number of eligible women interviewed 15,545 23,403 38,948 Eligible women response rate2 97.3 97.8 97.6 Interviews with men age 15-49 Number of eligible men 7,553 10,676 18,229 Number of eligible men interviewed 7,144 10,215 17,359 Eligible men response rate2 94.6 95.7 95.2 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics • 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 his chapter provides an overview of the socioeconomic characteristics of the population, including household conditions, sources of drinking water, sanitation facilities, availability of electricity, housing facilities, possession of household durable goods, and ownership of household effects and land. Information on household assets is used to create the wealth index, an indicator of household economic status. This chapter also describes the demographic characteristics of the household population, including age, sex, and educational attainment. In the 2013 NDHS, a household was defined as a person or group of persons, related or unrelated, who usually live together in the same dwelling unit, have common cooking and eating arrangements, and acknowledge one adult member as the head of the household. A member of the household is any person who usually lives in the household. Information was collected from all usual residents of a selected household (de jure population) as well as persons who stayed in the selected household the night before the interview (de facto population). The difference between these two populations is very small, and all tables in this report refer to the de facto population, unless otherwise specified, to maintain comparability with other NDHS reports. 2.1 HOUSEHOLD ENVIRONMENT The physical characteristics of a household’s environment are important determinants of the socioeconomic and health status of household members. The 2013 NDHS asked respondents about their household environment, including access to electricity, source of drinking water, type of sanitation facility, type of flooring material, and number of rooms in the dwelling. Results are presented for households and for the de jure household population. 2.1.1 Drinking Water Increasing access to improved drinking water is part of Millennium Development Goal (MDG) 7 (ensuring environmental sustainability), adopted by Nigeria and other nations worldwide (United Nations General Assembly, 2002). The goal in Nigeria is for 77 percent of the country’s residents to have access to an improved drinking water source by 2015 (Federal Republic of Nigeria, 2010a). T Key Findings • Sixty-one percent of households in Nigeria have access to an improved source of drinking water. • Thirty percent of households have an improved toilet facility that is not shared with other households. • Fifty-six percent of households have access to electricity. • Wood continues to be the main type of cooking fuel in Nigeria (64 percent). • Seventy-five percent of households have mobile phones. • Forty-six percent of Nigeria’s population is under age 15. • One in five households are headed by a female. • Thirty percent of children under age 5 have had their births registered, and 15 percent have a birth certificate. • More females than males have not attended school (40 percent versus 30 percent). 12 • Household Population and Housing Characteristics Table 2.1 presents 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. In Table 2.1, sources that are likely to provide water suitable for drinking are identified as improved sources. These include a piped source within the dwelling, yard, or plot; a public tap/stand pipe or a borehole; a protected well or spring; and rainwater (WHO and UNICEF, 2010). Lack of easy access to a water source may limit the quantity of suitable drinking water 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 become contaminated during transport or storage. Especially in such situations, home water treatment can be effective in improving the quality of household drinking water. Table 2.1 Household drinking water Percent distribution of households and the de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Nigeria 2013 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 75.6 49.2 60.6 77.6 47.7 59.6 Piped into dwelling/yard/plot 5.5 0.7 2.8 6.1 0.8 2.9 Public tap/standpipe 9.2 4.9 6.8 9.6 4.7 6.6 Tube well or borehole 44.2 32.0 37.3 45.8 30.0 36.3 Protected well 13.0 10.1 11.4 13.1 11.0 11.8 Protected spring 0.3 0.5 0.4 0.3 0.5 0.4 Rainwater 0.9 0.7 0.8 0.8 0.5 0.6 Bottled water 2.4 0.3 1.2 1.8 0.2 0.8 Non-improved source 24.2 50.5 39.1 22.2 52.0 40.1 Unprotected well 3.9 23.6 15.1 4.7 26.2 17.6 Unprotected spring 1.2 4.2 2.9 1.2 4.2 3.0 Tanker truck/cart with drum 3.4 0.8 1.9 3.6 0.6 1.8 Surface water 3.7 20.9 13.5 4.1 20.3 13.9 Sachet water 12.0 1.1 5.8 8.6 0.7 3.8 Other source 0.1 0.1 0.1 0.1 0.1 0.1 Missing 0.1 0.2 0.2 0.1 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 23.8 17.2 20.0 24.9 18.9 21.3 Less than 30 minutes 54.5 54.4 54.4 50.3 52.6 51.7 30 minutes or longer 20.0 27.6 24.3 23.0 27.8 25.9 Don’t know/missing 1.7 0.9 1.2 1.7 0.7 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 4.1 1.5 2.6 4.0 1.4 2.4 Bleach/chlorine added 2.9 0.9 1.7 3.1 0.9 1.7 Strained through cloth 1.5 3.5 2.7 1.9 3.6 2.9 Ceramic, sand, or other filter 1.0 0.5 0.7 1.1 0.5 0.8 Solar disinfection 0.1 0.0 0.0 0.1 0.0 0.0 Let stand and settle 1.7 1.3 1.5 1.7 1.3 1.4 Alum 2.2 3.1 2.7 2.3 3.3 2.9 Other 2.0 1.4 1.6 1.9 1.3 1.6 No treatment 87.5 89.2 88.4 87.1 89.0 88.2 Percentage using an appropriate treatment method2 7.6 2.8 4.9 7.7 2.7 4.7 Number 16,609 21,913 38,522 70,422 106,541 176,963 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, filtering, and solar disinfecting. As Table 2.1 shows, 61 percent of the households in Nigeria have access to an improved source of drinking water, with a much higher proportion among urban households (76 percent) than among rural households (49 percent). The results show an overall improvement in the quality of sources of water in Nigeria since the 2008 NDHS (when the figure was 56 percent). This improvement was higher in rural areas (45 to 49 percent) than in urban areas (75 to 76 percent). The most common source of improved drinking water in Nigeria is tube well or borehole water, used by 44 percent of urban and 32 percent of rural households. Thirteen percent of urban households and 10 percent of rural households have access to drinking water from a protected well. Use of sachet water, which is included under non-improved sources, is common in Nigeria, with 6 percent of households using it as their main source of drinking water. It is used more in urban areas than in rural areas (12 percent versus 1 percent). Household Population and Housing Characteristics • 13 In the 2013 NDHS, only 20 percent of households reported having water on their premises, as compared with 25 percent in the 2008 NDHS. Households not having water on their premises were asked how long it takes to fetch water. About a quarter of households (24 percent) travel 30 minutes or longer to obtain their drinking water (20 percent in urban areas and 28 percent in rural areas). In the 2013 NDHS, all households also were asked whether they treat their water prior to drinking. An overwhelming majority, 88 percent, do not treat their drinking water. Urban households (8 percent) are somewhat more likely than rural households (3 percent) to use an appropriate treatment method to ensure that their water is safe for drinking. Table A.2.1 indicates that many households in some of Nigeria’s states have no access to improved source of drinking water. For instance, only 3 in 10 households in Benue, Bauchi, Taraba, and Zamfara and only 2 in 10 households in Kebbi have access to an improved source of drinking water. 2.1.2 Household Sanitation Facilities Ensuring adequate sanitation facilities is also part of MDG 7. At the household level, adequate sanitation facilities include an improved toilet and a method of disposal that separates waste from human contact. A household is classified as having an improved toilet if the toilet is used only by household members (i.e., it is not shared with another household) and if the facility used by the household separates waste from human contact (WHO and UNICEF, 2010). Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Nigeria 2013 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility 36.6 25.1 30.1 42.7 28.2 34.0 Flush/pour flush to piped sewer system 6.1 1.5 3.5 6.1 1.2 3.1 Flush/pour flush to septic tank 11.2 1.9 5.9 11.4 1.7 5.5 Flush/pour flush to pit latrine 3.6 1.1 2.2 4.1 1.0 2.2 Ventilated improved pit (VIP) latrine 10.0 14.3 12.4 13.6 17.1 15.7 Pit latrine with slab 5.7 6.3 6.0 7.4 7.2 7.3 Composting toilet 0.1 0.1 0.1 0.1 0.1 0.1 Shared facility1 40.2 13.4 24.9 34.2 10.6 20.0 Flush/pour flush to piped sewer system 3.1 1.1 2.0 2.4 0.7 1.4 Flush/pour flush to septic tank 11.6 1.1 5.6 9.2 0.8 4.1 Flush/pour flush to pit latrine 6.0 1.2 3.3 5.0 0.8 2.5 Ventilated improved pit (VIP) latrine 10.7 6.1 8.1 10.2 5.5 7.3 Pit latrine with slab 8.5 3.5 5.7 7.1 2.6 4.4 Missing 0.3 0.3 0.3 0.3 0.2 0.2 Non-improved facility 23.1 61.5 45.0 23.1 61.3 46.1 Flush/pour flush not to sewer/septic tank/pit latrine 0.4 0.2 0.3 0.5 0.2 0.3 Pit latrine without slab/open pit 5.8 19.6 13.7 6.7 21.4 15.5 Bucket 0.2 0.0 0.1 0.1 0.0 0.1 Hanging toilet/hanging latrine 1.1 1.7 1.5 1.1 1.6 1.4 No facility/bush/field 15.5 39.9 29.4 14.6 38.1 28.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 16,609 21,913 38,522 70,422 106,541 176,963 1 Facilities that would be considered improved if they were not shared by two or more households Table 2.2 shows that 3 in 10 households in Nigeria use improved toilet facilities that are not shared with other households (37 percent in urban areas and 25 percent in rural areas). Twenty-five percent of households (40 percent in urban areas and 13 percent in rural areas) use shared toilet facilities, while 45 percent use non-improved facilities (62 percent in rural areas and 23 percent in urban areas). The most common type of non-improved toilet facility is an open pit latrine or pit latrine without slabs, used by 20 percent of households in rural areas and 6 percent of households in urban areas. Overall, 29 percent of households have no toilet facility (16 percent in urban areas and 40 percent in rural areas). 14 • Household Population and Housing Characteristics Table A.2.2 shows the percent distribu- tion of households and the de jure population by type of toilet/latrine facilities, according to state of residence. In Zamfara and Ogun states, less than 10 percent of households have access to an improved, not shared facility. In Benue, Kogi, Niger, Bauchi, Ebonyi, Bayelsa, Cross River, Ekiti, Ondo, Osun, and Oyo, between 10 percent and 20 percent of households have access to an improved, not shared facility. In Gombe and Kano, 6 in 10 households (67 percent and 64 percent, respectively) have access to such a facility. 2.1.3 Housing Characteristics Table 2.3 presents information on housing characteristics in Nigeria, which reflect a household’s socioeconomic situation. They also may influence environmental conditions (e.g., use of biomass fuels and resulting exposure to indoor air pollution) that have a direct bearing on the health and welfare of household members. Table 2.3 includes information on availability of electricity, type of flooring material, number of rooms used for sleeping, the place where cooking is done, and the type of fuel used for cooking. The table shows that 56 percent of households in Nigeria have access to electricity (84 percent in urban areas and 34 percent in rural areas). This is a slight improvement from 2008, when 50 percent of households had access to electricity (85 percent in urban areas and 31 per- cent in rural areas). Cement is the most common flooring ma- terial used in Nigerian households (46 percent). The use of cement has increased since 2008 (when the figure was 42 percent), and increases have been observed in both urban and rural areas. Urban households remain more likely to use cement (53 percent) than rural households (40 percent). Earth and sand are used in 3 out of 10 households, and they are used more often in rural areas (49 percent) than in urban areas (12 percent). Fourteen percent of households use carpet as a flooring material. The number of rooms used for sleeping in relation to the number of household members is an indication of the extent of crowding, which in turn increases the risk of contracting communicable diseases. The proportion of households using one room for sleeping has decreased from 43 percent to 39 percent over the past five years. Indoor air pollution has important implications for the health of household members. Cooking and heating with solid fuels can lead to high levels of indoor smoke, which consists of a complex mix of Table 2.3 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Nigeria 2013 Residence Total Housing characteristic Urban Rural Electricity Yes 83.6 34.4 55.6 No 16.3 65.4 44.2 Missing 0.1 0.2 0.2 Total 100.0 100.0 100.0 Flooring material Earth, sand 11.5 48.6 32.6 Dung 0.8 2.7 1.9 Wood/planks 0.1 0.4 0.3 Ceramic tiles 7.0 1.6 3.9 Cement 52.8 40.1 45.5 Carpet 26.2 5.2 14.2 Other1 1.4 1.0 1.2 Missing 0.3 0.3 0.3 Total 100.0 100.0 100.0 Rooms used for sleeping One 45.5 33.6 38.7 Two 28.2 32.8 30.8 Three or more 25.9 33.1 30.0 Missing 0.3 0.5 0.4 Total 100.0 100.0 100.0 Place for cooking In the house 46.8 46.0 46.3 In a separate building 19.5 22.9 21.4 Outdoors 30.7 28.5 29.4 No food cooked in household 2.9 2.4 2.6 Other 0.0 0.1 0.0 Total 100.0 100.0 100.0 Cooking fuel Electricity 0.7 0.2 0.4 LPG/natural gas/biogas 4.6 0.5 2.3 Kerosene 47.6 8.7 25.5 Coal/lignite 0.7 0.0 0.3 Charcoal 5.3 1.6 3.2 Wood 37.9 83.3 63.7 Agricultural crops/straw/ shrubs/grass 0.2 3.1 1.8 Animal dung 0.0 0.1 0.1 No food cooked in household 2.9 2.4 2.6 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking2 44.1 88.1 69.1 Frequency of smoking in the home Daily 6.0 6.1 6.0 Weekly 0.9 0.7 0.8 Monthly 0.1 0.1 0.1 Less than monthly 0.3 0.1 0.2 Never 92.5 92.8 92.7 Missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Number 16,609 21,913 38,522 LPG = Liquid petroleum gas 1 Includes palm/bamboo, parquet or polished wood, and vinyl or asphalt strips 2 Includes coal/lignite, charcoal, wood/agricultural crops/straw/shrubs/ grass, and animal dung Household Population and Housing Characteristics • 15 pollutants that can increase the risk of contracting diseases. Solid fuels include charcoal, wood, straw, shrubs, grass, agricultural crops, and animal dung. Forty-six percent of households cook in the housing unit where they live, 21 percent use a separate building, and 29 percent cook outdoors. Wood is the main type of cooking fuel, used by 64 percent of households (38 percent of urban households and 83 percent of rural households). In addition to wood, kerosene is an important type of cooking fuel in urban areas; 48 percent of urban households use kerosene for cooking. Reducing the proportion of households that rely on solid fuels is one of the aims of MDG 7. Nigeria has made some progress toward this goal, with the proportion of households using solid fuels decreasing from 78 percent in the 2008 NDHS to 69 percent in 2013. Information on smoking was collected in the 2013 NDHS to assess the percentage of household members who are exposed to secondhand smoke (SHS), which is a risk factor for those who do not smoke. Pregnant women who are exposed to SHS have a higher risk of delivering a low birth weight baby (Windham et al., 1999). In addition, children who are exposed to SHS are at a higher risk of respiratory and ear infections and poor lung development (U.S. Department of Health and Human Services, 2006). Table 2.3 provides information on the frequency of smoking in the home, which is used as a proxy for level of SHS exposure. Overall, 6 percent of households are exposed daily to SHS, with no differences between urban and rural areas. 2.1.4 Household Possessions Possession of durable consumer goods is another useful indicator of a household’s socio- economic status. The possession and use of household durable goods have multiple effects and implications. For instance, a radio or a televi- sion can bring household members information and new ideas, a refrigerator prolongs the whole- someness of foods, and a means of transport can increase access to many services that are beyond walking distance. Table 2.4 shows the extent of possession of selected consumer goods by area of residence. Sixty-eight percent of households have radios, 75 percent have mobile telephones, 48 percent have televisions, 3 percent have non- mobile telephones, and 18 percent have refrigerators. In both urban and rural areas, only a small percentage of households possess a means of transport. Rural households are slightly more likely than urban households to own a motorcycle or scooter (34 percent versus 27 percent) or a bicycle (23 percent versus 13 percent). Only 9 percent of households own a car or truck. Half of all households own agricultural land (58 percent) or farm animals (50 percent). Overall, 35 percent of households have a bank account, and more than half of urban households have an account (56 percent versus 18 percent in rural households). 2.2 WEALTH INDEX The wealth index used in this survey has been used in many DHS and other country-level surveys to indicate inequalities in household characteristics, in the use of health and other services, and in health outcomes (Rutstein et al., 2000). It serves as an indicator of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The index was constructed using household asset data via a principal components analysis. Table 2.4 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals, by residence, Nigeria 2013 Residence Total Possession Urban Rural Household effects Radio 77.7 61.3 68.3 Television 73.2 28.2 47.6 Mobile telephone 88.6 64.8 75.1 Non-mobile telephone 3.2 2.1 2.5 Refrigerator 32.5 7.5 18.3 Means of transport Canoe 1.0 3.3 2.3 Bicycle 12.7 22.6 18.3 Animal-drawn cart 1.3 5.4 3.6 Motorcycle/scooter 27.0 34.4 31.2 Car/truck 14.4 4.3 8.7 Boat with a motor 0.6 1.0 0.8 Ownership of agricultural land 31.2 78.1 57.8 Ownership of farm animals1 29.4 64.9 49.6 Ownership of bank account2 56.0 18.4 34.6 Number 16,609 21,913 38,522 1 Cattle, cows, bulls, horses, donkeys, goats, sheep, or chickens 2 At least one household member has an account. 16 • Household Population and Housing Characteristics In its current form, which takes better account of urban-rural differences in scores and indicators of wealth, the wealth index is created in three steps. In the first step, a subset of indicators common to urban and rural areas is used to create wealth scores for households in both areas. Categorical variables to be used are transformed into separate dichotomous (0-1) indicators. These indicators and those that are continuous are then examined using a principal components analysis to produce a common factor score for each household. In the second step, separate factor scores are produced for households in urban and rural areas using area-specific indicators. The third step combines the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting area-specific scores through a regression on the common factor scores. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index is computed, national-level wealth quintiles (from lowest to highest) are obtained by assigning household scores to each de jure household member, ranking each person in the population by his or her score, and then dividing the ranking into five equal categories, each comprising 20 percent of the population. Table 2.5 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini coefficient, according to residence and region, Nigeria 2013 Wealth quintile Total Number of persons Gini CoefficientResidence/region Lowest Second Middle Fourth Highest Residence Urban 3.0 6.6 16.3 30.9 43.3 100.0 70,422 0.18 Rural 31.3 28.9 22.5 12.8 4.6 100.0 106,541 0.35 Zone North Central 11.3 21.3 32.1 20.5 14.8 100.0 27,368 0.32 North East 40.4 26.1 15.0 11.2 7.4 100.0 26,927 0.25 North West 35.4 28.7 15.9 12.7 7.4 100.0 56,512 0.28 South East 4.7 13.3 25.5 28.5 27.9 100.0 18,777 0.24 South South 0.5 10.1 25.9 32.2 31.3 100.0 19,893 0.29 South West 1.7 6.6 13.4 28.5 49.8 100.0 27,486 0.18 Total 20.0 20.0 20.0 20.0 20.0 100.0 176,963 0.29 Table 2.5 presents wealth quintiles by residence and geographical zone. In urban areas, 43 percent of the population is in the highest wealth quintile, in sharp contrast to rural areas, where only 5 percent of the population is in the highest wealth quintile. Among regions, the wealth quintile distribution varies greatly; half of the population in the South West is in the highest quintile, while 3 in 10 households in the South South and South East are in the highest quintile. In contrast, a significant proportion of households in the North East and North West (40 percent and 35 percent, respectively) are in the lowest quintile. Table 2.5 also includes information on the Gini coefficient, which indicates the level of concentration of wealth (0 being an equal distribution and 1 a totally unequal distribution). This ratio is expressed as a proportion between 0 and 1. Wealth inequality is higher in rural than in urban areas. Inequality in wealth varies among the zones, with wealth being more evenly distributed in the South West (0.18). 2.3 HAND WASHING Hand washing with soap and water is ideal. However, hand washing with a non-soap cleaning agent such as ash or sand is an improvement over not using any cleansing agent. To obtain information on hand washing, interviewers asked to see the place where members of the household most often washed their hands; information on the availability of water and/or cleansing agents was recorded only for households where a hand washing place was observed. Table 2.6 shows that interviewers observed a place for hand washing in 40 percent of households. A hand washing place was observed more often in urban areas (43 percent) than in rural areas (37 percent). The most common reason interviewers were not able to observe the place where members of the household washed their hands was that there was no specific place designated for hand washing (data not shown). Household Population and Housing Characteristics • 17 Table 2.6 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, the percent distribution by availability of water, soap, and other cleansing agents, Nigeria 2013 Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed, percentage with: Number of households with place for hand washing observed Background characteristic Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, soap, or other cleansing agent Missing Total Residence Urban 42.5 16,609 38.7 1.1 16.1 2.4 2.4 39.3 0.1 100.0 7,066 Rural 37.1 21,913 15.6 4.5 13.4 1.8 8.2 56.3 0.2 100.0 8,141 Zone North Central 54.6 5,942 19.4 4.5 14.7 2.5 13.3 45.6 0.0 100.0 3,245 North East 48.0 5,115 2.8 0.2 9.9 0.9 0.1 86.1 0.1 100.0 2,455 North West 31.5 9,992 19.2 7.7 15.3 1.2 10.4 45.7 0.4 100.0 3,144 South East 11.1 4,687 50.1 0.0 21.0 11.0 0.0 16.9 1.0 100.0 520 South South 40.8 5,239 54.7 2.2 15.6 2.2 3.1 22.0 0.1 100.0 2,135 South West 49.1 7,546 34.3 0.1 15.7 1.8 0.4 47.7 0.0 100.0 3,708 States North Central FCT-Abuja 39.7 361 93.4 0.3 3.2 0.0 0.0 3.1 0.0 100.0 143 Benue 23.8 1,365 14.5 0.7 25.8 1.5 0.0 57.5 0.0 100.0 325 Kogi 55.3 876 28.3 11.3 25.3 1.8 4.7 28.5 0.0 100.0 485 Kwara 56.5 617 14.9 0.0 6.4 0.7 0.4 77.6 0.0 100.0 349 Nasarawa 74.6 550 22.8 1.0 5.5 1.2 1.3 68.2 0.0 100.0 410 Niger 90.6 1,504 8.6 5.9 14.8 4.0 29.1 37.6 0.0 100.0 1,362 Plateau 25.5 669 29.3 1.8 12.1 2.9 3.2 50.7 0.0 100.0 170 North East Adamawa 2.3 726 * * * * * * * 100.0 17 Bauchi 17.3 932 1.1 0.5 4.7 0.0 0.0 93.7 0.0 100.0 161 Borno 89.4 1,560 1.1 0.2 5.8 0.1 0.0 92.8 0.0 100.0 1,395 Gombe 40.7 464 4.0 0.6 3.9 7.9 0.0 83.6 0.0 100.0 189 Taraba 0.6 634 * * * * * * * 100.0 4 Yobe 86.4 799 6.0 0.0 20.9 0.8 0.3 72.1 0.0 100.0 690 North West Jigawa 15.4 1,152 24.3 7.6 17.8 3.6 6.4 39.2 1.0 100.0 178 Kaduna 53.1 1,915 29.5 1.1 17.1 0.2 24.2 27.8 0.1 100.0 1,017 Kano 2.4 2,606 (5.7) (9.7) (10.6) (0.0) (0.0) (65.7) (8.3) 100.0 63 Katsina 72.8 1,257 19.8 19.5 20.7 1.3 4.7 33.6 0.5 100.0 915 Kebbi 19.8 1,069 1.9 0.0 2.0 2.4 0.6 93.2 0.0 100.0 212 Sokoto 34.4 898 20.6 1.1 10.7 0.9 0.0 66.5 0.3 100.0 309 Zamfara 41.1 1,096 2.0 6.9 9.2 2.1 5.9 73.8 0.0 100.0 450 South East Abia 15.1 644 62.3 0.0 2.3 17.7 0.0 17.7 0.0 100.0 97 Anambra 8.8 1,050 61.8 0.0 18.7 13.2 0.0 6.3 0.0 100.0 92 Ebonyi 13.8 978 42.3 0.0 25.8 9.4 0.0 20.3 2.2 100.0 135 Enugu 3.1 920 (52.3) (0.0) (7.7) (28.9) (0.0) (11.1) (0.0) 100.0 28 Imo 15.3 1,096 42.6 0.0 31.3 4.2 0.0 20.4 1.5 100.0 167 South South Akwa Ibom 27.1 892 61.3 0.3 4.9 8.8 4.1 20.5 0.0 100.0 241 Bayelsa 4.7 322 (78.6) (0.0) (4.8) (9.4) (0.0) (7.1) (0.0) 100.0 15 Cross River 20.1 848 33.5 0.6 26.2 6.9 0.0 32.0 0.8 100.0 170 Delta 61.3 946 47.8 4.2 30.2 0.2 0.3 17.3 0.0 100.0 580 Edo 53.1 702 49.4 5.8 16.3 0.8 14.4 13.2 0.1 100.0 373 Rivers 49.5 1,529 64.7 0.0 5.4 1.2 0.1 28.5 0.1 100.0 756 South West Ekiti 56.8 376 28.6 0.1 12.2 2.6 0.0 56.4 0.0 100.0 213 Lagos 75.6 2,240 37.5 0.0 20.6 2.4 0.8 38.7 0.0 100.0 1,692 Ogun 14.6 1,355 15.7 0.0 9.1 4.0 0.0 71.2 0.0 100.0 198 Ondo 53.8 920 36.9 1.1 10.9 0.0 0.0 51.1 0.0 100.0 495 Osun 86.7 853 16.5 0.0 6.5 0.8 0.0 76.2 0.0 100.0 740 Oyo 20.5 1,802 65.2 0.0 23.1 1.6 0.0 10.0 0.0 100.0 369 Wealth quintile Lowest 40.1 6,245 3.1 4.5 12.5 0.5 9.6 69.7 0.2 100.0 2,505 Second 33.4 7,166 10.4 5.6 14.7 1.1 7.3 60.5 0.3 100.0 2,394 Middle 34.5 7,894 15.4 4.2 15.3 2.1 7.8 55.1 0.1 100.0 2,723 Fourth 35.3 8,310 25.5 2.1 15.5 2.5 5.7 48.7 0.0 100.0 2,934 Highest 52.2 8,907 54.0 0.6 14.8 3.0 1.0 26.4 0.2 100.0 4,651 Total 39.5 38,522 26.3 2.9 14.6 2.0 5.5 48.4 0.2 100.0 15,207 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 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only as well as those with soap and another cleansing agent 18 • Household Population and Housing Characteristics Soap and water were available in 26 percent of the households where a hand washing place was observed, and water only was available in 15 percent; 2 percent of households had soap but no water, 3 percent had water with another cleansing agent other than soap, and 6 percent had another cleansing agent but no water. In the case of 48 percent of the households, no water, soap, or any other cleansing agent was observed at the hand washing place. Lack of water and a cleansing agent decreased with increasing wealth quintile, from 70 percent in the lowest wealth quintile to 26 percent in the highest wealth quintile. 2.4 HOUSEHOLD POPULATION BY AGE, SEX, AND RESIDENCE The 2013 NDHS Household Questionnaire collected data on the demographic and social characteristics of all usual residents of the sampled household and on visitors who had spent the previous night in the household. Table 2.7 shows the distribution of the household population by five-year age groups, according to sex and residence. A total of 176,574 individuals were residing in the sampled households; 89,529 were female (51 percent), and 87,034 were male (49 percent) (information on gender was not available for 11 individuals). The sex ratio was 97 males per 100 females. Age and sex are important demographic variables and are the primary basis of demographic classifications in vital statistics, censuses, and surveys. They are also very important variables in the study of mortality, fertility, nuptiality, and migration. In general, a cross-classification by sex and age is useful for the effective analysis of all forms of data obtained in surveys. Table 2.7 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 2013 Urban Rural Male Female Total Age Male Female Total Male Female Total <5 15.7 15.2 15.5 18.6 17.7 18.1 17.4 16.7 17.1 5-9 14.8 14.3 14.6 18.0 17.0 17.5 16.8 15.9 16.3 10-14 12.5 12.0 12.2 12.8 11.8 12.3 12.7 11.9 12.3 15-19 9.1 9.5 9.3 8.3 8.7 8.5 8.6 9.0 8.8 20-24 7.4 8.0 7.7 6.2 7.6 6.9 6.7 7.8 7.2 25-29 7.3 8.6 8.0 6.1 8.1 7.1 6.6 8.3 7.4 30-34 6.7 7.0 6.9 5.4 5.7 5.6 5.9 6.2 6.1 35-39 5.8 5.7 5.8 4.9 5.2 5.0 5.2 5.4 5.3 40-44 4.7 4.2 4.4 4.1 3.9 4.0 4.3 4.0 4.2 45-49 3.9 3.9 3.9 3.8 3.6 3.7 3.9 3.7 3.8 50-54 3.0 3.2 3.1 2.4 3.3 2.9 2.6 3.3 2.9 55-59 2.7 2.3 2.5 2.4 2.3 2.3 2.5 2.3 2.4 60-64 2.2 2.1 2.1 2.3 1.9 2.1 2.3 2.0 2.1 65-69 1.4 1.4 1.4 1.5 1.1 1.3 1.5 1.2 1.3 70-74 1.2 1.1 1.2 1.4 1.0 1.2 1.3 1.0 1.2 75-79 0.7 0.5 0.6 0.7 0.4 0.5 0.7 0.5 0.6 80+ 0.9 0.8 0.9 1.1 0.7 0.9 1.0 0.8 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 34,692 35,744 70,439 52,342 53,785 106,135 87,034 89,529 176,574 Note: Total includes 11 persons whose sex was not stated. The age-sex structure of the population is shown in the population pyramid in Figure 2.1. The broad base of the pyramid indicates that Nigeria’s population is young, a scenario typical of countries with high fertility rates. The proportion of children under age 15 is around 46 percent, while the proportion of individuals age 65 and older is 4 percent. Household Population and Housing Characteristics • 19 Figure 2.1 Population pyramid 10 8 6 4 2 0 2 4 6 8 10 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Percentage Age Male Female NDHS 2013 2.5 HOUSEHOLD COMPOSITION Information on household composition is critical for understanding family size, household headship, and orphanhood and for implementing meaningful population-based policies and programmes. Household composition is also a determinant of health status and well-being. Table 2.8 presents information on household composition. The majority (82 percent) of households are headed by men, with only 19 percent headed by women. The proportion of female-headed households has remained almost the same in the last five years. The average household size is 4.6 persons, as compared with 4.4 in 2008; household sizes are larger in rural (4.9) than urban (4.2) areas. The proportion of households with nine or more members is higher in rural areas (12 percent) than in urban areas (7 percent). Information was also collected on the living arrangements and survival status of all children under age 18 residing in the NDHS sample households. These data can be used to assess the extent to which households are faced with a need to care for orphaned or foster children. Orphans include children whose mother or father has died (single orphans) as well as children who have lost both parents (double orphans). In the case of foster children, both parents are alive but the children are living in a household where neither Table 2.8 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 age 18, according to residence, Nigeria 2013 Residence Total Characteristic Urban Rural Household headship Male 77.1 84.8 81.5 Female 22.9 15.2 18.5 Total 100.0 100.0 100.0 Number of usual members 0 0.2 0.1 0.2 1 19.2 13.6 16.0 2 12.1 11.9 12.0 3 14.6 13.1 13.8 4 13.9 12.9 13.3 5 12.7 12.3 12.5 6 10.0 10.5 10.3 7 6.1 8.0 7.2 8 3.9 5.6 4.9 9+ 7.3 11.9 9.9 Total 100.0 100.0 100.0 Mean size of households 4.2 4.9 4.6 Percentage of households with orphans and foster children under age 18 Foster children1 15.0 16.6 15.9 Double orphans 0.7 0.7 0.7 Single orphans2 7.0 6.2 6.5 Foster and/or orphan children 18.6 19.8 19.3 Number of households 16,609 21,913 38,522 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. 2 Includes children with one dead parent and an unknown survival status of the other parent 20 • Household Population and Housing Characteristics their natural mother nor natural father resides. Foster children and orphans may be at an increased risk of neglect or exploitation because their mothers or fathers are not present to assist them. There is little difference in the distribution of orphans by rural and urban areas. Overall, 16 percent of households are caring for foster children, and more rural than urban households have foster children (17 percent and 15 percent, respectively). Single orphans are present in 7 percent of households, whereas double orphans are present in less than 1 percent of households.1 2.6 BIRTH REGISTRATION Birth registration is the inscription of the facts of each birth into an official log kept at the registrar’s office. According to the Births, Deaths, etc. (Compulsory Registration) Act No. 69 of 1992, registration of births and deaths is compulsory in all cases, and the National Population Commission (NPC) is responsible for registering these events nationwide (NPC, 1992). Information on registration of births was collected in the household interview, wherein respondents were asked whether children under age 5 residing in the household had ever been registered. If they reported that the child had been registered, an additional question was posed to ascertain whether the child’s birth had been registered with the birth and death registry or another agency. When it had been confirmed that the child was registered, interviewers asked to see the birth certificate. Table 2.9 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Nigeria 2013 Children whose births are registered Percentage registered Number of children Background characteristic Percentage with a birth certificate Percentage without a birth certificate Age <2 14.6 14.1 28.7 12,042 2-4 14.9 15.7 30.6 18,066 Sex Male 14.9 15.0 29.9 15,178 Female 14.6 15.1 29.8 14,929 Residence Urban 25.5 24.4 49.8 10,870 Rural 8.7 9.8 18.6 19,238 Zone North Central 11.6 16.2 27.8 4,161 North East 11.0 9.3 20.4 5,171 North West 10.8 8.7 19.5 10,973 South East 21.7 30.1 51.8 2,701 South South 20.0 17.3 37.3 2,888 South West 24.9 26.3 51.2 4,214 State North Central FCT-Abuja 34.0 27.2 61.2 204 Benue 8.2 15.4 23.5 885 Kogi 16.9 31.5 48.4 396 Kwara 25.1 33.4 58.5 397 Nasarawa 12.1 13.1 25.2 451 Niger 5.6 8.6 14.1 1,335 Plateau 9.1 10.6 19.7 492 North East Adamawa 20.3 15.5 35.8 692 Bauchi 5.4 8.9 14.2 1,260 Borno 16.0 8.2 24.2 1,077 Gombe 12.4 14.6 27.0 554 Taraba 10.8 9.9 20.7 694 Yobe 5.3 2.9 8.2 893 North West Jigawa 5.9 10.5 16.4 1,425 Kaduna 12.1 12.3 24.4 1,456 Kano 13.3 5.8 19.1 2,851 Katsina 28.1 17.9 46.0 1,614 Kebbi 2.3 7.4 9.6 1,158 Sokoto 5.1 5.6 10.7 1,059 Zamfara 0.6 2.4 3.0 1,410 Continued… 1 A more detailed discussion on orphan and vulnerable children can be found in Chapter 17 of this report. Household Population and Housing Characteristics • 21 Table 2.9—Continued Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Nigeria 2013 Children whose births are registered Percentage registered Number of children Background characteristic Percentage with a birth certificate Percentage without a birth certificate South East Abia 27.3 31.4 58.8 311 Anambra 26.0 35.2 61.2 617 Ebonyi 18.0 18.8 36.8 723 Enugu 18.0 28.1 46.1 536 Imo 21.9 41.3 63.2 515 South South Akwa Ibom 22.8 21.6 44.5 467 Bayelsa 9.4 14.6 24.1 227 Cross River 10.5 11.2 21.6 536 Delta 24.2 11.8 36.0 554 Edo 24.3 27.7 52.0 400 Rivers 23.1 18.4 41.4 702 South West Ekiti 29.2 21.2 50.5 194 Lagos 31.3 30.7 62.0 1,234 Ogun 15.0 20.7 35.6 719 Ondo 17.1 23.8 40.8 545 Osun 33.9 31.7 65.6 453 Oyo 23.4 25.1 48.6 1,068 Wealth quintile Lowest 3.2 3.5 6.7 6,896 Second 7.4 9.3 16.7 6,799 Middle 12.8 14.6 27.4 5,802 Fourth 22.6 22.4 45.0 5,478 Highest 33.8 31.1 64.9 5,133 Total 14.8 15.1 29.8 30,108 Note: Total includes 2 children with missing information on sex. Table 2.9 shows the percentage of de jure children under age 5 whose births were officially registered and the percentage who had a birth certificate at the time of the survey. Thirty percent of de jure children had their births registered. Fifteen percent had a birth certificate, and 15 percent did not. Almost equal proportions of male and female children had been registered, but children age 2-4 were more likely than those under age 2 to have been registered (31 percent and 29 percent, respectively). Children in urban households were more likely to have had their birth registered than children in rural households (50 percent and 19 percent, respectively). The proportion of registered births was highest in the South East and South West (52 percent and 51 percent, respectively) and lowest in the North West and North East (20 percent each). Across the states, Zamfara had the lowest percentage of children registered (3 percent). In Yobe and Kebbi the proportions were 8 percent and 10 percent, respectively. Households in the highest wealth quintile were most likely to register children’s births (65 percent), and households in the lowest quintile were least likely to do so (7 percent). In the case of children whose births were confirmed as registered, interviewers asked respondents about the place of registration. Table 2.10 shows that 57 percent of births were registered with the NPC, while 22 percent were registered in a private clinic/hospital. There has been an improvement in registration of births with the NPC since the 2008 NDHS (when the figure was 36 percent). In both urban and rural areas, more than half of births were registered with the NPC (58 percent and 55 percent, respectively). Registration of births with the NPC was lowest in Benue (27 percent) and in Kebbi and Kaduna (24 percent each). 22 • Household Population and Housing Characteristics Table 2.10 Birth registration of children under age 5 by authority Among de jure children under age 5 whose births are registered with the civil authorities, percent distribution of children by authority with which the birth is registered, according to background characteristics, Nigeria 2013 Authority where birth is registered Total Number of children Background characteristic National Population Commission Local Government Administration Private clinic/hospital Other Missing Age <2 58.6 10.8 22.7 5.9 2.0 100.0 3,569 2-4 56.0 14.5 20.8 6.6 2.2 100.0 5,698 Sex Male 58.1 12.9 20.4 6.5 2.1 100.0 4,676 Female 55.8 13.2 22.7 6.2 2.1 100.0 4,590 Residence Urban 58.4 11.6 23.3 5.4 1.2 100.0 5,546 Rural 54.8 15.2 18.9 7.7 3.4 100.0 3,720 Zone North Central 50.9 18.0 22.2 6.3 2.6 100.0 1,189 North East 54.9 16.3 19.1 5.4 4.4 100.0 1,128 North West 61.9 18.5 15.8 0.8 3.0 100.0 2,231 South East 49.5 3.5 37.7 8.5 0.8 100.0 1,411 South South 59.5 7.9 21.6 9.1 1.9 100.0 1,119 South West 59.9 12.0 17.7 9.6 0.7 100.0 2,190 State North Central FCT-Abuja 81.7 4.3 8.7 2.7 2.5 100.0 128 Benue 26.7 29.8 28.3 8.1 7.1 100.0 224 Kogi 54.4 13.1 23.2 9.2 0.0 100.0 191 Kwara 58.0 22.0 16.7 2.6 0.7 100.0 235 Nasarawa 41.5 9.8 38.7 7.4 2.6 100.0 117 Niger 44.4 24.9 23.8 4.3 2.6 100.0 194 Plateau 66.3 4.8 14.6 12.2 2.1 100.0 100 North East Adamawa 44.9 22.3 25.6 4.0 3.1 100.0 258 Bauchi 54.1 15.8 19.2 5.7 5.2 100.0 189 Borno 67.1 15.1 15.7 0.0 2.1 100.0 278 Gombe 60.6 24.9 5.0 3.4 6.2 100.0 160 Taraba 47.2 8.4 29.9 12.4 2.1 100.0 153 Yobe 49.8 1.4 17.4 17.1 14.2 100.0 89 North West Jigawa 67.9 16.5 13.2 0.9 1.5 100.0 240 Kaduna 23.6 19.4 54.2 1.0 1.8 100.0 373 Kano 78.3 15.5 3.9 0.1 2.2 100.0 557 Katsina 78.1 16.9 4.1 0.5 0.4 100.0 745 Kebbi 23.7 34.8 32.1 4.6 4.8 100.0 118 Sokoto 52.8 18.3 14.5 0.0 14.3 100.0 138 Zamfara (19.3) (38.3) (14.1) (2.5) (25.8) 100.0 59 South East Abia 51.2 3.3 43.3 2.2 0.0 100.0 183 Anambra 44.9 4.2 33.8 17.1 0.0 100.0 377 Ebonyi 66.2 1.7 24.8 3.2 4.0 100.0 277 Enugu 51.0 2.3 37.1 9.5 0.2 100.0 248 Imo 38.3 5.3 50.3 6.1 0.0 100.0 326 South South Akwa Ibom 59.0 5.5 24.3 10.5 0.6 100.0 209 Bayelsa 45.6 7.5 28.0 17.6 1.3 100.0 58 Cross River 69.2 1.9 22.2 2.2 4.5 100.0 121 Delta 71.1 7.5 10.1 6.4 4.9 100.0 220 Edo 61.0 11.6 21.1 4.9 1.4 100.0 219 Rivers 48.7 9.6 27.1 14.6 0.0 100.0 291 South West Ekiti 66.5 8.3 14.8 10.4 0.0 100.0 99 Lagos 62.5 16.9 12.9 7.6 0.1 100.0 768 Ogun 52.2 10.8 16.8 17.2 3.0 100.0 271 Ondo 36.7 17.0 28.5 16.6 1.3 100.0 228 Osun 68.4 7.6 18.2 5.8 0.0 100.0 297 Oyo 64.1 6.7 20.8 7.7 0.6 100.0 528 Wealth quintile Lowest 60.9 18.1 9.4 3.2 8.3 100.0 508 Second 54.8 19.5 14.9 6.6 4.2 100.0 1,188 Middle 55.5 15.9 20.6 6.2 1.9 100.0 1,637 Fourth 56.2 11.2 23.0 7.8 1.8 100.0 2,530 Highest 58.5 10.1 25.0 5.6 0.8 100.0 3,404 Total 57.0 13.1 21.5 6.3 2.1 100.0 9,267 Note: Total includes 1 child with missing information on sex. Figures in parentheses are based on 25-49 unweighted cases. Household Population and Housing Characteristics • 23 2.7 EDUCATION OF THE HOUSEHOLD POPULATION 2.7.1 Educational Attainment The educational level of household members is among the most important characteristics of a household because it is associated with many factors that have a significant impact on health-seeking behaviours, reproductive behaviours, use of contraception, and children’s health status. Table 2.11.1 Educational attainment of the female household population Percent distribution of the de facto female household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nigeria 2013 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age3 6-9 43.4 54.3 0.1 0.4 0.0 0.0 1.7 100.0 11,621 0.0 10-14 25.9 45.6 5.7 21.6 0.1 0.0 1.0 100.0 10,640 2.9 15-19 27.1 6.4 7.4 45.8 11.5 1.4 0.5 100.0 8,054 7.1 20-24 33.2 3.6 9.3 16.3 26.8 10.0 0.7 100.0 6,971 7.7 25-29 37.6 4.4 11.7 9.6 22.8 13.0 1.0 100.0 7,418 5.6 30-34 38.0 4.3 15.0 8.4 19.8 13.6 1.0 100.0 5,593 5.5 35-39 40.7 5.3 17.9 8.2 16.8 10.5 0.6 100.0 4,832 5.2 40-44 42.7 5.9 18.9 8.5 13.5 9.3 1.0 100.0 3,621 5.0 45-49 51.0 5.5 17.4 7.6 10.0 7.8 0.8 100.0 3,307 0.0 50-54 56.7 6.8 15.6 4.2 7.5 7.0 2.1 100.0 2,910 0.0 55-59 64.4 7.5 14.1 3.4 4.6 3.9 2.2 100.0 2,068 0.0 60-64 69.6 8.2 10.8 1.8 3.3 2.3 3.9 100.0 1,764 0.0 65+ 78.2 4.9 7.0 0.8 1.4 1.7 5.9 100.0 3,113 0.0 Residence Urban 21.5 20.6 10.8 18.1 17.5 10.6 0.9 100.0 29,345 5.6 Rural 53.5 18.2 8.7 10.0 5.9 2.1 1.7 100.0 42,590 0.0 Zone North Central 38.0 23.3 9.2 14.0 8.7 5.7 1.0 100.0 10,897 1.9 North East 61.1 16.7 5.9 7.1 4.5 2.9 1.7 100.0 10,505 0.0 North West 62.8 15.8 6.7 6.6 4.3 1.4 2.4 100.0 22,036 0.0 South East 18.7 22.0 13.0 18.5 18.0 8.8 0.9 100.0 8,523 5.6 South South 13.0 22.4 14.0 22.4 18.6 9.1 0.5 100.0 8,467 5.9 South West 17.1 19.5 12.8 20.3 19.0 11.0 0.3 100.0 11,507 5.9 State North Central FCT-Abuja 14.5 22.6 9.5 14.4 17.2 20.6 1.3 100.0 529 6.5 Benue 25.7 33.9 9.4 20.1 5.9 3.1 1.9 100.0 2,364 2.8 Kogi 25.7 24.6 11.8 16.3 14.6 6.5 0.6 100.0 1,414 4.9 Kwara 26.6 19.6 12.3 15.9 13.4 10.5 1.6 100.0 1,109 5.2 Nasarawa 41.3 23.1 9.4 13.1 7.1 5.3 0.7 100.0 1,163 1.4 Niger 61.6 17.5 6.0 6.9 5.2 2.4 0.4 100.0 3,017 0.0 Plateau 35.6 20.1 10.2 16.2 9.4 7.7 0.9 100.0 1,300 2.9 North East Adamawa 35.5 26.9 8.7 14.6 8.4 4.4 1.3 100.0 1,533 1.8 Bauchi 62.3 17.5 7.3 5.6 2.6 1.4 3.2 100.0 2,177 0.0 Borno 69.0 12.5 4.7 4.6 4.1 4.2 0.8 100.0 2,503 0.0 Gombe 61.6 17.0 4.9 7.6 5.1 2.0 1.9 100.0 1,113 0.0 Taraba 43.2 27.4 9.6 9.8 5.6 3.2 1.3 100.0 1,435 0.3 Yobe 85.3 4.0 1.2 3.6 2.8 1.7 1.4 100.0 1,744 0.0 North West Jigawa 71.3 16.3 6.4 3.5 0.8 0.3 1.4 100.0 2,528 0.0 Kaduna 40.3 18.5 9.2 13.8 11.4 5.4 1.4 100.0 3,565 1.7 Kano 54.2 20.8 8.3 8.6 5.0 1.0 2.0 100.0 6,209 0.0 Katsina 67.7 15.2 7.3 2.3 2.6 0.2 4.7 100.0 2,912 0.0 Kebbi 75.8 9.7 4.3 5.6 2.3 0.7 1.5 100.0 2,502 0.0 Sokoto 78.5 9.6 3.1 3.4 1.6 0.4 3.4 100.0 1,900 0.0 Zamfara 77.3 10.1 3.7 3.1 1.4 0.8 3.4 100.0 2,421 0.0 South East Abia 17.2 18.4 13.8 17.3 20.8 11.6 0.8 100.0 1,020 6.0 Anambra 10.1 22.4 12.2 17.6 23.5 13.4 0.9 100.0 1,879 7.6 Ebonyi 27.8 25.9 12.8 18.3 10.8 3.5 1.0 100.0 2,084 3.8 Enugu 23.1 20.7 14.5 17.5 16.5 6.6 1.1 100.0 1,815 5.4 Imo 13.4 20.6 12.3 21.6 20.7 10.8 0.7 100.0 1,725 6.7 South South Akwa Ibom 12.9 22.2 15.6 24.0 14.7 9.4 1.1 100.0 1,565 5.8 Bayelsa 10.4 27.6 13.9 23.8 19.7 4.7 0.0 100.0 613 5.7 Cross River 18.0 28.7 13.9 20.4 12.9 5.9 0.3 100.0 1,373 5.2 Delta 14.3 22.1 13.8 21.7 17.4 10.3 0.4 100.0 1,630 5.9 Edo 12.1 23.3 13.1 23.8 18.4 8.9 0.4 100.0 1,299 5.9 Rivers 10.0 16.4 13.7 21.8 26.3 11.4 0.3 100.0 1,989 8.1 Continued… 24 • Household Population and Housing Characteristics Table 2.11.1—Continued Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed South West Ekiti 15.2 18.0 11.5 20.4 18.5 15.9 0.4 100.0 610 7.4 Lagos 9.0 18.4 10.7 20.4 26.8 14.4 0.3 100.0 3,398 8.5 Ogun 24.1 20.0 21.2 18.0 12.3 4.0 0.4 100.0 1,723 5.3 Ondo 14.1 22.6 13.1 22.5 16.1 11.5 0.1 100.0 1,476 5.9 Osun 16.3 19.5 9.7 21.9 19.4 13.1 0.1 100.0 1,398 6.4 Oyo 24.9 19.1 11.9 19.8 15.2 8.7 0.4 100.0 2,902 5.4 Wealth quintile Lowest 81.0 10.9 3.5 2.1 0.4 0.1 2.1 100.0 13,855 0.0 Second 58.0 20.5 8.7 8.2 2.2 0.2 2.2 100.0 14,124 0.0 Middle 37.5 24.0 12.6 15.4 7.8 1.5 1.2 100.0 14,777 2.0 Fourth 20.7 22.0 14.1 20.0 17.1 5.4 0.8 100.0 14,440 5.4 Highest 7.7 18.1 8.5 20.1 24.8 20.2 0.5 100.0 14,738 9.7 Total 40.4 19.2 9.5 13.3 10.6 5.6 1.4 100.0 71,935 1.7 1 Completed grade 6 at the primary level 2 Completed grade 6 at the secondary level 3 Excludes 22 cases with missing information on age Table 2.11.2 Educational attainment of the male household population Percent distribution of the de facto male household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nigeria 2013 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age3 6-9 41.9 56.0 0.2 0.4 0.0 0.0 1.4 100.0 11,826 0.0 10-14 21.0 51.2 5.5 21.6 0.1 0.1 0.5 100.0 11,023 3.1 15-19 17.3 8.1 6.9 54.3 11.7 1.3 0.4 100.0 7,525 7.6 20-24 18.6 2.3 7.0 20.9 37.4 13.3 0.5 100.0 5,814 11.0 25-29 21.2 3.0 9.6 10.1 35.2 20.4 0.4 100.0 5,714 11.2 30-34 22.8 3.1 13.3 9.8 30.5 20.1 0.5 100.0 5,132 11.0 35-39 25.1 4.1 16.3 8.5 28.3 17.3 0.5 100.0 4,548 8.6 40-44 26.0 4.1 19.1 7.8 24.8 17.7 0.5 100.0 3,757 6.7 45-49 30.8 4.6 17.8 7.8 21.3 17.2 0.5 100.0 3,371 5.8 50-54 32.8 3.3 21.9 6.9 15.7 18.9 0.4 100.0 2,291 5.6 55-59 43.4 5.3 21.5 5.8 10.0 13.2 0.8 100.0 2,178 5.0 60-64 54.6 6.5 18.3 2.8 8.0 7.9 1.9 100.0 1,962 0.0 65+ 62.0 6.9 14.6 3.4 5.2 5.2 2.7 100.0 3,919 0.0 Residence Urban 13.9 21.2 10.1 17.4 22.1 14.8 0.5 100.0 28,299 7.0 Rural 40.4 20.7 9.6 13.0 10.5 4.9 1.0 100.0 40,787 1.5 Zone North Central 22.6 24.1 8.5 17.9 14.3 12.0 0.6 100.0 11,129 5.3 North East 52.4 18.0 5.1 9.4 7.9 6.2 1.0 100.0 10,293 0.0 North West 46.9 19.0 8.0 10.1 9.8 4.8 1.4 100.0 21,209 0.0 South East 10.7 25.7 17.6 19.0 17.9 8.5 0.6 100.0 7,283 5.7 South South 6.1 22.4 12.6 21.1 24.8 12.7 0.3 100.0 8,252 8.0 South West 11.6 19.7 11.6 18.3 24.6 13.9 0.2 100.0 10,921 7.6 State North Central FCT-Abuja 10.4 19.4 8.1 11.4 20.0 29.9 0.9 100.0 593 11.0 Benue 11.1 31.5 10.2 26.0 10.8 9.3 1.0 100.0 2,521 5.5 Kogi 14.1 20.2 9.5 19.6 21.8 14.3 0.5 100.0 1,307 7.3 Kwara 12.9 22.1 11.2 17.2 17.3 18.9 0.5 100.0 1,062 6.3 Nasarawa 20.6 25.8 8.6 19.1 15.4 9.8 0.6 100.0 1,174 5.3 Niger 40.2 21.9 5.4 11.6 12.5 8.1 0.3 100.0 3,212 1.8 Plateau 25.2 21.1 9.9 18.7 11.9 12.7 0.5 100.0 1,261 5.3 North East Adamawa 21.2 28.7 7.8 18.5 12.3 10.6 0.8 100.0 1,416 4.9 Bauchi 51.5 21.4 5.2 9.2 6.1 4.4 2.2 100.0 2,063 0.0 Borno 63.6 10.5 3.9 6.5 8.2 6.8 0.5 100.0 2,622 0.0 Gombe 46.4 20.8 4.9 12.7 8.0 6.7 0.7 100.0 1,046 0.0 Taraba 28.6 31.5 9.5 12.8 10.8 6.0 0.8 100.0 1,352 2.5 Yobe 83.3 5.1 1.1 2.3 3.8 3.5 0.8 100.0 1,794 0.0 North West Jigawa 54.7 20.4 8.4 7.5 4.6 3.4 1.2 100.0 2,258 0.0 Kaduna 31.8 18.9 7.7 13.3 18.1 9.5 0.7 100.0 3,673 4.6 Kano 37.8 20.5 10.3 13.0 12.8 4.7 0.9 100.0 6,077 2.2 Katsina 54.8 18.2 10.4 4.1 6.7 3.1 2.8 100.0 2,639 0.0 Kebbi 59.9 15.8 4.2 9.0 5.5 4.5 1.1 100.0 2,485 0.0 Sokoto 57.4 18.3 5.3 8.9 4.8 2.7 2.5 100.0 1,928 0.0 Zamfara 55.8 18.5 5.8 8.5 5.8 3.5 2.2 100.0 2,147 0.0 Continued… Household Population and Housing Characteristics • 25 Table 2.11.2—Continued Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed South East Abia 7.3 22.0 17.7 19.0 23.6 9.6 0.8 100.0 945 6.6 Anambra 7.9 23.4 18.4 18.9 20.7 10.3 0.4 100.0 1,757 6.0 Ebonyi 14.2 33.2 15.1 17.7 12.0 7.0 0.8 100.0 1,550 5.1 Enugu 17.0 25.3 20.5 17.3 13.1 6.5 0.3 100.0 1,455 5.4 Imo 6.9 23.2 16.4 21.8 21.8 9.1 0.7 100.0 1,576 6.7 South South Akwa Ibom 6.1 24.6 15.8 22.7 19.4 10.3 0.9 100.0 1,539 6.3 Bayelsa 4.5 23.9 8.0 24.3 28.1 11.1 0.0 100.0 627 8.1 Cross River 7.3 23.8 17.6 22.4 20.4 8.5 0.1 100.0 1,248 6.0 Delta 6.8 23.3 12.3 20.4 24.6 12.2 0.4 100.0 1,535 7.8 Edo 7.2 22.2 11.3 19.9 25.6 13.6 0.2 100.0 1,215 8.1 Rivers 4.8 18.7 9.5 19.3 30.1 17.5 0.1 100.0 2,087 10.6 South West Ekiti 6.5 17.6 11.5 21.7 20.5 21.5 0.6 100.0 545 9.3 Lagos 4.6 16.9 10.1 16.5 33.3 18.3 0.2 100.0 3,315 11.0 Ogun 15.1 23.7 20.7 16.2 17.2 6.9 0.1 100.0 1,552 5.5 Ondo 8.8 20.8 11.0 22.0 22.5 14.8 0.2 100.0 1,415 8.2 Osun 8.3 20.7 7.1 22.7 22.8 18.3 0.1 100.0 1,298 8.7 Oyo 21.9 20.2 10.7 17.0 21.1 8.6 0.3 100.0 2,795 5.6 Wealth quintile Lowest 71.1 14.0 6.0 4.9 2.4 0.4 1.2 100.0 13,158 0.0 Second 42.8 24.0 10.7 12.2 7.1 1.8 1.4 100.0 13,037 0.6 Middle 22.5 26.3 11.7 18.9 14.7 5.3 0.7 100.0 13,772 5.1 Fourth 11.6 23.4 12.4 19.7 22.6 9.8 0.5 100.0 14,503 6.2 Highest 4.6 16.8 8.0 17.3 27.3 25.6 0.4 100.0 14,616 11.1 Total 29.5 20.9 9.8 14.8 15.2 8.9 0.8 100.0 69,085 4.7 1 Completed grade 6 at the primary level 2 Completed grade 6 at the secondary level 3 Excludes 23 cases with missing information on age Tables 2.11.1 and 2.11.2 show the distribution of female and male household members age 6 and above by the highest level of schooling ever attended (even if they did not complete that level) and the median number of years of education completed according to age, urban-rural residence, geopolitical zone, and wealth quintile. Although the majority of Nigerians have attained some education, there are differences in educational attainment according to sex. Overall, 70 percent of males age 6 and over have ever attended school, as compared with 58 percent of females. About one in five females and males have completed some primary education (19 percent and 21 percent, respectively). Six percent of females and 9 percent of males have more than a secondary education. Large percentages of both females (40 percent) and males (30 percent) have no education. Households in rural areas are far below their urban counterparts in educational attainment; 54 percent of females in rural areas and 22 percent in urban areas have no education, and the corresponding figures for males are 40 percent and 14 percent. Across the geopolitical zones, the North East and North West lag behind others in educational attainment, with more than 60 percent of females and about half of males having no education. The most substantial variation in educational attainment occurs across the wealth quintiles. Only 8 percent of females in the wealthiest households have no education, as compared with 81 percent in the poorest households. Among males, 5 percent of those in the wealthiest households have no education, compared with 71 percent in the poorest households. Median number of years of educational attainment is higher for males (4.7 years) than for females (1.7 years). 26 • Household Population and Housing Characteristics 2.7.2 School Attendance Ratios Tables 2.12.1 and 2.12.2 present school attendance ratios by level of schooling and by sex, area of residence, geopolitical zone, state, and wealth quintile. The net attendance ratio (NAR) is an indicator of participation in schooling among children of official school age (age 6-12 for primary school and age 13- 18 for secondary school), and the gross attendance ratio (GAR) indicates participation at each level of schooling among those of any age between 5 and 24 years. The GAR is nearly always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level. Table 2.12.1 School attendance ratios: Primary school Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by sex at primary level of schooling, and the gender parity index (GPI), according to background characteristics, Nigeria 2013 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender parity index3 Male Female Total Gender parity index3 Residence Urban 73.1 69.4 71.2 0.95 105.2 99.3 102.2 0.94 Rural 54.7 48.8 51.8 0.89 82.4 72.9 77.7 0.88 Zone North Central 69.6 66.2 68.0 0.95 104.4 98.0 101.3 0.94 North East 46.7 41.5 44.1 0.89 71.0 63.4 67.2 0.89 North West 50.7 43.8 47.2 0.86 76.0 63.0 69.4 0.83 South East 82.3 80.3 81.4 0.98 119.7 116.5 118.2 0.97 South South 76.4 73.4 74.9 0.96 108.7 109.5 109.0 1.01 South West 70.5 69.5 70.0 0.99 101.6 99.7 100.6 0.98 State North Central FCT-Abuja 74.4 73.1 73.7 0.98 108.7 110.2 109.5 1.01 Benue 75.4 77.7 76.5 1.03 122.8 122.0 122.4 0.99 Kogi 71.4 76.9 74.3 1.08 102.1 110.7 106.6 1.08 Kwara 73.9 72.5 73.2 0.98 103.2 103.5 103.3 1.00 Nasarawa 72.6 69.3 71.0 0.96 108.0 102.6 105.4 0.95 Niger 64.1 51.4 57.9 0.80 93.8 74.7 84.6 0.80 Plateau 62.5 63.6 63.1 1.02 93.6 90.5 92.1 0.97 North East Adamawa 79.0 74.5 76.8 0.94 115.7 112.2 114.0 0.97 Bauchi 54.0 41.1 47.3 0.76 81.7 63.9 72.4 0.78 Borno 34.8 35.3 35.1 1.01 53.1 51.0 52.0 0.96 Gombe 50.9 39.3 44.6 0.77 80.4 58.4 68.4 0.73 Taraba 67.2 61.1 64.3 0.91 108.5 101.0 105.1 0.93 Yobe 14.3 11.0 12.8 0.77 19.2 16.2 17.9 0.84 North West Jigawa 48.6 38.1 43.2 0.78 80.3 60.8 70.2 0.76 Kaduna 58.9 57.3 58.1 0.97 88.7 80.5 84.6 0.91 Kano 60.5 58.6 59.5 0.97 86.4 81.9 84.1 0.95 Katsina 46.6 40.6 43.5 0.87 69.4 58.1 63.5 0.84 Kebbi 40.6 27.1 34.1 0.67 56.5 38.2 47.8 0.68 Sokoto 39.8 24.6 32.7 0.62 58.9 37.0 48.7 0.63 Zamfara 42.9 27.7 35.0 0.65 73.3 42.5 57.2 0.58 South East Abia 84.9 74.7 80.1 0.88 120.5 102.2 111.9 0.85 Anambra 81.6 82.4 82.0 1.01 117.3 123.2 120.1 1.05 Ebonyi 86.4 84.7 85.6 0.98 121.6 119.3 120.5 0.98 Enugu 81.8 81.2 81.5 0.99 118.3 113.6 116.0 0.96 Imo 76.6 73.8 75.3 0.96 120.7 116.2 118.6 0.96 South South Akwa Ibom 78.1 71.4 74.9 0.92 110.4 101.5 106.2 0.92 Bayelsa 76.2 80.4 78.1 1.06 110.6 115.9 113.1 1.05 Cross River 71.4 75.2 73.5 1.05 105.1 110.1 107.8 1.05 Delta 78.5 76.4 77.4 0.97 116.2 116.1 115.9 1.00 Edo 79.0 74.4 76.6 0.94 111.2 110.2 110.6 0.99 Rivers 74.9 66.9 71.4 0.89 101.1 107.2 103.8 1.06 Continued… Household Population and Housing Characteristics • 27 Table 2.12.1—Continued Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender parity index3 Male Female Total Gender parity index3 South West Ekiti 70.0 70.8 70.4 1.01 100.5 105.1 102.9 1.05 Lagos 70.4 67.9 69.0 0.96 107.3 99.6 103.2 0.93 Ogun 78.6 74.8 76.7 0.95 102.7 101.2 102.0 0.99 Ondo 73.6 74.6 74.1 1.01 118.3 111.7 114.9 0.94 Osun 75.1 71.2 73.1 0.95 111.1 101.3 106.2 0.91 Oyo 63.6 64.9 64.2 1.02 86.5 91.5 88.8 1.06 Wealth quintile Lowest 30.0 24.2 27.1 0.80 47.7 37.5 42.6 0.79 Second 59.9 52.7 56.3 0.88 91.7 78.9 85.3 0.86 Middle 74.5 71.3 72.9 0.96 108.2 102.6 105.5 0.95 Fourth 77.2 73.1 75.2 0.95 111.8 104.0 108.1 0.93 Highest 71.4 69.5 70.4 0.97 101.9 102.1 102.0 1.00 Total 61.6 56.7 59.1 0.92 90.9 83.0 87.0 0.91 1 The NAR for primary school is the percentage of the primary school age (6-12 years) population that is attending primary 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. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The GPI for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. Table 2.12.2 School attendance ratios: Secondary school Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by sex at secondary level of schooling, and the gender parity index (GPI), according to background characteristics, Nigeria 2013 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender parity index3 Male Female Total Gender parity index3 Residence Urban 66.0 62.1 64.0 0.94 101.8 94.0 97.8 0.92 Rural 43.1 32.6 37.8 0.76 65.7 47.6 56.6 0.72 Zone North Central 57.3 51.5 54.5 0.90 92.3 77.1 85.0 0.84 North East 34.6 23.0 28.5 0.66 53.3 33.8 43.0 0.63 North West 39.8 25.3 32.5 0.63 58.5 37.5 47.9 0.64 South East 70.1 69.2 69.6 0.99 98.2 95.3 96.7 0.97 South South 67.7 63.3 65.4 0.93 109.4 95.3 102.0 0.87 South West 67.0 69.3 68.1 1.03 105.8 109.1 107.5 1.03 State North Central FCT-Abuja 68.2 56.1 62.0 0.82 103.1 92.3 97.6 0.90 Benue 60.3 55.2 57.9 0.91 93.6 76.1 85.2 0.81 Kogi 75.7 64.7 70.0 0.85 123.5 95.8 109.2 0.78 Kwara 73.1 70.0 71.5 0.96 123.5 109.7 116.4 0.89 Nasarawa 60.2 45.6 53.7 0.76 93.7 72.6 84.3 0.78 Niger 41.8 33.2 38.0 0.80 69.4 52.7 62.0 0.76 Plateau 52.0 54.5 53.2 1.05 84.7 78.8 81.8 0.93 North East Adamawa 54.4 39.9 46.6 0.73 88.0 55.0 70.3 0.63 Bauchi 32.7 18.6 25.7 0.57 50.3 27.8 39.2 0.55 Borno 38.6 20.2 28.0 0.52 52.6 28.2 38.6 0.54 Gombe 38.9 24.5 31.8 0.63 64.3 33.9 49.3 0.53 Taraba 38.4 26.8 32.5 0.70 58.3 45.6 51.8 0.78 Yobe 10.7 13.7 12.3 1.28 18.8 21.5 20.2 1.14 North West Jigawa 28.3 9.8 18.3 0.35 52.7 18.2 34.0 0.34 Kaduna 46.7 38.4 42.5 0.82 68.3 59.4 63.8 0.87 Kano 50.8 35.6 43.3 0.70 71.9 48.3 60.3 0.67 Katsina 25.8 13.3 18.9 0.52 39.4 18.3 27.8 0.46 Kebbi 34.2 24.0 29.5 0.70 46.3 36.3 41.7 0.78 Sokoto 26.7 10.1 18.7 0.38 43.6 17.3 31.0 0.40 Zamfara 36.8 14.6 26.1 0.40 53.0 27.2 40.6 0.51 Continued… 28 • Household Population and Housing Characteristics Table 2.12.2—Continued Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender parity index3 Male Female Total Gender parity index3 South East Abia 73.2 70.4 71.9 0.96 99.6 117.7 107.6 1.18 Anambra 75.3 67.0 71.0 0.89 99.9 88.0 93.7 0.88 Ebonyi 60.4 64.5 62.8 1.07 93.0 84.0 87.8 0.90 Enugu 69.2 72.9 71.1 1.05 90.7 97.8 94.4 1.08 Imo 74.2 74.9 74.6 1.01 109.6 110.5 110.1 1.01 South South Akwa Ibom 70.6 67.3 68.8 0.95 111.7 100.5 105.7 0.90 Bayelsa 72.7 66.3 69.4 0.91 111.4 93.8 102.4 0.84 Cross River 69.5 55.5 63.1 0.80 119.4 102.7 111.7 0.86 Delta 64.7 64.4 64.6 1.00 105.5 88.1 96.1 0.83 Edo 69.8 64.1 66.7 0.92 100.7 92.0 96.0 0.91 Rivers 62.5 60.7 61.5 0.97 109.5 97.1 102.7 0.89 South West Ekiti 75.7 70.6 73.3 0.93 117.7 112.7 115.3 0.96 Lagos 69.0 69.6 69.3 1.01 114.7 118.5 116.7 1.03 Ogun 69.4 71.8 70.6 1.03 106.0 112.4 109.2 1.06 Ondo 67.6 62.9 65.2 0.93 97.0 92.1 94.5 0.95 Osun 75.1 74.9 75.0 1.00 115.0 118.4 116.6 1.03 Oyo 58.1 68.5 63.1 1.18 95.6 102.5 99.0 1.07 Wealth quintile Lowest 15.8 6.8 11.5 0.43 24.2 10.2 17.4 0.42 Second 39.1 26.1 32.3 0.67 59.3 37.0 47.5 0.62 Middle 61.1 50.9 56.0 0.83 92.1 72.5 82.3 0.79 Fourth 69.8 64.4 67.2 0.92 106.1 96.2 101.3 0.91 Highest 72.5 69.7 71.0 0.96 115.2 109.0 111.9 0.95 Total 52.6 45.1 48.8 0.86 80.7 67.2 73.8 0.83 1 The NAR for secondary school is the percentage of the secondary school age (13-18 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. 2 The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary school age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The GPI for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. The results in Tables 2.12.1 and 2.12.2 show that 59 percent of children age 6-12 attend primary school and 49 percent of children age 13-18 attend secondary school. There are differences in the NARs for males and females at both the primary and secondary levels. At the primary level, the NAR in urban areas is higher than in rural areas (71 percent and 52 percent, respectively), while there is a much wider gap in the NAR between urban and rural areas at the secondary level (64 percent and 38 percent, respectively). By geopolitical zone, the North East has the lowest NAR at the primary and secondary levels (44 percent and 29 percent, respectively), while the South East has the highest (81 percent and 70 percent, respectively). Attendance is higher among wealthy households than poorer households at both the primary and secondary levels. For example, the NAR at the primary level is 27 percent for children in the lowest wealth quintile, as compared with more than 70 percent in the middle and higher wealth quintiles. The same pattern occurs at the secondary level, with the NAR being 12 percent for children age 13 to 18 in the lowest wealth quintile and 71 percent in the highest wealth quintile. The GAR is higher than the NAR at the both the primary school level (87 percent versus 59 percent) and the secondary school level (74 percent versus 49 percent). This is an indication that fewer pupils attend secondary school than primary school. Tables 2.12.1 and 2.12.2 also show the gender parity index (GPI), which represents the ratio of the NAR and GAR for females to the NAR and GAR for males. A GPI below one indicates that a smaller proportion of females than males attend school. The indexes for NAR and GAR at the primary level are slightly less than one (0.9), indicating that the gender gap is very narrow. Age-specific attendance rates (ASARs) for the population age 5 to 24 are presented in Figure 2.2 by age and sex. The ASAR indicates participation in schooling at any level. The trends are the same for males and females. Approximately half of children attend school by age 6. In the 9-16 age group, 7 of 10 children attend school. At age 16, attendance rates begin to decline with increasing age, and the decline is faster for females than males after age 15. Household Population and Housing Characteristics • 29 Figure 2.2 Age-specific attendance rates 0 10 20 30 40 50 60 70 80 90 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percentage Age (years) Male Female NDHS 2013 Characteristics of Respondents • 31 CHARACTERISTICS OF RESPONDENTS 3 his chapter provides a profile of the respondents who were interviewed in the 2013 NDHS, that is, women and men age 15-49. Information is presented on a number of basic characteristics including age at the time of the survey, religion, marital status, residence, education, literacy status, and media access. In addition, the chapter explores adults’ employment status, occupation, and earnings. An analysis of these variables provides the socioeconomic context within which demographic and reproductive health issues are examined in the subsequent chapters. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 shows the percent distribution of women and men age 15-49 by their background characteristics. Fifty-six percent of women and 54 percent of men are under age 30. In general, the proportion of women and men in each age group declines with increasing age, reflecting the comparatively young age structure of the population in Nigeria, which is a result of a past history of high fertility. More than half of the respondents (52 percent of women and 51 percent of men) are Muslims, while 11 percent of women and 12 percent of men are Catholics. Other Christians (such as Pentecostals and orthodox) account for 36 percent of women and men. With respect to ethnicity, 28 percent of women and 27 percent of men are Hausa, while 15 percent of women and 13 percent of men belong to the Igbo ethnic group. Fourteen percent each of women and men identified themselves as Yoruba. The Fulani ethnic group constitutes only 7 percent of women and 6 percent of men. There are more than 250 ethnic groups in Nigeria, but most comprise only small numbers. For instance, the Ibibio, Ijaw, Kanuri, and Tiv ethnic groups each account for only 2 percent of the population. The majority of respondents are currently married or living together with a partner (71 percent of women and 50 percent of men). Twenty-four percent of women and 48 percent of men age 15-49 had never been married at the time of the survey. The universality of marriage in Nigeria probably reflects the social and economic security marriage is perceived to provide (National Population Commission [NPC], 1998). The proportion of women who are divorced, separated, or widowed (5 percent) is higher than the proportion among men (2 percent). Men are more likely than women to remarry after a divorce, separation, or widowhood. T Key Findings • More than half of women (56 percent) and men (54 percent) age 15-49 are under age 30. • A high proportion of respondents (71 percent of women and 50 percent of men) are currently married. • More than half of the respondents live in rural areas. • Thirty-eight percent of women and 21 percent of men have no education, while 45 percent of women and 62 percent of men have a secondary or higher education. • Ninety-three percent of women in the highest wealth quintile are literate. • Sixty-two percent of women are currently employed. • Nine in 10 women receive cash (including cash and in-kind) for their work. 32 • Characteristics of Respondents Over half of the respondents live in rural areas (58 percent of women and 56 percent of men), and 3 in 10 live in the North West zone. Fourteen to 16 percent each of women and men live in the North Central, North West, or South West zone. Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Nigeria 2013 Background characteristic Women Men Weighted percentage Weighted number Unweighted number Weighted percentage Weighted number Unweighted number Age 15-19 20.1 7,820 7,905 20.9 3,619 3,708 20-24 17.3 6,757 6,714 16.7 2,892 2,840 25-29 18.3 7,145 7,037 15.9 2,757 2,763 30-34 14.0 5,467 5,373 13.9 2,414 2,368 35-39 12.1 4,718 4,701 12.5 2,175 2,170 40-44 9.3 3,620 3,663 10.2 1,777 1,777 45-49 8.8 3,422 3,555 9.9 1,724 1,733 Religion Catholic 11.1 4,316 4,081 11.6 2,014 1,916 Other Christian 35.7 13,922 15,757 35.6 6,181 7,058 Islam 51.7 20,149 18,578 51.3 8,907 8,134 Traditionalist 0.9 359 352 0.9 161 157 Missing 0.5 192 166 0.5 79 77 Ethnic group Ekoi 0.1 22 34 0.1 20 31 Fulani 6.6 2,565 2,425 5.5 953 954 Hausa 27.5 10,699 9,386 27.2 4,719 4,100 Ibibio 2.2 841 849 2.4 419 435 Igala 1.0 371 416 1.1 196 210 Igbo 14.5 5,636 5,448 13.4 2,330 2,228 Ijaw/Izon 1.9 751 1,590 2.0 346 765 Kanuri/Beriberi 1.7 680 523 1.7 292 209 Tiv 2.1 836 621 2.6 448 312 Yoruba 14.1 5,482 5,606 13.5 2,341 2,416 Other 28.2 11,002 11,987 30.2 5,247 5,653 Don’t know 0.0 1 2 0.0 0 0 Missing 0.2 63 61 0.3 48 46 Marital status Never married 23.9 9,326 9,820 48.3 8,378 8,531 Married 69.4 27,043 26,403 49.1 8,520 8,292 Living together 2.0 787 871 1.2 203 265 Divorced/separated 2.1 826 861 1.2 206 217 Widowed 2.5 967 993 0.3 52 54 Residence Urban 42.1 16,414 15,545 43.8 7,611 7,144 Rural 57.9 22,534 23,403 56.2 9,748 10,215 Zone North Central 14.3 5,572 6,251 15.5 2,685 3,018 North East 14.8 5,766 6,630 14.5 2,515 2,843 North West 30.5 11,877 9,673 29.9 5,185 4,131 South East 11.5 4,476 4,462 9.7 1,686 1,681 South South 12.7 4,942 6,058 14.1 2,445 3,035 South West 16.2 6,314 5,874 16.4 2,843 2,651 State North Central FCT-Abuja 0.8 315 761 1.0 175 428 Benue 3.2 1,240 870 3.6 616 409 Kogi 1.8 704 859 1.9 333 425 Kwara 1.5 596 966 1.6 274 450 Nasarawa 1.5 594 874 1.6 282 401 Niger 3.8 1,462 1,046 4.0 701 512 Plateau 1.7 662 875 1.7 302 393 North East Adamawa 2.1 828 1,122 2.1 358 493 Bauchi 3.0 1,161 1,196 2.9 512 492 Borno 3.6 1,412 782 3.9 676 376 Gombe 1.4 550 1,076 1.5 255 490 Taraba 2.2 844 1,374 1.9 325 541 Yobe 2.5 971 1,080 2.2 390 451 North West Jigawa 3.5 1,353 1,211 2.9 510 462 Kaduna 5.5 2,136 1,243 6.0 1,033 602 Kano 8.2 3,189 2,228 9.2 1,592 1,108 Katsina 3.9 1,525 1,304 3.4 596 512 Kebbi 3.2 1,244 1,184 3.2 551 524 Sokoto 2.8 1,098 1,314 2.4 424 501 Zamfara 3.4 1,332 1,189 2.8 479 422 Continued… Characteristics of Respondents • 33 Table 3.1—Continued Background characteristic Women Men Weighted percentage Weighted number Unweighted number Weighted percentage Weighted number Unweighted number South East Abia 1.3 518 805 1.3 229 357 Anambra 2.7 1,052 903 2.6 446 366 Ebonyi 2.9 1,122 1,075 2.1 368 334 Enugu 2.4 951 965 1.8 320 355 Imo 2.1 833 714 1.9 323 269 South South Akwa Ibom 2.2 864 979 2.6 451 502 Bayelsa 0.9 364 1,224 1.1 187 652 Cross River 1.8 703 727 1.8 310 320 Delta 2.6 993 1,130 2.7 473 554 Edo 1.9 742 1,079 2.1 365 517 Rivers 3.3 1,276 919 3.8 658 490 South West Ekiti 0.8 326 863 0.8 148 394 Lagos 5.0 1,964 1,482 5.5 948 701 Ogun 2.3 883 672 2.1 358 268 Ondo 2.1 808 916 2.3 404 435 Osun 2.0 765 1,026 2.1 356 480 Oyo 4.0 1,568 915 3.6 629 373 Education No education 37.8 14,729 13,740 21.2 3,685 3,354 Primary 17.3 6,734 7,104 16.7 2,907 2,979 Secondary 35.8 13,927 14,407 47.7 8,281 8,390 More than secondary 9.1 3,558 3,697 14.3 2,486 2,636 Wealth quintile Lowest 18.3 7,132 6,602 16.5 2,862 2,646 Second 19.1 7,428 7,515 17.2 2,992 3,033 Middle 19.2 7,486 8,001 19.2 3,338 3,538 Fourth 20.5 7,992 8,450 22.1 3,835 4,042 Highest 22.9 8,910 8,380 25.0 4,332 4,100 Total 100.0 38,948 38,948 100.0 17,359 17,359 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Education is an important determinant of an individual’s attitudes and outlook on various aspects of life. Educational attainment in Nigeria is fairly high; 45 percent of women and 62 percent of men have a secondary or higher level of education. However, 38 percent of women and 21 percent of men have no education. With respect to wealth, men are more likely than women to be in the fourth and highest wealth quintiles, while women are more likely than men to be in the lowest two quintiles. 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Table 3.2.1 shows the relationship between respondents’ level of education and their background characteristics. The percentage of women with no education increases steadily by age group, from 31 percent among women age 15-24 to 54 percent among women age 45-49. There are urban-rural differences that are more pronounced at the lowest and highest educational levels. For example, more than half of rural women have no education, as compared with 16 percent of urban women. Forty-six percent of urban women have a secondary education or higher, compared with 14 percent of rural women. Women’s educational attainment differs markedly among the zones and states. The North West and North East have the highest proportions of women with no education (69 percent and 64 percent, respectively), and the South South and South East have the lowest proportions (5 percent each). Across states, the highest proportion of women with more than a secondary education is in Federal Capital Territory (FCT)-Abuja (30 percent), followed by Ekiti (26 percent). In these states, as well as in Abia, Anambra, Imo, Rivers, Lagos, and Osun, women have completed a median of 11 years of schooling or more. Access to education increases with women’s wealth. Eighty-seven percent of women in the lowest wealth quintile have no education, as compared with 3 percent in the highest wealth quintile. On the other hand, 87 percent of women in the highest wealth quintile have attended or completed secondary schooling or higher, compared with 4 percent of women in the lowest quintile. 34 • Characteristics of Respondents 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 2013 Highest level of schooling Total Median years completed Number of women Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 30.5 4.7 7.7 30.9 20.7 5.4 100.0 7.6 14,576 15-19 27.8 5.4 6.8 43.9 14.6 1.6 100.0 7.5 7,820 20-24 33.7 3.9 8.7 16.0 27.8 9.9 100.0 7.8 6,757 25-29 38.7 4.6 10.6 10.5 21.9 13.7 100.0 5.6 7,145 30-34 39.4 4.9 14.8 9.4 18.6 12.9 100.0 5.4 5,467 35-39 40.7 5.9 17.5 9.0 16.0 10.9 100.0 5.2 4,718 40-44 44.4 6.6 18.0 9.0 13.2 8.8 100.0 4.5 3,620 45-49 53.5 6.3 16.3 7.7 8.9 7.2 100.0 0.0 3,422 Residence Urban 15.5 4.1 12.5 22.0 29.0 16.9 100.0 10.2 16,414 Rural 54.1 6.0 11.8 14.1 10.5 3.5 100.0 0.0 22,534 Zone North Central 31.6 8.3 14.2 20.1 16.1 9.7 100.0 5.7 5,572 North East 64.4 5.8 8.0 9.3 7.7 4.9 100.0 0.0 5,766 North West 69.4 3.4 8.2 8.8 7.7 2.5 100.0 0.0 11,877 South East 5.3 6.6 14.4 29.0 30.6 14.2 100.0 10.3 4,476 South South 5.0 6.3 16.8 28.4 29.2 14.2 100.0 9.8 4,942 South West 8.4 3.4 16.0 22.1 32.8 17.4 100.0 11.0 6,314 State North Central FCT-Abuja 11.4 4.5 11.7 15.8 26.5 30.0 100.0 11.2 315 Benue 17.2 20.0 16.8 30.9 9.9 5.2 100.0 5.7 1,240 Kogi 13.4 5.6 19.5 23.0 27.4 11.2 100.0 8.8 704 Kwara 21.4 1.8 17.5 19.4 23.5 16.4 100.0 8.9 596 Nasarawa 31.6 10.4 15.6 19.4 14.1 8.9 100.0 5.5 594 Niger 65.8 2.0 7.4 9.5 10.3 4.9 100.0 0.0 1,462 Plateau 21.3 8.8 15.9 23.4 18.5 12.0 100.0 7.3 662 North East Adamawa 34.5 8.7 13.3 21.1 14.6 7.9 100.0 5.5 828 Bauchi 72.8 5.1 8.6 6.2 4.6 2.7 100.0 0.0 1,161 Borno 72.4 3.0 5.7 5.3 6.5 7.1 100.0 0.0 1,412 Gombe 63.0 5.5 7.6 10.2 10.3 3.5 100.0 0.0 550 Taraba 45.0 13.7 13.7 13.6 9.3 4.8 100.0 2.4 844 Yobe 85.6 1.4 1.3 4.3 4.7 2.7 100.0 0.0 971 North West Jigawa 83.2 4.9 6.2 3.9 1.5 0.4 100.0 0.0 1,353 Kaduna 40.3 3.6 11.2 17.8 18.7 8.4 100.0 5.5 2,136 Kano 60.2 4.6 11.2 12.1 9.9 2.0 100.0 0.0 3,189 Katsina 78.4 2.2 10.4 3.7 4.7 0.6 100.0 0.0 1,525 Kebbi 81.2 3.0 5.3 5.2 4.3 1.1 100.0 0.0 1,244 Sokoto 89.1 1.5 2.4 4.4 2.1 0.6 100.0 0.0 1,098 Zamfara 86.3 2.0 3.5 4.1 2.3 1.7 100.0 0.0 1,332 South East Abia 2.6 3.3 13.7 24.4 36.1 19.8 100.0 11.2 518 Anambra 2.9 3.8 10.1 26.3 37.7 19.2 100.0 11.2 1,052 Ebonyi 11.9 13.3 19.9 29.4 19.5 6.0 100.0 7.2 1,122 Enugu 5.7 6.6 17.4 31.3 28.5 10.6 100.0 9.7 951 Imo 0.5 3.0 9.5 32.0 35.7 19.3 100.0 11.1 833 South South Akwa Ibom 2.8 5.6 20.0 31.7 24.5 15.5 100.0 9.7 864 Bayelsa 4.7 10.2 16.3 31.7 30.5 6.7 100.0 8.7 364 Cross River 8.7 9.7 18.4 29.5 22.6 11.1 100.0 8.3 703 Delta 7.6 6.6 15.8 27.9 26.8 15.4 100.0 9.5 993 Edo 4.3 6.0 15.4 31.3 29.3 13.7 100.0 9.8 742 Rivers 3.1 3.9 15.6 23.4 37.3 16.8 100.0 11.1 1,276 South West Ekiti 2.0 2.4 10.3 27.6 32.1 25.5 100.0 11.2 326 Lagos 4.4 1.7 11.6 18.0 42.6 21.7 100.0 11.3 1,964 Ogun 11.9 5.2 28.8 21.7 25.4 7.0 100.0 7.6 883 Ondo 7.5 4.6 15.1 27.4 28.3 17.2 100.0 10.4 808 Osun 4.0 2.9 12.9 26.6 32.9 20.7 100.0 11.1 765 Oyo 15.4 4.2 17.5 21.3 27.0 14.6 100.0 9.1 1,568 Wealth quintile Lowest 87.3 4.4 4.8 2.9 0.7 0.1 100.0 0.0 7,132 Second 61.5 8.3 12.8 12.7 4.2 0.4 100.0 0.0 7,428 Middle 32.8 8.0 18.2 23.4 14.9 2.7 100.0 5.5 7,486 Fourth 14.8 4.5 16.9 26.1 28.8 8.8 100.0 8.8 7,992 Highest 3.3 1.5 8.0 20.1 37.7 29.4 100.0 11.4 8,910 Total 37.8 5.2 12.1 17.4 18.3 9.1 100.0 5.6 38,948 1 Completed grade 6 at the primary level 2 Completed grade 6 at the secondary level Characteristics of Respondents • 35 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 2013 Highest level of schooling Total Median years completed Number of men Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 16.6 4.4 7.4 38.1 26.4 7.1 100.0 9.1 6,511 15-19 16.6 5.8 7.6 52.3 16.3 1.4 100.0 8.2 3,619 20-24 16.6 2.5 7.1 20.4 39.0 14.3 100.0 11.1 2,892 25-29 20.8 3.5 10.1 10.3 34.8 20.5 100.0 11.2 2,757 30-34 22.4 3.7 12.7 10.4 31.2 19.5 100.0 11.0 2,414 35-39 24.3 5.1 17.3 9.0 26.2 18.0 100.0 8.3 2,175 40-44 23.8 5.6 20.6 9.3 24.0 16.7 100.0 6.0 1,777 45-49 31.0 5.2 18.8 8.4 19.3 17.2 100.0 5.7 1,724 Residence Urban 6.7 2.8 10.3 21.3 36.9 22.1 100.0 11.2 7,611 Rural 32.6 5.8 13.9 19.5 20.0 8.3 100.0 5.8 9,748 Zone North Central 12.5 5.4 9.8 27.0 26.4 19.0 100.0 10.3 2,685 North East 44.7 6.4 8.8 14.0 15.3 10.8 100.0 4.1 2,515 North West 39.0 3.8 13.5 14.9 19.9 8.9 100.0 5.5 5,185 South East 1.3 4.2 17.1 29.2 33.4 14.8 100.0 10.8 1,686 South South 1.1 4.0 13.3 25.4 38.3 17.9 100.0 11.2 2,445 South West 5.3 3.5 11.8 19.9 40.0 19.6 100.0 11.2 2,843 State North Central FCT-Abuja 5.6 3.1 7.2 14.9 30.4 38.7 100.0 11.6 175 Benue 3.4 10.6 9.3 43.1 18.2 15.4 100.0 9.4 616 Kogi 5.3 2.5 8.6 25.4 40.0 18.2 100.0 11.2 333 Kwara 4.2 1.2 15.9 19.6 29.0 30.2 100.0 11.3 274 Nasarawa 9.8 4.8 11.6 26.2 32.0 15.6 100.0 10.5 282 Niger 31.1 4.0 7.2 19.1 24.4 14.1 100.0 8.8 701 Plateau 10.0 6.7 12.3 28.3 22.7 20.0 100.0 10.0 302 North East Adamawa 13.9 5.6 12.2 28.4 24.0 15.9 100.0 8.9 358 Bauchi 47.9 10.3 8.4 14.3 10.8 8.3 100.0 1.3 512 Borno 53.6 2.8 8.8 7.0 15.7 12.0 100.0 0.0 676 Gombe 37.2 10.6 7.0 15.2 20.1 9.8 100.0 5.3 255 Taraba 19.5 12.6 16.0 23.9 18.1 10.0 100.0 6.7 325 Yobe 79.4 0.4 1.4 3.3 7.0 8.6 100.0 0.0 390 North West Jigawa 45.7 6.6 19.3 11.8 9.3 7.3 100.0 2.8 510 Kaduna 25.6 2.5 10.0 17.1 30.8 14.1 100.0 8.8 1,033 Kano 26.8 1.9 17.2 19.0 26.6 8.4 100.0 7.6 1,592 Katsina 53.5 3.7 18.0 6.1 12.5 6.2 100.0 0.0 596 Kebbi 55.6 3.4 5.7 13.1 12.9 9.4 100.0 0.0 551 Sokoto 53.0 9.8 9.2 12.3 10.7 4.9 100.0 0.0 424 Zamfara 51.9 5.4 10.0 14.8 10.5 7.5 100.0 0.0 479 South East Abia 0.3 3.5 9.0 29.2 42.2 15.8 100.0 11.2 229 Anambra 2.6 2.6 17.8 26.1 35.5 15.3 100.0 11.0 446 Ebonyi 0.8 9.7 17.0 34.8 22.3 15.3 100.0 9.2 368 Enugu 2.1 2.2 25.9 30.0 27.1 12.6 100.0 9.0 320 Imo 0.0 2.7 13.0 26.3 43.0 15.0 100.0 11.2 323 South South Akwa Ibom 1.1 5.8 17.9 28.5 30.9 15.7 100.0 10.6 451 Bayelsa 0.5 3.9 9.3 32.8 37.3 16.1 100.0 11.1 187 Cross River 1.4 4.4 19.9 26.0 36.5 11.9 100.0 10.7 310 Delta 1.9 3.8 12.7 25.2 38.6 17.8 100.0 11.2 473 Edo 0.8 3.7 10.5 26.5 39.3 19.0 100.0 11.2 365 Rivers 0.8 3.0 10.2 20.2 43.6 22.1 100.0 11.4 658 South West Ekiti 1.0 0.9 7.6 24.6 33.3 32.6 100.0 11.5 148 Lagos 1.7 2.6 10.3 16.7 46.2 22.4 100.0 11.4 948 Ogun 12.2 7.0 23.0 17.4 28.7 11.7 100.0 9.6 358 Ondo 1.5 4.1 10.0 21.8 42.0 20.7 100.0 11.3 404 Osun 0.9 1.4 7.2 25.1 40.6 24.7 100.0 11.4 356 Oyo 12.8 4.1 12.4 20.7 37.0 13.1 100.0 11.0 629 Wealth quintile Lowest 67.2 6.4 11.5 8.8 4.9 1.2 100.0 0.0 2,862 Second 35.6 8.3 18.5 20.8 14.0 2.7 100.0 5.3 2,992 Middle 13.7 5.6 15.0 28.2 28.5 9.0 100.0 8.9 3,338 Fourth 4.9 2.5 12.6 24.9 39.6 15.6 100.0 11.1 3,835 Highest 1.2 1.3 6.3 17.4 39.8 33.9 100.0 11.6 4,332 Total 21.2 4.4 12.3 20.3 27.4 14.3 100.0 9.1 17,359 1 Completed grade 6 at the primary level 2 Completed grade 6 at the secondary level 36 • Characteristics of Respondents The pattern of educational attainment among men is similar to that of women. At every level of education, however, percentages of attendance or completion are higher among men than among women. Tables 3.2.1 and 3.2.2 show that the median number of years of schooling is higher for men than for women (9.1 and 5.6 years, respectively). Men living in urban areas stay in school longer than those in rural areas (median years of schooling of 11.2 and 5.8, respectively). One in three rural men have no education, as compared with only 7 percent of urban men. Men’s educational attainment varies across zones and states. The percentage of men with no education ranges from 1 percent or lower in many states, especially those in the South South, to 53-56 percent in Katsina, Kebbi, and Sokoto in the North West zone. Education is positively related to wealth quintile; 67 percent of men in the lowest quintile have no education, as compared with only 1 percent of men in the highest quintile. 3.3 LITERACY The ability to read and write is an important personal asset, increasing an individual’s opportunities in life. In addition, literacy statistics can help programme managers, especially those working in health and family planning, determine the best ways to reach women and men with their print messages. In the 2013 NDHS, literacy status was determined by assessing the respondent’s ability to read all or part of a sentence. During data collection, interviewers carried a set of cards that had simple sentences printed in three major Nigerian languages, Igbo, Hausa, and Yoruba. Only women and men who had never been to school and those who had not completed a primary-level education were asked to read the cards (in the language they were most likely to be able to read). Those with a secondary education or higher were assumed to be literate. Table 3.3.1 shows that 53 percent of women age 15-49 are literate. Literacy levels decline with age, from 66 percent among women age 15-19 to 36 percent among women age 45-49. Literacy is much higher in urban than in rural areas. More than 7 in 10 urban women (77 percent) are literate, as compared with less than 4 in 10 rural women (36 percent). There are differences in literacy across zones, with literacy levels being highest among women in the South East (84 percent) and lowest among those in the North West (26 percent). Ninety percent or more of women in Abia, Anambra, Imo, Ekiti, and Osun are literate. On the other hand, only 10 percent of women in Sokoto, 11 percent in Jigawa, and 11 percent in Zamfara are literate. Literacy increases with increasing wealth, ranging from 7 percent among women in the lowest wealth quintile to 93 percent among those in the highest wealth quintile. Table 3.3.2 shows that men are much more likely than women to be literate (75 percent versus 53 percent). Similar to women, men age 15-24 (80 percent), men living in urban areas (91 percent), and men in the highest wealth quintile (97 percent) have the highest literacy levels. The gap in literacy levels between women and men is notable in the North Central, North East, and North West zones (Figure 3.1). Characteristics of Respondents • 37 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 2013 Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 57.1 1.2 4.5 36.4 0.3 0.0 0.5 100.0 62.8 14,576 15-19 60.1 1.4 4.6 33.2 0.2 0.0 0.6 100.0 66.0 7,820 20-24 53.7 1.0 4.4 40.0 0.4 0.0 0.5 100.0 59.1 6,757 25-29 46.1 1.0 5.4 46.9 0.1 0.0 0.5 100.0 52.5 7,145 30-34 40.9 1.8 7.3 49.4 0.2 0.1 0.5 100.0 49.9 5,467 35-39 35.9 3.2 8.4 51.6 0.2 0.0 0.6 100.0 47.6 4,718 40-44 31.0 3.5 8.3 56.1 0.4 0.1 0.5 100.0 42.9 3,620 45-49 23.9 2.5 9.8 62.4 0.3 0.3 0.7 100.0 36.2 3,422 Residence Urban 67.9 2.2 7.1 22.3 0.1 0.0 0.5 100.0 77.2 16,414 Rural 28.1 1.6 5.8 63.4 0.4 0.1 0.6 100.0 35.5 22,534 Zone North Central 45.9 1.7 6.7 44.6 0.1 0.0 1.0 100.0 54.3 5,572 North East 21.9 1.8 4.6 69.9 1.4 0.0 0.4 100.0 28.3 5,766 North West 19.0 1.6 5.2 73.7 0.0 0.1 0.5 100.0 25.8 11,877 South East 73.8 1.2 9.2 15.1 0.1 0.2 0.4 100.0 84.2 4,476 South South 71.8 2.4 6.8 18.1 0.1 0.1 0.7 100.0 81.0 4,942 South West 72.2 2.4 7.3 17.6 0.1 0.0 0.3 100.0 82.0 6,314 State North Central FCT-Abuja 72.4 0.9 5.5 20.6 0.0 0.0 0.6 100.0 78.8 315 Benue 46.0 1.5 5.4 45.9 0.0 0.0 1.3 100.0 52.8 1,240 Kogi 61.5 0.5 9.6 27.8 0.2 0.0 0.3 100.0 71.6 704 Kwara 59.3 3.4 5.2 31.8 0.0 0.0 0.4 100.0 67.9 596 Nasarawa 42.4 3.8 11.6 41.1 1.0 0.0 0.0 100.0 57.9 594 Niger 24.8 0.7 3.7 68.5 0.0 0.0 2.3 100.0 29.2 1,462 Plateau 54.0 2.9 10.1 33.0 0.0 0.0 0.1 100.0 66.9 662 North East Adamawa 43.6 2.9 6.7 46.6 0.1 0.0 0.1 100.0 53.2 828 Bauchi 13.5 2.1 4.5 72.6 6.6 0.0 0.7 100.0 20.1 1,161 Borno 19.0 0.9 2.3 77.2 0.4 0.0 0.3 100.0 22.2 1,412 Gombe 24.0 2.2 6.5 66.9 0.0 0.0 0.4 100.0 32.7 550 Taraba 27.6 2.8 9.7 59.6 0.0 0.0 0.3 100.0 40.1 844 Yobe 11.7 0.4 0.8 86.7 0.0 0.0 0.4 100.0 12.9 971 North West Jigawa 5.7 0.7 4.4 87.7 0.1 0.5 0.8 100.0 10.9 1,353 Kaduna 44.9 0.6 6.3 47.9 0.0 0.0 0.3 100.0 51.8 2,136 Kano 24.0 3.5 8.8 63.1 0.0 0.0 0.5 100.0 36.3 3,189 Katsina 8.9 1.5 4.7 84.4 0.0 0.0 0.4 100.0 15.2 1,525 Kebbi 10.5 1.5 1.2 86.6 0.0 0.0 0.2 100.0 13.2 1,244 Sokoto 7.0 0.7 2.5 89.0 0.0 0.0 0.7 100.0 10.2 1,098 Zamfara 8.2 0.2 2.3 88.9 0.0 0.0 0.5 100.0 10.6 1,332 South East Abia 80.4 0.9 10.6 8.1 0.0 0.0 0.1 100.0 91.9 518 Anambra 83.2 1.5 7.1 7.9 0.0 0.0 0.3 100.0 91.8 1,052 Ebonyi 54.9 2.3 11.3 30.8 0.2 0.1 0.4 100.0 68.6 1,122 Enugu 70.4 0.3 11.4 16.3 0.0 0.6 0.9 100.0 82.1 951 Imo 87.0 0.5 5.7 6.0 0.3 0.0 0.4 100.0 93.3 833 South South Akwa Ibom 71.6 4.1 8.9 13.2 0.2 0.7 1.3 100.0 84.6 864 Bayelsa 68.9 1.8 7.5 21.7 0.1 0.0 0.1 100.0 78.2 364 Cross River 63.1 2.1 7.5 26.6 0.2 0.0 0.4 100.0 72.8 703 Delta 70.0 0.8 6.9 21.5 0.0 0.0 0.7 100.0 77.8 993 Edo 74.3 1.8 7.9 15.2 0.0 0.0 0.6 100.0 84.1 742 Rivers 77.5 3.0 4.2 14.9 0.0 0.0 0.5 100.0 84.6 1,276 South West Ekiti 85.2 2.4 4.8 7.5 0.0 0.0 0.1 100.0 92.5 326 Lagos 82.2 1.7 5.4 10.0 0.1 0.0 0.6 100.0 89.3 1,964 Ogun 54.1 6.7 14.1 25.1 0.0 0.0 0.1 100.0 74.9 883 Ondo 72.8 1.6 4.5 20.9 0.0 0.2 0.0 100.0 78.9 808 Osun 80.2 1.5 9.9 8.0 0.1 0.0 0.3 100.0 91.5 765 Oyo 62.9 1.9 6.7 28.2 0.0 0.0 0.3 100.0 71.5 1,568 Wealth quintile Lowest 3.6 0.5 2.9 91.6 0.9 0.0 0.5 100.0 7.0 7,132 Second 17.4 1.3 6.6 74.0 0.2 0.1 0.5 100.0 25.3 7,428 Middle 41.0 2.7 9.1 46.2 0.1 0.1 0.8 100.0 52.8 7,486 Fourth 63.8 3.0 8.7 23.7 0.1 0.1 0.6 100.0 75.4 7,992 Highest 87.2 1.5 4.5 6.4 0.0 0.0 0.3 100.0 93.2 8,910 Total 44.9 1.8 6.3 46.1 0.3 0.1 0.5 100.0 53.1 38,948 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 38 • 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 2013 Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 71.6 2.1 6.4 19.4 0.1 0.0 0.4 100.0 80.2 6,511 15-19 70.0 2.7 7.2 19.7 0.0 0.0 0.4 100.0 79.9 3,619 20-24 73.7 1.4 5.4 18.9 0.1 0.0 0.4 100.0 80.5 2,892 25-29 65.6 2.3 9.2 22.4 0.1 0.0 0.5 100.0 77.0 2,757 30-34 61.1 3.3 10.1 24.8 0.2 0.0 0.5 100.0 74.4 2,414 35-39 53.2 5.1 13.2 27.9 0.0 0.0 0.6 100.0 71.6 2,175 40-44 50.0 5.4 14.2 29.7 0.0 0.0 0.7 100.0 69.6 1,777 45-49 44.9 5.5 14.8 33.9 0.1 0.3 0.4 100.0 65.2 1,724 Residence Urban 80.3 2.8 7.6 8.7 0.1 0.0 0.4 100.0 90.8 7,611 Rural 47.7 3.8 11.6 36.2 0.1 0.0 0.6 100.0 63.1 9,748 Zone North Central 72.3 1.8 8.2 17.0 0.1 0.0 0.5 100.0 82.3 2,685 North East 40.1 3.6 7.4 48.3 0.1 0.0 0.5 100.0 51.0 2,515 North West 43.6 4.6 14.0 37.2 0.0 0.1 0.6 100.0 62.2 5,185 South East 77.4 4.3 9.5 7.5 0.0 0.2 1.1 100.0 91.2 1,686 South South 81.5 2.7 8.9 6.5 0.1 0.0 0.3 100.0 93.1 2,445 South West 79.4 2.4 6.9 10.8 0.2 0.0 0.2 100.0 88.8 2,843 State North Central FCT-Abuja 84.1 2.8 3.4 8.6 0.0 0.4 0.7 100.0 90.3 175 Benue 76.7 0.7 15.2 7.2 0.0 0.0 0.3 100.0 92.6 616 Kogi 83.6 1.9 5.5 9.0 0.0 0.0 0.0 100.0 91.0 333 Kwara 78.7 5.0 5.3 9.5 0.5 0.0 1.0 100.0 89.0 274 Nasarawa 73.8 3.1 8.3 14.5 0.3 0.0 0.0 100.0 85.2 282 Niger 57.7 1.1 6.4 34.3 0.0 0.0 0.6 100.0 65.1 701 Plateau 71.0 0.7 6.8 20.0 0.0 0.0 1.5 100.0 78.5 302 North East Adamawa 68.3 2.8 6.6 22.3 0.0 0.0 0.0 100.0 77.7 358 Bauchi 33.4 8.8 7.7 49.0 0.0 0.0 1.0 100.0 50.0 512 Borno 34.7 1.6 5.3 57.6 0.5 0.0 0.2 100.0 41.7 676 Gombe 45.2 7.6 13.8 32.4 0.0 0.0 1.0 100.0 66.6 255 Taraba 51.9 1.0 15.5 30.8 0.0 0.0 0.7 100.0 68.5 325 Yobe 18.8 0.3 0.5 80.4 0.0 0.0 0.0 100.0 19.6 390 North West Jigawa 28.5 9.5 18.1 43.6 0.0 0.2 0.2 100.0 56.0 510 Kaduna 61.9 3.1 12.7 21.7 0.0 0.1 0.4 100.0 77.8 1,033 Kano 54.0 2.8 19.0 23.8 0.0 0.0 0.4 100.0 75.8 1,592 Katsina 24.8 10.3 8.9 53.6 0.0 0.2 2.2 100.0 44.0 596 Kebbi 35.3 0.6 4.4 59.6 0.0 0.0 0.1 100.0 40.3 551 Sokoto 28.0 7.1 6.4 57.8 0.0 0.0 0.7 100.0 41.5 424 Zamfara 32.7 3.4 19.7 44.2 0.0 0.0 0.0 100.0 55.8 479 South East Abia 87.2 1.5 5.8 4.8 0.0 0.0 0.7 100.0 94.5 229 Anambra 77.0 2.4 12.0 7.7 0.0 0.0 0.9 100.0 91.4 446 Ebonyi 72.4 5.7 12.5 8.2 0.0 0.0 1.1 100.0 90.7 368 Enugu 69.8 7.0 8.5 11.7 0.0 0.2 2.9 100.0 85.3 320 Imo 84.2 4.7 6.1 4.3 0.0 0.6 0.0 100.0 95.1 323 South South Akwa Ibom 75.2 3.3 11.4 9.4 0.4 0.0 0.2 100.0 89.9 451 Bayelsa 86.3 1.3 4.5 7.4 0.0 0.0 0.5 100.0 92.1 187 Cross River 74.3 2.9 14.5 8.1 0.0 0.0 0.2 100.0 91.6 310 Delta 81.6 3.2 8.1 6.6 0.0 0.1 0.3 100.0 93.0 473 Edo 84.9 2.2 5.4 7.1 0.0 0.0 0.5 100.0 92.5 365 Rivers 86.0 2.4 8.5 3.0 0.0 0.0 0.2 100.0 96.9 658 South West Ekiti 90.5 2.1 2.8 4.0 0.0 0.0 0.5 100.0 95.5 148 Lagos 85.3 2.2 7.6 4.5 0.0 0.0 0.4 100.0 95.1 948 Ogun 57.9 6.3 11.1 24.0 0.7 0.0 0.0 100.0 75.3 358 Ondo 84.5 0.5 2.8 12.3 0.0 0.0 0.0 100.0 87.7 404 Osun 90.5 1.0 4.7 3.6 0.0 0.0 0.2 100.0 96.2 356 Oyo 70.7 2.6 8.5 17.6 0.5 0.0 0.0 100.0 81.9 629 Wealth quintile Lowest 15.0 3.7 11.2 69.5 0.0 0.1 0.5 100.0 29.9 2,862 Second 37.6 5.0 16.9 39.2 0.2 0.1 1.0 100.0 59.5 2,992 Middle 65.7 3.8 11.6 18.3 0.2 0.0 0.4 100.0 81.2 3,338 Fourth 80.1 3.2 7.9 8.3 0.1 0.0 0.5 100.0 91.2 3,835 Highest 91.2 1.7 4.4 2.4 0.0 0.0 0.3 100.0 97.3 4,332 Total 62.0 3.3 9.8 24.2 0.1 0.0 0.5 100.0 75.2 17,359 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Respondents • 39 Figure 3.1 Literacy status of women and men age 15-49 by regions 54 28 26 84 81 8282 51 62 91 93 89 North Central North East North West South East South South South West Women Men NDHS 2013 Percentage literate 3.4 EXPOSURE TO MASS MEDIA Exposure to information on television and radio and in the print media can increase people’s knowledge and awareness of new ideas, social changes, and opportunities as well as affect their perceptions and behaviours, including those related to health. The 2013 NDHS assessed exposure to the media by asking respondents how often they read a newspaper, watch television, or listen to the radio. Tables 3.4.1 and 3.4.2 show the percentages of women and men who read newspapers, watch television, and listen to the radio at least once a week, according to age, urban or rural residence, zone, state, level of education, and wealth quintile. The results show that level of exposure to mass media, especially exposure to the print media, is low in Nigeria. Nine percent of women read a newspaper, 35 percent watch television, and 39 percent listen to the radio at least once a week. Only 7 percent of women have access to all three media at least once a week, and half do not have access to any of the three media at least once a week. There are slight variations by age. There is also a wide gap in exposure to mass media according to place of residence, education, and wealth. For example, the proportion of urban women who read a newspaper at least once a week is 15 percent, as compared with 5 percent among rural women. Urban women are much more likely than rural women to watch television once a week (55 percent versus 21 percent). Across states, women who reside in Abia are the most likely to access all three media at least once a week (44 percent). Exposure to media increases with increasing education and wealth. For example, 66 percent of women with a secondary education or higher listen to the radio at least once a week, as compared with 23 percent of women with no education. Men are more likely to be exposed to each type of mass media than women. Twenty percent of men age 15-49 read a newspaper at least once a week, 40 percent watch television, and 55 percent listen to the radio (Table 3.4.2). Fifteen percent of men are exposed to all three media sources at least once a week, while 38 percent have no regular exposure to the mass media. The proportion of men who regularly read a newspaper, listen to the radio, and watch television has declined since 2008. For example, the proportion of men who listen to the radio at least once a week has declined from 81 percent to 55 percent. At the same time, exposure to print media has decreased from 30 percent to 20 percent, and exposure to television has decreased from 52 percent to 40 percent. Overall, the proportion of men exposed to all three media has declined from 24 percent to 15 percent. 40 • Characteristics of Respondents 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 2013 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 9.8 37.3 37.3 7.0 50.0 7,820 20-24 10.0 37.1 39.3 7.2 49.5 6,757 25-29 9.8 36.6 40.0 7.0 49.7 7,145 30-34 9.6 36.4 40.7 7.6 49.3 5,467 35-39 8.4 34.7 41.2 6.4 49.6 4,718 40-44 7.8 31.1 37.6 6.0 54.6 3,620 45-49 6.4 28.6 39.8 4.5 52.4 3,422 Residence Urban 15.0 55.1 52.2 11.3 32.9 16,414 Rural 4.9 21.0 30.0 3.4 63.1 22,534 Zone North Central 9.2 43.1 42.5 7.5 44.5 5,572 North East 4.4 15.6 19.1 2.4 73.8 5,766 North West 4.6 17.1 32.9 3.6 63.4 11,877 South East 17.5 42.8 41.8 11.1 41.5 4,476 South South 15.2 51.5 41.8 11.7 40.4 4,942 South West 11.3 63.0 63.5 9.0 23.8 6,314 State North Central FCT-Abuja 16.4 61.3 50.4 12.9 29.6 315 Benue 3.6 39.8 43.5 3.2 43.7 1,240 Kogi 20.3 67.1 57.0 17.3 22.3 704 Kwara 17.6 46.9 67.5 15.2 28.4 596 Nasarawa 7.1 30.9 24.7 5.0 62.7 594 Niger 5.9 42.9 39.4 5.0 45.3 1,462 Plateau 5.6 22.7 22.0 3.5 72.8 662 North East Adamawa 10.4 30.1 38.1 5.1 50.2 828 Bauchi 5.8 15.0 30.6 4.5 66.0 1,161 Borno 2.5 15.6 11.6 1.3 79.9 1,412 Gombe 6.7 14.8 15.8 2.4 77.2 550 Taraba 1.9 12.0 10.4 0.6 81.1 844 Yobe 1.6 7.7 9.4 1.0 86.0 971 North West Jigawa 1.7 7.5 20.1 0.5 76.6 1,353 Kaduna 10.4 35.8 35.2 9.0 53.1 2,136 Kano 7.2 22.9 45.5 6.4 54.0 3,189 Katsina 1.1 5.5 34.3 0.4 63.3 1,525 Kebbi 2.7 13.6 23.7 0.8 72.6 1,244 Sokoto 0.8 14.5 40.9 0.6 55.7 1,098 Zamfara 0.6 1.7 12.8 0.4 86.5 1,332 South East Abia 46.2 71.4 68.8 43.6 22.5 518 Anambra 6.8 41.2 19.7 3.0 51.1 1,052 Ebonyi 5.2 25.9 44.3 3.7 52.1 1,122 Enugu 16.3 32.3 32.7 5.1 48.8 951 Imo 31.4 61.8 59.7 17.9 18.4 833 South South Akwa Ibom 16.4 51.4 48.3 13.7 39.5 864 Bayelsa 12.5 49.2 30.5 7.1 40.0 364 Cross River 12.9 48.1 46.1 9.9 43.7 703 Delta 12.5 47.0 34.1 9.8 46.2 993 Edo 24.2 65.4 59.1 20.2 26.8 742 Rivers 13.4 49.5 34.2 9.3 42.8 1,276 South West Ekiti 9.2 66.9 64.4 6.5 25.5 326 Lagos 16.5 74.0 61.3 12.9 20.3 1,964 Ogun 12.7 67.5 70.8 11.5 19.1 883 Ondo 13.2 52.2 47.4 9.2 35.4 808 Osun 7.9 60.8 67.8 7.4 22.8 765 Oyo 5.1 52.7 68.3 3.7 24.8 1,568 Education No education 0.1 9.7 23.1 0.0 73.8 14,729 Primary 2.0 31.8 37.5 1.2 52.2 6,734 Secondary 14.2 54.5 50.6 10.2 33.3 13,927 More than secondary 40.2 73.2 66.2 31.5 16.8 3,558 Wealth quintile Lowest 0.4 2.1 16.8 0.1 82.3 7,132 Second 1.6 9.8 24.7 0.6 71.5 7,428 Middle 5.5 29.6 37.4 3.3 52.3 7,486 Fourth 11.7 54.2 51.4 8.8 33.3 7,992 Highest 23.1 71.2 60.5 18.3 21.0 8,910 Total 9.1 35.4 39.4 6.8 50.4 38,948 Characteristics of Respondents • 41 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 2013 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of men Age 15-19 10.2 35.7 44.1 7.3 46.1 3,619 20-24 21.9 40.2 53.0 15.7 37.8 2,892 25-29 24.8 40.9 55.3 17.8 36.6 2,757 30-34 23.5 41.4 58.1 18.0 35.5 2,414 35-39 22.2 41.3 59.7 17.5 34.7 2,175 40-44 24.6 41.0 60.5 19.3 33.6 1,777 45-49 20.4 37.8 61.6 15.8 32.9 1,724 Residence Urban 28.9 54.5 62.2 22.7 27.4 7,611 Rural 13.6 27.8 48.8 9.4 45.8 9,748 Zone North Central 22.9 36.5 55.2 14.2 34.9 2,685 North East 7.5 14.8 30.2 3.2 63.9 2,515 North West 8.1 18.1 37.6 5.4 57.0 5,185 South East 30.3 45.2 61.8 19.8 26.1 1,686 South South 35.8 76.2 81.7 31.1 10.4 2,445 South West 32.1 68.6 79.6 28.4 12.5 2,843 State North Central FCT-Abuja 38.8 46.6 39.4 25.9 39.2 175 Benue 15.9 30.1 59.1 10.3 35.3 616 Kogi 25.8 44.8 62.7 23.3 31.7 333 Kwara 27.9 43.9 63.1 11.9 18.6 274 Nasarawa 27.4 38.7 66.0 16.2 27.0 282 Niger 21.8 40.2 52.6 15.1 38.2 701 Plateau 19.0 17.1 37.0 3.2 49.8 302 North East Adamawa 19.2 43.2 52.8 9.5 34.2 358 Bauchi 4.0 10.0 33.9 1.9 61.7 512 Borno 4.0 6.3 15.6 0.2 80.4 676 Gombe 17.9 34.2 53.9 10.5 37.5 255 Taraba 3.1 5.2 16.4 1.3 79.9 325 Yobe 4.5 4.9 25.7 0.9 69.1 390 North West Jigawa 12.7 20.7 56.6 7.1 38.6 510 Kaduna 19.9 43.3 75.4 17.6 20.9 1,033 Kano 3.0 14.1 15.2 1.1 74.8 1,592 Katsina 5.5 4.6 37.7 2.0 60.4 596 Kebbi 3.5 4.2 7.1 0.7 90.1 551 Sokoto 4.6 19.5 41.8 3.3 55.4 424 Zamfara 5.9 5.7 42.0 2.7 54.7 479 South East Abia 27.6 63.1 73.2 22.8 16.3 229 Anambra 24.7 31.2 38.1 10.1 45.8 446 Ebonyi 26.5 39.1 73.1 17.6 20.7 368 Enugu 14.2 34.4 62.7 9.2 26.9 320 Imo 60.4 69.2 72.5 43.8 11.0 323 South South Akwa Ibom 40.2 71.1 84.7 36.8 11.5 451 Bayelsa 14.7 77.2 72.2 14.2 16.4 187 Cross River 17.6 62.3 71.4 13.0 18.3 310 Delta 34.3 83.3 87.2 28.8 4.8 473 Edo 24.1 79.2 72.1 22.2 13.4 365 Rivers 55.1 79.1 88.4 47.4 6.7 658 South West Ekiti 24.9 67.9 59.7 22.7 27.7 148 Lagos 50.7 88.5 83.4 45.9 4.9 948 Ogun 46.0 85.6 91.8 44.6 4.9 358 Ondo 23.7 58.2 66.1 17.3 22.8 404 Osun 19.7 60.2 93.2 17.5 5.5 356 Oyo 10.2 40.5 72.4 7.6 22.0 629 Education No education 0.6 6.7 29.0 0.3 69.5 3,685 Primary 5.7 29.4 51.0 3.5 42.4 2,907 Secondary 23.2 49.8 61.8 17.2 28.8 8,281 More than secondary 56.8 65.9 73.2 44.5 15.0 2,486 Wealth quintile Lowest 2.0 5.1 27.2 0.8 71.0 2,862 Second 6.8 14.1 41.1 3.0 54.6 2,992 Middle 14.6 32.9 56.5 9.1 37.2 3,338 Fourth 23.0 54.1 64.6 17.4 25.4 3,835 Highest 43.7 72.1 72.0 36.0 15.4 4,332 Total 20.3 39.5 54.7 15.2 37.7 17,359 42 • Characteristics of Respondents 3.5 EMPLOYMENT The 2013 NDHS asked respondents whether they were employed at the time of the survey (that is, whether they had worked in the last 7 days) and, if not, whether they had worked at any time during the 12 months preceding the survey. Table 3.5.1 and Figure 3.2 show that 62 percent of women are currently employed. Twenty-eight percent of women age 15-19 are currently employed, rising to 66 percent among women age 25-29 and peaking at 83 percent among women age 45-49. Women who are divorced, separated, or widowed are most likely to be currently employed (81 percent). There are notable variations in the proportion of women currently employed by place of residence and by zone. Urban women are slightly more likely to be currently employed than rural women (63 percent versus 61 percent). Employment is highest in the South West zone, especially in Ogun, where 80 percent of women are currently employed. Fifty-six percent of women in the nation’s capital (FCT-Abuja) are currently employed. Women in Yobe and Borno are least likely to be currently employed (34 percent and 29 percent, respectively). Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Nigeria 2013 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of women Background characteristic Currently employed1 Not currently employed Age 15-19 28.0 1.1 70.8 0.1 100.0 7,820 20-24 50.6 1.6 47.7 0.1 100.0 6,757 25-29 65.8 2.0 32.2 0.1 100.0 7,145 30-34 75.8 1.9 22.2 0.1 100.0 5,467 35-39 80.4 1.9 17.7 0.1 100.0 4,718 40-44 82.2 1.3 16.4 0.0 100.0 3,620 45-49 83.1 1.4 15.5 0.0 100.0 3,422 Marital status Never married 35.2 1.1 63.7 0.1 100.0 9,326 Married or living together 69.4 1.8 28.7 0.1 100.0 27,830 Divorced/separated/ widowed 81.3 1.1 17.6 0.0 100.0 1,793 Number of living children 0 37.9 1.2 60.8 0.1 100.0 11,750 1-2 62.9 1.6 35.3 0.1 100.0 9,737 3-4 75.7 1.7 22.6 0.1 100.0 8,876 5+ 78.8 2.0 19.1 0.0 100.0 8,585 Residence Urban 63.2 1.5 35.2 0.1 100.0 16,414 Rural 60.7 1.7 37.5 0.1 100.0 22,534 Zone North Central 68.8 1.9 29.2 0.1 100.0 5,572 North East 45.8 1.9 52.1 0.2 100.0 5,766 North West 57.2 2.0 40.7 0.1 100.0 11,877 South East 63.8 1.7 34.5 0.0 100.0 4,476 South South 65.6 1.3 32.9 0.1 100.0 4,942 South West 74.2 0.6 25.2 0.0 100.0 6,314 State North Central FCT-Abuja 55.9 1.5 42.4 0.2 100.0 315 Benue 77.5 0.7 21.7 0.0 100.0 1,240 Kogi 71.3 0.4 28.3 0.0 100.0 704 Kwara 62.7 0.4 36.9 0.0 100.0 596 Nasarawa 55.3 11.8 32.9 0.0 100.0 594 Niger 79.1 0.6 20.1 0.2 100.0 1,462 Plateau 51.1 1.3 47.7 0.0 100.0 662 North East Adamawa 57.2 1.5 41.2 0.1 100.0 828 Bauchi 54.1 2.1 43.6 0.1 100.0 1,161 Borno 28.5 2.0 69.3 0.2 100.0 1,412 Gombe 50.4 1.7 47.6 0.4 100.0 550 Taraba 62.9 3.8 33.3 0.1 100.0 844 Yobe 34.0 0.5 65.3 0.2 100.0 971 Continued… Characteristics of Respondents • 43 Table 3.5.1—Continued Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of women Background characteristic Currently employed1 Not currently employed North West Jigawa 52.6 2.0 45.3 0.1 100.0 1,353 Kaduna 60.9 0.4 38.7 0.0 100.0 2,136 Kano 56.1 0.1 43.7 0.0 100.0 3,189 Katsina 56.8 9.8 33.2 0.3 100.0 1,525 Kebbi 61.1 1.8 37.1 0.0 100.0 1,244 Sokoto 45.8 0.4 53.7 0.1 100.0 1,098 Zamfara 65.2 1.4 33.4 0.0 100.0 1,332 South East Abia 66.7 1.1 32.2 0.0 100.0 518 Anambra 56.6 0.2 43.2 0.0 100.0 1,052 Ebonyi 75.3 3.4 21.3 0.0 100.0 1,122 Enugu 63.6 0.4 35.8 0.2 100.0 951 Imo 55.7 3.0 41.3 0.1 100.0 833 South South Akwa Ibom 60.8 1.6 36.9 0.7 100.0 864 Bayelsa 64.1 0.1 35.7 0.0 100.0 364 Cross River 68.4 2.7 28.9 0.0 100.0 703 Delta 56.7 0.2 43.1 0.0 100.0 993 Edo 61.8 1.0 37.2 0.0 100.0 742 Rivers 77.1 1.7 21.3 0.0 100.0 1,276 South West Ekiti 62.8 0.9 36.2 0.0 100.0 326 Lagos 72.5 0.8 26.5 0.1 100.0 1,964 Ogun 79.6 0.9 19.5 0.0 100.0 883 Ondo 68.4 0.5 31.1 0.0 100.0 808 Osun 71.7 0.1 28.2 0.0 100.0 765 Oyo 79.7 0.4 19.9 0.0 100.0 1,568 Education No education 59.3 1.9 38.6 0.1 100.0 14,729 Primary 75.6 1.7 22.7 0.0 100.0 6,734 Secondary 56.7 1.4 41.9 0.1 100.0 13,927 More than secondary 65.7 1.2 33.0 0.2 100.0 3,558 Wealth quintile Lowest 55.8 1.7 42.3 0.1 100.0 7,132 Second 61.6 2.1 36.3 0.1 100.0 7,428 Middle 62.2 1.8 36.0 0.0 100.0 7,486 Fourth 64.4 1.3 34.3 0.1 100.0 7,992 Highest 64.1 1.2 34.6 0.1 100.0 8,910 Total 61.8 1.6 36.5 0.1 100.0 38,948 1 “Currently employed” is defined as having done work in the past 7 days. Includes persons who did not work in the past 7 days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 44 • Characteristics of Respondents Figure 3.2 Women’s employment status in the past 12 months Currently employed 62% Not currently employed, but worked in last 12 months 2% Did not work in last 12 months 36% NDHS 2013 The likelihood that a woman is employed increases with her education. The proportion of women who are employed increases from 59 percent among those with no education to 66 percent among those with more than a secondary education. Likelihood of employment also increases with increasing wealth; 64 percent of women in the highest two quintiles are currently employed, as compared with 56 percent of women in the lowest quintile. More than three in four men are currently employed (76 percent) (Table 3.5.2). The proportion of currently employed men generally increases with age and number of living children. Rural men are more likely than urban men to be currently employed (79 percent versus 73 percent). There are notable variations by zone in the proportion of men employed in the previous 12 months; men in the North Central (83 percent) and North East (82 percent) zones are most likely to be currently employed, possibly because they are predominantly farmers. On the other hand, men in the South East zone are least likely to be currently employed (70 percent). Among states, Kebbi has the lowest employment (56 percent), whereas Niger has the highest (97 percent). The relationship between men’s employment and education is not linear, with men having a secondary education least likely to be employed. The same pattern was recorded in the 2008 NDHS. Wealth status has an inverse relationship with employment; current employment decreases from 81 percent among the poorest men to 74 percent among the wealthiest. Current employment among women age 15-49 increased from 59 percent in 2008 to 62 percent in 2013. In contrast, the proportion for men age 15-49 decreased from 80 percent to 76 percent. Characteristics of Respondents • 45 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Nigeria 2013 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of men Background characteristic Currently employed1 Not currently employed Age 15-19 36.6 5.0 58.2 0.2 100.0 3,619 20-24 66.5 3.7 29.5 0.3 100.0 2,892 25-29 84.5 3.1 12.2 0.2 100.0 2,757 30-34 92.7 3.2 4.1 0.0 100.0 2,414 35-39 96.2 2.6 1.2 0.1 100.0 2,175 40-44 96.1 2.7 1.2 0.0 100.0 1,777 45-49 94.4 4.4 1.1 0.1 100.0 1,724 Marital status Never married 55.7 3.9 40.2 0.2 100.0 8,378 Married or living together 95.7 3.3 0.9 0.1 100.0 8,723 Divorced/separated/ widowed 91.6 5.3 3.2 0.0 100.0 258 Number of living children 0 59.2 3.8 36.8 0.2 100.0 9,177 1-2 95.1 3.1 1.7 0.1 100.0 2,981 3-4 96.2 2.8 0.9 0.1 100.0 2,531 5+ 95.2 4.3 0.6 0.0 100.0 2,671 Residence Urban 73.2 2.2 24.5 0.1 100.0 7,611 Rural 78.7 4.8 16.4 0.2 100.0 9,748 Zone North Central 83.2 1.3 14.9 0.7 100.0 2,685 North East 82.3 6.5 11.2 0.0 100.0 2,515 North West 72.4 5.8 21.9 0.0 100.0 5,185 South East 70.4 2.7 26.9 0.1 100.0 1,686 South South 73.7 1.6 24.6 0.1 100.0 2,445 South West 77.5 1.8 20.7 0.0 100.0 2,843 State North Central FCT-Abuja 72.6 1.6 24.3 1.5 100.0 175 Benue 76.8 2.0 20.0 1.3 100.0 616 Kogi 71.8 0.4 27.8 0.0 100.0 333 Kwara 73.4 0.2 26.4 0.0 100.0 274 Nasarawa 84.6 1.7 13.7 0.0 100.0 282 Niger 96.7 0.4 2.3 0.6 100.0 701 Plateau 91.4 2.9 4.7 1.0 100.0 302 North East Adamawa 73.3 7.5 19.2 0.0 100.0 358 Bauchi 75.2 22.0 2.8 0.0 100.0 512 Borno 88.5 1.3 10.2 0.0 100.0 676 Gombe 86.2 3.8 9.8 0.2 100.0 255 Taraba 85.5 0.2 14.4 0.0 100.0 325 Yobe 83.9 1.2 15.0 0.0 100.0 390 North West Jigawa 89.8 4.4 5.7 0.0 100.0 510 Kaduna 76.2 2.6 21.3 0.0 100.0 1,033 Kano 62.2 1.7 36.1 0.0 100.0 1,592 Katsina 82.9 2.4 14.7 0.0 100.0 596 Kebbi 55.7 27.5 16.8 0.0 100.0 551 Sokoto 66.8 6.2 27.0 0.0 100.0 424 Zamfara 90.2 6.4 3.4 0.0 100.0 479 South East Abia 71.1 1.0 27.9 0.0 100.0 229 Anambra 65.8 1.6 32.6 0.0 100.0 446 Ebonyi 83.8 5.1 11.1 0.0 100.0 368 Enugu 66.5 3.5 29.6 0.4 100.0 320 Imo 64.8 1.7 33.5 0.0 100.0 323 South South Akwa Ibom 71.5 1.8 26.5 0.2 100.0 451 Bayelsa 73.7 1.6 24.5 0.2 100.0 187 Cross River 75.8 0.1 24.1 0.0 100.0 310 Delta 65.8 1.7 32.5 0.0 100.0 473 Edo 71.0 4.9 23.7 0.4 100.0 365 Rivers 81.3 0.4 18.4 0.0 100.0 658 Continued… 46 • Characteristics of Respondents Table 3.5.2—Continued Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of men Background characteristic Currently employed1 Not currently employed South West Ekiti 65.4 0.8 33.8 0.0 100.0 148 Lagos 81.8 3.3 14.9 0.0 100.0 948 Ogun 79.8 0.7 19.5 0.0 100.0 358 Ondo 70.9 0.5 28.6 0.0 100.0 404 Osun 74.6 3.8 21.6 0.0 100.0 356 Oyo 78.3 0.0 21.7 0.0 100.0 629 Education No education 84.4 7.5 8.1 0.0 100.0 3,685 Primary 86.8 2.5 10.6 0.0 100.0 2,907 Secondary 68.5 2.6 28.8 0.1 100.0 8,281 More than secondary 78.0 2.7 18.9 0.3 100.0 2,486 Wealth quintile Lowest 81.0 8.3 10.6 0.1 100.0 2,862 Second 79.6 5.0 15.2 0.2 100.0 2,992 Middle 74.9 2.6 22.2 0.2 100.0 3,338 Fourth 74.5 1.8 23.7 0.0 100.0 3,835 Highest 73.5 2.1 24.3 0.1 100.0 4,332 Total 76.3 3.6 19.9 0.1 100.0 17,359 1 “Currently employed” is defined as having done work in the past 7 days. Includes persons who did not work in the past 7 days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 3.6 OCCUPATION Currently employed respondents were asked about their occupation. Table 3.6.1 shows that 7 percent of women are employed in professional, technical, or managerial positions. The largest group of women (61 percent) are engaged in sales and services. The remaining women are working in agriculture (16 percent), in skilled manual jobs (14 percent), and in unskilled manual jobs (1 percent). 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 2013 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of women Age 15-19 2.7 0.8 59.0 15.6 1.9 17.3 2.7 100.0 2,275 20-24 6.2 1.7 56.4 20.5 0.7 13.9 0.4 100.0 3,527 25-29 7.9 1.5 60.1 16.6 0.4 12.8 0.6 100.0 4,840 30-34 8.7 0.8 61.8 14.6 0.2 13.5 0.5 100.0 4,251 35-39 8.3 0.9 63.4 11.9 0.2 14.8 0.6 100.0 3,880 40-44 8.7 0.5 60.3 10.2 0.2 19.7 0.3 100.0 3,025 45-49 7.1 0.6 61.6 9.1 0.3 20.8 0.5 100.0 2,889 Marital status Never married 13.0 3.9 53.5 13.7 2.1 12.2 1.7 100.0 3,380 Married or living together 6.5 0.5 62.0 14.8 0.2 15.4 0.6 100.0 19,830 Divorced/separated/ widowed 6.9 0.9 56.3 9.2 0.8 25.7 0.2 100.0 1,477 Number of living children 0 11.9 3.0 52.5 16.5 1.6 13.1 1.5 100.0 4,593 1-2 9.1 0.8 60.0 16.1 0.4 13.1 0.6 100.0 6,288 3-4 6.6 0.7 63.6 13.4 0.1 15.2 0.4 100.0 6,869 5+ 3.7 0.2 63.1 12.2 0.2 19.9 0.6 100.0 6,937 Residence Urban 12.3 1.8 64.6 13.1 0.8 6.6 0.7 100.0 10,621 Rural 3.7 0.4 57.4 15.2 0.2 22.4 0.7 100.0 14,067 Zone North Central 6.7 0.8 52.0 7.5 0.3 32.2 0.5 100.0 3,942 North East 4.5 0.8 48.3 23.9 0.7 20.0 1.8 100.0 2,754 North West 2.0 0.1 72.9 21.2 0.1 3.0 0.7 100.0 7,033 South East 11.0 1.8 54.1 8.2 0.4 24.0 0.7 100.0 2,930 South South 11.4 2.0 53.9 7.8 1.0 23.1 0.8 100.0 3,308 South West 12.6 1.6 64.8 12.7 0.8 7.4 0.2 100.0 4,721 Continued… Characteristics of Respondents • 47 Table 3.6.1—Continued Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of women State North Central FCT-Abuja 19.6 3.3 53.3 9.8 2.5 11.6 0.0 100.0 181 Benue 2.8 0.2 18.7 2.7 0.0 74.8 0.8 100.0 971 Kogi 9.6 0.8 61.0 13.1 0.2 14.6 0.8 100.0 505 Kwara 14.9 1.8 63.5 14.6 0.4 4.4 0.5 100.0 376 Nasarawa 8.0 0.3 32.6 7.8 0.6 50.6 0.0 100.0 398 Niger 3.1 0.6 81.2 5.9 0.0 8.9 0.4 100.0 1,165 Plateau 8.8 1.3 43.4 8.7 0.6 36.4 0.7 100.0 346 North East Adamawa 5.5 1.5 40.8 19.5 0.2 31.9 0.6 100.0 486 Bauchi 2.1 0.1 52.0 41.1 0.1 3.3 1.2 100.0 653 Borno 8.0 1.5 44.6 23.4 0.0 21.2 1.2 100.0 431 Gombe 3.8 0.3 58.8 15.7 5.8 4.5 11.1 100.0 286 Taraba 4.1 0.4 43.0 16.2 0.1 36.0 0.3 100.0 562 Yobe 4.6 0.9 56.7 17.4 0.0 20.1 0.4 100.0 335 North West Jigawa 0.3 0.0 67.5 27.9 0.1 2.9 1.3 100.0 739 Kaduna 6.4 0.2 81.5 7.1 0.7 4.2 0.0 100.0 1,308 Kano 1.3 0.0 60.6 37.0 0.0 0.8 0.3 100.0 1,795 Katsina 0.6 0.0 81.0 14.2 0.0 3.3 0.8 100.0 1,015 Kebbi 1.5 0.1 72.4 14.7 0.1 9.0 2.2 100.0 782 Sokoto 1.1 0.0 72.0 26.1 0.0 0.4 0.4 100.0 507 Zamfara 1.1 0.0 81.1 15.0 0.0 1.8 1.0 100.0 887 South East Abia 15.6 2.2 46.1 8.6 0.2 27.4 0.0 100.0 351 Anambra 13.6 1.0 69.7 4.7 0.5 10.3 0.1 100.0 597 Ebonyi 5.4 1.4 46.4 10.1 0.2 34.9 1.6 100.0 883 Enugu 10.6 1.7 53.9 7.0 0.4 26.0 0.4 100.0 609 Imo 15.3 3.1 54.7 10.1 0.3 16.1 0.4 100.0 489 South South Akwa Ibom 14.7 2.4 56.7 9.9 1.0 13.4 2.0 100.0 539 Bayelsa 8.5 1.3 60.5 3.6 0.1 24.8 1.1 100.0 234 Cross River 5.9 1.2 43.3 8.3 2.1 38.0 1.3 100.0 500 Delta 13.4 1.1 56.3 6.6 0.6 21.5 0.5 100.0 565 Edo 13.8 1.7 55.7 13.1 0.1 15.6 0.0 100.0 466 Rivers 10.9 3.2 53.8 5.6 1.2 25.0 0.3 100.0 1,005 South West Ekiti 19.9 2.4 58.7 12.6 0.2 6.3 0.0 100.0 208 Lagos 13.9 2.4 66.0 14.2 2.3 1.1 0.0 100.0 1,441 Ogun 8.7 0.6 65.7 10.3 0.2 14.3 0.2 100.0 711 Ondo 11.1 1.0 59.6 11.5 0.2 16.5 0.1 100.0 557 Osun 14.1 1.6 68.1 10.4 0.3 5.3 0.2 100.0 549 Oyo 11.9 1.4 64.8 13.7 0.0 7.8 0.3 100.0 1,256 Education No education 0.3 0.0 65.7 18.6 0.1 14.4 0.8 100.0 9,025 Primary 1.2 0.2 56.0 13.2 0.5 28.7 0.4 100.0 5,202 Secondary 6.1 1.5 65.0 13.0 1.0 12.5 0.9 100.0 8,081 More than secondary 52.2 5.2 35.0 5.2 0.2 1.7 0.6 100.0 2,379 Wealth quintile Lowest 0.2 0.0 63.4 20.6 0.0 15.0 0.8 100.0 4,104 Second 0.7 0.0 53.4 15.7 0.3 29.0 0.9 100.0 4,727 Middle 3.5 0.5 56.7 12.8 0.4 25.5 0.7 100.0 4,792 Fourth 8.8 1.2 65.8 13.4 0.3 9.9 0.5 100.0 5,246 Highest 19.9 2.8 62.5 10.9 1.3 2.1 0.7 100.0 5,818 Total 7.4 1.0 60.5 14.3 0.5 15.6 0.7 100.0 24,688 The proportion of women in professional, technical, or managerial positions increases with age, while the proportion of women in sales and services varies little by age. Women in the oldest age groups (21 percent); women who are divorced, separated, or widowed (26 percent); women with five or more children (20 percent); rural women (22 percent); and women with a primary education (29 percent) are more likely to work in the agricultural sector. Men show a different pattern. Across age groups, men age 15-19 are most likely to be involved in agriculture (46 percent) (Table 3.6.2). In rural areas, one in two men are employed in agricultural work. Employment in the professional and managerial sector is most common among men with more than a secondary education (50 percent) and men in the highest wealth quintile (26 percent). 48 • Characteristics of Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Nigeria 2013 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of men Age 15-19 2.3 0.9 20.6 21.4 3.8 46.4 4.5 100.0 1,505 20-24 6.3 1.2 24.6 27.1 5.8 33.4 1.5 100.0 2,032 25-29 9.2 1.0 25.8 23.8 7.5 31.6 1.3 100.0 2,418 30-34 13.7 0.8 29.6 22.9 5.8 26.5 0.8 100.0 2,315 35-39 15.1 1.2 24.6 23.7 3.5 31.6 0.3 100.0 2,148 40-44 15.2 0.8 24.2 22.1 3.8 33.4 0.4 100.0 1,756 45-49 16.0 1.4 21.6 19.0 2.9 38.4 0.7 100.0 1,703 Marital status Never married 8.8 1.4 26.2 26.3 5.4 29.3 2.6 100.0 4,992 Married or living together 12.7 0.8 24.2 21.0 4.6 36.1 0.5 100.0 8,635 Divorced/separated/ widowed 11.3 0.5 16.4 27.9 6.5 37.3 0.0 100.0 250 Number of living children 0 9.0 1.3 26.3 24.9 5.5 30.8 2.3 100.0 5,786 1-2 13.2 0.6 26.8 23.5 5.7 29.8 0.5 100.0 2,928 3-4 14.3 1.1 23.8 23.6 4.0 32.8 0.3 100.0 2,505 5+ 11.3 1.0 20.3 17.9 3.6 45.1 0.7 100.0 2,656 Residence Urban 17.9 1.6 32.1 32.5 4.4 10.2 1.2 100.0 5,742 Rural 6.6 0.6 19.6 16.4 5.3 50.2 1.3 100.0 8,134 Zone North Central 13.0 1.0 15.6 19.4 4.0 43.3 3.7 100.0 2,267 North East 7.3 0.6 21.4 18.2 3.9 47.6 1.0 100.0 2,232 North West 7.8 0.6 28.5 18.2 5.8 38.5 0.6 100.0 4,051 South East 13.0 1.7 28.7 27.8 4.8 23.6 0.3 100.0 1,232 South South 13.4 0.9 28.7 29.7 5.9 20.0 1.3 100.0 1,841 South West 17.2 2.0 25.4 32.3 4.4 18.1 0.6 100.0 2,254 State North Central FCT-Abuja 26.7 0.9 40.0 13.1 1.0 17.3 1.0 100.0 130 Benue 8.7 0.8 7.7 11.1 4.3 60.9 6.5 100.0 485 Kogi 15.5 1.1 22.9 28.8 5.0 26.1 0.5 100.0 241 Kwara 21.9 2.7 16.8 39.4 4.2 14.3 0.6 100.0 202 Nasarawa 9.4 0.6 18.4 22.2 6.9 40.6 1.9 100.0 244 Niger 11.1 1.1 12.7 15.8 3.5 51.9 3.9 100.0 681 Plateau 13.3 0.4 15.7 20.5 2.0 41.8 6.4 100.0 285 North East Adamawa 8.8 1.5 27.5 21.5 7.9 32.0 0.8 100.0 289 Bauchi 6.3 0.0 23.2 18.3 5.8 45.2 1.3 100.0 497 Borno 7.4 0.9 17.9 18.9 0.8 52.8 1.3 100.0 607 Gombe 7.6 0.6 21.1 24.3 5.9 39.2 1.4 100.0 230 Taraba 9.4 0.5 18.2 16.6 4.5 50.3 0.5 100.0 278 Yobe 5.4 0.5 22.3 10.9 1.2 59.1 0.6 100.0 332 North West Jigawa 3.7 0.0 33.4 13.4 5.9 42.7 0.9 100.0 481 Kaduna 13.2 0.7 22.8 23.8 6.7 32.4 0.5 100.0 813 Kano 8.1 0.3 37.1 20.6 5.2 28.6 0.1 100.0 1,018 Katsina 6.4 0.8 26.2 12.5 8.1 45.3 0.7 100.0 508 Kebbi 5.9 0.8 8.8 19.4 4.6 58.8 1.8 100.0 458 Sokoto 5.5 0.7 32.5 13.7 8.2 38.2 1.2 100.0 310 Zamfara 6.7 1.0 33.9 15.6 3.1 39.5 0.2 100.0 462 South East Abia 16.1 1.6 34.1 28.6 3.2 16.3 0.0 100.0 165 Anambra 11.5 0.2 46.9 22.8 4.5 14.1 0.0 100.0 301 Ebonyi 13.6 3.4 16.1 15.2 2.8 47.8 1.2 100.0 327 Enugu 12.2 1.8 20.0 40.9 6.7 18.2 0.1 100.0 224 Imo 12.3 1.2 27.4 40.0 7.9 11.2 0.0 100.0 215 South South Akwa Ibom 14.3 1.0 28.7 40.8 6.9 7.0 1.3 100.0 331 Bayelsa 16.0 1.6 28.4 23.1 3.0 27.7 0.2 100.0 141 Cross River 10.9 0.9 15.5 20.9 1.8 49.6 0.5 100.0 236 Delta 12.7 0.9 27.0 30.8 9.1 18.8 0.8 100.0 319 Edo 13.6 0.6 21.7 37.4 6.8 19.4 0.5 100.0 277 Rivers 13.5 0.9 39.3 23.8 5.7 14.1 2.7 100.0 537 Continued… Characteristics of Respondents • 49 Table 3.6.2—Continued Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of men South West Ekiti 23.4 3.2 21.1 24.9 5.5 21.8 0.0 100.0 98 Lagos 20.1 3.1 34.2 36.3 2.4 3.2 0.8 100.0 807 Ogun 11.7 0.3 19.6 34.5 9.4 24.0 0.4 100.0 289 Ondo 15.4 0.7 21.8 21.6 5.5 34.5 0.5 100.0 288 Osun 13.8 2.3 21.3 32.6 7.0 22.6 0.5 100.0 280 Oyo 17.3 1.6 19.7 32.0 2.4 26.3 0.5 100.0 493 Education No education 2.1 0.1 19.1 10.6 4.6 62.7 0.8 100.0 3,386 Primary 2.7 0.3 24.0 26.8 6.1 39.3 0.8 100.0 2,596 Secondary 7.4 1.2 28.9 32.2 5.5 23.3 1.5 100.0 5,887 More than secondary 49.5 2.9 23.5 12.3 2.0 7.9 1.8 100.0 2,007 Wealth quintile Lowest 1.4 0.1 17.7 8.3 3.5 68.5 0.5 100.0 2,557 Second 3.1 0.2 19.5 14.2 6.3 55.4 1.3 100.0 2,531 Middle 7.7 1.2 22.1 23.2 5.7 38.7 1.5 100.0 2,589 Fourth 13.6 1.3 27.3 35.9 6.0 14.2 1.6 100.0 2,925 Highest 26.1 2.1 34.3 29.8 3.4 3.2 1.3 100.0 3,275 Total 11.3 1.0 24.8 23.0 4.9 33.7 1.3 100.0 13,876 3.7 TYPE OF EMPLOYMENT Table 3.7.1 shows that 9 in 10 women are paid for their work, with 8 in 10 receiving cash only and 10 percent receiving payment in cash and in-kind. Women who work in agriculture are much less likely than women engaged in nonagricultural work to be paid in cash only (46 percent and 87 percent, respectively). The majority of women (79 percent) are self-employed. Eight in 10 women work all year, and 13 percent work seasonally. As expected, women employed in the agricultural sector are more likely to work according to season than those employed in nonagricultural occupations. 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 nonagricultural), Nigeria 2013 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 45.5 87.3 80.4 Cash and in-kind 25.2 7.2 10.0 In-kind only 2.7 0.6 0.9 Not paid 26.3 4.5 8.2 Missing 0.3 0.4 0.4 Total 100.0 100.0 100.0 Type of employer Employed by family member 22.9 6.3 9.0 Employed by non-family member 1.8 13.2 11.4 Self-employed 74.9 79.9 79.0 Missing 0.4 0.6 0.6 Total 100.0 100.0 100.0 Continuity of employment All year 57.5 87.1 82.4 Seasonal 39.7 8.2 13.2 Occasional 2.8 4.5 4.2 Missing 0.1 0.2 0.2 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 3,850 20,664 24,688 Note: Total includes women with missing information on type of employment who are not shown separately. 50 • Characteristics of Respondents Men are slightly less likely than women to be paid in cash only (80 percent and 74 percent, respectively) and to work all year (82 percent and 76 percent, respectively) (Table 3.7.2). Similar to women, seasonal work is mostly in the agricultural sector (41 percent). 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 and continuity of employment, according to type of employment (agricultural or nonagricultural), Nigeria 2013 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 48.4 87.5 73.9 Cash and in-kind 27.9 10.0 16.0 In-kind only 3.9 0.4 1.8 Not paid 19.5 1.8 8.1 Missing 0.3 0.2 0.2 Total 100.0 100.0 100.0 Continuity of employment All year 57.0 86.5 76.3 Seasonal 41.2 8.2 19.4 Occasional 1.8 5.2 4.1 Total 100.0 100.0 100.0 Number of men employed during the last 12 months 4,673 9,029 13,876 Note: Total includes men with missing information on type of employment who are not shown separately. The appendix tables show the differentials in earnings and employment by state. Appendix Table A.3.7.1 shows that women in the majority of states receive cash earnings for their work. Women in Benue, Taraba, and Ebonyi are more likely than those in other states to receive both cash and in-kind payment (37 percent, 28 percent, and 30 percent, respectively). Gombe has the highest proportion of women (34 percent) who are not paid for their work. As is the case for women, men in the majority of states receive payment for their work; 8 percent are not paid for their work (Table A.3.7.2). Three in 10 men in Yobe (32 percent), Adamawa (31 percent), and Ebonyi (29 percent) are not paid for their work. Table A.3.7.3 shows that type of employer varies by state. Overall, 11 percent of women are employed by a family member, while this proportion is more than double in Niger and Delta (26 percent each). In contrast, 31 percent of women in FCT-Abuja are employed by non-family members, and 64 percent are self-employed. Appendix Tables A.3.7.4 and A.3.7.5 show continuity of employment by state for women and men, respectively. Practically all women (95 percent or more) in Kwara, Ekiti, Ogun, Osun, and Oyo work throughout the year. The states with the highest proportions of men who work throughout the year are Kwara, Lagos, and Oyo. Overall, two in five men work seasonally, while the proportion is as high as 4 in 10 in Plateau, Taraba, and Kebbi. 3.8 HEALTH INSURANCE COVERAGE Although Nigeria’s National Health Insurance Scheme was established in 1999 to ensure health insurance coverage for the general population, very few people have registered. Less than 2 percent of women age 15-49 have health insurance, and this figure has changed only minimally since the 2008 NDHS (NPC and ICF Macro, 2009). Although most coverage is employer-based, it accounts for only 1 percent of women and 2 percent of men age 15-49 (Tables 3.8.1 and 3.8.2). The practice of purchasing health insurance is basically urban-centred and is more common among those living in the South West, South South, and North Central than among those residing in the other zones. Health insurance coverage is also more common among better-educated women and men and those in the highest wealth quintile. Characteristics of Respondents • 51 Table 3.8.1 Health insurance coverage: Women Percentage of women age 15-49 with specific types of health insurance coverage, according to background characteristics, Nigeria 2013 Background characteristic Employer-based insurance Mutual Health Organization/ community-based insurance Privately purchased commercial insurance Other None Number of women Age 15-19 0.7 0.1 0.0 0.0 99.1 7,820 20-24 1.1 0.4 0.3 0.0 98.3 6,757 25-29 1.2 0.2 0.3 0.0 98.3 7,145 30-34 2.1 0.2 0.2 0.0 97.5 5,467 35-39 2.1 0.3 0.2 0.1 97.4 4,718 40-44 2.0 0.3 0.2 0.1 97.5 3,620 45-49 1.3 0.2 0.1 0.0 98.4 3,422 Residence Urban 2.7 0.3 0.4 0.0 96.7 16,414 Rural 0.5 0.2 0.1 0.0 99.3 22,534 Zone North Central 1.8 0.6 0.2 0.0 97.4 5,572 North East 1.5 0.1 0.2 0.0 98.3 5,766 North West 0.5 0.1 0.0 0.0 99.4 11,877 South East 1.3 0.3 0.5 0.0 97.9 4,476 South South 2.5 0.4 0.5 0.1 96.6 4,942 South West 1.8 0.1 0.2 0.1 97.8 6,314 Education No education 0.1 0.1 0.0 0.0 99.8 14,729 Primary 0.5 0.1 0.1 0.0 99.4 6,734 Secondary 1.4 0.3 0.3 0.0 98.1 13,927 More than secondary 8.6 0.9 0.9 0.2 89.4 3,558 Wealth quintile Lowest 0.0 0.0 0.0 0.0 100.0 7,132 Second 0.0 0.0 0.0 0.0 99.9 7,428 Middle 0.4 0.1 0.1 0.0 99.3 7,486 Fourth 1.2 0.2 0.2 0.0 98.3 7,992 Highest 4.6 0.7 0.5 0.1 94.1 8,910 Total 1.4 0.2 0.2 0.0 98.2 38,948 Table 3.8.2 Health insurance coverage: Men Percentage of men age 15-49 with specific types of health insurance coverage, according to background characteristics, Nigeria 2013 Background characteristic Employer-based insurance Mutual Health Organization/ community-based insurance Privately purchased commercial insurance Other None Number of men Age 15-19 0.6 0.1 0.1 0.2 99.1 3,619 20-24 1.0 0.3 0.2 0.3 98.1 2,892 25-29 1.8 0.3 0.1 0.1 97.7 2,757 30-34 3.5 0.6 0.0 0.1 95.9 2,414 35-39 3.5 0.4 0.3 0.1 95.8 2,175 40-44 4.4 0.4 0.4 0.0 94.8 1,777 45-49 4.5 0.4 0.2 0.0 94.9 1,724 Residence Urban 4.1 0.5 0.3 0.1 95.0 7,611 Rural 1.1 0.2 0.1 0.1 98.5 9,748 Zone North Central 3.4 1.0 0.1 0.4 95.2 2,685 North East 1.6 0.3 0.1 0.5 97.6 2,515 North West 1.0 0.2 0.1 0.0 98.7 5,185 South East 2.1 0.1 0.1 0.0 97.6 1,686 South South 3.5 0.3 0.2 0.0 96.0 2,445 South West 4.1 0.1 0.3 0.0 95.4 2,843 Education No education 0.0 0.0 0.0 0.0 100.0 3,685 Primary 0.5 0.2 0.0 0.0 99.3 2,907 Secondary 1.8 0.2 0.1 0.1 97.8 8,281 More than secondary 10.1 1.5 0.9 0.7 86.8 2,486 Wealth quintile Lowest 0.0 0.0 0.0 0.0 100.0 2,862 Second 0.1 0.1 0.0 0.0 99.7 2,992 Middle 1.0 0.1 0.1 0.1 98.6 3,338 Fourth 1.8 0.4 0.1 0.1 97.6 3,835 Highest 7.1 0.8 0.5 0.3 91.3 4,332 Total 2.4 0.3 0.2 0.1 97.0 17,359 52 • Characteristics of Respondents 3.9 USE OF TOBACCO 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 secondhand or “environmental” tobacco smoke (WHO, 2002). Information on women’s and men’s use of tobacco was collected during the 2013 NDHS. The majority of women in Nigeria do not use tobacco (data not shown). Thus, an in-depth assessment of tobacco smoking among women is not possible. Table 3.9 shows that 92 percent of men in Nigeria do not smoke tobacco. The majority of men who use tobacco tend to smoke cigarettes (7 percent). Cigarette smoking among men is highest in the 30-34 and 40-44 age groups (10 percent each). Men in the South East (17 percent) are more likely to use tobacco products than those in the other zones. Tobacco use is highest among men with a primary education (17 percent). Among men who smoke, 25 percent smoked 10 or more cigarettes in the 24 hours before the survey, 30 percent smoked 3-5 cigarettes, and 22 percent smoked 1 or 2 cigarettes. Older men, those in the North West, those with no education, and those in the second wealth quintile were most likely to have smoked 10 or more cigarettes in the past 24 hours. Table 3.9 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 the preceding 24 hours, according to background characteristics, Nigeria 2013 Uses tobacco Does not use tobacco Number of men Percent distribution of men who smoke cigarettes by number of cigarettes smoked in the past 24 hours Total Number of cigarette smokers Background characteristic Cigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 0.7 0.1 0.5 99.0 3,619 * * * * * * 100.0 24 20-24 4.4 0.3 1.9 94.4 2,892 4.8 34.8 27.6 9.6 16.2 7.0 100.0 127 25-29 8.9 0.5 3.8 89.4 2,757 2.0 23.9 24.7 11.8 29.9 7.7 100.0 245 30-34 9.5 0.2 3.5 88.1 2,414 1.8 16.9 36.5 17.8 21.1 5.8 100.0 230 35-39 7.6 0.4 3.3 90.0 2,175 3.6 22.2 32.7 17.4 17.5 6.7 100.0 166 40-44 9.5 0.3 5.4 86.7 1,777 2.1 18.9 30.5 10.2 29.2 9.2 100.0 169 45-49 9.3 0.5 4.9 87.1 1,724 4.2 19.9 26.7 13.1 33.5 2.5 100.0 161 Residence Urban 6.7 0.2 2.8 91.7 7,611 3.3 24.7 27.5 12.6 24.1 7.6 100.0 512 Rural 6.3 0.4 3.1 91.6 9,748 2.4 19.6 31.9 15.1 25.1 6.0 100.0 610 Zone North Central 8.4 0.5 4.5 88.5 2,685 1.6 17.3 28.3 18.9 24.5 9.5 100.0 226 North East 4.2 0.2 3.2 93.5 2,515 1.1 17.2 33.1 17.1 26.0 5.5 100.0 105 North West 4.0 0.3 1.4 95.2 5,185 0.0 19.1 18.3 14.1 47.6 0.8 100.0 209 South East 10.9 0.4 5.2 85.2 1,686 5.8 26.0 37.5 9.9 13.2 7.6 100.0 183 South South 9.3 0.4 2.4 89.0 2,445 3.5 20.7 34.3 15.0 20.9 5.6 100.0 228 South West 6.0 0.0 3.4 92.5 2,843 4.7 31.9 30.3 8.3 13.2 11.6 100.0 171 Education No education 4.6 0.5 2.7 93.5 3,685 1.3 7.8 29.0 19.4 40.1 2.4 100.0 169 Primary 10.6 0.3 5.9 85.5 2,907 2.2 19.6 32.8 16.1 22.6 6.7 100.0 309 Secondary 6.3 0.2 2.5 92.2 8,281 2.7 26.7 28.5 11.9 22.1 8.2 100.0 524 More than secondary 4.8 0.1 1.7 94.1 2,486 7.0 27.3 29.9 9.8 19.7 6.3 100.0 120 Wealth quintile Lowest 4.1 0.6 2.5 93.9 2,862 1.4 19.0 33.6 18.1 25.5 2.4 100.0 118 Second 7.3 0.3 3.4 90.3 2,992 0.8 16.9 27.0 18.5 31.6 5.2 100.0 219 Middle 7.1 0.3 4.1 90.4 3,338 2.8 20.6 28.7 12.7 27.1 8.0 100.0 237 Fourth 6.9 0.2 2.9 91.2 3,835 3.3 25.9 33.0 11.2 22.2 4.4 100.0 265 Highest 6.5 0.2 2.1 92.4 4,332 4.5 24.6 28.7 12.3 19.2 10.8 100.0 283 Total 6.5 0.3 3.0 91.6 17,359 2.8 22.0 29.9 14.0 24.7 6.7 100.0 1,122 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Marriage and Sexual Activity • 53 MARRIAGE AND SEXUAL ACTIVITY 4 arriage is a primary indication of women’s exposure to the risk of pregnancy; therefore, it is important for an understanding of fertility. Populations in which women marry at a young age tend to have high fertility and early childbearing. For this reason, there is an interest in age at marriage. In addition to marriage patterns and age at first marriage, this chapter includes information on two other direct measures of exposure to pregnancy, namely age at first sexual intercourse and frequency of intercourse. 4.1 MARITAL STATUS Table 4.1 presents the percent distribution of women and men by current marital status. The proportion of women who have never married (or lived with a man) declines sharply with age, from 70 percent among women age 15-19 to 1 percent among women age 45-49. Marriage is thus nearly universal in Nigeria. Although most men eventually marry, men tend to marry later than women; therefore, a higher percentage of men than women age 15-49 are not currently married (48 percent versus 24 percent). Seven in 10 women and 5 in 10 men age 15-49 are currently married or living together with a partner as though married. Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Nigeria 2013 Marital status Total Percentage of respondents currently in union Number of respondents Age Never married Married Living together Divorced Separated Widowed WOMEN 15-19 70.4 28.2 0.6 0.5 0.1 0.1 100.0 28.8 7,820 20-24 33.1 61.3 3.3 1.3 0.8 0.3 100.0 64.6 6,757 25-29 14.1 79.8 3.0 1.1 1.1 0.9 100.0 82.8 7,145 30-34 6.7 86.6 2.5 1.1 1.5 1.6 100.0 89.1 5,467 35-39 2.7 89.4 1.7 1.3 1.4 3.4 100.0 91.2 4,718 40-44 1.5 87.8 1.3 1.4 1.4 6.6 100.0 89.1 3,620 45-49 0.7 83.9 1.0 1.4 1.8 11.1 100.0 85.0 3,422 Total 23.9 69.4 2.0 1.1 1.0 2.5 100.0 71.5 38,948 MEN 15-19 98.7 1.1 0.0 0.1 0.0 0.1 100.0 1.1 3,619 20-24 84.8 14.0 0.5 0.4 0.3 0.0 100.0 14.4 2,892 25-29 53.3 43.7 1.2 0.8 0.7 0.2 100.0 45.0 2,757 30-34 25.6 70.6 1.9 0.7 1.0 0.3 100.0 72.5 2,414 35-39 8.8 87.3 1.8 0.8 1.0 0.4 100.0 89.0 2,175 40-44 3.1 92.8 2.3 0.8 0.7 0.4 100.0 95.0 1,777 45-49 1.0 94.0 1.7 0.7 1.4 1.3 100.0 95.7 1,724 Total 48.3 49.1 1.2 0.5 0.6 0.3 100.0 50.2 17,359 M Key Findings • The median age at first marriage among women age 25-49 is 18.1 years; the median age at first marriage among men age 30-49 is 27.2 years. • Women and men in Nigeria tend to initiate sexual activity before marriage. The median age at first sexual intercourse is 17.6 years for women and 21.1 years for men age 25-49. • Thirty-three percent of currently married women are married to men who are in a polygynous union; 17 percent of currently married men are in a polygynous union. 54 • Marriage and Sexual Activity Two percent of women and 1 percent of men are separated or divorced, the same percentages observed in the 2008 NDHS. Three percent of women and less than 1 percent of men are widowed. 4.2 POLYGYNY Polygyny (the practice of having more than one wife) has implications for frequency of exposure to sexual activity and therefore fertility. The extent of polygyny in Nigeria was measured by asking all women currently married or living with a man the following question: “Does your husband/partner have other wives, or does he live with other women as if married?” If the answer was yes, the woman was asked “Including yourself, in total, how many wives or live-in partners does he have?” Currently married men or men living with a woman were asked “Do you have other wives, or do you live with other women as if married?” If the answer was yes, the man was asked “Altogether, how many wives or live-in partners do you have?” Table 4.2.1 shows the distribution of currently married women by number of co-wives, according to selected background characteristics. The majority of married women report that their husband or partner has no other wives (67 percent). Thirty-three percent of women report that their husbands have more than one wife, while less than 1 percent do not know if their husbands have other wives. These figures are similar to those reported in the 2008 NDHS. Table 4.2.1 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 2013 Background characteristic Number of co-wives Total Number of women 0 1 2+ Don’t know Missing Age 15-19 74.8 21.7 3.1 0.0 0.5 100.0 2,251 20-24 74.2 21.7 3.3 0.2 0.5 100.0 4,362 25-29 70.5 24.0 4.7 0.3 0.4 100.0 5,913 30-34 65.9 26.8 6.5 0.3 0.5 100.0 4,869 35-39 62.0 28.9 8.4 0.4 0.3 100.0 4,302 40-44 60.4 28.6 10.5 0.2 0.3 100.0 3,226 45-49 57.9 29.5 12.3 0.1 0.2 100.0 2,907 Residence Urban 77.6 16.2 5.4 0.4 0.4 100.0 10,124 Rural 60.7 31.3 7.4 0.2 0.4 100.0 17,705 Zone North Central 69.6 24.2 5.6 0.1 0.6 100.0 3,895 North East 59.2 31.1 9.3 0.1 0.3 100.0 4,679 North West 56.0 35.5 8.2 0.0 0.3 100.0 10,034 South East 86.9 9.1 2.4 0.3 1.3 100.0 2,333 South South 85.9 9.8 3.3 0.7 0.4 100.0 2,699 South West 75.4 18.0 5.8 0.7 0.1 100.0 4,189 State North Central FCT-Abuja 81.6 12.9 4.6 0.1 0.8 100.0 200 Benue 74.5 20.0 5.5 0.0 0.0 100.0 827 Kogi 68.2 25.1 6.0 0.0 0.7 100.0 433 Kwara 66.0 27.8 6.0 0.1 0.1 100.0 384 Nasarawa 61.3 27.2 10.8 0.4 0.2 100.0 420 Niger 67.5 27.7 4.2 0.0 0.6 100.0 1,190 Plateau 72.9 20.9 4.2 0.0 2.0 100.0 442 North East Adamawa 59.3 28.0 12.2 0.0 0.4 100.0 586 Bauchi 48.9 40.3 10.9 0.0 0.0 100.0 1,051 Borno 73.6 21.1 4.2 0.4 0.7 100.0 1,120 Gombe 54.5 35.1 10.4 0.0 0.0 100.0 467 Taraba 56.4 28.3 15.1 0.1 0.1 100.0 632 Yobe 57.5 34.9 7.4 0.0 0.2 100.0 824 North West Jigawa 55.5 35.5 8.6 0.0 0.4 100.0 1,256 Kaduna 71.3 23.8 4.7 0.2 0.0 100.0 1,594 Kano 54.9 35.2 9.8 0.0 0.1 100.0 2,521 Katsina 47.3 40.1 11.2 0.1 1.2 100.0 1,408 Kebbi 55.7 39.2 4.7 0.0 0.4 100.0 1,074 Sokoto 58.8 32.8 7.8 0.0 0.6 100.0 956 Zamfara 46.7 44.9 8.4 0.0 0.0 100.0 1,226 Continued… Marriage and Sexual Activity • 55 Table 4.2.1—Continued Background characteristic Number of co-wives Total Number of women 0 1 2+ Don’t know Missing South East Abia 84.7 9.1 3.1 0.0 3.1 100.0 292 Anambra 92.6 5.7 0.4 0.4 0.8 100.0 564 Ebonyi 72.7 19.5 7.9 0.0 0.0 100.0 564 Enugu 91.0 7.2 0.0 0.0 1.7 100.0 467 Imo 94.7 2.3 0.2 1.0 1.9 100.0 446 South South Akwa Ibom 92.9 5.3 1.4 0.1 0.3 100.0 410 Bayelsa 74.3 17.6 6.8 1.3 0.0 100.0 202 Cross River 84.6 11.0 1.1 3.0 0.4 100.0 437 Delta 82.1 11.0 6.5 0.2 0.2 100.0 551 Edo 83.4 11.9 4.3 0.2 0.2 100.0 395 Rivers 90.3 7.4 1.6 0.0 0.7 100.0 704 South West Ekiti 75.4 16.2 7.2 0.4 0.8 100.0 194 Lagos 85.1 10.0 3.0 1.9 0.0 100.0 1,236 Ogun 70.9 23.0 5.7 0.5 0.0 100.0 655 Ondo 67.5 22.4 9.2 0.7 0.2 100.0 510 Osun 79.3 15.2 5.5 0.0 0.0 100.0 465 Oyo 69.5 23.2 7.3 0.0 0.0 100.0 1,129 Education No education 54.0 36.7 8.8 0.1 0.4 100.0 13,470 Primary 68.7 23.8 7.0 0.3 0.2 100.0 5,336 Secondary 83.4 11.9 3.6 0.5 0.6 100.0 6,981 More than secondary 89.7 7.4 2.2 0.3 0.4 100.0 2,043 Wealth quintile Lowest 54.0 38.4 7.3 0.0 0.3 100.0 6,424 Second 58.7 33.4 7.5 0.1 0.3 100.0 5,986 Middle 66.4 24.6 8.1 0.3 0.6 100.0 4,983 Fourth 74.5 18.4 6.5 0.3 0.3 100.0 5,042 Highest 84.4 10.6 3.9 0.6 0.5 100.0 5,395 Total 66.8 25.8 6.7 0.2 0.4 100.0 27,830 The proportion of women with co-wives increases with age. The proportions of women who report having no co-wives is highest in the South East (87 percent) and lowest in the North West (56 percent). The percentage of women with co-wives is highest in Zamfara state (53 percent) and lowest in Imo (3 percent). The high proportion of co-wives in Zamfara may be attributed to the Islamic religion and culture, which allow a man to have more than one wife. There is an inverse relationship between education and polygyny. Women with no education are more likely to report having co-wives (46 percent) than women who are educated. The difference is especially pronounced in the case of women who have more than a secondary education (10 percent). Overall, the percentage of women who report having one or more co-wives decreases with increasing wealth quintile, from 46 percent among women in the lowest quintile to 15 percent among women in the highest quintile. Table 4.2.2 shows the results for men. Overall, 17 percent of currently married men are in polygynous unions. Similar to women, older men are more likely to be in polygynous unions. The percentage of men age 15-49 who report being in a polygynous union is higher in rural areas (21 percent) than in urban areas (9 percent). Men in the northern zones are more likely than men in the southern zones to report more than one wife. For instance, 26 percent of currently married men in the North West, 21 percent in the North East, and 16 percent in the North Central zone report having more than one wife. In contrast, 9 percent of men in the South West, 7 percent in the South South, and 4 percent in the South East report having more than one wife. Among the states, the proportion of men in polygynous unions is highest in Zamfara (36 percent). Almost no men in Abia and Imo report having more than one wife. The percentage of men age 15-49 who report being in a polygynous union declines with increasing education and wealth quintile. 56 • Marriage and Sexual Activity Table 4.2.2 Number of men’s wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Nigeria 2013 Background characteristic Number of wives Total Number of men 1 2+ Age 15-19 (96.8) (3.2) 100.0 41 20-24 98.4 1.6 100.0 418 25-29 94.4 5.6 100.0 1,240 30-34 88.0 12.0 100.0 1,750 35-39 82.8 17.2 100.0 1,937 40-44 77.0 23.0 100.0 1,688 45-49 72.1 27.9 100.0 1,649 Residence Urban 90.6 9.4 100.0 3,302 Rural 78.7 21.3 100.0 5,421 Zone North Central 83.6 16.4 100.0 1,395 North East 79.3 20.7 100.0 1,404 North West 74.4 25.6 100.0 2,846 South East 95.9 4.1 100.0 643 South South 93.1 6.9 100.0 1,020 South West 91.2 8.8 100.0 1,414 State North Central FCT-Abuja 92.8 7.2 100.0 96 Benue 87.4 12.6 100.0 283 Kogi 87.8 12.2 100.0 142 Kwara 80.5 19.5 100.0 132 Nasarawa 81.6 18.4 100.0 136 Niger 79.9 20.1 100.0 447 Plateau 82.2 17.8 100.0 158 North East Adamawa 83.1 16.9 100.0 174 Bauchi 71.6 28.4 100.0 325 Borno 87.7 12.3 100.0 368 Gombe 72.0 28.0 100.0 131 Taraba 78.9 21.1 100.0 177 Yobe 78.6 21.4 100.0 229 North West Jigawa 73.7 26.3 100.0 334 Kaduna 86.1 13.9 100.0 569 Kano 72.4 27.6 100.0 691 Katsina 68.4 31.6 100.0 390 Kebbi 77.1 22.9 100.0 314 Sokoto 73.6 26.4 100.0 236 Zamfara 63.8 36.2 100.0 312 South East Abia 100.0 0.0 100.0 77 Anambra 99.5 0.5 100.0 188 Ebonyi 87.1 12.9 100.0 145 Enugu 93.4 6.6 100.0 104 Imo 100.0 0.0 100.0 129 South South Akwa Ibom 96.0 4.0 100.0 175 Bayelsa 88.1 11.9 100.0 80 Cross River 96.2 3.8 100.0 131 Delta 89.0 11.0 100.0 199 Edo 89.2 10.8 100.0 131 Rivers 95.6 4.4 100.0 304 South West Ekiti 92.3 7.7 100.0 70 Lagos 95.5 4.5 100.0 435 Ogun 88.2 11.8 100.0 210 Ondo 90.2 9.8 100.0 183 Osun 90.0 10.0 100.0 167 Oyo 88.4 11.6 100.0 349 Education No education 73.5 26.5 100.0 2,594 Primary 80.3 19.7 100.0 1,854 Secondary 89.6 10.4 100.0 2,961 More than secondary 91.7 8.3 100.0 1,313 Continued… Marriage and Sexual Activity • 57 Table 4.2.2—Continued Background characteristic Number of wives Total Number of men 1 2+ Wealth quintile Lowest 72.5 27.5 100.0 1,795 Second 77.2 22.8 100.0 1,732 Middle 82.1 17.9 100.0 1,506 Fourth 88.7 11.3 100.0 1,697 Highest 94.1 5.9 100.0 1,992 Total 83.2 16.8 100.0 8,723 Note: Figures in parentheses are based on 25-49 unweighted cases. 4.3 AGE AT FIRST MARRIAGE In most societies, marriage marks the point in a woman’s life when childbearing first becomes socially acceptable. Women who marry early will, on average, have longer exposure to pregnancy and a greater number of lifetime births. Information on age at first marriage was obtained by asking all ever- married respondents the month and year they started living together with their first spouse. Table 4.3 presents the percentages of both women and men who first married by specific exact ages and the median age at first marriage, according to current age. The results show that almost half (49 percent) of women age 25-49 were married by age 18, and 61 percent were married by age 20. The proportion of women who married by age 18 decreases from 56 percent among women who are currently age 45-49 to 43 percent among women age 20-24. The median age at first marriage increases from 17.3 years among women age 45-49 to 19 years among women age 20-24. This is an indication of a gradual increase in age at marriage among the younger generation. Table 4.3 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 2013 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 11.6 na na na na 70.4 7,820 a 20-24 17.3 42.8 56.0 na na 33.1 6,757 19.0 25-29 21.8 46.3 58.1 67.7 78.9 14.1 7,145 18.6 30-34 23.7 48.8 59.9 69.2 79.6 6.7 5,467 18.2 35-39 22.3 48.3 61.5 72.1 83.8 2.7 4,718 18.2 40-44 24.8 50.1 64.7 74.6 84.2 1.5 3,620 18.0 45-49 28.9 55.5 66.8 76.5 85.7 0.7 3,422 17.3 20-49 22.4 47.7 60.2 na na 12.3 31,128 18.3 25-49 23.8 49.1 61.4 71.1 81.8 6.5 24,372 18.1 MEN 15-19 0.0 na na na na 98.7 3,619 a 20-24 0.0 2.4 7.2 na na 84.8 2,892 a 25-29 0.0 3.7 9.5 17.8 34.7 53.3 2,757 a 30-34 0.0 3.6 11.0 20.4 35.4 25.6 2,414 27.4 35-39 0.0 4.8 10.4 20.4 38.2 8.8 2,175 26.9 40-44 0.0 4.8 11.9 19.9 35.2 3.1 1,777 27.5 45-49 0.0 4.5 12.1 21.5 38.3 1.0 1,724 27.1 20-49 0.0 3.8 10.1 na na 35.0 13,740 a 25-49 0.0 4.2 10.8 19.8 36.2 21.7 10,848 a 30-49 0.0 4.4 11.3 20.5 36.7 10.9 8,090 27.2 Note: 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 or men began living with their spouse or partner for the first time before reaching the beginning of the age group 58 • Marriage and Sexual Activity Nigerian men enter into marriage at a later age than women. For this reason, the analysis for men was carried out for the 30-49 age group in addition to the 25-49 age group. The median age at first marriage among men age 30-49 is 27.2 years. A comparison between women and men in the 30-34 age group in- dicates that the median age at first marriage among men in that age group is 27.4 years, nine years later than women (18.2 years). Only 1 in 10 men age 20-49 marry by age 20, as compared with 6 in 10 women in the same age group. Table 4.4 presents the median age at first marriage among women and men, by background characteristics. Among women age 25-49, the median age at marriage is four years higher among those liv- ing in urban areas (20.8 years) than among those re- siding in rural areas (16.6 years). By zone, the lowest median age at marriage among women is observed in the North West (15.3 years), while the highest is in the South East (22.7 years). Among the states, the median age at marriage is as low as 14.4 years in Zamfara. There is a marked relationship between women’s level of education and their median age at first marriage. The median age at first marriage among women age 25-49 with no formal education is 15.5 years, and it rises steadily to 21.5 years among those with a secondary education. There is a positive association between wealth and age at marriage. The median age at marriage among women age 25-49 in the lowest wealth quintile is eight years lower than among women in the highest quintile (15.2 and 23.2 years, respectively). Differences in the median age at first mar- riage among men age 30-49 by background character- istics are not as large as those observed among wom- en. However, urban men (29.3 years) and those living in the South South (29.2 years) tend to marry later than other men. Median age at marriage increases with increasing education and wealth. 4.4 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage can be used as a proxy for the beginning of exposure to the risk of pregnan- cy. However, because some women are sexually ac- tive before marriage, the age at which women initiate sexual intercourse more precisely marks the begin- ning of their exposure to reproductive risks. Table 4.4 Median age at first marriage by background characteristics Median age at first marriage among women age 20-49 and age 25- 49, and median age at first marriage among men age 30-49, according to background characteristics, Nigeria 2013 Background characteristic Women age Men age 30-49 20-49 25-49 Residence Urban a 20.8 29.3 Rural 16.7 16.6 25.6 Zone North Central 19.1 18.9 26.4 North East 16.4 16.3 25.5 North West 15.4 15.3 25.6 South East a 22.7 a South South a 21.5 29.2 South West a 21.8 28.4 State North Central FCT-Abuja a 22.7 a Benue 17.9 17.6 26.4 Kogi a 19.8 29.6 Kwara a 20.9 27.8 Nasarawa 19.7 19.4 26.6 Niger 17.7 17.7 23.6 Plateau a 20.4 27.2 North East Adamawa 17.5 17.1 26.9 Bauchi 15.0 15.0 22.5 Borno 17.3 17.4 27.5 Gombe 16.0 15.8 23.1 Taraba 17.3 17.1 25.5 Yobe 16.3 16.1 25.5 North West Jigawa 15.2 15.1 22.6 Kaduna 17.5 17.3 26.7 Kano 15.6 15.4 28.5 Katsina 15.0 14.9 23.6 Kebbi 15.7 15.5 25.2 Sokoto 14.8 14.7 24.8 Zamfara 14.5 14.4 23.4 South East Abia a 24.3 a Anambra a 23.8 a Ebonyi a 20.7 a Enugu a 22.1 a Imo a 23.7 a South South Akwa Ibom a 21.0 28.7 Bayelsa 18.7 18.1 27.6 Cross River a 21.2 29.2 Delta a 21.0 28.4 Edo a 21.3 28.8 Rivers a 23.7 a South West Ekiti a 22.2 28.7 Lagos a 23.8 a Ogun a 20.5 26.7 Ondo a 21.0 28.2 Osun a 22.4 28.3 Oyo a 20.3 26.6 Education No education 15.6 15.5 24.4 Primary 17.9 18.0 26.3 Secondary a 21.5 28.3 Higher a a a Wealth quintile Lowest 15.3 15.2 23.7 Second 16.2 16.0 25.1 Middle 18.2 17.9 26.6 Fourth 19.9 19.5 28.4 Highest a 23.2 a Total 18.3 18.1 27.2 Note: Age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50 percent of the respondents began living with their spouse or partner for the first time before reaching the beginning of the age group Marriage and Sexual Activity • 59 The percentages of women and men who had sexual intercourse by specific exact ages are presented in Table 4.5. The median age at first intercourse among women age 25-49 is 17.6 years. Twenty- four percent of women report that they had sexual intercourse by age 15 and 54 percent by age 18. Approximately 7 in 10 Nigerian women reported having had sexual intercourse by age 20. Table 4.5 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 sexual intercourse, and median age at first sexual intercourse, according to current age, Nigeria 2013 Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourseCurrent age 15 18 20 22 25 WOMEN 15-19 15.6 na na na na 56.2 7,820 a 20-24 18.7 51.1 71.0 na na 13.0 6,757 17.9 25-29 22.0 51.7 67.4 79.1 88.0 3.1 7,145 17.8 30-34 23.7 53.4 68.0 78.3 85.7 1.2 5,467 17.6 35-39 22.1 53.9 69.0 79.7 87.4 0.3 4,718 17.6 40-44 24.7 53.4 68.4 78.0 84.3 0.2 3,620 17.6 45-49 28.4 57.0 69.4 78.9 85.0 0.1 3,422 17.1 20-49 22.6 53.0 68.9 na na 3.8 31,128 17.7 25-49 23.7 53.5 68.3 78.8 86.4 1.3 24,372 17.6 15-24 17.0 na na na na 36.2 14,576 a MEN 15-19 2.9 na na na na 84.5 3,619 a 20-24 4.0 18.6 40.1 na na 43.2 2,892 a 25-29 3.1 19.2 39.2 57.8 74.8 15.8 2,757 20.9 30-34 2.5 19.4 38.2 55.9 70.9 5.4 2,414 21.0 35-39 2.1 18.8 36.8 53.3 68.6 1.3 2,175 21.4 40-44 3.1 19.7 37.0 53.7 67.8 0.6 1,777 21.2 45-49 2.2 17.4 33.7 52.9 66.3 0.3 1,724 21.4 20-49 2.9 18.9 37.8 na na 13.5 13,740 a 25-49 2.6 19.0 37.2 55.0 70.2 5.6 10,848 21.1 15-24 3.4 na na na na 66.2 6,511 a na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Nigerian men exhibit a slightly older median age at first intercourse than women. Among men age 25-49, the median age at first intercourse is 21.1 years. Three percent of men reported having had sexual intercourse by age 15 and 19 percent by age 18. By age 20, more than one in three men had initiated sexual intercourse (37 percent). Table 4.6 presents the median age at first sexual intercourse among women and men by background characteristics. The most notable pattern is the increasing median age with increasing education among women. The median age rises steadily from 15.6 years among women with no education to 21.2 years among women with more than a secondary education. Similarly, median age at first sexual intercourse among women increases from 15.3 years in the lowest wealth quintile to 20.1 years in the highest quintile. However, this pattern does not apply for men. Men with no education and those in the lowest wealth quintile have a higher median age at first sexual intercourse than men who are educated and are in the higher wealth quintiles. 60 • Marriage and Sexual Activity Table 4.6 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 20-49 and age 25-49, and median age at first sexual intercourse among men age 25-49, according to background characteristics, Nigeria 2013 Background characteristic Women age Men age 25-49 20-49 25-49 Residence Urban 19.0 18.9 20.9 Rural 16.4 16.4 21.3 Zone North Central 18.7 18.7 20.7 North East 16.4 16.2 23.0 North West 15.5 15.4 24.9 South East a 20.2 20.2 South South 18.5 18.6 19.0 South West 19.6 19.7 20.1 State North Central FCT-Abuja a 19.9 23.5 Benue 16.9 16.8 18.7 Kogi a 20.1 23.7 Kwara 19.8 19.7 20.6 Nasarawa 18.9 19.0 19.2 Niger 18.3 18.4 21.0 Plateau a 20.1 22.0 North East Adamawa 16.9 16.6 22.9 Bauchi 15.1 15.1 22.4 Borno 17.6 17.7 24.8 Gombe 16.0 15.9 22.4 Taraba 16.5 16.4 20.2 Yobe 16.3 16.2 a North West Jigawa 15.3 15.2 23.0 Kaduna 16.8 16.8 21.3 Kano 15.6 15.5 a Katsina 15.1 15.0 23.8 Kebbi 15.9 15.7 24.9 Sokoto 14.9 14.8 a Zamfara 14.6 14.4 23.7 South East Abia a 20.9 20.8 Anambra a 20.5 19.8 Ebonyi 18.8 18.8 20.6 Enugu a 20.6 20.4 Imo a 20.3 19.5 South South Akwa Ibom 18.1 18.2 18.9 Bayelsa 16.3 16.1 17.8 Cross River 18.6 18.8 19.1 Delta 18.5 18.5 18.9 Edo 19.5 19.5 19.8 Rivers 18.8 18.8 19.1 South West Ekiti 19.4 19.6 18.8 Lagos a 20.4 20.2 Ogun 19.1 19.1 19.8 Ondo 19.0 19.1 18.4 Osun a 20.3 21.0 Oyo 18.7 18.8 20.6 Education No education 15.6 15.6 23.7 Primary 17.3 17.4 20.7 Secondary 19.2 19.3 20.5 More than secondary a 21.2 20.9 Wealth quintile Lowest 15.3 15.3 23.0 Second 16.0 15.9 22.6 Middle 17.6 17.5 20.9 Fourth 18.5 18.4 20.6 Highest a 20.1 20.5 Total 17.7 17.6 21.1 a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Marriage and Sexual Activity • 61 4.5 RECENT SEXUAL ACTIVITY In the absence of effective contraception, the probability of pregnancy is highly dependent upon the frequency of intercourse. Therefore, information on sexual activity can be used to refine measures of exposure to pregnancy. Men and women who have had sex were asked how long ago their most recent sexual intercourse occurred. Tables 4.7.1 and 4.7.2 shows the distribution of women and men by timing of last sexual intercourse, according to background characteristics. Sixty percent of women age 15-49 were sexually active during the four weeks preceding the interview. Another 17 percent reported that they had been sexually active in the 12 months preceding the survey (excluding 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. The proportion of women who were sexually active in the four weeks preceding the survey increases with age, peaking in the 30-34 age group (74 percent) and decreasing thereafter. As expected, the frequency of sexual activity among teenagers and women who are not currently in a union is lower than that among older women and women who are married or living with a man. Twenty-nine percent of women age 15-19 were sexually active in the four weeks preceding the survey, and 14 percent of never-married women were sexually active during the same period. Women in urban areas were less likely to be sexually active during the past four weeks (53 percent) than their counterparts in rural areas (66 percent). By zone, the proportion of women who were sexually active during the four weeks preceding the survey was highest in the North West (77 percent) and lowest in the South East (39 percent). The results show that women with no education (77 percent) are more likely to have been sexually active in the past four weeks than educated women, while women with a secondary education are least likely to have been sexually active in the past weeks (44 percent). The prevalence of recent sexual activity decreases with increasing wealth status. Five in 10 men age 15-49 reported having had sexual intercourse within the four weeks preceding the interview. Sixteen percent of men had been sexually active within the 12-month period prior to the survey but not in the month prior to the interview, and 5 percent had not been sexually active for one or more years. Twenty-eight percent of men reported never having had sexual intercourse. The proportion of men who were sexually active in the four weeks preceding the survey increases with age, peaking in the 45-49 age group (82 percent). Men who are in a union are much more likely to have been sexually active in the past four weeks than men who have never been married or lived together with a woman (84 percent and 16 percent, respectively). In addition, men in rural areas are more likely to have been sexually active in the past four weeks than men in urban areas (55 percent and 44 percent, respectively). Recent sexual activity among men is highest in the North East (55 percent) and lowest in the South East (35 percent). As in the 2008 NDHS, men with a secondary education are less likely to have been sexually active in the past four weeks (39 percent) and more likely to report never having had sexual intercourse (37 percent) than their counterparts in other categories. Recent sexual activity among men decreases from the lowest to the middle wealth quintile (from 60 to 44 percent) before increasing in the fourth (46 percent) and highest (48 percent) quintiles. 62 • Marriage and Sexual Activity Table 4.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Nigeria 2013 Timing of last sexual intercourse Never had sexual intercourse Total Number of women Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 29.1 10.8 3.7 0.2 56.2 100.0 7,820 20-24 59.3 21.3 6.2 0.2 13.0 100.0 6,757 25-29 70.4 20.1 6.3 0.1 3.1 100.0 7,145 30-34 73.5 18.5 6.5 0.3 1.2 100.0 5,467 35-39 73.1 18.2 8.1 0.2 0.3 100.0 4,718 40-44 71.5 15.8 12.1 0.4 0.2 100.0 3,620 45-49 63.2 16.9 19.3 0.4 0.1 100.0 3,422 Marital status Never married 14.4 16.4 9.2 0.2 59.8 100.0 9,326 Married or living together 78.9 17.1 3.8 0.2 0.0 100.0 27,830 Divorced/separated/wido wed 12.9 25.9 60.5 0.6 0.1 100.0 1,793 Marital duration2 0-4 years 77.8 18.9 3.0 0.1 0.1 100.0 5,772 5-9 years 79.6 17.4 2.8 0.2 0.0 100.0 5,025 10-14 years 79.8 16.7 3.2 0.3 0.0 100.0 4,663 15-19 years 80.8 15.4 3.6 0.2 0.0 100.0 3,510 20-24 years 78.9 16.1 4.7 0.3 0.0 100.0 2,851 25+ years 76.0 16.2 7.4 0.3 0.0 100.0 3,101 Married more than once 79.2 17.2 3.5 0.1 0.0 100.0 2,907 Residence Urban 52.6 18.0 9.6 0.3 19.5 100.0 16,414 Rural 66.1 16.8 6.3 0.2 10.6 100.0 22,534 Zone North Central 49.6 22.1 10.5 0.3 17.5 100.0 5,572 North East 71.0 12.3 4.8 0.2 11.6 100.0 5,766 North West 77.3 9.2 2.9 0.2 10.4 100.0 11,877 South East 38.6 23.5 16.7 0.2 20.9 100.0 4,476 South South 52.6 22.5 9.3 0.2 15.3 100.0 4,942 South West 50.0 24.3 9.3 0.3 16.0 100.0 6,314 State North Central FCT-Abuja 53.5 18.3 10.4 0.9 16.9 100.0 315 Benue 51.4 25.7 7.1 0.1 15.7 100.0 1,240 Kogi 43.3 22.1 10.9 0.0 23.6 100.0 704 Kwara 39.7 24.1 12.9 0.9 22.4 100.0 596 Nasarawa 52.8 21.8 11.4 0.2 13.9 100.0 594 Niger 56.3 18.5 9.7 0.3 15.1 100.0 1,462 Plateau 42.5 23.4 15.0 0.3 18.7 100.0 662 North East Adamawa 58.0 18.7 6.8 0.1 16.3 100.0 828 Bauchi 75.8 13.6 2.7 0.5 7.3 100.0 1,161 Borno 75.1 5.4 5.3 0.1 14.1 100.0 1,412 Gombe 76.0 10.1 3.4 0.4 10.1 100.0 550 Taraba 55.0 26.0 8.7 0.4 9.8 100.0 844 Yobe 81.3 4.8 2.2 0.0 11.7 100.0 971 North West Jigawa 78.9 14.5 2.4 0.1 4.0 100.0 1,353 Kaduna 76.2 7.8 5.0 0.1 10.9 100.0 2,136 Kano 70.7 9.0 2.8 0.1 17.4 100.0 3,189 Katsina 89.2 3.5 2.0 0.2 5.0 100.0 1,525 Kebbi 80.2 7.0 2.3 0.0 10.5 100.0 1,244 Sokoto 71.8 14.6 3.2 0.5 9.9 100.0 1,098 Zamfara 81.6 10.8 1.4 0.2 6.0 100.0 1,332 South East Abia 44.6 26.5 11.4 0.1 17.4 100.0 518 Anambra 42.1 20.0 17.2 0.3 20.4 100.0 1,052 Ebonyi 35.3 25.0 19.9 0.1 19.8 100.0 1,122 Enugu 33.2 25.4 15.7 0.0 25.8 100.0 951 Imo 41.4 22.1 16.5 0.2 19.8 100.0 833 South South Akwa Ibom 48.9 24.8 11.4 0.2 14.6 100.0 864 Bayelsa 58.4 19.1 6.5 0.2 15.8 100.0 364 Cross River 47.0 30.6 11.3 0.1 11.1 100.0 703 Delta 56.2 19.4 6.9 0.0 17.5 100.0 993 Edo 46.6 22.5 8.3 0.4 22.2 100.0 742 Rivers 57.2 20.1 10.1 0.5 12.1 100.0 1,276 South West Ekiti 46.9 27.5 8.4 0.0 17.2 100.0 326 Lagos 51.4 23.5 9.1 0.4 15.7 100.0 1,964 Ogun 53.8 25.6 7.9 0.2 12.4 100.0 883 Ondo 40.4 31.5 13.3 0.9 14.0 100.0 808 Osun 49.5 18.1 9.1 0.0 23.3 100.0 765 Oyo 52.1 23.4 8.8 0.2 15.5 100.0 1,568 Continued… Marriage and Sexual Activity • 63 Table 4.7.1—Continued Timing of last sexual intercourse Never had sexual intercourse Total Number of women Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Education No education 77.4 12.7 5.6 0.2 4.1 100.0 14,729 Primary 60.8 20.2 10.4 0.2 8.4 100.0 6,734 Secondary 44.0 19.5 7.7 0.2 28.6 100.0 13,927 More than secondary 53.7 22.3 11.4 0.5 12.1 100.0 3,558 Wealth quintile Lowest 78.2 11.8 3.4 0.1 6.5 100.0 7,132 Second 67.2 15.7 7.0 0.2 9.9 100.0 7,428 Middle 53.6 19.4 10.3 0.3 16.4 100.0 7,486 Fourth 52.7 20.0 8.9 0.2 18.2 100.0 7,992 Highest 53.3 18.9 8.4 0.3 19.1 100.0 8,910 Total 60.4 17.3 7.7 0.2 14.3 100.0 38,948 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married Table 4.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Nigeria 2013 Timing of last sexual intercourse Never had sexual intercourse Total Number of men Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 4.5 7.2 3.7 0.0 84.5 100.0 3,619 20-24 27.1 20.8 8.9 0.0 43.2 100.0 2,892 25-29 55.0 21.5 7.6 0.2 15.8 100.0 2,757 30-34 69.4 19.6 5.2 0.4 5.4 100.0 2,414 35-39 78.7 16.2 3.4 0.4 1.3 100.0 2,175 40-44 80.5 15.4 3.3 0.3 0.6 100.0 1,777 45-49 81.7 13.6 4.3 0.2 0.3 100.0 1,724 Marital status Never married 15.8 17.3 8.1 0.1 58.7 100.0 8,378 Married or living together 83.6 14.4 1.7 0.3 0.0 100.0 8,723 Divorced/separated/wido wed 29.0 32.7 38.3 0.0 0.0 100.0 258 Marital duration2 0-4 years 82.7 15.2 1.8 0.2 0.1 100.0 2,157 5-9 years 80.3 17.5 1.6 0.6 0.0 100.0 1,650 10-14 years 81.9 15.7 2.2 0.2 0.0 100.0 1,295 15-19 years 82.6 15.3 1.7 0.4 0.0 100.0 752 20-24 years 79.8 17.2 2.6 0.5 0.0 100.0 401 25+ years 78.0 16.0 6.0 0.0 0.0 100.0 179 Married more than once 89.1 9.6 1.0 0.3 0.0 100.0 2,289 Residence Urban 43.5 19.2 6.1 0.3 30.9 100.0 7,611 Rural 55.2 13.6 4.8 0.1 26.3 100.0 9,748 Zone North Central 49.1 21.1 8.0 0.1 21.7 100.0 2,685 North East 55.3 9.2 4.1 0.1 31.3 100.0 2,515 North West 54.5 4.2 1.4 0.2 39.8 100.0 5,185 South East 34.8 27.9 12.0 0.4 24.9 100.0 1,686 South South 52.1 23.5 6.3 0.1 18.0 100.0 2,445 South West 45.5 25.6 6.5 0.5 21.9 100.0 2,843 State North Central FCT-Abuja 51.0 17.6 5.6 0.7 25.2 100.0 175 Benue 50.6 27.5 3.3 0.0 18.6 100.0 616 Kogi 51.5 14.3 6.1 0.1 28.0 100.0 333 Kwara 41.0 24.8 11.4 0.0 22.8 100.0 274 Nasarawa 48.4 22.1 9.3 0.0 20.2 100.0 282 Niger 51.9 17.1 11.1 0.0 19.8 100.0 701 Plateau 43.4 22.7 9.9 0.0 24.0 100.0 302 North East Adamawa 42.9 16.6 10.7 0.0 29.8 100.0 358 Bauchi 59.9 7.5 1.7 0.0 30.9 100.0 512 Borno 58.0 6.5 3.9 0.2 31.3 100.0 676 Gombe 50.5 9.2 5.3 0.7 34.4 100.0 255 Taraba 57.1 18.5 3.5 0.0 21.0 100.0 325 Yobe 57.7 1.7 1.2 0.0 39.4 100.0 390 Continued… 64 • Marriage and Sexual Activity Table 4.7.2—Continued Timing of last sexual intercourse Never had sexual intercourse Total Number of men Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing North West Jigawa 63.9 3.0 1.9 0.2 31.0 100.0 510 Kaduna 57.9 11.0 2.5 0.1 28.6 100.0 1,033 Kano 42.9 0.5 0.4 0.0 56.2 100.0 1,592 Katsina 65.7 3.5 1.7 0.6 28.5 100.0 596 Kebbi 55.0 4.3 1.3 0.0 39.3 100.0 551 Sokoto 53.7 1.9 2.8 0.6 41.0 100.0 424 Zamfara 61.7 5.3 0.1 0.0 32.9 100.0 479 South East Abia 31.6 30.3 13.0 0.0 25.1 100.0 229 Anambra 41.2 25.5 12.9 0.6 19.8 100.0 446 Ebonyi 33.0 30.5 9.5 0.6 26.5 100.0 368 Enugu 26.1 25.6 12.8 0.4 35.1 100.0 320 Imo 39.0 29.1 12.0 0.0 19.9 100.0 323 South South Akwa Ibom 46.9 31.6 5.9 0.0 15.6 100.0 451 Bayelsa 52.6 23.2 6.3 0.0 17.9 100.0 187 Cross River 45.5 28.4 6.2 0.0 19.9 100.0 310 Delta 57.3 17.1 7.4 0.0 18.2 100.0 473 Edo 43.0 25.3 7.6 0.8 23.3 100.0 365 Rivers 59.8 19.4 5.0 0.0 15.7 100.0 658 South West Ekiti 45.3 24.9 6.1 0.0 23.7 100.0 148 Lagos 43.6 28.7 6.8 0.7 20.3 100.0 948 Ogun 54.2 19.4 5.3 0.8 20.4 100.0 358 Ondo 40.2 29.5 8.6 0.5 21.3 100.0 404 Osun 46.8 23.0 3.9 0.0 26.2 100.0 356 Oyo 46.1 23.7 6.9 0.4 22.8 100.0 629 Education No education 66.0 6.6 2.2 0.2 25.1 100.0 3,685 Primary 56.8 17.0 5.1 0.1 20.9 100.0 2,907 Secondary 38.6 18.0 6.5 0.1 36.9 100.0 8,281 More than secondary 56.7 22.7 6.6 0.6 13.4 100.0 2,486 Wealth quintile Lowest 60.3 5.2 2.6 0.2 31.7 100.0 2,862 Second 55.0 11.8 4.0 0.1 29.1 100.0 2,992 Middle 44.3 18.1 7.0 0.1 30.5 100.0 3,338 Fourth 45.8 19.4 6.1 0.1 28.6 100.0 3,835 Highest 48.1 21.6 6.1 0.5 23.6 100.0 4,332 Total 50.0 16.1 5.4 0.2 28.3 100.0 17,359 1 Excludes men who had sexual intercourse within the last 4 weeks 2 Excludes men who are not currently married Fertility • 65 FERTILITY 5 ertility is one of the principal components of population dynamics that determine the size, structure, and composition of the population in any country. 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 project population growth. 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 well-being of both the mother and the child. Data on childbearing patterns were collected in the 2013 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. 5.1 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. The goal of the National Policy on Population for Sustainable Development is to achieve a reduction in the total fertility rate of at least 0.6 children every five years (National Population Commission, 2004). The fertility measures outlined here will provide insight into current fertility rates, allowing a determination of whether Nigeria is achieving this target and what efforts need to be put in place to achieve it. Measures of current fertility presented in this chapter include age-specific fertility rates (ASFRs), the total fertility rate (TFR), the general fertility rate (GFR), and the crude birth rate (CBR). The rates are generally presented for the period 1-36 months preceding the survey, determined from the date of the 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 associated with 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 F Key Findings • The total fertility rate for the three years preceding the survey is 5.5 births per woman, as compared with 5.7 births per woman in 2003 and 2008. • Twenty-three percent of women age 15-19 have already begun childbearing and about one-third (32 percent) of women age 20-49 have had a birth by age 18. • The median age at first birth among women age 25-49 is 20.2 years. • Among women who had a live birth in the three years preceding the survey, the median duration of insusceptibility to pregnancy is 12.6 months. • Nine percent of women age 30-49 are menopausal. 66 • Fertility 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 average 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 5.1 for the country as a whole and by urban-rural residence. The 2013 NDHS results indicate that the TFR is 5.5 births per woman. This means that, on average, Nigerian women will give birth to 5.5 children by the end of their childbearing years. The current TFR of 5.5 is 0.2 children per woman less than that reported in the 2003 and 2008 NDHS surveys (5.7 each). Fertility peaks in the 25-29 age group in urban areas (237 births per 1,000 women) and the 20-24 age group in rural areas (267 births per 1,000 women) and declines thereafter. Table 5.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Nigeria 2013 Residence Total Age group Urban Rural 15-19 62 162 122 20-24 188 267 235 25-29 237 265 253 30-34 218 247 234 35-39 148 169 160 40-44 59 91 78 45-49 20 35 29 TFR (15-49) 4.7 6.2 5.5 GFR 159 213 190 CBR 35 42 39 Notes: Age-specific fertility rates are per 1,000 women. Rates for the 45-49 age group may be slightly biased due to truncation. Rates are for the period 1-36 months prior to the interview. TFR: Total fertility rate, expressed per woman GFR: General fertility rate, expressed per 1,000 women age 15-44 CBR: Crude birth rate, expressed per 1,000 population The general fertility rate is 190, which means that there were 190 births for every 1,000 women during the three-year period preceding the survey. Table 5.1 shows that the crude birth rate was 39 per 1,000 population for the same period. Rural areas have a much higher TFR than urban areas (6.2 versus 4.7), and there are large urban- rural differences in ASFRs for all age groups. The largest variations are in the 15-19 and 20-24 age groups; in these groups, the rates for rural women exceed those for urban women by 100 and 79 births per 1,000 women, respectively. Adolescent fertility in rural areas more than doubles that in urban areas. Figure 5.1 shows age-specific fertility rates by urban-rural residence. Fertility • 67 Figure 5.1 Trends in age-specific fertility rates by urban-rural residence 0 50 100 150 200 250 300 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group Urban Rural Total Births per 1,000 women NDHS 2013 Figure 5.2 Total fertility rates of selected ECOWAS countries 4.0 4.9 5.0 5.0 5.1 5.2 5.5 6.0 6.6 7.6 Ghana 2008 DHS Benin 2011- 12 DHS Cote d'Ivoire 2011-12 DHS Senegal 2010-11 DHS Sierra Leone 2008 DHS Liberia 2007 DHS Nigeria 2013 DHS Burkina Faso 2010 DHS Mali 2006 DHS Niger 2012 DHS Source: MEASURE DHS STATcompiler, 2014 Figure 5.2 shows the fertility levels of selected countries in the Economic Community of West African States (ECOWAS). Nigeria’s fertility rate falls roughly in the middle of this group of countries, whose TFRs range from 4.0 in Ghana to 7.6 in Niger. 5.2 FERTILITY DIFFERENTIALS Table 5.2 presents several fertility indicators (TFR, percentage of women age 15-49 who are currently pregnant, and 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. The latter indicator summarises the fertility behaviour of older women who are nearing the end of their reproductive period. It serves as a marker of average completed fertility for women who began childbearing in the three decades preceding the survey. 68 • Fertility 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 6.3. 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 comparisons of the TFR and the mean number of children ever born because older women may understate their total childbearing experience. Table 5.2 shows variations in TFR by residence, zone, states, education, and wealth quintile. Figure 5.3 shows variations in TFR by zone. The more urbanised zones, the South East (4.7), South South (4.3), and South West (4.6), have lower fertility rates than the three mostly rural northern zones. The highest TFR is seen in the North West (6.7), followed by the North East (6.3). The TFR decreases with increasing level of education. Women with more than a secondary education have a TFR of 3.1, as compared with a TFR of 6.9 among women with no education. Women in the highest wealth quintile have an average of three fewer children than women in the lowest quintile (3.9 and 7.0 births per woman, respectively). Table 5.2 shows that 12 percent of interviewed women 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 5.2 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 2013 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 9.5 5.6 Rural 6.2 14.0 6.8 Zone North Central 5.3 11.7 5.8 North East 6.3 13.9 7.1 North West 6.7 16.1 7.6 South East 4.7 7.9 5.7 South South 4.3 8.6 5.4 South West 4.6 9.0 4.8 States North Central FCT-Abuja 4.5 8.3 4.7 Benue 5.2 13.0 6.8 Kogi 4.2 9.4 5.7 Kwara 5.1 7.2 5.2 Nasarawa 5.4 10.8 5.8 Niger 6.1 14.8 5.8 Plateau 5.4 11.2 5.6 North East Adamawa 5.8 15.6 6.7 Bauchi 8.1 16.9 8.4 Borno 4.7 12.7 5.2 Gombe 7.0 14.3 7.9 Taraba 6.0 10.6 7.1 Yobe 6.6 13.4 7.4 North West Jigawa 7.6 15.1 7.6 Kaduna 4.1 21.0 5.7 Kano 6.8 12.6 7.7 Katsina 7.4 17.3 8.4 Kebbi 6.7 16.9 8.2 Sokoto 7.0 14.1 7.3 Zamfara 8.4 17.0 8.7 Continued… Fertility • 69 Table 5.2—Continued Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 South East Abia 4.2 7.3 5.0 Anambra 4.2 6.0 4.7 Ebonyi 5.3 9.1 7.1 Enugu 4.8 8.4 5.9 Imo 4.8 8.3 5.0 South South Akwa Ibom 3.9 5.3 5.4 Bayelsa 4.5 11.3 6.1 Cross River 5.4 9.1 5.5 Delta 4.1 10.6 5.6 Edo 4.4 6.3 5.7 Rivers 3.8 9.5 4.9 South West Ekiti 4.3 7.0 5.2 Lagos 4.1 7.2 4.3 Ogun 5.4 10.6 4.9 Ondo 5.2 9.1 5.2 Osun 4.1 6.8 4.3 Oyo 4.5 11.9 5.1 Education No education 6.9 15.6 7.3 Primary 6.1 12.6 6.3 Secondary 4.6 9.2 4.9 More than secondary 3.1 8.0 3.9 Wealth quintile Lowest 7.0 16.2 7.6 Second 6.7 15.0 7.2 Middle 5.7 11.6 6.5 Fourth 4.9 10.2 5.7 Highest 3.9 8.4 4.5 Total 5.5 12.1 6.3 Note: Total fertility rates are for the period 1-36 months prior to the interview. Figure 5.3 Fertility differentials by zone 4.6 4.3 4.7 6.7 6.3 5.3 5.5 South West South South South East North West North East North Central Nigeria Births per woman NDHS 2013 70 • Fertility 5.3 FERTILITY TRENDS Table 5.3.1 uses information from the retrospective birth histories obtained from the 2013 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 periods 5-9 years or more preceding the survey because women in that age group would have been age 50 or older at the time of the survey. Table 5.3.1 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 2013 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 123 146 148 147 20-24 239 255 259 257 25-29 260 290 284 283 30-34 240 264 253 [278] 35-39 163 189 [218] 40-44 81 [112] 45-49 [33] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of the interview. The results in Table 5.3.1 show that fertility decreased in all age groups over the most recent five- year period preceding the survey. Another way to examine fertility trends is to compare current estimates with earlier surveys. Table 5.3.2 and Figure 5.4 show estimates of ASFRs from the 2003, 2008, and 2013 NDHS surveys. Overall, fertility remained constant at 5.7 births per woman between 2003 and 2008 and is estimated at 5.5 births in 2013. Table 5.3.2 Trends in age-specific and total fertility rates Trends in age-specific and total fertility rates for the three-year period preceding the 2003, 2008, and 2013 NDHS surveys, by mother’s age at the time of the birth Mother’s age at birth Survey 2003 NDHS 2008 NDHS 2013 NDHS 15-19 126 121 122 20-24 229 225 235 25-29 274 265 253 30-34 244 241 234 35-39 168 161 160 40-44 72 87 78 45-49 18 44 29 TFR 15-49 5.7 5.7 5.5 Note: Age-specific fertility rates are per 1,000 women. Rates exclude the month of the interview. Fertility • 71 Figure 5.4 Trends in age-specific fertility rates, 2003-2013 0 50 100 150 200 250 300 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Births per 1,000 women Age NDHS 2003 NDHS 2008 NDHS 2013 5.4 CHILDREN EVER BORN AND LIVING Table 5.4 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. Comparisons of the mean number of children ever born to all women and the mean number of living children show the cumulative effects of mortality during the childbearing period. More than four-fifths of women age 15-19 (83 percent) have never given birth (Table 5.4). However, this proportion declines to 9 percent among 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 (6.8) children. The same pattern is seen for currently married women, except that the mean number of children ever born is higher (4.0 children) in this group than among all women (3.1 children). The difference in mean number of children ever born between all women and currently married women can be attributed to the substantial proportion of young and unmarried women in the former category. The percentage of women in their 40s 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 2013 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 are unable to have more children (secondary infertility). 72 • Fertility Table 5.4 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 2013 Number of children ever born Total Number of women Mean number of children ever born Mean number of living children Age 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 82.9 13.6 3.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 7,820 0.21 0.19 20-24 38.7 24.2 20.3 12.1 3.6 0.9 0.1 0.0 0.0 0.0 0.0 100.0 6,757 1.21 1.07 25-29 17.5 13.6 18.0 18.8 15.9 9.7 4.4 1.4 0.5 0.0 0.0 100.0 7,145 2.60 2.24 30-34 9.3 7.1 10.6 14.1 17.1 15.8 12.7 7.3 3.9 1.5 0.6 100.0 5,467 3.96 3.37 35-39 4.6 3.9 7.2 9.9 13.8 14.2 13.4 12.2 9.7 6.3 4.8 100.0 4,718 5.25 4.39 40-44 4.2 3.1 5.0 8.1 11.7 13.3 13.9 11.2 9.7 8.5 11.4 100.0 3,620 5.90 4.82 45-49 3.0 2.0 3.9 6.5 9.5 11.5 11.3 12.6 9.7 8.3 21.8 100.0 3,422 6.76 5.20 Total 29.1 11.3 10.6 10.1 9.5 8.1 6.5 4.9 3.6 2.5 3.6 100.0 38,948 3.06 2.54 CURRENTLY MARRIED WOMEN 15-19 48.2 40.1 9.9 1.6 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,251 0.65 0.57 20-24 13.4 31.5 29.8 18.3 5.4 1.4 0.2 0.0 0.0 0.0 0.0 100.0 4,362 1.76 1.56 25-29 6.1 13.6 20.6 22.0 18.6 11.5 5.1 1.7 0.7 0.1 0.0 100.0 5,913 3.01 2.59 30-34 3.8 6.6 10.8 14.8 18.5 17.1 13.9 8.0 4.3 1.7 0.6 100.0 4,869 4.27 3.63 35-39 2.5 3.2 6.8 9.9 13.7 14.7 14.0 12.9 10.4 6.7 5.2 100.0 4,302 5.48 4.58 40-44 2.9 3.0 4.6 8.1 11.2 13.3 13.6 11.8 10.3 9.0 12.4 100.0 3,226 6.09 4.95 45-49 2.1 1.8 3.2 5.9 9.3 11.6 10.7 12.5 10.1 8.5 24.3 100.0 2,907 7.02 5.37 Total 8.9 13.3 13.6 13.4 12.4 10.7 8.4 6.4 4.7 3.3 4.9 100.0 27,830 4.00 3.32 5.5 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 the health status of young children. Research has shown that short birth intervals (less than 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 mother and child. Table 5.5 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 5.5 shows that 7 percent of births are less than 18 months apart and 23 percent have an interval of less than two years. Two in five births (39 percent) take place 24-35 months after the previous birth, and 20 percent occur 36-47 months after the previous birth. The median birth interval is 31.7 months, roughly the same as the median interval in the 2008 NDHS (31.4 months). Thirty-nine 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 26.3 months among mothers age 15-19 to 37.7 months among mothers age 40-49. The median birth interval does not vary substantially by birth order or sex of the preceding birth. However, there are notable variations in the median birth interval according to age, survival of the preceding birth, and zone. The median birth interval is higher (32.3 months) when the preceding sibling is living than when the preceding sibling has died (27.3 months). The median birth interval varies by zone from 28.4 months among women in the South East to 35.1 months among women in the South West. There is little variation in median birth interval by birth order, residence, educational attainment, or wealth quintile. Fertility • 73 Table 5.5 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 2013 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 12.9 26.0 46.7 11.6 2.4 0.5 100.0 301 26.3 20-29 8.0 18.7 43.1 18.2 6.9 5.1 100.0 10,827 29.6 30-39 6.5 14.9 37.7 21.0 9.5 10.4 100.0 11,240 32.7 40-49 4.4 12.0 29.9 21.4 11.8 20.6 100.0 3,175 37.7 Sex of preceding birth Male 7.1 16.5 38.7 20.1 8.6 9.0 100.0 13,000 31.7 Female 6.8 16.1 39.6 19.4 8.6 9.5 100.0 12,542 31.7 Survival of preceding birth Living 5.2 15.8 40.0 20.5 9.0 9.6 100.0 21,990 32.3 Dead 17.9 19.4 33.9 15.1 6.3 7.4 100.0 3,552 27.3 Birth order 2-3 7.2 17.2 40.6 18.4 7.6 9.1 100.0 10,311 30.9 4-6 6.3 15.5 38.7 20.3 9.1 10.0 100.0 10,011 32.3 7+ 7.6 16.0 37.1 21.4 9.7 8.1 100.0 5,221 32.3 Residence Urban 7.0 15.9 37.4 19.2 9.5 11.0 100.0 8,617 32.5 Rural 6.9 16.5 40.0 20.0 8.1 8.4 100.0 16,926 31.3 Zone North Central 5.5 14.0 40.8 19.3 9.0 11.5 100.0 3,405 32.3 North East 8.1 17.8 40.2 19.9 7.8 6.1 100.0 4,608 30.2 North West 6.6 16.8 40.0 21.2 8.3 7.1 100.0 9,854 31.6 South East 10.5 20.0 41.3 13.4 6.3 8.4 100.0 2,190 28.4 South South 6.9 16.4 35.3 18.4 9.0 14.0 100.0 2,168 32.4 South West 5.3 12.6 34.4 20.9 11.4 15.4 100.0 3,318 35.1 State North Central FCT-Abuja 6.9 15.2 37.3 17.0 13.8 9.8 100.0 158 32.3 Benue 7.3 14.9 47.5 16.5 6.5 7.4 100.0 785 29.9 Kogi 4.0 11.3 34.0 22.9 12.6 15.2 100.0 300 36.3 Kwara 2.4 10.2 40.4 22.9 9.1 14.9 100.0 314 34.9 Nasarawa 6.8 13.0 36.4 22.5 8.6 12.7 100.0 354 34.0 Niger 4.5 16.5 40.8 17.4 8.8 12.0 100.0 1,109 31.6 Plateau 6.6 10.2 38.0 22.8 10.5 12.0 100.0 386 34.3 North East Adamawa 7.7 15.8 41.9 18.9 7.5 8.1 100.0 587 30.1 Bauchi 10.6 17.6 39.3 19.5 7.6 5.4 100.0 1,230 30.0 Borno 10.3 16.7 40.3 19.8 7.2 5.8 100.0 874 29.7 Gombe 6.6 18.7 41.5 19.9 7.3 6.1 100.0 494 30.0 Taraba 5.8 17.9 38.2 21.0 8.8 8.3 100.0 625 31.3 Yobe 5.0 20.4 41.3 20.4 8.5 4.4 100.0 797 30.1 North West Jigawa 9.0 17.9 41.6 19.6 6.1 5.8 100.0 1,340 29.9 Kaduna 4.7 12.7 38.9 25.1 10.1 8.5 100.0 1,134 34.4 Kano 6.1 17.3 37.6 22.0 9.1 8.0 100.0 2,538 32.3 Katsina 5.9 17.0 40.7 20.4 10.3 5.8 100.0 1,426 32.1 Kebbi 6.7 18.1 34.2 23.5 7.5 10.1 100.0 1,059 32.6 Sokoto 6.7 16.7 43.6 19.9 7.2 5.9 100.0 987 30.7 Zamfara 7.6 17.3 45.1 18.0 6.7 5.3 100.0 1,371 29.6 South East Abia 12.2 18.8 40.1 12.1 6.1 10.8 100.0 249 28.7 Anambra 14.1 21.6 37.0 12.1 5.6 9.5 100.0 501 27.6 Ebonyi 5.8 15.4 49.5 15.5 8.3 5.4 100.0 590 29.5 Enugu 11.1 18.3 37.6 13.9 7.5 11.5 100.0 430 29.9 Imo 11.3 26.8 39.5 12.4 3.2 6.8 100.0 419 26.1 South South Akwa Ibom 7.0 16.7 33.1 15.0 9.7 18.4 100.0 324 33.3 Bayelsa 7.1 13.9 36.2 19.7 10.2 12.9 100.0 188 32.8 Cross River 3.4 13.9 38.4 20.6 11.2 12.6 100.0 408 33.5 Delta 9.6 16.2 34.9 17.2 8.1 13.9 100.0 430 31.8 Edo 5.2 17.2 37.3 20.8 7.1 12.5 100.0 316 31.7 Rivers 8.2 18.7 33.1 18.0 8.4 13.6 100.0 502 30.5 Continued… 74 • Fertility Table 5.5—Continued Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ South West Ekiti 5.0 13.2 30.8 19.4 10.5 21.0 100.0 140 36.3 Lagos 9.4 15.7 33.3 17.3 10.3 13.9 100.0 945 32.7 Ogun 3.6 12.0 35.3 23.0 12.5 13.6 100.0 577 35.7 Ondo 5.9 11.7 35.1 21.8 10.1 15.5 100.0 444 35.3 Osun 2.8 10.0 35.2 25.2 11.1 15.7 100.0 336 36.5 Oyo 2.9 10.8 35.0 21.3 12.9 17.0 100.0 875 36.3 Education No education 6.8 16.9 40.3 20.3 8.3 7.5 100.0 13,342 31.2 Primary 6.1 14.9 38.9 20.0 9.4 10.6 100.0 5,241 32.6 Secondary 7.8 16.4 37.6 18.8 8.5 10.9 100.0 5,755 31.8 More than secondary 7.9 15.3 35.4 16.8 9.1 15.5 100.0 1,205 32.4 Wealth quintile Lowest 6.4 16.7 41.7 20.1 8.6 6.5 100.0 6,373 31.2 Second 7.9 17.4 39.8 20.2 7.6 7.2 100.0 6,052 30.4 Middle 6.1 16.2 38.8 20.4 8.1 10.3 100.0 4,785 32.0 Fourth 6.8 15.5 38.0 19.6 9.3 10.8 100.0 4,432 32.6 Highest 7.5 15.0 35.7 17.8 10.0 14.0 100.0 3,900 33.0 Total 6.9 16.3 39.1 19.8 8.6 9.3 100.0 25,543 31.7 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. 5.6 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea is the period between the birth of a child and the resumption of menstruation, during which the risk of pregnancy is very low. Postpartum protection from conception can be influenced by the intensity and length of breastfeeding. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. Delaying the resumption of sexual relations after a birth prolongs the period of postpartum protection. A woman is considered insusceptible to pregnancy if she is not exposed to the risk of pregnancy either because she is amenorrheic or because she is abstaining from sexual intercourse following a birth. The durations of amenorrhoea and sexual abstinence following birth jointly determine the length of insusceptibility. Postpartum amenorrhoea and sexual abstinence affect the duration of a woman’s insusceptibility to pregnancy, which affects birth spacing. The onset of menopause marks the end of a woman’s reproductive life. These variables, taken together, determine the length and pace of a woman’s reproductive life, and therefore they are important for understanding fertility levels and differentials. In the 2013 NDHS, information was obtained about the duration of postpartum amenorrhoea, sexual abstinence, and insusceptibility for births in the three years preceding the survey. The median duration of postpartum insusceptibility to pregnancy is 12.6 months. Table 5.6 shows that Nigerian women are amenorrheic for a median duration of 10.6 months and abstain for a median duration of 2.8 months. In general, the proportion of women who are amenorrheic or abstaining decreases with increasing months after delivery. The proportion of women who are amenorrheic drops from 95 percent in the first two months after birth to 29 percent at 16-17 months and less than 5 percent at 28 months or later. The majority of Nigerian women (89 percent) are still abstaining in the first two months following birth. Almost all women (98 percent) are insusceptible to pregnancy during the first two months following childbirth. The period of postpartum amenorrhoea is considerably longer than the period of postpartum abstinence and is by far the major determinant of the length of postpartum insusceptibility to pregnancy. At 10 to 11 months after birth, almost half of women are still amenorrheic, but only 16 percent are abstaining. At 16 to 17 months after birth, the proportion of women who are amenorrheic is 29 percent, while 9 percent of women are abstaining. Fertility • 75 Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Nigeria 2013 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 <2 95.2 88.9 98.4 816 2-3 85.8 50.1 89.9 1,082 4-5 75.4 31.1 80.3 1,182 6-7 67.1 23.1 72.8 1,160 8-9 56.0 18.1 62.9 1,173 10-11 49.4 15.9 57.1 1,096 12-13 46.2 10.2 50.4 1,281 14-15 39.4 9.7 44.5 1,258 16-17 29.4 8.7 34.1 1,017 18-19 22.1 6.8 27.5 943 20-21 17.4 6.2 21.4 913 22-23 11.3 4.6 15.1 825 24-25 6.8 3.3 9.1 1,225 26-27 8.5 3.1 11.1 1,047 28-29 4.0 2.7 6.2 927 30-31 3.4 2.2 5.5 889 32-33 2.6 1.7 4.1 958 34-35 1.5 1.2 2.6 928 Total 35.8 15.7 39.9 18,722 Median 10.6 2.8 12.6 na Mean 12.7 6.1 14.1 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 amenorrheic or still abstaining (or both) following birth A comparison of the 2013 NDHS results with those of earlier NDHS surveys indicates that the duration of abstinence has decreased gradually. The median duration of postpartum amenorrhoea has steadily decreased over time, from 13.2 months in 2003 to 11.5 months in 2008 and 10.6 months in 2013. Similarly, there has been a slow but steady decline in the median duration of insusceptibility, from 15.1 months in 2003 to 13.8 months in 2008 and 12.6 months in 2013. Table 5.7 shows that the median duration of postpartum amenorrhoea is longer among women age 30-49 (11.7 months) than among women age 15-29 (10.0 months). The duration of postpartum insusceptibility is also longer among older women (12.9 months) than younger women (12.4 months). However, the median length of postpartum abstinence is approximately the same for younger and older women. Rural women have a much longer period of postpartum amenorrhoea than urban women (12.7 and 8.4 months, respectively) and a longer median period of postpartum insusceptibility (14.5 and 10.0 months, respectively). However, the median length of postpartum abstinence is almost the same. There are considerable regional variations in postpartum amenorrhoea and abstinence. The median duration of postpartum amenorrhoea ranges from 6.4 months in the South East to 15.5 months in the North West. While the median durations of amenorrhoea and insusceptibility decline as education increases, the median duration of abstinence is lowest among women with no education (2.3 months). The pattern is similar with respect to wealth quintile. 76 • Fertility Table 5.7 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 2013 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother’s age 15-29 10.0 2.8 12.4 30-49 11.7 2.9 12.9 Residence Urban 8.4 2.7 10.0 Rural 12.7 2.9 14.5 Zone North Central 9.8 8.8 13.1 North East 13.1 2.4 13.9 North West 15.5 2.0 15.7 South East 6.4 4.6 10.6 South South 6.6 3.7 7.8 South West 8.9 3.8 10.5 State North Central FCT-Abuja (8.0) (3.8) 9.6 Benue 11.3 8.9 13.0 Kogi 9.5 10.9 13.5 Kwara 8.0 7.1 11.1 Nasarawa 9.5 7.2 13.2 Niger 9.7 7.9 13.1 Plateau 11.4 12.0 14.0 North East Adamawa 10.0 4.1 11.6 Bauchi 13.9 2.3 14.5 Borno 9.2 (1.9) 9.6 Gombe 14.9 2.5 15.2 Taraba 12.9 6.1 14.3 Yobe 20.8 1.5 20.8 North West Jigawa 16.2 1.9 16.2 Kaduna 8.3 2.1 8.9 Kano 17.1 2.1 17.2 Katsina 13.2 1.4 13.8 Kebbi 14.8 1.9 14.8 Sokoto 16.5 2.7 16.7 Zamfara 16.4 2.1 16.4 South East Abia 5.2 2.7 10.2 Anambra (5.6) (2.4) 7.5 Ebonyi 8.7 8.3 13.6 Enugu 7.0 7.1 13.3 Imo 4.5 3.4 8.6 South South Akwa Ibom 6.8 3.5 7.8 Bayelsa 6.3 3.6 7.0 Cross River 7.9 6.1 11.2 Delta 7.9 2.4 8.5 Edo 7.3 4.1 9.3 Rivers (4.3) (3.0) 5.2 South West Ekiti 8.6 4.9 9.9 Lagos 7.7 2.3 9.0 Ogun 8.9 4.1 9.9 Ondo 10.1 7.7 12.7 Osun 6.3 4.5 7.5 Oyo 11.6 6.0 12.1 Education No education 15.3 2.3 16.2 Primary 10.5 3.8 13.4 Secondary 7.4 3.6 9.6 More than secondary 5.6 2.8 7.0 Wealth quintile Lowest 15.9 2.3 16.5 Second 14.5 3.0 16.0 Middle 10.3 3.6 12.9 Fourth 8.4 3.2 10.1 Highest 6.2 2.6 7.7 Total 10.6 2.8 12.6 Note: Medians are based on status at the time of the survey (current status). Figures in parentheses are based on 25-49 unweighted cases (smoothed data). 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth Fertility • 77 5.7 MENOPAUSE The risk of becoming pregnant declines with age. After age 30, women’s susceptibility to pregnancy declines as an increasing proportion of women become infecund. The term infecundity denotes a process rather than a well-defined event. Although the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a group of women. One indicator of infecundity is the onset of menopause. Menopause is the culmination of a gradual decline in fecundity with increasing age. The 2013 NDHS defines menopausal women as women who are neither pregnant nor postpartum amenorrheic and who have not had a menstrual period in the six months preceding the survey. Women who report that they have had a hysterectomy are also defined as menopausal. Table 5.8 presents data on menopause for women age 30 and older. Nine percent of women age 30-49 are estimated to be menopausal. The proportion of women who are menopausal increases with age, from 1 percent among women age 30- 34 to 44 percent among women age 48-49. These findings are similar to those in the 2008 NDHS. 5.8 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, delays in first births as a result of an increase in the age at marriage have contributed to a decrease in fertility. Table 5.9 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 among women age 25-49 in Nigeria is 20.2 years. The median age at first birth increases from 19.5 years among women age 45-49 to 20.3 years among women age 25-29. In Nigeria, 8 percent of women age 25-49 have given birth by age 15, and 49 percent have become mothers by age 20. Comparing the proportions of women who have given birth by age 18 across age groups is another way to view trends in age at first birth over time. Whereas 29 percent of women age 20- 24 gave birth by age 18, the corresponding proportion for women age 45-49 is 37 percent. This reduction in the percentage of women giving birth early supports the findings indicating that age at first childbirth has been increasing slowly. Table 5.9 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 2013 Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth Current age 15 18 20 22 25 15-19 2.4 na na na na 82.9 7,820 a 20-24 5.9 29.1 46.7 na na 38.7 6,757 a 25-29 7.0 31.9 47.5 61.1 75.1 17.5 7,145 20.3 30-34 7.8 32.7 48.0 60.8 74.9 9.3 5,467 20.3 35-39 7.7 31.7 48.5 62.2 77.5 4.6 4,718 20.2 40-44 8.1 32.0 48.1 62.9 77.4 4.2 3,620 20.2 45-49 9.5 36.9 54.0 65.8 79.6 3.0 3,422 19.5 20-49 7.4 31.9 48.4 na na 15.6 31,128 a 25-49 7.8 32.7 48.8 62.2 76.5 9.2 24,372 20.2 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 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Nigeria 2013 Age Percentage menopausal1 Number of women 30-34 0.9 5,467 35-39 1.3 4,718 40-41 6.5 2,004 42-43 10.4 1,241 44-45 18.7 1,509 46-47 26.8 823 48-49 44.0 1,465 Total 8.8 17,227 1 Percentage of all women who are not pregnant and not postpartum amenorrheic whose last menstrual period occurred six or more months preceding the survey 78 • Fertility Table 5.10 shows the median age at first birth across age cohorts for key subgroups 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 (22.0 years) than their rural counterparts (19.0 years). A comparison of the zones shows that the median age at first birth among women age 25-49 ranges from 17.9 years in the North West to 23.7 years in the 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 18.1 years, as compared with 22.4 years among women who have a secondary education, a difference of almost four years. There is also a positive correlation between age at first birth and wealth quintile. As the socioeconomic status of household increases, so does the median age at first birth, from 18.0 years among women in the lowest wealth quintile to 24.1 years among those in the highest quintile. 5.9 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 the 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 5.11 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 (17 percent have had a child and 5 percent are pregnant with their first child). A larger proportion of teenagers in rural areas than in urban areas have begun childbearing (32 percent versus 10 percent). A comparison of the geopolitical zones shows that the North West has the largest proportion (36 percent) of teenagers who have started childbearing, while the South East (8 percent) and South West (8 percent) have the lowest proportions. The percentage of teenagers who have started childbearing decreases with increasing education. Teenagers with no education represent about half of those who have begun childbearing, while only 2 percent of teenagers with more than a 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 (43 percent and 21 percent, respectively) and almost 10 times as likely as those in the highest quintile. Childbearing begins earlier in Katsina than in any other state in Nigeria; 53 percent of women age 15-19 have begun childbearing in that state, as compared with 1 percent of teenage women in Osun. Possible reasons for this wide variation are the high median age at first marriage in Osun relative to Katsina and the differences between the two states in educational and socioeconomic characteristics. Table 5.10 Median age at first birth Median age at first birth among women age 25-49, according to background characteristics, Nigeria 2013 Background characteristic Women age 25-49 Residence Urban 22.0 Rural 19.0 Zone North Central 20.6 North East 18.8 North West 17.9 South East 23.7 South South 21.8 South West 22.7 State North Central FCT-Abuja 23.6 Benue 18.9 Kogi 21.0 Kwara 22.1 Nasarawa 20.6 Niger 19.8 Plateau 21.9 North East Adamawa 19.1 Bauchi 17.7 Borno 20.4 Gombe 18.1 Taraba 18.9 Yobe 18.9 North West Jigawa 17.7 Kaduna 19.4 Kano 18.2 Katsina 17.3 Kebbi 17.9 Sokoto 17.4 Zamfara 17.6 South East Abia a Anambra 24.8 Ebonyi 21.4 Enugu 22.9 Imo a South South Akwa Ibom 21.2 Bayelsa 19.2 Cross River 21.0 Delta 22.0 Edo 22.5 Rivers 23.1 South West Ekiti 22.8 Lagos 24.5 Ogun 21.6 Ondo 21.9 Osun 23.5 Oyo 21.4 Education No education 18.1 Primary 19.5 Secondary 22.4 More than secondary a Wealth quintile Lowest 18.0 Second 18.5 Middle 19.5 Fourth 20.8 Highest 24.1 Total 20.2 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group Fertility • 79 Table 5.11 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 2013 Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Background characteristic Have had a live birth Are pregnant with first child Age 15 2.2 2.9 5.1 2,021 16 8.0 5.4 13.4 1,466 17 15.9 6.6 22.6 1,380 18 30.2 7.0 37.2 1,786 19 35.5 5.8 41.3 1,166 Residence Urban 7.5 2.2 9.7 3,308 Rural 24.1 7.7 31.8 4,511 Zone North Central 12.4 6.5 18.8 1,154 North East 25.4 6.6 32.1 1,190 North West 26.3 9.4 35.7 2,428 South East 6.9 1.3 8.2 894 South South 11.2 1.1 12.3 1,033 South West 6.5 1.7 8.2 1,121 State North Central FCT-Abuja 6.9 2.3 9.2 48 Benue 11.2 11.3 22.5 284 Kogi 13.7 4.0 17.8 190 Kwara 3.9 2.0 5.9 136 Nasarawa 11.9 3.5 15.4 96 Niger 19.6 7.7 27.3 284 Plateau 8.0 5.1 13.1 117 North East Adamawa 21.0 7.7 28.7 175 Bauchi 37.8 10.3 48.1 222 Borno 22.7 6.1 28.8 317 Gombe 28.7 7.6 36.4 104 Taraba 22.7 3.7 26.4 159 Yobe 20.7 4.4 25.1 213 North West Jigawa 43.5 8.2 51.7 239 Kaduna 20.9 12.2 33.2 464 Kano 17.3 5.9 23.2 739 Katsina 41.2 12.2 53.3 283 Kebbi 26.4 8.0 34.4 232 Sokoto 24.7 11.2 36.0 227 Zamfara 31.4 11.8 43.2 245 South East Abia 4.6 2.0 6.6 75 Anambra 2.7 0.0 2.7 187 Ebonyi 7.9 1.7 9.6 270 Enugu 8.5 0.9 9.4 206 Imo 9.3 2.1 11.4 157 South South Akwa Ibom 16.2 1.7 17.9 194 Bayelsa 14.2 2.5 16.7 95 Cross River 17.0 1.4 18.4 103 Delta 7.1 1.2 8.3 233 Edo 3.4 0.5 3.9 186 Rivers 13.7 0.2 13.9 223 South West Ekiti 4.5 0.8 5.3 71 Lagos 3.5 1.3 4.8 309 Ogun 7.1 2.9 10.0 120 Ondo 11.0 2.6 13.5 180 Osun 1.1 0.0 1.1 160 Oyo 10.3 2.0 12.4 281 Education No education 37.1 10.6 47.6 2,170 Primary 22.7 9.5 32.2 952 Secondary 6.9 2.2 9.1 4,571 More than secondary 0.7 1.0 1.7 126 Wealth quintile Lowest 34.1 9.1 43.3 1,322 Second 25.5 9.0 34.5 1,577 Middle 16.0 5.4 21.4 1,645 Fourth 9.8 3.2 13.0 1,658 Highest 3.5 1.1 4.6 1,618 Total 17.1 5.4 22.5 7,820 80 • Fertility The 2013 NDHS findings on teenage pregnancy and motherhood by age are shown in Figure 5.5. Rates of teen motherhood increase steadily from age 15 to 19, with especially large increases between the ages of 17 and 18. Figure 5.5 Percentage of teenagers who have begun childbearing and who are pregnant with their first child by age 2 8 16 30 36 3 5 7 7 6 15 years 16 years 17 years 18 years 19 years Percentage Age Have had a live birth Are pregnant with first child NDHS 2013 Fertility Preferences • 81 FERTILITY PREFERENCES 6 nformation on fertility preferences is of considerable importance to family planning programs because it allows planners to assess the desire for children as well as the extent of unwanted and mistimed pregnancies. Data on fertility preferences also indicate possible future fertility trends. One of the objectives of Nigeria’s National Policy on Population is to reduce the high level of fertility in the country (National Population Commission [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 is, all couples and individuals should decide freely and responsibly on the timing, number, and spacing of their children for a manageable family size, and 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. As in previous NDHS surveys, the 2013 NDHS asked women a series of questions to ascertain their fertility preferences. The resulting data were used to quantify fertility preferences: whether couples want to cease childbearing altogether or merely delay the next pregnancy. Ideal number of children is an important indicator of fertility preferences that shows the number of children a woman or man would want in total if she or he could start afresh. Information on ideal family size provides two measures. First, for women and men who have not yet started a family, the data provide an idea of future fertility (to the extent that couples are able to realise their fertility desires). Second, the excess of past fertility over ideal family size provides a measure of unwanted fertility. Other topics discussed in this chapter are fertility planning, the effects of unwanted births on fertility rates, and how fertility preferences between women and men vary. 6.1 DESIRE FOR MORE CHILDREN Information about the desire for more children is important in understanding future reproductive behaviour. The provision of adequate and accessible family planning services depends on the availability of such information. In the 2013 NDHS, currently married women (whether pregnant or not) and men were asked about their intentions to have another child and, if they had such intentions, how soon they wanted the child. The question was phrased differently in the case of pregnant women to refer to the wantedness of subsequent children after the completion of the current pregnancy. Sterilised women were considered to want no more children. Men who had been sterilised or who reported that their wife/wives or partners had been sterilised were considered to want no more children. This group of women and men were not asked questions about their desire for more children. I Key Findings • Nineteen percent of currently married women in Nigeria want no more children or have been sterilised, while 33 percent want to have another child within two years. • The desire to stop childbearing among currently married women has changed only minimally over the past decade (18 percent in 2003 and 19 percent in 2013). • Currently married women report an ideal family size of 7.1 children, a decrease of 0.2 children since 2003. • Overall, Nigerian women have about one child more than the number they want. This implies that the total fertility rate of 5.5 children per woman is 15 percent higher than it would be if all unwanted births were avoided. 82 • Fertility Preferences Table 6.1 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 2013 Number of living children Total 15- 49 Desire for children 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 84.2 43.4 37.4 31.6 25.5 22.9 17.8 33.4 Have another later3 3.2 48.7 47.4 42.2 32.3 27.9 21.5 34.3 Have another, undecided when 2.8 3.0 4.0 3.1 2.6 1.9 1.2 2.6 Undecided 3.8 2.7 4.4 6.9 9.4 10.4 12.5 7.5 Want no more 0.6 0.8 4.5 12.5 26.3 32.6 40.2 18.3 Sterilised4 0.1 0.0 0.2 0.6 0.3 0.5 0.6 0.4 Declared infecund 5.0 1.1 1.6 2.5 2.8 3.4 5.5 3.0 Missing 0.4 0.2 0.5 0.6 0.7 0.4 0.8 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,881 4,292 4,500 4,451 4,126 3,272 5,308 27,830 MEN5 Have another soon2 72.0 42.4 34.5 31.2 27.6 28.7 30.2 35.4 Have another later3 12.8 47.4 52.1 45.1 36.7 34.1 36.5 40.2 Have another, undecided when 10.5 7.6 5.6 6.4 5.7 9.5 7.6 7.2 Undecided 1.6 0.7 2.2 3.9 6.5 5.1 5.3 3.7 Want no more 1.7 0.4 4.1 12.1 22.0 22.2 18.6 12.0 Sterilised4 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 Declared infecund 0.5 0.3 0.1 0.2 0.0 0.0 0.2 0.2 Missing 0.9 1.2 1.5 1.1 1.6 0.3 1.5 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 614 1,389 1,390 1,386 1,153 893 1,899 8,723 1 The number of living children includes the current pregnancy. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilisation 5 The number of living children includes one additional child if the respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Table 6.1 shows the percent distribution of currently married women and men age 15-49 by desire for another child, according to the number of living children. Overall, 19 percent of currently married women in Nigeria want to limit childbearing (including those who have been sterilised), 33 percent say they want a child within two years, and 34 percent say they want to have another child but later. The proportion of women and men who want another child generally decreases with increasing number of living children. In contrast, the proportion of women and men who want to stop childbearing (including those who have been sterilised) increases with increasing number of living children. The proportion of women who reported that they wanted to have another child in the next two years was lower than that in the 2003 NDHS (33 percent versus 37 percent). The proportion of women reporting that they wanted to have another child after two or more years was the same as in 2003 (34 percent), while the proportion who reported that they did not want any more children or had been sterilised changed only minimally over the past decade (18 percent in 2003 and 19 percent in 2013). There are considerable differences in fertility preferences between women and men. Overall, the proportion of currently married men who want no more children is 12 percent, as compared with 19 percent among currently married women. There are also differences according to number of living children. Whereas 84 percent of women with no children want to have a child within two years, the corresponding proportion among men is 72 percent. In addition, 41 percent of women (including those who have been sterilised) and only 19 percent of men with six or more living children want to have no more children (Figure 6.1). Fertility Preferences • 83 Figure 6.1 Percentage of currently married women and men who want no more children, by number of living children 1 1 5 13 27 33 41 2 0 4 12 22 22 19 0 1 2 3 4 5 6+ Percent Number of living children Women Men NDHS 2013 6.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS The proportion of couples who want no more children is an important and easily understood measure of fertility preference. Tables 6.2.1 and 6.2.2 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 in urban areas are more likely than those in rural areas to want to limit childbearing (26 percent and 15 percent, respectively). Urban-rural variations are especially clear among women with three or more children. For example, more than twice as many urban women (49 percent) as rural women (24 percent) with five or more children want to limit childbearing. At the zonal level, the proportion of women who want no more children varies from 8 percent in the North West to 35 percent in the South West. In all of the southern zones, at least 30 percent of women do not wish to have more children. However, women in the northern zones are less likely to want to limit childbearing, regardless of the number of living children they already have. Only 19 percent of women in the North West zone with six or more children say that they want no more children, as compared with 79 percent in the South West. The desire to limit childbearing is lowest among women with no education. Overall, 11 percent of women with no education want to limit childbearing, compared with 27 percent of women with more than a secondary education. The desire to limit childbearing increases with increasing wealth, ranging from 9 percent of women in the lowest wealth quintile to 29 percent of women in the highest quintile. Women and men exhibit similar patterns of desired fertility by background characteristics. Desire to limit childbearing is higher among men living in urban areas, those with more living children, those with more education, and those in the higher wealth quintiles. This is particularly true among men with three or more living children. 84 • Fertility Preferences Table 6.2.1 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 2013 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 0.3 1.0 6.3 20.7 42.7 49.3 50.2 25.7 Rural 0.8 0.7 3.6 8.2 16.2 24.4 36.4 14.6 Zone North Central 0.4 0.9 5.2 15.3 28.9 39.6 58.7 23.0 North East 0.9 0.6 2.9 3.9 9.8 13.1 29.4 10.2 North West 0.9 0.7 3.1 5.7 8.1 8.8 19.0 7.9 South East 0.0 1.1 4.3 9.8 36.4 56.4 78.5 31.5 South South 0.0 0.8 5.8 15.6 43.7 57.3 72.0 29.7 South West 0.0 1.2 8.3 30.3 56.9 77.5 79.3 35.4 Education No education 1.1 0.8 3.7 5.4 9.9 13.8 27.2 11.1 Primary 0.0 1.0 5.0 14.0 31.1 44.8 59.4 29.2 Secondary 0.0 0.8 4.6 17.8 43.0 59.3 65.2 22.8 More than secondary 0.0 0.7 9.1 34.8 59.5 63.7 71.2 26.6 Wealth quintile Lowest 1.4 0.9 2.8 3.7 7.7 10.8 22.2 8.7 Second 0.7 0.9 5.2 6.4 12.2 20.2 35.1 13.2 Middle 0.3 0.7 3.3 8.2 19.8 35.2 49.9 20.6 Fourth 0.0 0.5 4.0 13.3 38.2 48.4 53.8 25.0 Highest 0.0 1.1 7.5 29.4 53.1 65.0 65.3 28.8 Total 0.6 0.8 4.7 13.1 26.6 33.0 40.8 18.6 Note: Women who have been sterilised are considered to want no more children. 1 The number of living children includes the current pregnancy. Table 6.2.2 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 2013 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 2.4 0.2 5.8 18.6 32.5 38.2 26.6 17.5 Rural 1.4 0.5 2.8 6.9 14.7 13.0 15.5 8.7 Zone North Central 0.3 0.6 7.1 12.0 22.1 17.4 26.2 13.9 North East 0.0 0.0 0.7 3.7 4.4 3.0 6.8 3.1 North West 2.4 0.4 0.6 3.0 2.3 2.9 3.2 2.2 South East (5.1) 1.5 8.9 11.8 30.6 61.6 53.4 22.4 South South 2.9 0.0 3.6 16.3 38.7 49.7 53.3 22.8 South West (1.1) 0.0 7.3 25.1 49.1 57.4 41.9 26.1 Education No education 1.9 0.5 0.6 1.6 1.6 3.8 4.7 2.5 Primary 1.5 0.8 3.4 7.3 22.0 21.9 24.6 14.6 Secondary 2.5 0.2 4.6 15.2 32.9 32.7 30.5 15.9 More than secondary 0.0 0.2 8.1 26.4 31.4 41.5 28.6 18.3 Wealth quintile Lowest 0.0 0.8 0.5 0.4 0.8 1.9 4.7 2.0 Second 0.9 0.0 1.9 2.7 9.4 10.5 10.5 5.7 Middle 3.4 0.0 2.0 8.4 19.4 14.1 23.9 11.9 Fourth 4.4 0.8 3.5 11.2 28.3 37.4 33.2 17.6 Highest 1.8 0.2 8.6 25.8 42.4 51.9 42.7 21.8 Total 1.7 0.4 4.1 12.1 22.0 22.2 18.7 12.0 Note: Men who have been sterilised or who state in response to the question about desire for children that their wife has been sterilised are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. 1 The number of living children includes one additional child if the respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Fertility Preferences • 85 6.3 IDEAL FAMILY SIZE Women and men who were interviewed in the 2013 NDHS were asked two questions to determine their ideal family size. Respondents who did not have any living children were asked “If you could choose exactly the number of children to have in your lifetime, how many would that be?” For respondents who had living children, the question was rephrased as follows: “If you could go back to the time you did not have any children and could choose exactly the number of children to have in your lifetime, how many would that be?” Table 6.3 shows the distribution of women and men age 15-49 by their ideal number of children, according to the number of living children. Table 6.3 Ideal number of children by number of living children Percent distribution of women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to the number of living children, Nigeria 2013 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN1 0 0.7 0.4 0.4 0.4 0.6 0.6 1.3 0.6 1 0.2 0.2 0.2 0.0 0.1 0.0 0.1 0.1 2 2.9 1.6 1.9 1.1 0.9 0.2 0.4 1.5 3 12.4 9.7 5.9 4.8 1.5 1.2 0.6 6.4 4 30.9 23.9 24.3 18.6 18.0 6.9 4.5 20.2 5 16.9 15.6 15.4 16.5 12.6 15.2 5.8 14.2 6+ 31.3 42.7 45.2 51.3 58.1 65.8 75.9 49.5 Non-numeric response 4.8 5.9 6.9 7.4 8.2 10.1 11.4 7.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 10,723 5,087 4,873 4,740 4,420 3,478 5,628 38,948 Mean ideal number of children for:2 All women 5.3 6.0 6.2 6.6 6.9 7.7 8.8 6.5 Number of women 10,204 4,785 4,539 4,390 4,058 3,127 4,988 36,091 Currently married women 6.9 6.3 6.2 6.7 7.0 7.8 8.9 7.1 Number of currently married women 1,697 4,030 4,194 4,125 3,793 2,941 4,699 25,480 MEN3 0 0.5 0.0 0.2 0.4 0.3 0.3 0.3 0.4 1 0.4 0.2 0.0 0.3 0.0 0.1 0.0 0.3 2 3.1 2.1 1.8 2.6 1.0 1.0 0.9 2.4 3 10.9 10.9 8.3 5.9 2.8 3.0 1.2 8.2 4 22.5 20.2 20.9 16.7 18.2 6.5 3.7 18.5 5 19.0 16.6 18.0 18.8 15.1 13.9 5.4 16.7 6+ 39.6 44.3 45.7 49.1 57.1 67.1 78.2 48.2 Non-numeric response 4.0 5.6 5.2 6.2 5.5 8.2 10.4 5.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 8,894 1,571 1,471 1,421 1,178 909 1,916 17,359 Mean ideal number of children for:2 All men 6.7 7.2 7.1 7.6 8.4 10.2 14.1 8.0 Number of men 8,541 1,483 1,395 1,332 1,114 835 1,717 16,415 Currently married men 8.2 7.4 7.2 7.6 8.5 10.3 14.2 9.3 Number of currently married men 583 1,303 1,318 1,297 1,090 819 1,702 8,112 1 The number of living children includes the 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 the respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Nigerian women consider a large family size to be desirable. Ideal numbers of children are 6.5 for all women and 7.1 for currently married women. About half of all women consider six 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 5.3 for those without any children to 8.8 among those with six or more living children. 86 • Fertility Preferences On average, Nigerian men want more children than women: 8.0 children for all men age 15-49 compared with 6.5 for all women age 15-49. The mean ideal number of children among currently married men is more than two children higher than that reported by currently married women (9.3 versus 7.1). Ideal numbers of children for all women and men who currently have no children are 5.3 and 6.7, respectively. These findings are similar to those from the 1999, 2003, and 2008 NDHS surveys (NPC, 2000; NPC and ORC Macro, 2004, 2009). Table 6.4 shows the mean ideal number of children for all women age 15-49 by background characteristics. The mean ideal number of increases steadily with age, from 5.7 children among women age 15-19 to 7.8 children among women age 45-49. Urban women prefer to have fewer children than rural women (5.6 versus 7.2). The mean ideal number of children is highest in the North West and North East (8.4 and 8.1 children, respectively) and lowest in the South West (4.5 children). Across states, the mean ideal number of children is lowest in Lagos (4.1 children) and highest in Katsina (9.1 children). The mean ideal number of children decreases as women’s level of education and wealth status increase. Women with no education want 8.6 children, while those with more than a secondary education desire 4.5 children. Similarly, women in the lowest wealth quintile want 8.7 children, while women in the highest quintile want 4.7 children. 6.4 FERTILITY PLANNING STATUS The issue of unplanned and unwanted fertility was further investigated in the 2013 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 requires respondents to recall accurately their wishes at one or more points in time over the past five years. Table 6.5 shows the percent distribution of births in the five years preceding the 2013 survey, by the planning status of the birth. Ninety percent of the births were wanted at the time they occurred, 7 percent were wanted later (mistimed), and 2 percent were not wanted. First-order births are more likely to be mistimed (11 percent). The proportion of mistimed births declines as the mother’s age at birth increases. Table 6.4 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Nigeria 2013 Background characteristic Mean Number of women1 Age 15-19 5.7 7,351 20-24 6.1 6,378 25-29 6.4 6,676 30-34 6.7 5,058 35-39 7.1 4,342 40-44 7.2 3,242 45-49 7.8 3,044 Residence Urban 5.6 15,581 Rural 7.2 20,510 Zone North Central 5.6 5,011 North East 8.1 4,522 North West 8.4 11,551 South East 5.5 4,450 South South 4.9 4,605 South West 4.5 5,952 State North Central FCT-Abuja 4.6 277 Benue 5.6 1,222 Kogi 5.2 632 Kwara 5.0 558 Nasarawa 5.7 585 Niger 6.6 1,088 Plateau 4.6 648 North East Adamawa 7.1 692 Bauchi 9.0 746 Borno 8.5 917 Gombe 8.5 527 Taraba 6.8 723 Yobe 8.5 917 North West Jigawa 8.7 1,349 Kaduna 6.8 2,122 Kano 8.7 3,189 Katsina 9.1 1,487 Kebbi 8.8 982 Sokoto 8.7 1,092 Zamfara 8.8 1,330 South East Abia 5.1 518 Anambra 5.1 1,042 Ebonyi 6.4 1,118 Enugu 5.6 950 Imo 5.0 821 South South Akwa Ibom 4.8 861 Bayelsa 5.8 353 Cross River 5.3 645 Delta 5.0 853 Edo 4.5 717 Rivers 4.7 1,176 South West Ekiti 4.2 315 Lagos 4.1 1,862 Ogun 4.6 853 Ondo 5.0 726 Osun 4.2 753 Oyo 4.9 1,443 Education No education 8.6 13,068 Primary 6.5 6,168 Secondary 5.1 13,396 More than secondary 4.5 3,459 Wealth quintile Lowest 8.7 6,413 Second 7.7 6,843 Middle 6.6 6,837 Fourth 5.6 7,474 Highest 4.7 8,525 Total 6.5 36,091 1 Number of women who gave a numeric response Fertility Preferences • 87 Table 6.5 Fertility planning status Percent distribution of births to 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 2013 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 87.8 10.5 0.2 1.5 100.0 7,193 2 91.6 6.7 0.2 1.4 100.0 6,274 3 91.8 6.4 0.4 1.4 100.0 5,588 4+ 89.9 5.0 3.2 1.9 100.0 17,483 Mother’s age at birth <20 89.0 9.0 0.2 1.8 100.0 5,302 20-24 90.4 7.8 0.3 1.5 100.0 9,243 25-29 91.1 6.6 0.6 1.7 100.0 9,597 30-34 90.2 6.0 2.4 1.4 100.0 6,656 35-39 89.0 3.7 5.5 1.8 100.0 3,910 40-44 87.4 2.4 7.7 2.5 100.0 1,514 45-49 88.0 2.2 6.4 3.4 100.0 315 Total 90.0 6.6 1.7 1.7 100.0 36,538 6.5 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 but excludes unwanted births from the numerator. A birth is considered wanted if the number of living children at the time of conception is lower 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. This measure may be an underestimate to the extent that women may not report an ideal family size lower than their actual family size. The total wanted fertility rates in Table 6.6 represent the levels of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been avoided. Overall, Nigerian women have 0.7 children more than their wanted number of 4.8 children. This implies that the total fertility rate is 15 percent higher than it would be if unwanted births were avoided. The wanted fertility rate is highest in the North West zone (6.3 children) and lowest in the South South zone (3.6 children). Across states, the highest wanted fertility rate is in Zamfara (8.0 children), while the lowest is in Borno (2.8 children). The difference between wanted and observed total fertility rates decreases with increasing level of education and wealth quintile, indicating that educated and wealthier women are more likely than other women to translate their fertility desires into reality. Overall, there has been a considerable decrease in the total wanted fertility rate among Nigerian women, from 5.3 children in 2003 and 2008 to 4.8 in 2013 (NPC and ORC Macro, 2004, 2009). 88 • Fertility Preferences Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Nigeria 2013 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 4.1 4.7 Rural 5.3 6.2 Zone North Central 4.2 5.3 North East 4.6 6.3 North West 6.3 6.7 South East 4.3 4.7 South South 3.6 4.3 South West 4.0 4.6 State North Central FCT-Abuja 3.8 4.5 Benue 4.3 5.2 Kogi 3.5 4.2 Kwara 4.3 5.1 Nasarawa 4.9 5.4 Niger 4.1 6.1 Plateau 4.3 5.4 North East Adamawa 4.5 5.8 Bauchi 4.5 8.1 Borno 2.8 4.7 Gombe 6.4 7.0 Taraba 4.7 6.0 Yobe 6.1 6.6 North West Jigawa 7.3 7.6 Kaduna 3.8 4.1 Kano 6.5 6.8 Katsina 7.3 7.4 Kebbi 5.1 6.7 Sokoto 6.8 7.0 Zamfara 8.0 8.4 South East Abia 4.0 4.2 Anambra 3.8 4.2 Ebonyi 4.9 5.3 Enugu 4.6 4.8 Imo 4.2 4.8 South South Akwa Ibom 3.4 3.9 Bayelsa 3.9 4.5 Cross River 4.7 5.4 Delta 3.1 4.1 Edo 3.6 4.4 Rivers 3.3 3.8 South West Ekiti 4.0 4.3 Lagos 3.6 4.1 Ogun 4.6 5.4 Ondo 4.4 5.2 Osun 3.7 4.1 Oyo 3.9 4.5 Education No education 5.9 6.9 Primary 5.2 6.1 Secondary 4.0 4.6 More than secondary 2.8 3.1 Wealth quintile Lowest 6.0 7.0 Second 5.8 6.7 Middle 4.7 5.7 Fourth 4.2 4.9 Highest 3.5 3.9 Total 4.8 5.5 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 5.2. Family Planning • 89 FAMILY PLANNING 7 amily 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 2013 NDHS on a number of aspects of contraception: knowledge of specific contraceptive methods, attitudes and behaviours regarding contraceptive use, current use, and source of current contraceptive methods. The chapter focuses on women who are sexually active because these women have the greatest risk of exposure to pregnancy and 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 behaviours. Comparisons are also made, where feasible, with findings from previous surveys to evaluate changes in contraceptive measures over time. The federal government of Nigeria, through the Federal Ministry of Health (FMoH), is unswerving in its efforts to ensure that Nigeria attains the Millennium Development Goals. In line with this, the Federal Ministry of Health distributed free contraceptives to states and to family planning and child spacing programmes in April 2011. Various studies on Nigerians’ ability and willingness to pay for contraceptives have shown that, to achieve the desired increase in the contraceptive prevalence rate, cost barriers should be removed so that even the very poor can have unlimited access to contraceptives. This reasoning informed the federal government’s intensified efforts to ensure that Nigerians have access to contraceptives. Recently, government efforts to meet the unmet need for family planning led to the approval of distribution of free family planning supplies in public health facilities and an increased commitment by reproductive health programmes (FMoH, 2013a). 7.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Information on knowledge and use of family planning methods was obtained from female and male respondents by asking them if they had heard of the various ways or methods by which a couple could delay or avoid pregnancy. In all, the interviewer asked the respondent about 15 different methods. F Key Findings • Knowledge of contraception is widespread in Nigeria; 85 percent of women and 95 percent of men report knowing about a contraceptive method. • Fifteen percent of currently married women use a contraceptive method, an increase of only 2 percentage points from the 2003 NDHS. Ten percent of currently married women report using a modern method. • Injectables remain the most popular contraceptive method, used by 3 percent of currently married women. • Private sector facilities continue to be the chief providers of contraceptive methods in Nigeria; 60 percent of users of modern contraceptive methods obtain them from the private sector. • Unmet need for family planning, currently 16 percent among married women, has improved since 2008 (when the figure was 20 percent). • Reducing discontinuations of contraceptive use is important in addressing unmet need. Discontinuations occur most often because of a desire to become pregnant (42 percent), method failure (14 percent), and method-related side effects or health concerns (7 percent). 90 • Family Planning Contraceptive methods are classified as modern or traditional methods. Modern methods include female sterilisation, male sterilisation, the pill, the intrauterine device (IUD), injectables, implants, male condoms, female condoms, the diaphragm, foam/jelly, the lactational amenorrhoea method (LAM), and emergency contraception. Traditional methods include the rhythm (periodic abstinence) and withdrawal methods. Provision was also made in the questionnaire to record any other methods mentioned by the respondents, including folk methods such as strings and herbs. Table 7.1 shows that knowledge of any contraceptive method is widespread in Nigeria, with 85 percent of all women and 95 percent of all men knowing at least one method of contraception. Modern methods are more widely known than traditional methods; 84 percent of all women know of a modern method, while only 56 percent know a traditional method. Similarly, 94 percent of all men know of a modern method, while 65 percent know of a traditional method. Table 7.1 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 2013 Women Men Method All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 85.2 84.6 97.9 94.6 97.0 99.4 Any modern method 83.8 82.8 97.8 93.7 95.7 99.3 Female sterilisation 42.0 43.6 47.2 42.8 50.2 41.8 Male sterilisation 15.5 15.6 23.3 26.9 30.4 28.6 Pill 70.9 72.9 83.9 64.9 71.5 76.5 IUD 31.8 33.5 41.5 20.0 24.0 17.3 Injectables 68.3 71.4 78.0 59.9 69.0 64.2 Implants 24.7 25.9 33.5 17.9 20.5 16.9 Male condom 67.1 61.5 96.7 90.8 92.4 99.2 Female condom 28.6 26.3 57.4 32.8 34.2 54.8 Lactational amenorrhea (LAM) 37.1 40.9 38.3 20.0 29.9 17.1 Emergency contraception 30.3 29.2 55.7 31.9 36.1 47.3 Other modern method 21.0 21.1 32.5 43.6 53.9 55.7 Any traditional method 56.2 57.9 81.7 65.1 76.6 86.7 Rhythm 41.2 40.5 68.8 41.8 50.4 58.2 Withdrawal 44.5 45.3 73.7 59.0 70.0 84.3 Other 11.9 14.1 13.1 7.7 10.3 6.0 Mean number of methods known by respondents 5.6 5.6 7.7 5.6 6.4 6.7 Number of respondents 38,948 27,830 1,577 17,359 8,723 1,409 1 Had last sexual intercourse within 30 days preceding the survey The modern method most commonly known among women is the pill (71 percent), followed by injectables and male condoms (68 percent and 67 percent, respectively). Although the least known modern methods are male sterilization, female condoms, and implants (16 percent, 29 percent, and 25 percent, respectively), knowledge of these three methods has increased markedly since 2008 (when the proportions were 8 percent, 15 percent and 10 percent, respectively). Currently married women are less likely than sexually active unmarried women to know of a contraceptive method (85 percent and 98 percent, respectively). Among traditional methods, withdrawal and rhythm are the most commonly known (45 percent and 41 percent, respectively) among women. Overall, women know a mean of 5.6 contraceptive methods. The most commonly known modern method among men is the male condom (91 percent). Similar to women, withdrawal is the most commonly known traditional method among men (59 percent). Knowledge of the rhythm method is similar for men and women (42 percent and 41 percent, respectively). The mean number of methods known among men is the same as for women (5.6). Family Planning • 91 7.2 KNOWLEDGE OF CONTRACEPTIVE METHODS BY BACKGROUND CHARACTERISTICS Table 7.2 shows knowledge of contraceptive methods among women and men according to 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 East are least likely to know of a contraceptive method (67 percent and 73 percent, respectively). As expected, knowledge of contraceptive methods is higher among women living in urban areas (95 percent) than among those living in rural areas (78 percent). Among the states, knowledge of contraceptive methods is lowest for women in Niger (56 percent) and in Kebbi (51 percent). Similarly, knowledge of contraceptive methods is lowest among women with no education and those in the lowest wealth quintile (72 percent and 67 percent, respectively). Among men, there are only small differences in knowledge of any contraceptive method by age group, but the differentials are greater by place of residence, zone, educational level, and wealth quintile. Table 7.2 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 2013 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 67.0 64.4 2,251 (86.7) (85.7) 41 20-24 83.1 81.0 4,362 90.4 87.3 418 25-29 85.4 83.9 5,913 95.5 94.2 1,240 30-34 87.9 86.7 4,869 97.6 96.2 1,750 35-39 88.2 86.6 4,302 97.8 96.6 1,937 40-44 86.9 85.2 3,226 98.2 97.4 1,688 45-49 85.3 82.8 2,907 97.3 96.1 1,649 Residence Urban 95.4 95.0 10,124 99.4 99.1 3,302 Rural 78.4 75.8 17,705 95.6 93.7 5,421 Zone North Central 78.6 78.0 3,895 94.4 92.7 1,395 North East 73.2 70.1 4,679 94.1 91.3 1,404 North West 81.1 78.4 10,034 97.4 96.0 2,846 South East 95.9 95.4 2,333 99.6 99.3 643 South South 97.7 97.5 2,699 99.7 99.4 1,020 South West 96.4 95.7 4,189 98.8 98.4 1,414 State North Central FCT-Abuja 92.7 92.0 200 96.7 96.7 96 Benue 96.4 96.0 827 99.2 99.2 283 Kogi 77.5 77.0 433 96.3 96.1 142 Kwara 94.7 94.6 384 100.0 99.5 132 Nasarawa 84.4 83.6 420 97.8 97.8 136 Niger 55.5 54.6 1,190 89.1 84.0 447 Plateau 82.4 82.0 442 90.2 89.9 158 North East Adamawa 83.7 83.7 586 98.1 96.7 174 Bauchi 66.8 66.6 1,051 94.6 93.3 325 Borno 64.3 57.5 1,120 96.4 88.1 368 Gombe 64.0 61.8 467 91.3 90.5 131 Taraba 86.9 86.7 632 96.3 96.3 177 Yobe 80.5 74.2 824 86.3 86.0 229 North West Jigawa 75.1 70.9 1,256 95.9 94.2 334 Kaduna 98.2 93.7 1,594 98.2 98.2 569 Kano 82.0 79.8 2,521 99.1 95.9 691 Katsina 89.8 89.0 1,408 99.1 96.0 390 Kebbi 51.0 47.0 1,074 91.7 91.5 314 Sokoto 75.3 74.9 956 96.8 96.8 236 Zamfara 84.1 80.9 1,226 98.0 98.0 312 Continued… 92 • Family Planning Table 7.2—Continued Women Men Background characteristic Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number South East Abia 95.4 94.5 292 98.7 98.7 77 Anambra 97.1 96.6 564 99.3 99.3 188 Ebonyi 89.1 88.8 564 100.0 100.0 145 Enugu 99.4 99.2 467 100.0 98.5 104 Imo 99.7 98.9 446 99.5 99.5 129 South South Akwa Ibom 98.2 98.0 410 99.7 98.8 175 Bayelsa 99.6 99.6 202 100.0 100.0 80 Cross River 96.0 95.8 437 98.2 97.7 131 Delta 94.8 94.4 551 100.0 100.0 199 Edo 98.5 98.5 395 100.0 99.3 131 Rivers 99.8 99.6 704 100.0 100.0 304 South West Ekiti 98.9 98.9 194 100.0 100.0 70 Lagos 99.9 99.9 1,236 100.0 100.0 435 Ogun 99.1 99.1 655 96.7 95.0 210 Ondo 92.8 91.3 510 94.8 94.1 183 Osun 99.5 99.5 465 100.0 99.6 167 Oyo 90.9 88.9 1,129 100.0 100.0 349 Education No education 72.3 68.9 13,470 92.3 88.7 2,594 Primary 92.5 92.0 5,336 97.7 97.3 1,854 Secondary 97.8 97.6 6,981 99.4 99.1 2,961 More than secondary 99.7 99.7 2,043 99.9 99.9 1,313 Wealth quintile Lowest 66.7 62.3 6,424 91.2 86.8 1,795 Second 79.5 77.0 5,986 96.2 94.8 1,732 Middle 87.0 86.1 4,983 98.5 98.1 1,506 Fourth 95.5 95.3 5,042 99.6 99.4 1,697 Highest 99.1 99.0 5,395 99.9 99.8 1,992 Total 84.6 82.8 27,830 97.0 95.8 8,723 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), standard days method (SDM), and emergency contraception 7.3 CURRENT USE OF CONTRACEPTION 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 practices 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 reductions in fertility attributable to contraception. The contraceptive prevalence rate is usually defined as the percentage of currently married women who are using a method of contraception. This section focuses on levels of and differentials in current use of contraception in Nigeria. Table 7.3 shows the percent distribution of all women, currently married women, and sexually active unmarried women who are currently using specific family planning methods, according to age. Overall, 15 percent of currently married women in Nigeria are using a contraceptive method, an increase of only 2 percentage points since the 2003 NDHS. Most of these contraceptive users rely on a modern method (10 percent); 5 percent use traditional methods. Injectables (3 percent), male condoms (2 percent), and the pill (2 percent) are the most commonly used modern methods. Other modern methods are used by 1 percent of women or less. Interestingly, 3 percent of currently married women use withdrawal as a method of contraception. The use of contraceptive methods among currently married women increases with age from 2 percent among women age 15-19 to 22 percent among women age 40-44, after which it falls to 13 percent among women age 45-49. Fa m ily P la nn in g • 9 3 Ta bl e 7. 3 C ur re nt u se o f c on tra ce pt io n by a ge P er ce nt d is tri bu tio 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 01 3 A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tra di tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en A ge Fe m al e st er ili - sa tio n P ill IU D In je ct - ab le s Im pl an ts M al e co nd om LA M S ta nd ar d da ys m et ho d O th er 1 R hy th m W ith - dr aw al O th er A LL W O M E N 15 -1 9 6. 1 4. 8 0. 0 0. 5 0. 0 0. 1 0. 0 3. 8 0. 1 0. 0 0. 3 1. 3 0. 5 0. 6 0. 2 93 .9 10 0. 0 7, 82 0 20 -2 4 17 .1 13 .2 0. 0 1. 9 0. 1 1. 3 0. 1 8. 7 0. 4 0. 0 0. 7 3. 9 1. 4 1. 8 0. 7 82 .9 10 0. 0 6, 75 7 25 -2 9 18 .4 12 .6 0. 1 2. 1 0. 5 2. 4 0. 2 6. 2 0. 5 0. 1 0. 6 5. 8 2. 5 2. 6 0. 7 81 .6 10 0. 0 7, 14 5 30 -3 4 20 .3 13 .7 0. 2 2. 5 1. 2 3. 7 0. 8 4. 1 0. 7 0. 1 0. 5 6. 6 2. 2 3. 7 0. 8 79 .7 10 0. 0 5, 46 7 35 -3 9 20 .6 13 .6 0. 4 2. 7 1. 6 5. 0 0. 5 2. 3 0. 4 0. 1 0. 5 7. 1 3. 3 3. 0 0. 8 79 .4 10 0. 0 4, 71 8 40 -4 4 21 .2 14 .0 1. 1 2. 4 2. 1 5. 1 0. 3 2. 2 0. 2 0. 2 0. 5 7. 2 3. 5 2. 7 1. 0 78 .8 10 0. 0 3, 62 0 45 -4 9 12 .4 8. 0 0. 9 1. 6 1. 8 2. 3 0. 2 0. 9 0. 0 0. 1 0. 3 4. 4 2. 4 1. 2 0. 8 87 .6 10 0. 0 3, 42 2 To ta l 16 .0 11 .1 0. 3 1. 9 0. 8 2. 5 0. 3 4. 5 0. 3 0. 1 0. 5 4. 8 2. 0 2. 2 0. 6 84 .0 10 0. 0 38 ,9 48 C U R R EN TL Y M AR R IE D W O M EN 15 -1 9 2. 1 1. 2 0. 0 0. 3 0. 1 0. 2 0. 0 0. 3 0. 2 0. 0 0. 0 1. 0 0. 3 0. 6 0. 1 97 .9 10 0. 0 2, 25 1 20 -2 4 9. 6 6. 2 0. 0 1. 3 0. 0 1. 7 0. 2 2. 3 0. 5 0. 0 0. 3 3. 3 1. 0 1. 7 0. 6 90 .4 10 0. 0 4, 36 2 25 -2 9 14 .1 8. 8 0. 1 1. 6 0. 6 2. 6 0. 2 2. 8 0. 6 0. 2 0. 3 5. 3 2. 0 2. 6 0. 7 85 .9 10 0. 0 5, 91 3 30 -3 4 19 .1 12 .6 0. 2 2. 3 1. 2 3. 9 0. 9 2. 8 0. 8 0. 2 0. 4 6. 6 2. 0 3. 8 0. 7 80 .9 10 0. 0 4, 86 9 35 -3 9 21 .0 13 .6 0. 4 2. 7 1. 7 5. 3 0. 6 2. 0 0. 4 0. 1 0. 4 7. 4 3. 4 3. 2 0. 8 79 .0 10 0. 0 4, 30 2 40 -4 4 21 .7 14 .4 1. 1 2. 5 2. 2 5. 3 0. 3 2. 1 0. 3 0. 2 0. 3 7. 3 3. 5 2. 8 1. 0 78 .3 10 0. 0 3, 22 6 45 -4 9 13 .2 8. 3 1. 0 1. 6 1. 9 2. 3 0. 2 0. 9 0. 0 0. 1 0. 4 4. 9 2. 7 1. 4 0. 8 86 .8 10 0. 0 2, 90 7 To ta l 15 .1 9. 8 0. 3 1. 8 1. 1 3. 2 0. 4 2. 1 0. 4 0. 1 0. 3 5. 4 2. 2 2. 5 0. 7 84 .9 10 0. 0 27 ,8 30 S EX U A LL Y A C TI VE U N M A R R IE D W O M E N 2 15 -1 9 61 .1 49 .7 0. 0 6. 4 0. 0 0. 1 0. 0 40 .7 0. 0 0. 0 2. 6 11 .3 4. 3 4. 5 2. 6 38 .9 10 0. 0 36 3 20 -2 4 76 .3 63 .5 0. 0 7. 8 1. 3 1. 2 0. 0 48 .9 0. 0 0. 1 4. 2 12 .8 5. 0 5. 7 2. 0 23 .7 10 0. 0 52 8 25 -2 9 70 .5 57 .8 0. 0 10 .6 0. 0 2. 7 1. 2 40 .7 0. 0 0. 0 2. 6 12 .7 6. 7 5. 4 0. 7 29 .5 10 0. 0 37 7 30 -3 4 66 .3 49 .2 1. 4 7. 1 2. 4 4. 5 1. 1 31 .9 0. 0 0. 0 0. 9 17 .1 7. 2 6. 4 3. 5 33 .7 10 0. 0 14 9 35 -3 9 51 .1 41 .9 0. 0 10 .9 0. 0 9. 8 0. 0 12 .6 0. 0 1. 1 7. 4 9. 2 4. 9 2. 9 1. 4 48 .9 10 0. 0 72 40 -4 4 58 .6 34 .4 0. 0 3. 4 3. 4 12 .8 0. 0 9. 1 0. 0 0. 0 5. 7 24 .1 10 .8 8. 2 5. 1 41 .4 10 0. 0 60 45 -4 9 (4 6. 4) (3 0. 5) (0 .0 ) (4 .2 ) (1 4. 0) (7 .5 ) (0 .0 ) (4 .9 ) (0 .0 ) (0 .0 ) (0 .0 ) (1 6. 0) (1 6. 0) (0 .0 ) (0 .0 ) (5 3. 6) 10 0. 0 30 To ta l 68 .1 54 .9 0. 1 8. 0 1. 0 2. 5 0. 4 39 .5 0. 0 0. 1 3. 3 13 .2 5. 9 5. 3 2. 0 31 .9 10 0. 0 1, 57 7 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. 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. LA M = L ac ta tio na l a m en or rh oe a m et ho d 1 I nc lu de s m al e st er ili sa tio n, fe m al e co nd om , d ia ph ra gm , f oa m /je lly , a nd o th er m od er n m et ho ds 2 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 Family Planning • 93 94 • Family Planning The overall contraceptive prevalence among women in Nigeria is 16 percent. The use of any family planning method increases with age from 6 percent among women age 15-19 to 21 percent among women age 35-39, after which it declines to 12 percent among women age 45-49. Most women currently using contraception use a modern method (11 percent), while 5 percent use traditional methods. The male condom is the most commonly used modern method (5 percent), followed by injectables and pills (3 percent and 2 percent, respectively), while female sterilisation and implants are the least used modern methods (less than 1 percent each). Among the traditional methods, the rhythm method and withdrawal are the most commonly used (2 percent each). As expected, the use of family planning methods is higher among sexually active unmarried women than among currently married women (68 percent versus 15 percent). In addition, more sexually active unmarried women (55 percent) than currently married women (10 percent) use modern family planning methods. There is also a notable difference between sexually active unmarried women and currently married women in use of the pill (8 percent versus 2 percent). The most striking difference between these two groups of women is that 40 percent of sexually active unmarried women use male condoms, as compared with only 2 percent of married women. Among sexually active unmarried women, the rhythm method and withdrawal are the most widely used traditional methods (6 percent and 5 percent, respectively). Similar differences in modern contraceptive use between currently married women and sexually active unmarried women were observed in the 2008 NDHS. 7.4 CURRENT USE OF CONTRACEPTION BY BACKGROUND CHARACTERISTICS Analysing current use of contraception by background characteristics is important because it helps identify subgroups of the population to target for family planning services. It also allows a comparison of levels of current contraceptive use across major population groups and an examination of differences in use within various subgroups. Table 7.4 presents information on current use of contraceptives among currently married women age 15-49 by background characteristics. There is a direct association between women’s use of family planning methods and the number of children they have. In general, women do not begin to use contraception until they have had at least one child. Few women without children use any contraceptive method (2 percent), while those with one or more children are more likely to use contraception. Contraceptive use is highest among women with three or four living children (21 percent). Current use of contraception varies with residence, zone, education, and wealth quintile. Women in rural areas are less likely to use contraceptive methods than their counterparts in urban areas (9 percent versus 27 percent). This trend is observed across all modern methods of contraception. The South West zone has the highest proportion of women currently using a family planning method (38 percent), followed by the South East (29 percent). The lowest proportion of married women using a family planning method is in the North East (3 percent). Among the states, Lagos and Kwara have the highest percentages of women using any method (48 percent and 40 percent, respectively). In six states—Jigawa, Kano, Katsina, Kebbi, Sokoto, and Yobe—only 1 percent of women use any method of contraception. Contraceptive use is positively associated with women’s level of education. Contraceptive use increases with educational attainment. Thirty-seven percent of women who have more than a secondary education use a contraceptive method, as compared with only 3 percent of women with no education. By wealth quintile, women in the lowest quintile are least likely to use a contraceptive method (2 percent), while women in the highest quintile are most likely to do so (37 percent). Fa m ily P la nn in g • 9 5 Ta bl e 7. 4 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 is tri bu tio 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 rre nt ly 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 01 3 A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tr ad i- tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en B ac kg ro un d ch ar ac te ris tic Fe m al e st er ili - sa tio n P ill IU D In je ct - ab le s Im pl an ts M al e co nd om LA M S ta nd ar d da ys m et ho d O th er 1 R hy th m W ith - dr aw al O th er N um be r o f l iv in g ch ild re n 0 2. 4 1. 2 0. 0 0. 2 0. 0 0. 0 0. 0 0. 8 0. 0 0. 1 0. 1 1. 1 0. 6 0. 4 0. 1 97 .6 10 0. 0 2, 82 3 1- 2 12 .9 8. 2 0. 1 1. 6 0. 4 1. 8 0. 2 3. 1 0. 5 0. 1 0. 3 4. 7 1. 5 2. 4 0. 8 87 .1 10 0. 0 8, 63 7 3- 4 20 .9 13 .0 0. 4 2. 3 1. 5 4. 4 0. 5 2. 6 0. 6 0. 2 0. 5 7. 8 3. 5 3. 7 0. 7 79 .1 10 0. 0 8, 30 5 5+ 16 .2 11 .1 0. 6 2. 2 1. 7 4. 5 0. 5 0. 9 0. 4 0. 1 0. 2 5. 1 2. 1 2. 1 0. 8 83 .8 10 0. 0 8, 06 5 R es id en ce U rb an 26 .8 16 .9 0. 5 3. 2 2. 1 4. 4 0. 8 4. 4 0. 7 0. 2 0. 6 9. 9 4. 1 4. 8 1. 0 73 .2 10 0. 0 10 ,1 24 R ur al 8. 5 5. 7 0. 3 1. 1 0. 5 2. 5 0. 2 0. 7 0. 3 0. 1 0. 1 2. 8 1. 1 1. 2 0. 6 91 .5 10 0. 0 17 ,7 05 Zo ne N or th C en tra l 15 .6 12 .4 1. 0 2. 1 1. 0 4. 6 0. 6 2. 1 0. 3 0. 3 0. 5 3. 2 1. 0 1. 5 0. 6 84 .4 10 0. 0 3, 89 5 N or th E as t 3. 2 2. 7 0. 3 0. 5 0. 1 1. 2 0. 2 0. 2 0. 0 0. 1 0. 0 0. 4 0. 1 0. 2 0. 2 96 .8 10 0. 0 4, 67 9 N or th W es t 4. 3 3. 6 0. 2 0. 5 0. 2 1. 8 0. 4 0. 1 0. 2 0. 1 0. 1 0. 6 0. 1 0. 2 0. 4 95 .7 10 0. 0 10 ,0 34 S ou th E as t 29 .3 11 .0 0. 3 1. 8 1. 5 2. 2 0. 3 4. 1 0. 5 0. 3 0. 1 18 .2 7. 9 9. 9 0. 5 70 .7 10 0. 0 2, 33 3 S ou th S ou th 28 .1 16 .4 0. 5 3. 8 1. 0 5. 5 0. 4 2. 5 1. 9 0. 1 0. 8 11 .7 5. 6 4. 4 1. 6 71 .9 10 0. 0 2, 69 9 S ou th W es t 38 .0 24 .9 0. 2 5. 0 4. 0 6. 4 0. 3 7. 5 0. 8 0. 1 0. 8 13 .1 5. 1 6. 3 1. 7 62 .0 10 0. 0 4, 18 9 St at e N or th C en tra l FC T- A bu ja 25 .2 20 .6 0. 5 3. 5 4. 4 4. 7 3. 1 3. 2 0. 2 0. 3 0. 6 4. 6 3. 2 1. 1 0. 3 74 .8 10 0. 0 20 0 B en ue 16 .5 12 .1 2. 9 1. 4 1. 0 1. 8 0. 5 2. 6 0. 7 0. 2 0. 9 4. 4 2. 4 1. 5 0. 5 83 .5 10 0. 0 82 7 K og i 10 .5 8. 5 0. 1 2. 3 0. 4 3. 0 0. 0 1. 5 0. 1 0. 4 0. 8 2. 0 1. 1 0. 4 0. 5 89 .5 10 0. 0 43 3 K w ar a 40 .2 27 .7 0. 6 5. 9 2. 5 8. 5 0. 4 7. 8 0. 0 0. 2 1. 7 12 .5 1. 2 8. 4 2. 9 59 .8 10 0. 0 38 4 N as ar aw a 18 .1 16 .3 1. 1 3. 0 0. 7 9. 1 1. 4 0. 7 0. 1 0. 1 0. 0 1. 8 0. 1 0. 6 1. 1 81 .9 10 0. 0 42 0 N ig er 6. 6 5. 6 0. 2 0. 8 0. 4 2. 7 0. 3 0. 6 0. 2 0. 4 0. 1 1. 0 0. 3 0. 6 0. 1 93 .4 10 0. 0 1, 19 0 P la te au 15 .2 14 .4 0. 9 2. 3 0. 3 8. 9 0. 3 1. 4 0. 2 0. 1 0. 0 0. 7 0. 3 0. 4 0. 0 84 .8 10 0. 0 44 2 N or th E as t A da m aw a 4. 4 3. 5 0. 4 0. 8 0. 0 1. 2 0. 2 0. 6 0. 0 0. 3 0. 0 0. 8 0. 0 0. 7 0. 1 95 .6 10 0. 0 58 6 B au ch i 2. 2 2. 1 0. 1 0. 6 0. 0 1. 4 0. 1 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 1 97 .8 10 0. 0 1, 05 1 B or no 1. 8 1. 8 0. 4 0. 2 0. 2 0. 7 0. 1 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 98 .2 10 0. 0 1, 12 0 G om be 4. 0 4. 0 0. 7 0. 1 0. 3 1. 5 0. 5 0. 3 0. 3 0. 0 0. 2 0. 1 0. 1 0. 0 0. 0 96 .0 10 0. 0 46 7 Ta ra ba 8. 0 6. 5 0. 5 1. 2 0. 3 3. 0 0. 6 0. 6 0. 0 0. 0 0. 2 1. 5 0. 5 0. 5 0. 5 92 .0 10 0. 0 63 2 Yo be 1. 1 0. 5 0. 0 0. 1 0. 0 0. 2 0. 0 0. 1 0. 0 0. 1 0. 0 0. 6 0. 0 0. 1 0. 5 98 .9 10 0. 0 82 4 N or th W es t Ji ga w a 0. 9 0. 6 0. 0 0. 2 0. 0 0. 2 0. 0 0. 0 0. 2 0. 0 0. 0 0. 4 0. 1 0. 0 0. 3 99 .1 10 0. 0 1, 25 6 K ad un a 20 .2 18 .5 1. 0 2. 1 1. 2 9. 0 2. 6 0. 8 0. 8 0. 3 0. 6 1. 7 0. 2 1. 0 0. 5 79 .8 10 0. 0 1, 59 4 K an o 0. 6 0. 5 0. 0 0. 2 0. 2 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 1 99 .4 10 0. 0 2, 52 1 K at si na 1. 3 1. 1 0. 0 0. 1 0. 0 1. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 0. 1 0. 1 98 .7 10 0. 0 1, 40 8 K eb bi 1. 3 1. 2 0. 0 0. 7 0. 0 0. 5 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 1 98 .7 10 0. 0 1, 07 4 S ok ot o 1. 1 0. 7 0. 1 0. 1 0. 0 0. 4 0. 1 0. 0 0. 0 0. 0 0. 0 0. 3 0. 3 0. 0 0. 0 98 .9 10 0. 0 95 6 Za m fa ra 3. 0 1. 3 0. 0 0. 1 0. 2 0. 9 0. 1 0. 0 0. 0 0. 0 0. 0 1. 7 0. 0 0. 0 1. 7 97 .0 10 0. 0 1, 22 6 C on tin ue d… Family Planning • 95 96 • F am ily P la nn in g Ta bl e 7. 4— C on tin ue d A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tr ad i- tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en B ac kg ro un d ch ar ac te ris tic Fe m al e st er ili - sa tio n P ill IU D In je ct - ab le s Im pl an ts M al e co nd om LA M S ta nd ar d da ys m et ho d O th er 1 R hy th m W ith - dr aw al O th er S ou th E as t A bi a 33 .4 15 .6 0. 0 2. 0 1. 5 7. 0 0. 0 3. 5 0. 9 0. 7 0. 0 17 .9 7. 8 9. 5 0. 6 66 .6 10 0. 0 29 2 A na m br a 35 .0 11 .7 0. 3 2. 0 2. 3 1. 3 0. 8 4. 6 0. 3 0. 0 0. 0 23 .3 14 .7 8. 2 0. 4 65 .0 10 0. 0 56 4 E bo ny i 15 .7 5. 6 0. 2 1. 3 0. 2 1. 0 0. 4 1. 7 0. 2 0. 7 0. 0 10 .1 3. 2 6. 7 0. 2 84 .3 10 0. 0 56 4 E nu gu 31 .4 14 .3 0. 2 2. 1 2. 9 1. 8 0. 0 6. 6 0. 7 0. 0 0. 0 17 .1 5. 6 11 .5 0. 0 68 .6 10 0. 0 46 7 Im o 34 .1 10 .7 0. 5 1. 6 0. 8 2. 3 0. 0 4. 2 0. 8 0. 0 0. 3 23 .4 7. 7 14 .4 1. 3 65 .9 10 0. 0 44 6 S ou th S ou th A kw a Ib om 25 .5 16 .5 0. 3 5. 1 0. 6 6. 6 0. 7 2. 2 0. 8 0. 0 0. 1 9. 0 7. 2 1. 5 0. 2 74 .5 10 0. 0 41 0 B ay el sa 13 .3 10 .1 0. 0 2. 9 0. 0 4. 2 0. 0 1. 8 0. 4 0. 0 0. 8 3. 2 1. 0 1. 1 1. 1 86 .7 10 0. 0 20 2 C ro ss R iv er 24 .0 14 .4 0. 1 3. 6 1. 5 5. 9 0. 2 2. 1 0. 0 0. 0 0. 9 9. 7 4. 2 4. 0 1. 4 76 .0 10 0. 0 43 7 D el ta 28 .7 16 .8 0. 6 2. 4 1. 2 2. 5 0. 4 2. 1 5. 8 0. 0 1. 8 11 .9 4. 6 4. 3 3. 1 71 .3 10 0. 0 55 1 E do 30 .3 19 .1 0. 6 5. 6 0. 9 6. 8 0. 0 2. 4 2. 4 0. 0 0. 4 11 .2 5. 1 4. 1 2. 0 69 .7 10 0. 0 39 5 R iv er s 34 .5 17 .5 1. 0 3. 3 1. 1 6. 6 0. 5 3. 3 0. 8 0. 3 0. 5 17 .1 8. 1 7. 6 1. 3 65 .5 10 0. 0 70 4 S ou th W es t E ki ti 34 .5 26 .6 0. 1 7. 1 3. 6 6. 9 0. 0 8. 2 0. 0 0. 0 0. 6 7. 8 4. 4 3. 1 0. 4 65 .5 10 0. 0 19 4 La go s 48 .3 26 .4 0. 1 6. 5 2. 4 4. 6 0. 3 10 .3 0. 9 0. 0 1. 2 21 .9 10 .2 9. 0 2. 7 51 .7 10 0. 0 1, 23 6 O gu n 26 .0 21 .5 0. 0 5. 3 1. 0 9. 0 0. 3 4. 4 0. 3 0. 2 0. 9 4. 6 0. 9 2. 2 1. 4 74 .0 10 0. 0 65 5 O nd o 31 .1 20 .4 0. 4 3. 0 5. 9 5. 7 0. 0 4. 1 0. 4 0. 3 0. 7 10 .7 4. 6 4. 9 1. 2 68 .9 10 0. 0 51 0 O su n 38 .3 31 .6 0. 0 5. 0 5. 3 7. 2 0. 0 13 .1 0. 6 0. 0 0. 4 6. 7 1. 5 4. 7 0. 5 61 .7 10 0. 0 46 5 O yo 37 .4 24 .4 0. 2 3. 7 6. 1 6. 5 0. 5 5. 4 1. 2 0. 0 0. 7 13 .0 3. 9 7. 5 1. 6 62 .6 10 0. 0 1, 12 9 Ed uc at io n N o ed uc at io n 2. 7 1. 7 0. 2 0. 3 0. 1 0. 7 0. 1 0. 1 0. 1 0. 0 0. 0 0. 9 0. 2 0. 3 0. 4 97 .3 10 0. 0 13 ,4 70 P rim ar y 19 .9 13 .6 0. 5 2. 8 1. 7 5. 1 0. 4 2. 1 0. 5 0. 1 0. 4 6. 3 2. 4 2. 7 1. 3 80 .1 10 0. 0 5, 33 6 S ec on da ry 29 .2 18 .7 0. 4 3. 5 1. 6 6. 1 0. 7 4. 6 0. 8 0. 2 0. 7 10 .5 4. 4 5. 3 0. 8 70 .8 10 0. 0 6, 98 1 M or e th an s ec on da ry 37 .0 22 .4 1. 0 3. 5 3. 6 4. 5 1. 3 6. 5 1. 0 0. 3 0. 7 14 .6 7. 1 6. 9 0. 6 63 .0 10 0. 0 2, 04 3 W ea lth q ui nt ile Lo w es t 1. 7 0. 9 0. 1 0. 1 0. 0 0. 4 0. 0 0. 1 0. 1 0. 0 0. 0 0. 8 0. 1 0. 2 0. 5 98 .3 10 0. 0 6, 42 4 S ec on d 5. 1 3. 7 0. 3 0. 7 0. 3 1. 7 0. 1 0. 3 0. 3 0. 0 0. 1 1. 4 0. 5 0. 6 0. 3 94 .9 10 0. 0 5, 98 6 M id dl e 13 .3 9. 1 0. 6 1. 3 1. 0 3. 8 0. 3 1. 3 0. 4 0. 2 0. 2 4. 1 1. 3 2. 3 0. 5 86 .7 10 0. 0 4, 98 3 Fo ur th 23 .1 14 .4 0. 4 3. 1 1. 7 4. 8 0. 5 2. 9 0. 4 0. 2 0. 4 8. 6 3. 8 3. 7 1. 2 76 .9 10 0. 0 5, 04 2 H ig he st 36 .7 23 .4 0. 5 4. 4 2. 7 6. 1 1. 0 6. 4 1. 1 0. 1 1. 0 13 .3 5. 8 6. 5 1. 1 63 .3 10 0. 0 5, 39 5 To ta l 15 .1 9. 8 0. 3 1. 8 1. 1 3. 2 0. 4 2. 1 0. 4 0. 1 0. 3 5. 4 2. 2 2. 5 0. 7 84 .9 10 0. 0 27 ,8 30 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. LA M = L ac ta tio na l a m en or rh ea m et ho d 1 I nc lu de s m al e st er ili sa tio n, fe m al e co nd om , d ia ph ra gm , a nd o th er m od er n m et ho ds 96 • Family Planning Family Planning • 97 Figure 7.1 presents differentials in contraceptive use by urban-rural residence, zone, and education. It is clear from these results that area of residence and educational level play a role in contraceptive use. Figure 7.1 Differentials in contraceptive use, Nigeria 37 29 20 3 38 28 29 4 3 16 9 27 More than secondary Secondary Primary No education South West South South South East North West North East North Central Rural Urban Percentage NDHS 2013 7.5 TRENDS IN CONTRACEPTIVE USE Trends in current use of family planning can be used to monitor and evaluate the success of family planning programmes over time. Table 7.5 shows trends in current use of specific contraceptive methods among currently married women from 1990 to 2013. Over the 23-year period, contraceptive prevalence increased from 6 percent in 1990 to 15 percent in 2013. Use of modern methods increased from 4 percent to 10 percent. Use of injectables increased from 1 percent in 1990 to 3 percent in 2013. Condom use increased from less than 1 percent to 2 percent within the same period. Use of traditional methods has also increased over the years (from 3 percent in 1990 to 5 percent in 2013). Table 7.5 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, 2008, and 2013 Method 1990 NDHS 2003 NDHS 2008 NDHS 2013 NDHS Any method 6.0 12.6 14.6 15.1 Any modern method 3.5 8.2 9.7 9.8 Female sterilisation 0.3 0.2 0.4 0.3 Pill 1.2 1.8 1.7 1.8 IUD 0.8 0.7 1.0 1.1 Injectables 0.7 2.0 2.6 3.2 Male condom 0.4 1.9 2.4 2.1 LAM u 1.4 1.6 0.4 Any traditional method 2.5 4.3 4.9 5.4 Rhythm 2.1 2.1 2.1 2.2 Withdrawal 2.0 1.3 2.0 2.5 Folk method 0.6 1.0 0.9 0.7 Not currently using 94.0 87.4 85.4 84.9 Total 100.0 100.0 100.0 100.0 Number of women 6,880 5,336 23,578 27,830 LAM = Lactational amenorrhoea method u = Unknown (not available) 98 • Family Planning 7.6 SOURCE OF MODERN CONTRACEPTIVE METHODS Information on where women obtain their contraceptive method is important for programme managers and implementers in designing family planning policies and programmes. All current users of modern contraceptive methods at the time of the survey were asked the most recent source of their methods. 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 7.6 shows that the private medical sector is the most common source for users of modern contraceptive methods (60 percent). Less than one-third (29 percent) of current users of modern methods obtain their method from the public sector, mostly public government hospitals (17 percent). Nine percent of users of modern methods use other sources. The public sector supplies the majority of implants and IUDs (65 percent each), injectables (58 percent), and female sterilisation (56 percent). The private sector is the main source for male condoms (74 percent) and oral contraceptives (72 percent). Use of the public sector as a source has increased over the past five years (from 23 percent to 29 percent). Table 7.6 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 2013 Source Female sterilisation Pill IUD Injectables Implants Male condom Total Public sector 56.1 22.5 64.5 58.3 65.4 4.9 28.9 Government hospital 52.2 8.8 41.0 31.9 48.2 2.7 16.6 Government health centre 4.0 9.7 16.9 21.5 13.3 1.0 9.2 Family planning clinic 0.0 3.6 6.6 3.6 3.9 0.9 2.6 Mobile clinic 0.0 0.1 0.0 0.5 0.0 0.0 0.2 Fieldworker 0.0 0.3 0.0 0.7 0.0 0.2 0.3 Other public sector 0.0 0.0 0.0 0.0 0.0 0.1 0.1 Private sector 40.3 72.1 33.5 39.9 34.2 73.5 59.9 Private hospital/clinic 36.6 3.2 32.1 20.7 33.3 0.4 10.3 Pharmacy 0.0 16.4 0.0 3.7 0.0 13.9 10.0 Chemist/Patent Medical Store 0.0 51.8 0.0 12.6 0.0 58.3 38.2 Private doctor 3.3 0.2 1.4 1.2 0.9 0.2 0.7 Mobile clinic 0.0 0.3 0.0 0.3 0.0 0.1 0.2 NGO 0.4 0.0 0.0 0.0 0.0 0.2 0.1 Fieldworker 0.0 0.1 0.0 1.4 0.0 0.3 0.5 Other private medical sector 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Other source 0.0 1.8 0.0 0.0 0.0 19.6 9.0 Shop 0.0 0.5 0.0 0.0 0.0 4.1 1.9 Friend/relative 0.0 1.3 0.0 0.0 0.0 15.5 7.1 Other 0.0 0.6 0.0 0.0 0.0 0.4 0.3 Missing 3.5 2.9 2.0 1.8 0.4 1.7 2.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 105 724 322 963 112 1,771 4,014 Note: Total includes other modern methods but excludes lactational amenorrhoea method (LAM). 7.7 USE OF SOCIAL MARKETING BRAND PILLS Women currently using oral contraceptives and injectables were asked for the brand name of the pills and injectables they last used. Information on women’s use of social marketing brand contraceptives is useful for monitoring the success of social marketing programmes that promote a specific brand. The Federal Ministry of Health has set a national target of increasing the contraceptive prevalence rate to 36 percent by 2018. DKT Nigeria will contribute to reaching that goal by providing a variety of contraceptive options such as condoms, IUDs, oral contraceptives, emergency contraceptives, injectables, Family Planning • 99 and implants using innovative marketing. In addition, DKT will target adolescents with youth-friendly reproductive services by branding and promoting products that consider the multicultural diversity of Nigeria. Product promotions will also target modern market advertising venues such as social media (DKT International, 2014). Table 7.7 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 Duofem Confidence (44 percent) and Postinor (21 percent). Among women using injectables, Depo Provera (67 percent) and Noristerat (21 percent) are the most commonly used brands. Table 7.7 Use of social marketing brand pills and injectables Percent distribution of pill and injectables brand names used among women age 15-49, by background characteristics, Nigeria 2013 Brand of pill Brand of injectables1 Background characteristic Duofem Confidence Micro- gynon Lofemenal Neogynon Postinor Total Number of women using the pill Noristerat (2 months) Norigynon (2 months) Depo Provera (3 months) Other Total Number of women using injectables Age 15-19 (19.2) (25.3) (2.7) (26.7) (26.1) 100.0 28 * * * * 100.0 9 20-24 33.9 18.1 1.3 6.1 40.6 100.0 89 26.8 17.8 54.8 0.7 100.0 82 25-29 40.0 23.7 3.8 7.7 24.8 100.0 106 29.2 14.6 55.4 0.8 100.0 169 30-34 48.8 14.4 4.3 14.7 17.7 100.0 90 22.8 14.6 60.2 2.5 100.0 199 35-39 54.3 15.1 7.6 13.0 9.9 100.0 98 17.0 8.4 74.3 0.4 100.0 237 40-44 45.3 20.8 6.8 19.9 7.2 100.0 58 18.1 7.1 73.7 1.1 100.0 180 45-49 (50.3) (22.4) (3.5) (11.5) (12.3) 100.0 39 6.6 7.2 86.1 0.0 100.0 76 Residence Urban 38.2 21.0 3.7 13.5 23.5 100.0 327 20.9 9.0 69.8 0.3 100.0 471 Rural 53.2 15.5 5.7 10.4 15.1 100.0 181 20.1 13.3 64.8 1.8 100.0 479 Zone North Central 68.5 14.6 3.0 13.2 0.8 100.0 69 31.6 17.5 49.2 1.7 100.0 184 North East (35.8) (23.9) (11.6) (28.7) (0.0) 100.0 20 47.1 4.2 48.7 0.0 100.0 58 North West (39.9) (23.6) (2.1) (29.5) (4.9) 100.0 59 15.5 12.4 71.7 0.5 100.0 180 South East (35.0) (31.7) (4.6) (17.0) (11.7) 100.0 42 10.5 2.6 84.9 2.1 100.0 57 South South 35.0 27.8 3.6 7.6 25.9 100.0 143 21.5 12.7 63.2 2.6 100.0 176 South West 44.8 8.7 5.6 7.5 33.4 100.0 176 12.7 8.6 78.7 0.0 100.0 294 Education No education (45.4) (23.5) (0.0) (27.4) (3.7) 100.0 30 25.5 6.1 64.8 3.6 100.0 100 Primary 43.9 19.0 6.7 14.1 16.4 100.0 116 15.0 13.4 71.0 0.5 100.0 301 Secondary 47.8 14.3 4.4 10.5 23.1 100.0 265 20.5 9.5 69.0 1.0 100.0 455 More than secondary 30.9 31.0 3.4 11.1 23.7 100.0 96 32.3 17.5 50.2 0.0 100.0 94 Wealth quintile Lowest * * * * * * 7 (17.9) (0.0) (78.9) (3.2) 100.0 27 Second (50.2) (13.5) (13.0) (5.9) (17.4) 100.0 33 20.3 14.2 63.5 2.0 100.0 112 Middle 49.3 10.2 4.5 25.1 10.9 100.0 57 15.6 18.1 65.4 1.0 100.0 207 Fourth 43.6 22.7 5.0 9.2 19.6 100.0 167 19.2 8.6 71.0 1.3 100.0 260 Highest 41.7 18.5 3.1 12.4 24.4 100.0 243 24.7 8.9 66.0 0.4 100.0 343 Total 43.5 19.1 4.4 12.4 20.5 100.0 507 20.5 11.2 67.3 1.0 100.0 950 Note: Table excludes pill and injectables users who do not know the brand name. 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 Among injectables users not also using the pill. 7.8 USE OF SOCIAL MARKETING BRAND CONDOMS Women who reported that they currently use male condoms for contraception were asked for the brand name of the condoms they last used. Table 7.8.1 shows the percent distribution of 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 (77 percent). Eight percent of women use Rough Rider, and 6 percent use Durex. Nine percent of women do not know the brand of condom they last used. Men age 15-49 who reported that they 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. As reported for women, the majority of men use Gold Circle male condoms (81 percent), while 8 percent use Rough Rider (Table 7.8.2). Six percent of men do not know the brand of condom they last used. 100 • Family Planning Table 7.8.1 Use of social marketing brand condoms: Women Percent distribution of condom brand names used among women age 15-49, by background characteristics, Nigeria 2013 Brand of condoms Background characteristic Gold Circle Durex Rough Rider Twin Lotus Other1 Total Number of women using condoms Age 15-19 81.5 3.5 3.5 1.5 10.0 100.0 341 20-24 78.4 4.8 8.4 0.5 7.9 100.0 619 25-29 70.4 7.3 12.5 0.2 9.6 100.0 449 30-34 80.0 7.6 5.2 1.0 6.2 100.0 210 35-39 75.9 6.9 3.4 1.7 12.1 100.0 116 40-44 80.5 2.6 3.9 0.0 13.0 100.0 77 45-49 78.1 6.3 3.1 0.0 12.5 100.0 32 Residence Urban 75.4 6.7 8.2 1.0 8.6 100.0 1,215 Rural 80.4 3.3 6.2 0.2 9.9 100.0 629 Zone North Central 75.1 8.4 3.9 0.0 12.6 100.0 285 North East 57.1 0.0 8.2 0.0 34.7 100.0 49 North West 47.1 17.6 27.5 2.0 5.9 100.0 51 South East 77.2 2.8 8.6 2.3 9.1 100.0 429 South South 74.5 5.2 9.8 0.2 10.3 100.0 458 South West 84.6 5.9 4.9 0.2 4.4 100.0 572 Education No education 87.5 0.0 0.0 0.0 12.5 100.0 24 Primary 78.5 5.1 2.5 0.0 13.9 100.0 158 Secondary 79.6 3.9 6.8 0.8 8.8 100.0 1,120 More than secondary 71.0 9.4 10.9 0.7 7.9 100.0 542 Wealth quintile Lowest 85.7 0.0 0.0 0.0 14.3 100.0 14 Second 72.8 5.4 1.1 0.0 20.7 100.0 92 Middle 84.3 3.7 3.1 0.3 8.6 100.0 325 Fourth 79.5 3.9 8.1 0.5 8.1 100.0 570 Highest 73.1 7.6 9.7 1.1 8.5 100.0 843 Total 77.1 5.6 7.5 0.7 9.1 100.0 1,844 Note: Table excludes condom users who do not know the brand name. Condom use is based on women’s reports. 1 Includes plain condoms, female plain condoms, other condoms, don’t know, and missing Family Planning • 101 Table 7.8.2 Use of social marketing brand condoms: Men Percent distribution of condom brand names used among men age 15-49, by background characteristics, Nigeria 2013 Brand of condoms Background characteristic Gold Circle Durex Rough Rider Twin Lotus Other1 Total Number of men using condoms Age 15-19 91.3 2.4 2.4 0.0 3.8 100.0 208 20-24 81.7 6.1 7.6 0.1 4.5 100.0 671 25-29 81.9 4.6 8.7 0.3 4.6 100.0 634 30-34 77.4 3.6 11.3 0.5 7.2 100.0 390 35-39 77.4 4.9 8.6 0.8 8.2 100.0 243 40-44 77.5 3.9 6.2 0.0 12.4 100.0 129 45-49 79.3 0.0 6.9 0.0 13.8 100.0 87 Residence Urban 78.3 5.8 9.7 0.4 5.8 100.0 1,354 Rural 84.9 2.7 5.9 0.1 6.4 100.0 1,008 Zone North Central 76.5 7.4 8.5 0.3 7.3 100.0 591 North East 83.8 1.5 4.6 0.8 9.2 100.0 130 North West 63.3 10.1 7.6 0.0 19.0 100.0 79 South East 77.1 5.5 13.2 0.3 3.9 100.0 363 South South 86.6 1.7 8.3 0.0 3.4 100.0 648 South West 84.2 3.8 4.7 0.5 6.7 100.0 551 Education No education 77.6 2.0 0.0 0.0 20.4 100.0 49 Primary 84.8 2.1 3.8 0.8 8.4 100.0 237 Secondary 84.9 2.9 6.7 0.4 5.1 100.0 1,387 More than secondary 72.4 8.7 12.8 0.0 6.1 100.0 689 Wealth quintile Lowest 78.6 0.0 0.0 0.0 21.4 100.0 28 Second 88.9 1.7 0.0 0.6 8.9 100.0 180 Middle 86.1 2.7 4.9 0.0 6.3 100.0 445 Fourth 85.3 3.4 6.8 0.1 4.4 100.0 770 Highest 73.9 6.9 12.4 0.5 6.3 100.0 939 Total 81.1 4.5 8.0 0.3 6.1 100.0 2,362 Note: Table excludes condom users who do not know the brand name. Condom use is based on men’s reports. 1 Includes plain condoms, femidom, other condoms, don’t know, and missing 7.9 INFORMED CHOICE Informed choice is an important principle in the delivery of family planning services. As an aspect of informed choice, it is required that all family planning providers inform users about potential side effects of a method and what they should do if they encounter such side effects. Contraceptive users should also be informed of other methods available to them. This information assists the user in coping with side effects and thus decreases discontinuation of temporary methods. Women currently using a modern contraceptive method who started their last episode of use within five years of the survey 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 7.9 shows the results by method type and source of the method. Sixty 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 64 percent were informed of other available methods of contraception. Seventy-six percent of women who obtained their current family planning method from public sector facilities were informed about side effects or method-related problems, and 72 percent were told what to do if they experienced side effects. Women who used implants were most likely to be informed of side effects, what to do if they experienced side effects, and other methods they could use. 102 • Family Planning Users were slightly less likely to receive information about side effects or problems from a private medical facility (47 percent) than from a government hospital (79 percent). The same was true of information on what to do if side effects were experienced; 40 percent of users were given such information in private medical facilities, as compared with 76 percent in government hospitals. Table 7.9 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, the 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 initial source, Nigeria 2013 Among women who started last episode of modern contraceptive method within five years preceding the survey: Method/source Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if side effects experienced Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilisation (53.6) (42.8) (31.5) 42 Pill 43.2 36.9 52.6 637 IUD 77.7 74.4 78.6 237 Injectables 64.5 59.3 68.4 849 Implants 83.6 81.0 84.3 95 Initial source of method1 Public sector 75.5 72.1 80.0 888 Government hospital 78.6 76.0 83.3 476 Government health centre 71.5 66.7 76.6 328 Family planning clinic 75.2 76.4 79.1 64 Other public sector * * * 20 Private medical sector 47.1 39.8 51.9 865 Private hospital/clinic 66.8 61.0 68.1 307 Pharmacy 37.0 25.0 51.5 130 Chemist/PMS store 34.8 27.9 38.9 397 Private doctor * * * 17 Mobile clinic/NGO/fieldworker * * * 14 Other private sector 38.7 30.9 51.5 60 Friend/relative 41.7 33.3 55.5 56 Other * * * 6 Missing (14.2) (10.1) (7.1) 45 Total 59.6 54.3 64.3 1,861 Note: Table includes users of only the methods listed individually. 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 Source at start of current episode of use 7.10 RATES OF DISCONTINUING CONTRACEPTIVE METHODS Couples can realise their reproductive goals only when they consistently and correctly use reliable contraceptive methods. A prominent concern for family planning programmes is the rate at which contraceptive users discontinue using their methods and the reasons for such discontinuation. Provided with this information, family planning providers will be able to better advise potential users of the advantages and disadvantages of each contraceptive method, allowing women to make a more informed decision about the method that best suits their needs. The calendar section of the Woman’s Questionnaire records all segments of contraceptive use from 3-59 months prior to the survey. The month of the interview and the two months prior to the survey are ignored in order to avoid bias that may be introduced by unrecognised pregnancies. One-year contraceptive discontinuation rates based on the calendar data are presented in Table 7.10. Women who started an episode of contraceptive use within the five years preceding the survey and discontinued it within 12 months were asked the reason for the discontinuation. Overall, 28 percent of Family Planning • 103 episodes were discontinued within 12 months (Table 7.10). Eight percent of discontinuations occurred because the woman wanted to become pregnant and 4 percent because of method failure. Discontinuation rates vary by method. Among modern methods, rates are highest for pills and injectables (26 percent and 23 percent, respectively), followed by male condoms (20 percent). Table 7.10 Twelve-month contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months, by reason for discontinuation and specific method, Nigeria 2013 Method Method failure Desire to become pregnant Other fertility- related reasons2 Side effects/ health concerns Wanted more effective method Other method- related reasons3 Other reasons Any reason4 Switched to another method5 Number of episodes of use6 Pill 5.2 11.1 1.3 3.2 0.8 1.5 2.9 26.1 1.8 1,077 IUD 1.0 5.2 0.0 2.2 0.0 0.0 0.7 9.1 0.5 296 Injectables 1.7 6.0 0.7 9.6 0.5 1.3 3.3 23.1 2.7 1,261 Male condom 1.9 7.3 3.9 0.5 1.0 0.9 4.7 20.1 1.6 2,125 Other modern method 0.8 7.8 2.3 2.3 2.0 0.1 2.3 17.6 1.5 252 Rhythm 6.5 9.3 1.0 0.0 1.3 0.0 3.3 21.5 1.6 956 Withdrawal 6.9 12.4 1.8 0.0 2.8 0.1 4.3 28.3 3.0 1,277 Other1 2.1 4.9 3.0 0.2 13.7 3.8 40.3 68.0 26.3 976 All methods 3.6 8.2 2.1 2.1 2.6 1.1 7.9 27.6 4.8 8,370 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months preceding the survey. 1 Includes LAM and implants not shown separately 2 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation 3 Includes lack of access/too far, costs too much, and inconvenient to use 4 Reasons for discontinuation are mutually exclusive and add to the total given in this column. 5 The episodes of use included in this column are a subset of the discontinued episodes included in the discontinuation rate. A woman is considered to have switched to another method if she used a different method in the month following discontinuation or if she gave “wanted a more effective method” as the reason for discontinuation and started another method within 2 months of discontinuation. 6 Number of episodes of use includes both episodes of use that were discontinued during the period of observation and episodes of use that were not discontinued during the period of observation. 7.11 REASONS FOR DISCONTINUING CONTRACEPTIVE METHODS Table 7.11 shows the percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by the main reason stated for discontinuation, according to specific method. In total, 4,970 discontinuations occurred within this time period. Across all contraceptive methods, the most common reason for discontinuation was the desire to become pregnant (42 percent), followed by becoming pregnant while using the method (14 percent) and concern over side effects/health concerns (7 percent). Across specific contraceptive methods, the reasons for discontinuation vary widely. For example, among pill users, 49 percent of discontinuations occurred because users wanted to become pregnant, 16 percent occurred because users became pregnant while using the pill, and 11 percent were due to side effects or health concerns. A similar pattern was observed among users of injectables: 42 percent of discontinuations occurred because the user wanted to become pregnant, 29 percent were due to side effects or health concerns, and 10 percent occurred because the user became pregnant during the episode of use. 104 • Family Planning Table 7.11 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method, Nigeria 2013 Reason Pill IUD Injection Male condom Lactational amenorrhoe a Rhythm Withdrawal Other All methods Became pregnant while using 16.0 4.1 9.7 12.1 0.7 21.1 24.7 17.7 14.3 Wanted to become pregnant 48.8 59.9 41.9 42.4 6.3 54.1 49.1 40.6 41.9 Husband disapproved 1.2 1.2 2.1 3.4 0.9 0.1 1.5 1.5 1.7 Wanted a more effective method 4.3 0.0 1.9 4.7 19.7 4.8 6.7 8.3 6.4 Side effects/health concerns 10.7 20.4 28.9 1.4 0.1 0.0 0.2 3.7 7.1 Lack of access/too far 0.7 1.5 0.8 0.4 0.8 0.0 0.0 0.3 0.5 Cost too much 1.1 0.0 0.6 0.8 0.0 0.1 0.0 0.0 0.4 Inconvenient to use 1.9 2.0 1.8 2.9 5.0 0.0 0.2 1.5 1.9 Up to God/fatalistic 0.0 0.7 0.3 0.6 0.0 0.0 0.0 0.0 0.2 Difficult to get pregnant/ menopausal 0.2 1.3 0.1 0.0 0.3 0.8 0.4 0.0 0.3 Infrequent sex/husband away 3.8 1.9 3.4 12.9 4.2 4.6 4.3 3.5 5.8 Marital dissolution/separation 0.2 0.0 0.2 0.5 0.0 0.1 0.4 0.0 0.2 Other 0.7 0.0 1.3 1.7 5.9 0.9 0.2 3.5 1.7 Don’t know 0.2 0.0 0.2 0.5 1.2 0.1 0.3 0.8 0.4 Missing 10.2 6.9 7.0 15.6 54.8 13.3 12.1 18.5 17.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 764 130 750 1,014 585 584 806 302 4,970 Note: Total includes 34 women who reported discontinuation while using other modern methods not shown separately. 7.12 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for successful practice of coitus-associated methods such as withdrawal and condoms. Such knowledge is particularly critical in the use of the rhythm method. The 2013 NDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during the menstrual cycle. Respondents were asked, “From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?” If the 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 7.12 shows the results for women who use the rhythm method and those who do not use it. Among all women, only 20 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 nonusers; 37 percent of women who used the rhythm method correctly identified the middle of the cycle as the fertile period, as compared with 20 percent of women who did not use the rhythm method. Table 7.12 generally shows that knowledge of the fertile period is minimal among women in Nigeria. These results indicate a continued need for education about women’s reproductive physiology and the effective use of contraceptive methods. 7.13 NEED AND DEMAND FOR FAMILY PLANNING This section provides information on the need and potential demand for family planning services in Nigeria. The definition of unmet need for family planning has been revised so that levels of unmet need Table 7.12 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 2013 Perceived fertile period Users of rhythm method Nonusers of rhythm method All women Just before her menstrual period begins 3.7 7.4 7.3 During her menstrual period 0.6 2.5 2.5 Right after her menstrual period has ended 54.0 45.6 45.7 Halfway between two menstrual periods 36.9 20.1 20.4 Other 0.8 0.1 0.1 No specific time 1.8 12.1 11.9 Don’t know 0.5 11.5 11.3 Missing 1.7 0.8 0.8 Total 100.0 100.0 100.0 Number of women 793 38,155 38,948 Family Planning • 105 are comparable over time and across surveys (Bradley et al., 2012). In the past, the definition of unmet need was based on information from the contraceptive calendar and other questions that were not included in every survey. The revised definition includes only information that has been collected in every survey so that unmet need can be measured in the same way over time. Unmet need for family planning refers to fecund women who are not using contraception but who wish to postpone their next birth (spacing) or stop childbearing altogether (limiting). Specifically, women are considered to have an unmet need for spacing if they are: • At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years or are unsure if or when they want to become pregnant. • Pregnant with a mistimed pregnancy. • Postpartum amenorrheic for up to two years following a mistimed birth and not using contraception. Women are considered to have an unmet need for limiting if they are: • At risk of becoming pregnant, not using contraception, and want no (more) children. • Pregnant with an unwanted pregnancy. • Postpartum amenorrheic for up to two years following an unwanted birth and not using contraception. Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Women who are using contraception are considered to have a met need. Women using contraception who say they want no (more) children are considered to have a met need for limiting, and women who are using contraception and say they want to delay having a child or are unsure if or when they want a (another) child are considered to have a met need for spacing. Unmet need, total demand, percentage of demand satisfied, and percentage of demand satisfied by modern methods are defined as follows: • Unmet need: the sum of unmet need for spacing and unmet need for limiting • Total demand for family planning: the sum of unmet need and total contraceptive use • Percentage of demand satisfied: total contraceptive use divided by the sum of unmet need and total contraceptive use (any method) • Percentage of demand satisfied by modern methods: total modern contraceptive use divided by the sum of unmet need and total contraceptive use (any method) Tables 7.13.1, 7.13.2, and 7.13.3 present data on unmet need, met need, and total demand for family planning among currently married women, all women, and women who are not currently married, respectively. These indicators help to evaluate the extent to which the family planning programme in Nigeria is meeting the demand for services. Table 7.13.1 presents results among currently married women according to whether the need or demand is for spacing or limiting births. Overall, 16 percent of currently married women have an unmet need for family planning services (12 percent for spacing and 4 percent for limiting births). Fifteen percent 106 • Family Planning of married women have a met need for family planning or are currently using a contraceptive method. Thirty-one percent of currently married women have a demand for family planning. At present, about one- third of the potential demand for family planning is being met. Thus, if all currently married women who say they want to space or limit their children were to use family planning methods, the contraceptive prevalence rate would increase to 31 percent. Of the total demand for family planning methods, 49 percent is met by using any method and 31 percent is met by using modern methods. As expected, unmet need for spacing is high among younger women, while unmet need for limiting childbearing is high among older women (Table 7.13.1). There is a slight difference in unmet need between rural (17 percent) and urban (15 percent) areas. The North Central zone has the highest unmet need (24 percent) and the North West the lowest (12 percent). Unmet need is inversely associated with a woman’s education; it is lower among women with more than a secondary education (12 percent) than among those with a primary education or no education (19 percent and 15 percent, respectively). Unmet need is also inversely associated with a woman’s wealth status. Among women in the lowest two wealth quintiles, 14 percent and 15 percent, respectively, have an unmet need, while 13 percent of their counterparts in the highest quintile have an unmet need. Unmet need is highest in the middle and fourth wealth quintiles (20 percent and 19 percent, respectively). Wealth is positively associated with use of family planning services. Married women in the highest wealth quintile have a higher met need for family planning than those in the lowest quintile (37 percent and 2 percent, respectively). Table 7.13.1 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 of the demand for contraception that is satisfied, by background characteristics, Nigeria 2013 Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 13.0 0.1 13.1 2.0 0.1 2.1 15.0 0.1 15.2 13.9 7.6 2,251 20-24 16.1 0.4 16.6 9.3 0.2 9.6 25.5 0.7 26.1 36.6 23.8 4,362 25-29 15.7 1.1 16.8 12.4 1.7 14.1 28.2 2.7 30.9 45.6 28.6 5,913 30-34 13.0 4.1 17.1 13.0 6.1 19.1 26.1 10.2 36.3 52.7 34.6 4,869 35-39 9.6 8.1 17.6 8.7 12.3 21.0 18.3 20.3 38.6 54.4 35.1 4,302 40-44 7.0 9.8 16.8 4.2 17.4 21.7 11.2 27.3 38.5 56.3 37.3 3,226 45-49 4.0 7.5 11.5 1.4 11.8 13.2 5.5 19.3 24.7 53.4 33.6 2,907 Residence Urban 10.3 4.7 14.9 15.2 11.6 26.8 25.4 16.3 41.7 64.2 40.5 10,124 Rural 12.8 3.9 16.8 4.8 3.7 8.5 17.6 7.7 25.2 33.6 22.6 17,705 Zone North Central 16.9 6.6 23.5 8.6 7.0 15.6 25.4 13.7 39.1 39.9 31.7 3,895 North East 14.2 3.3 17.5 1.8 1.4 3.2 16.0 4.7 20.7 15.2 13.1 4,679 North West 10.4 1.6 12.0 3.0 1.2 4.3 13.4 2.9 16.3 26.2 22.4 10,034 South East 7.4 5.1 12.5 16.0 13.2 29.3 23.4 18.3 41.8 70.0 26.4 2,333 South South 14.9 7.3 22.2 16.6 11.4 28.1 31.5 18.7 50.2 55.9 32.6 2,699 South West 9.0 6.5 15.4 19.9 18.1 38.0 28.9 24.6 53.5 71.1 46.6 4,189 State North Central FCT-Abuja 13.6 6.2 19.7 12.2 12.9 25.2 25.8 19.1 44.9 56.0 45.8 200 Benue 18.0 13.4 31.4 7.3 9.2 16.5 25.3 22.6 47.9 34.4 25.2 827 Kogi 11.4 9.6 20.9 7.1 3.4 10.5 18.5 13.0 31.5 33.4 27.2 433 Kwara 8.1 4.2 12.2 20.5 19.7 40.2 28.5 23.9 52.4 76.7 52.9 384 Nasarawa 14.6 6.2 20.8 9.0 9.1 18.1 23.6 15.4 38.9 46.5 41.9 420 Niger 22.5 1.8 24.3 5.2 1.4 6.6 27.7 3.2 30.9 21.4 18.2 1,190 Plateau 16.2 6.8 23.0 9.2 5.9 15.2 25.4 12.8 38.2 39.7 37.8 442 North East Adamawa 16.0 5.8 21.8 3.0 1.4 4.4 19.0 7.2 26.1 16.8 13.5 586 Bauchi 14.2 2.2 16.4 1.5 0.7 2.2 15.8 2.8 18.6 11.9 11.5 1,051 Borno 15.0 2.0 17.1 0.8 1.0 1.8 15.8 3.0 18.8 9.4 9.4 1,120 Gombe 14.3 5.1 19.4 2.3 1.7 4.0 16.6 6.8 23.4 17.2 16.9 467 Taraba 14.2 5.3 19.5 3.3 4.7 8.0 17.5 10.1 27.5 29.0 23.4 632 Yobe 11.8 2.3 14.1 1.0 0.1 1.1 12.9 2.4 15.3 7.5 3.6 824 Continued… Family Planning • 107 Table 7.13.1—Continued Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total North West Jigawa 14.8 1.8 16.5 0.7 0.3 0.9 15.4 2.1 17.5 5.4 3.2 1,256 Kaduna 4.2 1.6 5.8 13.4 6.8 20.2 17.6 8.3 25.9 77.7 71.3 1,594 Kano 9.4 1.6 11.1 0.4 0.1 0.6 9.9 1.8 11.6 5.1 4.4 2,521 Katsina 13.2 1.3 14.5 1.3 0.0 1.3 14.5 1.3 15.8 8.2 7.2 1,408 Kebbi 16.9 1.3 18.2 1.0 0.3 1.3 17.9 1.6 19.5 6.6 6.2 1,074 Sokoto 5.0 2.5 7.5 0.8 0.3 1.1 5.7 2.8 8.6 12.4 8.4 956 Zamfara 11.4 1.4 12.8 2.7 0.4 3.0 14.1 1.8 15.9 19.1 8.1 1,226 South East Abia 5.2 5.9 11.2 14.8 18.7 33.4 20.0 24.6 44.6 75.0 35.0 292 Anambra 5.1 2.0 7.1 19.2 15.8 35.0 24.3 17.7 42.1 83.2 27.9 564 Ebonyi 13.1 7.5 20.5 11.5 4.2 15.7 24.6 11.6 36.2 43.3 15.4 564 Enugu 5.8 5.9 11.7 15.0 16.4 31.4 20.8 22.3 43.1 72.9 33.2 467 Imo 6.3 4.8 11.1 19.6 14.5 34.1 25.9 19.3 45.2 75.5 23.6 446 South South Akwa Ibom 18.8 10.3 29.1 17.5 7.9 25.5 36.3 18.3 54.6 46.7 30.2 410 Bayelsa 22.2 6.3 28.5 10.7 2.6 13.3 32.9 8.8 41.7 31.8 24.3 202 Cross River 24.2 6.6 30.8 17.5 6.5 24.0 41.8 13.1 54.8 43.8 26.2 437 Delta 11.6 4.4 16.1 14.1 14.6 28.7 25.7 19.1 44.8 64.1 37.5 551 Edo 9.9 8.9 18.9 14.7 15.7 30.3 24.6 24.6 49.2 61.6 38.9 395 Rivers 9.9 7.6 17.6 20.3 14.2 34.5 30.3 21.8 52.1 66.3 33.5 704 South West Ekiti 11.4 7.4 18.7 12.6 21.9 34.5 23.9 29.3 53.2 64.8 50.1 194 Lagos 8.3 3.5 11.8 26.4 21.9 48.3 34.7 25.3 60.1 80.4 43.9 1,236 Ogun 14.6 8.7 23.4 14.8 11.2 26.0 29.4 20.0 49.4 52.7 43.5 655 Ondo 10.2 6.7 16.9 13.9 17.2 31.1 24.1 23.9 48.0 64.8 42.5 510 Osun 7.9 8.6 16.5 17.7 20.7 38.3 25.6 29.3 54.9 69.9 57.6 465 Oyo 5.8 7.4 13.2 20.8 16.6 37.4 26.6 24.0 50.6 73.9 48.2 1,129 Education No education 12.0 2.9 14.9 1.4 1.3 2.7 13.4 4.2 17.5 15.2 9.8 13,470 Primary 12.2 7.1 19.3 9.2 10.7 19.9 21.4 17.9 39.3 50.8 34.7 5,336 Secondary 12.7 4.6 17.3 18.0 11.1 29.2 30.7 15.7 46.4 62.8 40.2 6,981 More than secondary 8.0 3.7 11.7 21.5 15.5 37.0 29.5 19.2 48.7 75.9 46.0 2,043 Wealth quintile Lowest 12.0 2.3 14.3 0.8 0.8 1.7 12.8 3.1 15.9 10.4 5.3 6,424 Second 11.7 3.7 15.4 2.9 2.2 5.1 14.6 5.9 20.6 24.9 18.1 5,986 Middle 14.8 5.3 20.0 6.9 6.3 13.3 21.7 11.6 33.3 39.8 27.4 4,983 Fourth 12.9 5.8 18.7 13.7 9.3 23.1 26.6 15.2 41.8 55.2 34.6 5,042 Highest 8.5 4.5 13.0 20.6 16.1 36.7 29.1 20.5 49.6 73.9 47.0 5,395 Total 11.9 4.2 16.1 8.5 6.6 15.1 20.4 10.8 31.2 48.5 31.3 27,830 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, and lactational amenorrhoea method (LAM). The data for all women and women who are not currently married follow the same trends observed among currently married women (Tables 7.13.2 and 7.13.3). Total demand for family planning is high among all women (between 30 percent and 37 percent) in each age group between 20 and 44 years. These groups represent women of childbearing age. Unmet need among unmarried women is higher than that among currently married women (22 percent versus 16 percent). 108 • Family Planning Table 7.13.2 Need and demand for family planning for all women Percentage of all women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Nigeria 2013 Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 6.2 0.0 6.2 6.1 0.1 6.1 12.2 0.1 12.3 49.8 39.3 7,820 20-24 12.3 0.3 12.6 16.9 0.2 17.1 29.2 0.5 29.7 57.6 44.4 6,757 25-29 14.1 0.9 15.0 17.0 1.4 18.4 31.0 2.4 33.4 55.1 37.8 7,145 30-34 12.2 3.8 15.9 14.5 5.8 20.3 26.7 9.5 36.3 56.0 37.8 5,467 35-39 9.0 7.6 16.6 8.9 11.8 20.6 17.8 19.4 37.2 55.5 36.5 4,718 40-44 6.5 9.0 15.5 4.5 16.7 21.2 10.9 25.7 36.7 57.8 38.3 3,620 45-49 3.4 6.5 9.9 1.5 11.0 12.4 4.9 17.5 22.4 55.5 35.7 3,422 Residence Urban 7.4 2.9 10.4 16.6 7.5 24.1 24.1 10.4 34.5 70.0 48.5 16,414 Rural 11.3 3.2 14.5 6.8 3.3 10.1 18.0 6.5 24.5 41.0 28.9 22,534 Zone North Central 12.8 4.9 17.7 9.0 5.3 14.3 21.8 10.2 32.0 44.7 36.7 5,572 North East 12.6 2.8 15.4 2.0 1.2 3.1 14.6 3.9 18.5 16.9 14.6 5,766 North West 9.1 1.4 10.4 3.6 1.1 4.6 12.6 2.5 15.1 30.8 27.2 11,877 South East 5.7 2.8 8.5 19.2 7.4 26.6 25.0 10.1 35.1 75.8 40.9 4,476 South South 11.1 4.2 15.3 21.4 7.2 28.6 32.6 11.3 43.9 65.2 43.7 4,942 South West 6.9 4.4 11.3 20.5 12.6 33.1 27.4 17.0 44.4 74.6 51.9 6,314 State North Central FCT-Abuja 9.6 4.1 13.7 13.8 8.3 22.0 23.4 12.4 35.8 61.6 50.9 315 Benue 13.7 10.0 23.7 9.6 7.3 16.9 23.3 17.3 40.6 41.6 32.6 1,240 Kogi 8.3 6.0 14.3 10.2 2.1 12.3 18.4 8.1 26.5 46.2 41.2 704 Kwara 5.4 2.7 8.1 17.3 13.2 30.5 22.7 15.9 38.6 79.0 55.8 596 Nasarawa 12.9 4.4 17.3 7.3 6.6 13.9 20.2 11.0 31.2 44.5 39.9 594 Niger 18.5 1.4 20.0 4.7 1.2 5.9 23.2 2.6 25.8 22.8 19.7 1,462 Plateau 11.5 4.6 16.1 8.1 4.3 12.5 19.6 8.9 28.5 43.7 42.0 662 North East Adamawa 14.3 4.1 18.4 2.5 1.0 3.5 16.7 5.1 21.8 15.9 13.1 828 Bauchi 13.0 2.0 15.0 1.4 0.6 2.0 14.4 2.6 17.0 11.8 11.4 1,161 Borno 12.4 1.6 14.0 1.0 0.8 1.7 13.4 2.4 15.8 11.1 11.1 1,412 Gombe 12.8 4.4 17.2 2.3 1.5 3.8 15.1 5.9 21.1 18.2 17.1 550 Taraba 13.3 4.4 17.7 4.9 3.7 8.7 18.3 8.1 26.4 32.9 27.1 844 Yobe 10.1 2.0 12.0 0.9 0.1 1.0 11.0 2.1 13.1 7.7 3.8 971 North West Jigawa 13.7 1.6 15.3 0.6 0.3 0.9 14.3 1.9 16.2 5.4 3.2 1,353 Kaduna 4.3 1.2 5.5 15.7 5.2 20.9 20.0 6.4 26.3 79.2 73.8 2,136 Kano 7.5 1.3 8.8 0.3 0.1 0.5 7.9 1.4 9.3 5.0 4.3 3,189 Katsina 12.2 1.2 13.4 1.2 0.0 1.2 13.4 1.2 14.6 8.2 7.2 1,525 Kebbi 14.9 1.1 16.0 0.9 0.2 1.1 15.8 1.4 17.1 6.5 6.1 1,244 Sokoto 4.4 2.2 6.6 0.7 0.3 0.9 5.0 2.5 7.5 12.4 8.3 1,098 Zamfara 10.6 1.3 11.9 2.5 0.3 2.8 13.0 1.7 14.7 19.0 8.0 1,332 South East Abia 4.6 3.3 8.0 19.9 11.7 31.6 24.5 15.0 39.6 79.9 49.5 518 Anambra 3.2 1.1 4.3 22.0 8.5 30.5 25.2 9.6 34.8 87.5 43.1 1,052 Ebonyi 10.7 3.9 14.6 14.1 2.3 16.4 24.8 6.2 31.0 52.9 28.1 1,122 Enugu 3.6 3.1 6.7 20.3 8.9 29.3 24.0 12.0 36.0 81.4 50.1 951 Imo 5.3 2.6 7.8 20.9 8.4 29.4 26.2 11.0 37.2 78.9 37.0 833 South South Akwa Ibom 13.3 5.3 18.6 23.4 4.4 27.8 36.7 9.7 46.4 59.9 41.3 864 Bayelsa 17.1 3.5 20.6 17.1 1.5 18.7 34.3 5.0 39.3 47.5 40.3 364 Cross River 17.7 4.2 21.9 19.5 5.3 24.7 37.2 9.4 46.6 53.1 36.6 703 Delta 9.8 2.5 12.2 21.3 8.6 29.9 31.0 11.1 42.1 71.0 50.2 993 Edo 6.3 5.0 11.2 19.8 8.8 28.6 26.1 13.8 39.9 71.8 52.6 742 Rivers 8.2 4.4 12.6 23.5 9.6 33.1 31.7 14.0 45.7 72.5 41.1 1,276 South West Ekiti 9.7 4.6 14.3 15.9 13.9 29.7 25.6 18.4 44.0 67.6 54.3 326 Lagos 5.9 2.2 8.1 25.8 14.7 40.5 31.7 16.9 48.6 83.4 51.1 1,964 Ogun 12.0 6.9 18.9 14.5 8.9 23.4 26.5 15.8 42.3 55.2 45.6 883 Ondo 8.6 4.2 12.8 18.1 11.4 29.5 26.7 15.6 42.4 69.7 48.9 808 Osun 4.9 5.2 10.1 19.5 12.9 32.4 24.4 18.1 42.5 76.3 63.5 765 Oyo 4.9 5.3 10.2 19.9 12.3 32.2 24.8 17.6 42.4 76.0 51.8 1,568 Education No education 11.2 2.7 13.9 1.4 1.2 2.6 12.6 3.9 16.5 16.0 10.3 14,729 Primary 10.9 5.8 16.7 8.9 9.4 18.3 19.8 15.2 35.0 52.3 36.6 6,734 Secondary 8.5 2.4 10.9 17.5 6.0 23.5 26.0 8.4 34.4 68.4 48.0 13,927 More than secondary 5.5 2.2 7.7 28.2 9.1 37.3 33.7 11.2 44.9 82.9 57.8 3,558 Continued… Family Planning • 109 Table 7.13.2—Continued Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Wealth quintile Lowest 11.2 2.1 13.3 1.0 0.8 1.7 12.1 2.9 15.0 11.5 6.1 7,132 Second 10.7 3.2 13.8 3.9 2.0 5.9 14.6 5.2 19.7 29.9 22.0 7,428 Middle 11.4 3.6 15.1 9.3 4.7 14.0 20.7 8.3 29.1 48.1 34.6 7,486 Fourth 9.6 3.8 13.4 15.6 6.6 22.2 25.3 10.3 35.6 62.3 42.9 7,992 Highest 6.1 2.7 8.8 21.9 10.0 31.9 28.0 12.7 40.7 78.4 54.6 8,910 Total 9.7 3.1 12.7 10.9 5.1 16.0 20.6 8.1 28.7 55.7 38.8 38,948 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, and lactational amenorrhoea method (LAM). Table 7.13.3 Need and demand for family planning for sexually active unmarried women Percentage of sexually active unmarried 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 2013 Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 35.3 0.0 35.3 60.6 0.5 61.1 95.9 0.5 96.3 63.4 51.6 363 20-24 16.8 0.1 16.9 76.2 0.1 76.3 93.0 0.2 93.2 81.9 68.1 528 25-29 15.5 0.4 15.9 70.2 0.3 70.5 85.6 0.7 86.3 81.6 66.9 377 30-34 16.7 1.7 18.4 59.7 6.6 66.3 76.4 8.3 84.8 78.2 58.1 149 35-39 12.4 15.4 27.9 30.6 20.4 51.1 43.0 35.9 78.9 64.7 53.1 72 40-44 15.3 10.2 25.5 23.9 34.7 58.6 39.2 44.9 84.1 69.7 41.0 60 45-49 (1.9) (10.1) (12.0) (8.7) (37.8) (46.4) (10.6) (47.9) (58.4) (79.5) (52.2) 30 Residence Urban 14.7 0.6 15.3 72.6 2.2 74.8 87.3 2.8 90.1 83.0 69.7 877 Rural 27.1 2.8 29.9 53.9 5.8 59.7 81.0 8.6 89.5 66.6 50.3 700 Zone North Central 26.7 7.1 33.8 51.6 5.5 57.1 78.3 12.6 90.9 62.8 55.6 163 North East 60.6 3.3 63.9 22.4 1.5 23.9 83.0 4.8 87.8 27.2 24.0 76 North West 21.4 0.0 21.4 72.6 0.0 72.6 93.9 0.0 93.9 77.2 75.4 130 South East 17.4 0.3 17.7 73.0 3.3 76.3 90.4 3.6 94.0 81.2 60.7 264 South South 19.0 0.9 19.9 66.1 3.5 69.6 85.1 4.4 89.6 77.7 59.9 614 South West 11.6 1.3 12.9 66.6 5.9 72.4 78.2 7.2 85.4 84.9 69.4 330 Education No education 39.6 9.5 49.1 22.2 4.0 26.1 61.7 13.5 75.2 34.8 21.1 70 Primary 25.3 5.7 31.1 32.5 14.8 47.3 57.8 20.5 78.4 60.4 49.5 192 Secondary 21.9 0.6 22.5 66.1 2.9 69.1 88.0 3.6 91.6 75.4 60.3 977 More than secondary 8.5 0.3 8.8 85.6 0.0 85.6 94.1 0.3 94.4 90.7 75.5 339 Wealth quintile Lowest (43.9) (3.5) (47.4) (25.4) (7.4) (32.8) (69.3) (10.9) (80.2) (40.9) (29.0) 34 Second 37.4 4.7 42.1 40.4 2.9 43.2 77.8 7.5 85.3 50.7 33.2 166 Middle 24.0 2.3 26.3 56.1 4.9 61.0 80.1 7.2 87.3 69.8 53.4 327 Fourth 18.5 1.6 20.0 65.1 5.8 70.9 83.6 7.4 90.9 78.0 62.1 483 Highest 13.0 0.1 13.1 77.7 1.5 79.1 90.7 1.6 92.3 85.8 73.7 567 Total 20.2 1.6 21.8 64.3 3.8 68.1 84.5 5.4 89.8 75.8 61.1 1,577 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. Figures in parentheses are based on 25-49 unweighted cases. This table is based on sexually active unmarried women, which includes women who have had sexual intercourse within 30 days preceding the survey. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, and lactational amenorrhoea method (LAM). Overall, unmet need decreased from 22 percent in the 1990 NDHS to 16 percent in 2013 (Figure 7.2). 110 • Family Planning Figure 7.2 Trends in unmet need for family planning 22 20 18 20 16 1990 NDHS 1999 NDHS 2003 NDHS 2008 NDHS 2013 NDHS Percent Note: Estimates for all years are based on the revised definition of unmet need. 7.14 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which non- users plan to use contraception in the future. Currently married women who were not using contraception at the time of the survey were asked about their intention to use family planning in the future. Table 7.14 shows that 23 percent of currently married nonusers intend to use family planning methods in the future, while 63 percent report that they do not intend to use a method. The proportion of women who intend to use a method varies with the number of living children they have. The proportion is highest among women with one to two children and lowest among those with no living children (14 percent). Table 7.14 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 2013 Number of living children1 Total Intention 0 1 2 3 4+ Intends to use 13.9 27.5 27.1 26.0 21.0 23.3 Unsure 14.8 12.0 11.2 9.0 8.8 10.2 Does not intend to use 68.0 57.8 58.6 61.6 66.7 63.3 Missing 3.3 2.7 3.0 3.3 3.5 3.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,814 3,841 3,838 3,601 10,520 23,613 1 Includes current pregnancy 7.15 EXPOSURE TO FAMILY PLANNING MESSAGES IN THE MEDIA The mass media and interpersonal communication can be major sources of family planning messages. Information about public exposure to messages through a particular medium allows policymakers to ensure the use of the most effective means of communication for various target groups in the population. To assess the effectiveness of dissemination of family planning information through different media, interviewers asked respondents in the 2013 NDHS whether they had been exposed to any family planning messages in the past few months. Interviewers asked about family planning messages on the radio or television; in a newspaper, magazine, pamphlet, poster, or leaflet; or at a community event. Family Planning • 111 Table 7.15 shows that radio is the most frequent source of family planning messages for both women (33 percent) and men (48 percent). One in every five women and one-fourth 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 among both women and men (7 percent and 14 percent, respectively). Sixty-two percent of women and 47 percent of men did not receive family planning information from any of the sources. Exposure to family planning messages is more common among men than women and more common in urban areas than rural areas. Among the zones, women in the South West and men in the South East and South South 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 type of mass media. Media exposure also increases with increasing wealth quintile among both women and men. Table 7.15 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on radio, on television, or in a newspaper or magazine in the past few months, according to background characteristics, Nigeria 2013 Women Men Background characteristic Radio Tele- vision News- paper/ maga- zine Poster/ leaflet or brochure Other None of these media sources Number of women Radio Tele- vision News- paper/ maga- zine Poster/ leaflet or brochure Other None of these media sources Number of men Age 15-19 24.0 12.6 4.0 9.0 3.4 71.2 7,820 28.9 14.6 4.4 10.8 3.3 65.2 3,619 20-24 32.4 18.5 7.2 13.6 4.6 62.8 6,757 44.1 24.6 11.8 19.1 7.0 49.3 2,892 25-29 36.1 22.4 7.8 15.0 5.8 59.4 7,145 50.4 25.9 15.8 23.8 7.0 42.8 2,757 30-34 37.8 23.4 8.6 16.4 6.5 57.5 5,467 53.9 30.8 17.4 22.5 7.2 40.7 2,414 35-39 38.0 22.4 7.6 15.2 6.5 57.7 4,718 56.3 31.7 17.3 24.0 7.4 40.1 2,175 40-44 35.2 22.0 7.6 14.1 6.6 60.6 3,620 56.0 31.4 19.6 23.5 8.7 39.9 1,777 45-49 32.2 17.6 5.3 11.3 5.7 64.1 3,422 58.2 31.3 17.4 21.8 9.3 38.9 1,724 Residence Urban 49.6 34.7 12.6 21.2 9.0 43.5 16,414 53.4 37.5 19.5 24.1 8.9 39.6 7,611 Rural 21.0 8.3 2.5 7.7 2.7 76.1 22,534 42.8 16.7 9.2 16.6 5.0 53.2 9,748 Zone North Central 25.2 15.2 6.3 15.3 6.3 69.0 5,572 48.7 24.8 15.4 25.6 10.2 44.5 2,685 North East 15.3 7.1 2.3 9.3 0.8 80.7 5,766 32.6 12.6 7.3 21.8 7.1 60.4 2,515 North West 24.5 5.6 2.3 5.5 0.1 73.4 11,877 33.8 7.5 4.2 15.1 1.3 63.1 5,185 South East 38.4 23.6 12.4 15.5 2.8 56.5 4,476 49.2 30.6 19.2 13.7 5.9 45.2 1,686 South South 38.1 30.1 11.6 17.4 9.5 55.2 4,942 70.2 53.9 27.2 22.3 9.2 24.3 2,445 South West 64.6 49.1 11.9 25.6 17.3 28.9 6,314 63.7 44.9 20.1 23.3 11.1 30.3 2,843 State North Central FCT-Abuja 48.8 42.6 18.5 40.6 4.1 38.7 315 69.8 63.1 48.7 45.6 5.2 18.3 175 Benue 23.7 8.1 2.7 3.0 3.1 74.5 1,240 68.8 20.1 17.6 24.2 20.6 22.8 616 Kogi 22.3 19.0 10.8 23.8 17.7 60.6 704 42.1 25.5 7.7 31.5 1.4 49.2 333 Kwara 69.5 37.2 16.4 54.7 19.0 20.5 596 71.1 30.2 22.2 29.0 24.6 25.9 274 Nasarawa 14.2 9.5 3.8 9.4 3.1 79.0 594 39.8 23.5 15.6 14.3 13.0 53.3 282 Niger 14.1 9.1 2.7 6.4 2.9 84.4 1,462 34.5 22.4 9.1 28.4 0.8 60.3 701 Plateau 14.3 10.3 4.0 7.0 0.6 82.6 662 23.8 13.5 8.7 11.7 7.7 70.8 302 North East Adamawa 25.7 10.9 4.5 20.2 1.5 66.3 828 47.1 15.1 11.7 31.8 7.1 34.0 358 Bauchi 18.3 6.7 1.7 14.9 0.7 76.8 1,161 20.6 4.3 4.4 18.6 9.8 71.1 512 Borno 17.5 8.3 1.9 2.0 0.2 80.2 1,412 36.8 25.7 11.4 14.4 11.1 60.1 676 Gombe 11.8 6.9 2.1 8.8 1.9 84.4 550 39.8 12.3 8.7 28.8 4.2 52.0 255 Taraba 4.6 2.6 1.4 5.9 0.2 90.9 844 52.3 7.9 4.0 48.7 2.7 41.7 325 Yobe 10.9 7.0 2.8 7.1 0.9 87.3 971 6.9 2.5 1.8 3.0 2.3 92.0 390 North West Jigawa 13.1 1.1 0.2 3.8 0.3 85.9 1,353 56.4 8.5 3.5 17.4 4.2 42.0 510 Kaduna 33.0 26.1 10.5 20.5 0.1 58.9 2,136 50.2 19.2 13.5 29.1 1.0 39.6 1,033 Kano 36.0 2.1 1.1 2.5 0.0 62.7 3,189 16.6 2.0 1.0 4.1 1.3 83.4 1,592 Katsina 36.9 0.7 0.3 4.2 0.2 62.6 1,525 54.3 8.1 1.9 43.7 0.9 41.6 596 Kebbi 5.4 0.9 0.1 0.1 0.0 94.4 1,244 14.5 4.0 1.9 3.0 0.3 83.4 551 Sokoto 2.5 0.3 0.1 0.6 0.1 97.1 1,098 26.3 7.3 2.4 4.9 2.2 72.4 424 Zamfara 16.6 0.1 0.0 1.1 0.0 83.1 1,332 34.9 2.9 2.6 6.3 0.3 63.5 479 South East Abia 43.6 30.4 12.6 7.4 1.0 52.2 518 49.2 42.7 27.6 27.4 15.0 42.5 229 Anambra 19.7 16.6 11.2 15.7 1.3 71.6 1,052 29.0 23.9 14.9 10.4 0.6 61.8 446 Ebonyi 45.3 26.5 13.7 23.2 6.5 48.8 1,122 71.9 20.8 18.2 6.8 0.4 26.7 368 Enugu 40.1 23.6 12.4 8.7 1.2 58.1 951 33.1 21.8 6.8 8.4 0.8 62.9 320 Imo 47.5 24.4 12.1 17.9 2.8 48.7 833 67.2 51.3 32.9 21.5 18.1 28.0 323 Continued… 112 • Family Planning Table 7.15—Continued Women Men Background characteristic Radio Tele- vision News- paper/ maga- zine Poster/ leaflet or brochure Other None of these media sources Number of women Radio Tele- vision News- paper/ maga- zine Poster/ leaflet or brochure Other None of these media sources Number of men South South Akwa Ibom 49.0 33.6 10.5 17.8 5.9 45.9 864 79.9 56.3 23.7 18.0 15.0 16.1 451 Bayelsa 44.9 41.0 17.7 27.0 21.8 42.0 364 50.7 49.5 11.1 2.5 2.5 41.3 187 Cross River 46.7 29.2 6.9 36.1 12.8 41.5 703 57.0 33.0 16.0 16.4 3.9 37.1 310 Delta 29.3 24.9 13.8 11.4 10.0 67.3 993 58.0 34.9 7.9 13.8 2.0 40.3 473 Edo 49.8 45.3 20.4 23.3 16.5 42.2 742 62.6 59.0 17.6 19.9 2.9 25.4 365 Rivers 24.1 20.4 6.3 5.3 2.3 71.0 1,276 88.4 74.1 58.7 41.1 18.3 6.9 658 South West Ekiti 67.2 61.9 13.9 44.1 28.4 26.0 326 91.1 77.8 33.4 69.3 4.3 4.7 148 Lagos 63.2 58.3 22.7 25.0 19.3 25.3 1,964 55.7 53.9 22.6 18.3 7.4 31.6 948 Ogun 60.7 50.3 4.3 24.9 11.2 35.4 883 77.6 70.3 42.7 27.2 10.2 20.1 358 Ondo 49.5 34.2 5.2 18.4 6.5 45.4 808 51.9 39.2 20.5 23.1 11.4 43.8 404 Osun 74.5 53.5 10.5 31.8 32.4 22.7 765 91.1 26.8 8.0 10.4 1.1 7.8 356 Oyo 71.0 40.0 6.2 23.4 14.1 24.7 1,568 53.4 23.2 7.0 25.1 24.3 44.2 629 Education No education 14.3 2.2 0.2 3.2 0.9 84.1 14,729 25.4 2.9 0.5 7.7 1.5 72.7 3,685 Primary 32.7 15.8 2.3 10.7 5.6 62.9 6,734 45.0 17.2 4.6 12.8 5.1 51.1 2,907 Secondary 44.2 29.3 9.3 19.1 8.0 49.2 13,927 50.4 29.8 14.1 20.2 7.2 43.2 8,281 More than secondary 67.9 59.1 32.5 38.5 12.8 23.2 3,558 73.3 56.9 42.9 45.4 14.6 18.5 2,486 Wealth quintile Lowest 9.0 0.5 0.1 1.9 0.2 90.2 7,132 25.5 1.6 0.9 8.2 1.7 72.7 2,862 Second 16.1 2.7 0.6 5.1 1.4 81.5 7,428 37.4 6.5 4.1 13.5 4.0 58.9 2,992 Middle 28.5 10.9 3.3 10.1 4.4 67.3 7,486 46.5 19.1 9.1 17.4 5.5 48.2 3,338 Fourth 47.0 28.0 7.6 18.2 8.2 47.2 7,992 54.2 34.2 15.7 23.2 7.8 40.3 3,835 Highest 57.8 48.0 19.3 28.1 11.2 33.7 8,910 63.7 52.9 30.6 31.1 11.7 27.8 4,332 Total 33.1 19.4 6.8 13.4 5.4 62.4 38,948 47.5 25.8 13.7 19.9 6.7 47.2 17,359 7.16 EXPOSURE TO SPECIFIC FAMILY PLANNING MESSAGES Respondents in the 2013 NDHS were asked if they had heard or seen specific family planning or health messages in the past few months. Table 7.16 shows the percent distribution of women and men age 15-49 who heard or saw specific messages, by background characteristics. Overall, 12 percent of women and 22 percent of men heard or saw “Well-spaced children are every parent’s joy,” 18 percent of women and 21 percent of men heard or saw “Unspaced children makes the going tough,” and 13 percent of women and 19 percent of men 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. In general, Nigerian men have higher exposure levels to each specific message than women. Women and men age 15-19 have the lowest levels of exposure to all of the specified messages. Urban respondents, those with more education, and those in the highest wealth quintile are more likely than their counterparts to have been exposed to specific family planning messages. Family Planning • 113 Table 7.16 Exposure to specific family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message in the past few months, according to background characteristics, Nigeria 2013 Women Men 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 pro- gramme Number of women 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 pro- gramme Number of men Age 15-19 8.7 11.2 8.4 7.6 4.4 0.5 7,820 12.5 10.3 11.6 8.6 4.6 0.5 3,619 20-24 14.3 16.8 11.3 10.1 7.1 0.3 6,757 18.0 18.0 21.0 13.5 7.5 0.4 2,892 25-29 15.0 19.0 13.5 10.6 8.2 0.6 7,145 20.7 22.0 24.2 13.2 8.0 0.6 2,757 30-34 15.3 21.7 14.2 10.2 8.8 0.6 5,467 20.9 26.0 24.0 13.7 8.9 0.4 2,414 35-39 14.5 21.2 15.6 9.4 8.1 0.7 4,718 20.6 26.6 27.0 15.7 9.4 0.6 2,175 40-44 14.8 19.5 13.4 9.6 8.9 0.4 3,620 21.9 27.4 26.4 15.8 8.8 0.4 1,777 45-49 11.1 16.8 12.1 7.6 7.4 0.3 3,422 20.3 24.4 29.8 16.6 9.7 0.3 1,724 Residence Urban 20.2 27.7 19.5 15.6 11.3 0.8 16,414 22.7 25.9 26.8 16.7 8.3 0.7 7,611 Rural 8.2 10.2 7.1 4.8 4.4 0.3 22,534 15.5 16.9 18.5 10.6 7.3 0.3 9,748 Zone North Central 9.0 13.1 11.5 8.9 5.6 0.8 5,572 23.4 20.4 20.2 11.8 4.5 0.7 2,685 North East 6.1 10.2 7.8 4.6 3.9 0.1 5,766 10.3 18.2 17.7 10.0 7.6 0.2 2,515 North West 3.4 12.1 5.8 3.9 5.0 0.4 11,877 9.6 10.5 17.1 6.4 6.1 0.3 5,185 South East 17.5 22.4 19.5 15.0 9.8 0.3 4,476 32.4 25.2 19.8 12.1 10.2 0.1 1,686 South South 26.4 16.3 14.2 12.1 9.8 0.2 4,942 26.5 33.2 31.6 26.5 12.9 0.3 2,445 South West 28.6 35.8 23.0 18.2 12.5 1.2 6,314 23.0 29.1 30.4 19.4 8.2 1.1 2,843 State North Central FCT-Abuja 5.6 30.2 28.5 25.4 21.1 0.8 315 10.3 66.9 36.1 3.1 1.7 0.2 175 Benue 18.1 11.9 6.1 4.8 1.9 0.4 1,240 66.6 14.7 21.2 9.4 4.4 0.0 616 Kogi 15.1 16.9 13.0 13.5 10.7 0.3 704 14.0 16.3 26.2 19.8 14.1 1.2 333 Kwara 5.8 25.5 33.7 25.3 9.2 5.4 596 6.5 16.0 46.5 6.8 1.3 5.0 274 Nasarawa 9.3 8.7 6.8 3.6 3.9 0.3 594 25.5 26.6 16.9 20.4 5.7 0.0 282 Niger 2.7 7.1 7.3 4.6 3.4 0.0 1,462 1.5 18.1 8.2 13.4 1.6 0.0 701 Plateau 4.2 9.3 5.2 3.7 2.8 0.2 662 17.6 13.3 9.1 5.6 4.6 0.0 302 North East Adamawa 16.5 16.1 8.8 10.0 5.1 0.0 828 13.0 28.2 28.3 7.3 14.6 0.3 358 Bauchi 3.2 10.6 15.5 3.9 4.7 0.2 1,161 12.6 9.2 19.8 8.6 7.5 0.0 512 Borno 6.5 12.9 6.5 3.8 2.9 0.0 1,412 9.2 16.3 23.1 5.9 5.9 0.0 676 Gombe 4.5 6.6 3.9 5.1 4.4 0.2 550 26.5 10.3 19.8 7.9 16.5 0.5 255 Taraba 3.5 6.5 2.0 1.0 0.5 0.2 844 0.9 49.3 7.2 36.3 3.0 1.2 325 Yobe 3.2 6.2 6.9 5.1 6.0 0.0 971 4.0 3.2 3.1 1.0 2.2 0.0 390 North West Jigawa 1.3 5.5 3.5 1.7 2.6 0.7 1,353 10.8 22.6 26.1 2.4 10.5 1.6 510 Kaduna 9.5 17.2 12.8 17.2 12.6 0.6 2,136 15.4 24.5 36.2 19.7 3.0 0.0 1,033 Kano 3.6 22.4 7.8 1.1 6.2 0.0 3,189 8.4 3.1 3.1 1.4 2.8 0.0 1,592 Katsina 1.9 8.8 1.7 0.7 2.8 1.3 1,525 10.5 4.6 7.0 3.7 27.8 1.6 596 Kebbi 2.0 2.5 1.3 1.7 0.8 0.0 1,244 3.0 1.8 12.0 4.8 2.1 0.0 551 Sokoto 0.2 2.0 0.6 0.4 0.1 0.0 1,098 2.9 15.4 23.7 8.8 0.3 0.0 424 Zamfara 1.3 7.4 5.4 0.4 3.0 0.0 1,332 12.4 4.7 25.3 1.3 1.6 0.0 479 South East Abia 20.6 21.7 14.3 4.1 4.8 0.0 518 31.1 36.7 35.2 32.0 31.6 0.5 229 Anambra 14.7 13.9 13.3 15.2 8.4 0.5 1,052 17.6 14.0 9.0 0.6 1.1 0.0 446 Ebonyi 16.7 31.0 27.9 23.4 20.1 0.4 1,122 45.1 34.5 33.8 17.8 14.5 0.0 368 Enugu 20.5 21.3 12.9 13.4 2.5 0.2 951 20.5 27.0 10.7 3.5 2.3 0.2 320 Imo 16.8 23.4 26.6 12.0 9.0 0.2 833 51.1 19.9 16.9 15.9 10.4 0.2 323 South South Akwa Ibom 27.4 25.1 13.7 12.8 12.3 0.3 864 26.2 27.2 35.8 22.2 25.7 0.7 451 Bayelsa 34.0 18.0 26.0 22.2 16.1 0.0 364 24.5 21.8 27.6 6.2 12.6 0.0 187 Cross River 46.6 21.2 17.7 9.3 19.2 0.3 703 39.9 18.5 16.5 10.6 11.5 0.0 310 Delta 22.8 14.9 13.2 8.3 6.3 0.1 993 36.4 37.1 21.4 11.0 0.7 0.2 473 Edo 33.3 18.7 8.9 18.8 6.0 0.2 742 36.8 17.9 32.2 31.3 5.3 0.3 365 Rivers 11.1 7.0 13.0 9.3 6.3 0.2 1,276 8.2 53.3 43.9 51.3 17.8 0.2 658 South West Ekiti 36.8 44.9 25.4 26.3 8.0 0.2 326 68.4 47.6 41.5 44.1 19.7 0.0 148 Lagos 39.4 28.2 12.4 21.5 12.1 1.6 1,964 33.3 17.4 26.2 17.3 8.0 2.0 948 Ogun 38.9 24.7 13.6 11.2 25.5 0.0 883 27.4 56.3 37.8 29.5 18.2 0.8 358 Ondo 15.1 32.0 17.4 12.9 5.2 0.8 808 4.4 25.3 24.2 21.8 0.0 0.2 404 Osun 6.6 41.7 43.6 34.0 7.1 0.4 765 13.4 46.9 44.5 7.9 3.5 1.0 356 Oyo 25.3 48.7 34.0 11.1 12.9 2.4 1,568 11.8 19.4 25.9 15.9 7.8 0.9 629 Continued… 114 • Family Planning Table 7.16—Continued Women Men 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 pro- gramme Number of women 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 pro- gramme Number of men Education No education 2.2 6.5 4.0 1.9 2.8 0.3 14,729 5.6 7.7 10.4 3.2 4.5 0.3 3,685 Primary 11.8 17.2 11.2 6.9 6.4 0.4 6,734 17.4 17.6 17.7 10.3 6.4 0.5 2,907 Secondary 20.0 23.2 16.4 14.2 9.6 0.6 13,927 20.0 22.2 23.4 15.3 7.3 0.5 8,281 More than secondary 35.2 41.7 33.1 25.8 18.3 1.2 3,558 34.8 39.5 40.4 25.0 15.9 0.7 2,486 Wealth quintile Lowest 1.1 3.6 2.3 1.0 1.3 0.1 7,132 6.5 7.6 9.8 3.1 5.1 0.4 2,862 Second 4.5 7.8 5.5 3.0 3.4 0.2 7,428 14.2 12.7 14.9 7.2 5.9 0.3 2,992 Middle 10.8 15.1 9.4 7.6 6.2 0.4 7,486 17.9 20.3 20.3 12.7 6.4 0.2 3,338 Fourth 18.7 25.1 18.0 13.2 9.9 0.6 7,992 21.5 25.0 27.1 17.0 9.4 0.3 3,835 Highest 27.3 32.1 23.5 19.5 13.9 1.0 8,910 27.7 31.8 32.4 21.3 10.4 1.1 4,332 Total 13.2 17.5 12.3 9.4 7.3 0.5 38,948 18.6 20.8 22.1 13.3 7.8 0.5 17,359 7.17 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS In the 2013 NDHS, women who were not using any contraceptive method were asked whether they had been visited by a fieldworker 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 reach nonusers. Improving access to services and providing reliable information to women about their family planning options is at the heart of the mission of Marie Stopes International in Nigeria. Expanding the scope and capacity of MSI service channels is vital for programmes to have a significant impact on the uptake of sexual and reproductive health services. MSI teamed up with government and existing private health care providers to increase access to high-quality care among underserved communities in Nigeria (Marie Stopes International, 2014). Nonusers were also asked if they had visited a health facility in the preceding 12 months for any reason and, if so, whether any staff member at the facility had spoken to them about family planning. These questions help to assess the extent of missed opportunities to inform women about contraception. The results in Table 7.17 indicate that 6 percent of nonusers reported discussing family planning when a fieldworker visited them. Seven percent of nonusers reported that they had visited a health facility and discussed family planning, while 14 percent of nonusers had visited a health facility but did not discuss family planning. Staff at health facilities are more likely to discuss family planning with women age 20-44 than with younger women (age 15-19) or older women (age 45-49). 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 percent versus 4 percent). The proportion of nonusers who visited a health facility and discussed family planning was highest in the South West (19 percent) and lowest in the North West (3 percent). Women with higher levels of education and those in the higher wealth quintiles were more likely than their counterparts to visit a health facility and discuss family planning with a provider. Overall, 91 percent of nonusers did not discuss family planning with a fieldworker or a staff member at a health facility. This represents a large pool of potential users who could be targeted for family planning counselling. A more vigorous outreach programme will be needed to reach these women. Family Planning • 115 Table 7.17 Contact of nonusers 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 did not discuss family planning either with a fieldworker or at a health facility, by background characteristics, Nigeria 2013 Percentage of women who were visited by fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who did not discuss family planning either with fieldworker or at a health facility Number of women Background characteristic Discussed family planning Did not discuss family planning Age 15-19 2.2 1.6 8.2 96.9 7,340 20-24 6.3 7.4 14.7 89.9 5,601 25-29 8.6 10.7 17.8 86.1 5,830 30-34 9.0 10.7 17.5 85.8 4,356 35-39 8.3 9.2 16.8 87.2 3,744 40-44 5.9 5.7 12.9 91.0 2,853 45-49 3.3 2.4 12.6 95.4 2,997 Residence Urban 9.4 11.1 18.2 85.2 12,454 Rural 4.1 4.1 11.5 93.8 20,268 Zone North Central 5.5 5.9 13.8 91.1 4,774 North East 3.8 3.6 12.5 93.4 5,585 North West 1.5 3.2 14.8 95.9 11,324 South East 9.0 6.6 17.5 89.1 3,285 South South 5.8 9.4 11.8 88.0 3,528 South West 20.1 19.2 13.8 75.1 4,224 State North Central FCT-Abuja 3.8 5.4 36.5 91.6 246 Benue 2.5 4.8 16.9 93.4 1,031 Kogi 5.7 9.6 25.1 87.8 617 Kwara 11.9 8.6 6.8 87.3 414 Nasarawa 2.9 2.8 13.6 95.2 511 Niger 4.6 4.3 6.7 93.6 1,376 Plateau 11.3 8.8 8.4 83.8 579 North East Adamawa 12.6 4.5 16.6 84.7 799 Bauchi 3.1 2.7 12.1 95.0 1,138 Borno 1.4 2.4 10.2 96.8 1,388 Gombe 1.7 3.5 4.8 95.9 529 Taraba 1.6 7.5 16.6 91.5 771 Yobe 3.8 2.6 13.6 94.0 961 North West Jigawa 1.5 2.3 18.8 97.0 1,341 Kaduna 4.5 6.1 33.9 91.1 1,690 Kano 1.1 6.1 17.3 93.2 3,175 Katsina 0.7 0.2 9.6 99.2 1,506 Kebbi 0.3 0.0 0.3 99.7 1,230 Sokoto 1.0 1.2 6.0 98.0 1,088 Zamfara 1.0 1.4 6.9 98.2 1,295 South East Abia 13.5 5.4 2.7 86.2 354 Anambra 6.0 2.9 16.8 93.8 731 Ebonyi 10.5 10.1 20.0 85.8 938 Enugu 9.8 6.8 21.4 88.3 673 Imo 6.5 6.1 18.6 91.4 589 South South Akwa Ibom 6.3 8.3 11.3 88.8 624 Bayelsa 4.6 4.8 9.3 91.6 296 Cross River 14.7 18.7 17.9 77.4 529 Delta 5.2 10.1 3.1 86.2 696 Edo 2.0 3.9 21.0 94.8 529 Rivers 3.1 8.7 10.7 90.0 853 South West Ekiti 28.1 20.6 8.9 71.0 229 Lagos 18.4 17.6 15.9 77.3 1,168 Ogun 20.0 12.0 18.1 77.8 677 Ondo 10.5 11.4 15.6 85.0 569 Osun 30.6 29.8 10.8 67.5 517 Oyo 20.2 24.2 10.3 70.2 1,064 Education No education 2.2 2.3 11.2 96.2 14,340 Primary 7.6 8.4 17.0 88.0 5,500 Secondary 9.1 10.0 15.0 86.4 10,650 More than secondary 13.0 15.0 20.9 79.9 2,232 Wealth quintile Lowest 1.3 1.1 7.9 97.9 7,009 Second 3.5 3.2 12.7 94.7 6,989 Middle 6.2 6.7 15.6 90.2 6,440 Fourth 9.7 11.1 17.0 85.1 6,220 Highest 10.8 12.8 18.3 83.2 6,064 Total 6.1 6.7 14.1 90.5 32,722 Infant and Child Mortality • 117 INFANT AND CHILD MORTALITY 8 his chapter presents levels of and trends and differentials in perinatal, neonatal, postneonatal, infant, child, and under-5 mortality in Nigeria. This information can enhance understanding of population dynamics and assist in the planning and evaluation of health policies and programmes. Estimates of infant and child mortality rates can be used to prepare population projections. Information on childhood mortality also helps the health sector identify population groups that are at high risk. One of the targets of the Millennium Development Goals (MDGs) is to reduce under-5 mortality to 64 deaths per 1,000 live births and infant mortality to 30 deaths per 1,000 live births by 2015 (Federal Republic of Nigeria, 2010a). Programmes designed to increase the proportion of births attended by skilled health personnel, to increase immunisations against vaccine-preventable diseases, to provide early care and treatment to sick children, and to upgrade the status of women through education and enhanced participation in the labour force can all help to improve the probability of survival of young children. Results from the 2013 NDHS are timely in that they allow an evaluation of the impact of major national policies such as the National Policy on Population for Sustainable Development, the National Gender Policy, and the National Health Policy on the achievement of this MDG target. The data used to estimate infant and childhood mortality were collected in the birth history section of the Woman’s Questionnaire. The birth history section begins with questions about the respondent’s experience with childbearing (i.e., the number of sons and daughters living with the mother, the number who live elsewhere, and the number who have died). These questions are followed by a retrospective birth history in which each respondent is asked to list each of her births, starting with the first birth. For each birth, data were obtained on sex, month and year of birth, survivorship status, and current age or, if the child is dead, age at death. This information is used to directly estimate mortality rates. In this report, age- specific mortality rates are categorised and defined as follows: Neonatal mortality (NN): the probability of dying within the first month of life Postneonatal mortality (PNN): the probability of dying after the first month of life but before the first birthday (the difference between infant and neonatal mortality) Infant mortality (1q0): the probability of dying before the first birthday Child mortality (4q1): the probability of dying between the first and fifth birthdays Under-5 mortality (5q0): the probability of dying between birth and the fifth birthday T Key Findings • Infant and under-5 mortality rates in the past five years are 69 and 128 deaths per 1,000 live births, respectively. At these mortality levels, one in every 15 Nigerian children die before reaching age 1, and one in every eight do not survive to their fifth birthday. • Infant mortality has declined by 26 percent over the last 15 years, while under-5 mortality has declined by 31 percent over the same period. • Childhood mortality rates are higher in rural areas than in urban areas. Also, childhood mortality is highest in the North West. • The neonatal mortality rate is 37 deaths per 1,000 live births, the postneonatal mortality rate is 31 deaths per 1,000 live births, and the perinatal mortality rate is 41 per 1,000 pregnancies. 118 • Infant and Child Mortality All rates are expressed per 1,000 live births with the exception of child mortality, which is expressed per 1,000 children surviving to age 12 months. 8.1 DATA QUALITY Estimates of infant and child mortality that are based on retrospective birth histories are subject to possible reporting errors that may adversely affect the quality of the data. These estimates may be affected by the completeness with which births and deaths are reported and recorded, as well as the accuracy of information on current age and age at death for children who died. A lack of accurate information on age at death may distort the age pattern of mortality. Estimates will be biased if age at death is misreported and the net effect of this misreporting is transference from one age bracket to another. For example, a net transfer of deaths from under 1 month to a higher age will affect the estimates of neonatal and postneonatal mortality. To minimise errors in reporting age at death, interviewers were instructed to record age at death in days if the death took place in the month following the birth, in months if the child died before age 2, and in years if the child died at age 2 or above. Interviewers were also asked to probe for deaths reported at age 1 to determine a more precise age at death in terms of months. Despite the emphasis during interviewer training and fieldwork monitoring on probing for accurate age at death, Appendix Table D.6 shows that, for the five years preceding the survey, there is considerable heaping of deaths at age 12 months. This heaping at age 12 months can potentially bias the mortality rates reported in the tables in this chapter. Although age heaping at 12 months to the extent shown in Appendix Table D.6 is likely to have only a minor underestimation effect on estimates of infant mortality, it is likely to lead to some overestimation of child mortality. Another potential data quality problem is selective omission from birth histories of births that did not survive, which can lead to underestimation of mortality rates. When selective omission of childhood deaths occurs, it is usually most severe for deaths occurring early in infancy. One way that such omissions can be detected is by examining the proportion of infant deaths that are neonatal deaths. Generally, if there is substantial underreporting of deaths, the result is an abnormally low ratio of neonatal deaths to infant deaths. The proportion of infant deaths occurring in the first month of life was 59 percent in the five-year period preceding the 2013 NDHS (Appendix Table D.6), which is within the normal range (although this proportion represents a slight decline from previous periods). Furthermore, it appears that early neonatal deaths among births that occurred in the first month of life have not been underreported, since 78 percent of neonatal deaths were early neonatal deaths (Appendix Table D.5). The proportion is slightly lower for deaths occurring 15-19 years before the survey, which is not surprising given the greater likelihood of recall errors for deaths occurring further in the past. Appendix Table D.4 shows high rates of completeness of birth dates. These rates vary from 97 percent to 100 percent for the years under observation (2008-2013) and are higher for living children than for dead children. The sex ratios at birth in Appendix Table D.4 also show a high level of accuracy in female-male birth reporting. 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY 8.2.1 Early Childhood Mortality Rates Table 8.1 shows neonatal, postneonatal, infant, child, and under-5 mortality rates for successive five-year periods before the survey. The infant mortality rate was 69 per 1,000 live births for the five years preceding the survey, the child mortality rate was 64 per 1,000 children surviving to age 12 months, and the under-5 mortality rate was 128 per 1,000 live births. This implies that one in 15 Nigerian children die before their first birthday and that one in eight die before their fifth birthday. During the same five-year period, the neonatal mortality rate was 37 deaths per 1,000 live births, and the postneonatal mortality rate was 31 deaths per 1,000 live births. Infant and Child Mortality • 119 Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Nigeria 2013 Years preceding the survey Approximate time period of estimated rates Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 2009-2013 37 31 69 64 128 5-9 2004-2008 43 42 86 83 162 10-14 1999-2003 46 47 93 102 185 1 Computed as the difference between the infant and neonatal mortality rates 8.2.2 Trends in Early Childhood Mortality Mortality trends can be examined in two ways: by comparing mortality rates for the three five- year periods preceding a single survey or by comparing mortality estimates obtained from several surveys over time. It should be noted that sampling errors associated with mortality estimates are large and should be taken into account when examining trends between surveys. Results from the 2013 NDHS show a considerable decline in all levels of childhood mortality. Infant mortality declined by 26 percent over the 15-year period preceding the survey, from 93 deaths per 1,000 live births to 69 deaths per 1,000 live births. Under-5 mortality declined by 31 percent over the same period, from 185 deaths per 1,000 live births to 128 deaths per 1,000 live births. Finally, neonatal mortality decreased by 20 percent, from 46 deaths per 1,000 live births to 37 deaths per 1,000 live births. Mortality trends can also be examined by comparing data from the NDHS surveys conducted in 2003, 2008, and 2013. The infant and under-5 mortality rates reported in these surveys show a continuous declining trend. Under-5 mortality declined from 201 deaths per 1,000 live births in the 2003 survey to 128 deaths in 2013, while infant mortality declined from 100 deaths per 1,000 live births in 2003 to 69 in 2013. Neonatal mortality also declined during the period (Figure 8.1). Figure 8.1 Trends in childhood mortality, 1999-2013 48 52 100 112 201 40 35 75 88 157 37 31 69 64 128 Neonatal mortality Postneonatal mortality Infant mortality Child mortality Under-5 mortality Deaths per 1,000 live births NDHS 2003 (1999-2003) NDHS 2008 (2004-2008) NDHS 2013 (2009-2013) 120 • Infant and Child Mortality 8.3 EARLY CHILDHOOD MORTALITY RATES BY SOCIOECONOMIC CHARACTERISTICS Mortality differences by place of residence, zone, mother’s education, and household wealth are presented in Table 8.2. Mortality rates are presented for the 10-year period preceding the survey to ensure a sufficient number of births to study mortality differentials across population subgroups. The table shows that infant and child survival are strongly influenced by these socioeconomic characteristics. Mortality rates in urban areas are consistently lower than those in rural areas. Infant mortality is 43 percent higher in rural areas (86 deaths per 1,000 live births) than in urban areas (60 deaths per 1,000 live births). The urban- rural difference is even more pronounced in the case of under-5 mortality. There are zonal differences in infant and under-5 mortality as well. Under-5 mortality rates range from a low of 90 deaths per 1,000 live births in the South West to a high of 185 deaths per 1,000 live births in the North West. Under-5 mortality is also relatively high in the North East and South East (Table 8.2 and Figure 8.2). Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by background characteristics, Nigeria 2013 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 34 26 60 42 100 Rural 44 42 86 89 167 Zone North Central 35 31 66 36 100 North East 43 33 77 90 160 North West 44 46 89 105 185 South East 37 45 82 54 131 South South 32 26 58 35 91 South West 39 21 61 31 90 Mother’s education No education 44 45 89 100 180 Primary 42 33 74 57 128 Secondary 34 24 58 35 91 More than secondary 30 20 50 13 62 Wealth quintile Lowest 45 47 92 108 190 Second 45 49 94 103 187 Middle 39 31 71 61 127 Fourth 37 28 65 38 100 Highest 30 18 48 26 73 1 Computed as the difference between the infant and neonatal mortality rates As expected, mother’s education is inversely related to a child’s risk of dying. Under-5 mortality among children born to mothers with no education (180 deaths per 1,000 live births) is almost twice as high as that among children born to mothers with a secondary education (91 deaths per 1,000 live births) and about three times as high as that among children of mothers with more than a secondary education (62 deaths per 1,000 live births). The beneficial effect of educating mothers is evident for all childhood mortality categories. Also, childhood mortality generally decreases as wealth increases, although rates are similar in the two lower quintiles. Infant and Child Mortality • 121 Figure 8.2 Under-5 mortality in the 10 years preceding the survey by socioeconomic characteristics 73 100 127 187190 62 91 128 180 9091 131 185 160 100100 167 H ig he st Fo ur th M id dl e Se co nd Lo w es t M or e th an s ec on da ry Se co nd ar y Pr im ar y N o ed uc at io n So ut h W es t So ut h So ut h So ut h Ea st N or th W es t N or th E as t N or th C en tra l U rb an R ur al Wealth quintileMother's educationZoneResidence Deaths per 1,000 live births NDHS 2013 8.4 DEMOGRAPHIC DIFFERENTIALS IN EARLY CHILDHOOD MORTALITY RATES The demographic characteristics of both mothers and children have been found to play an important role in child survival. Table 8.3 presents childhood mortality rates according to sex of the child, mother’s age at birth, birth order, previous birth interval, and the infant’s size at birth. Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by demographic characteristics, Nigeria 2013 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 45 38 84 73 151 Female 35 35 70 72 137 Mother’s age at birth <20 53 42 95 93 179 20-29 35 36 71 68 134 30-39 40 33 73 68 136 40-49 58 42 100 83 174 Birth order 1 51 32 83 60 139 2-3 32 34 65 64 125 4-6 35 37 72 76 142 7+ 55 48 103 104 196 Previous birth interval2 <2 years 62 60 122 103 213 2 years 32 35 67 78 140 3 years 22 24 46 60 103 4+ years 27 18 45 36 79 Birth size3 Small/very small 64 37 101 na na Average or larger 30 28 58 na na na = Not available 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 122 • Infant and Child Mortality As noted in earlier DHS surveys, mortality rates are generally higher among male children than female children. This is true for all categories of mortality. With the exception of mothers in the 40-49 age group, infant mortality is higher for mothers under age 20 than for older mothers. Infant mortality is also higher for first births and seventh- and higher-order births than for births of orders 2-6. Short birth intervals, especially intervals of less than two years, substantially reduce children’s chances of survival. For example, children born less than two years after the preceding birth are more than 2.5 times as likely to die within the first year of life and more than twice as likely to die within the first five years of life as children born three years after the preceding birth (Table 8.3 and Figure 8.3). Since most births in Nigeria occur at home, where children often are not weighed at birth, data on birth weight are available for only a few children. However, mothers were asked whether their children born in the past five years were very large, larger than average, average, smaller than average, or very small at birth, since this has been found to be a good proxy for a child’s weight. The data show that children who were small or very small at birth were more likely to die before their first birthday than those whose weights were average or above. Figure 8.3 Infant mortality rate in the 10 years preceding the survey by selected demographic characteristics 95 71 73 100 83 65 72 103 122 67 46 45 84 70 <20 20-29 30-39 40-49 1 2-3 4-6 7+ <2 years 2 years3 years 4+ years Male Female Mother's age at birth Birth order Previous birth interval Child's sex Deaths per 1,000 live births NDHS 2013 8.5 PERINATAL MORTALITY The 2013 NDHS asked women to report any pregnancy loss that occurred in the five years preceding the survey. For each pregnancy that did not end in a live birth, the duration of the pregnancy was recorded. Pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths to live births within the first seven days of life (early neonatal deaths) are defined as perinatal deaths. The distinction between a stillbirth and an early neonatal death may be a fine one, often depending on observing and sometimes remembering faint signs of life after delivery. The causes of stillbirths and early neonatal deaths are closely linked, and examining only one or the other can understate the true level of mortality around the time of delivery. The perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the sum of stillbirths and live births, expressed per 1,000 pregnancies that lasted seven or more months. Infant and Child Mortality • 123 Table 8.4 presents the number of stillbirths and early neonatal deaths and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics. The perinatal mortality rate is 41 deaths per 1,000 pregnancies of seven or more months of gestation. Since the rate is subject to a high degree of sampling variation, differences by background characteristics should be interpreted with caution. The perinatal mortality rate is higher among young mothers (below age 20) and mothers age 40- 49, as well as among births that occur less than 15 months after the previous birth. Although perinatal mortality generally decreases with increasing education and household wealth, the pattern is not always consistent. Table 8.4 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 2013 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 77 173 52 4,803 20-29 166 427 36 16,638 30-39 119 257 41 9,226 40-49 34 67 65 1,556 Previous pregnancy interval in months4 First pregnancy 101 233 55 6,085 <15 56 210 52 5,082 15-26 79 243 36 8,950 27-38 45 119 28 5,953 39+ 115 119 38 6,153 Residence Urban 114 265 34 11,240 Rural 281 660 45 20,983 Zone North Central 35 112 34 4,375 North East 92 164 45 5,670 North West 164 357 44 11,939 South East 18 84 36 2,859 South South 31 79 37 2,966 South West 55 129 42 4,415 Mother’s education No education 199 460 42 15,856 Primary 88 201 46 6,215 Secondary 88 218 37 8,298 More than secondary 21 47 36 1,854 Wealth quintile Lowest 116 233 46 7,612 Second 107 234 46 7,463 Middle 58 171 38 6,059 Fourth 52 163 38 5,708 Highest 62 125 35 5,383 Total 396 925 41 32,224 1 Stillbirths are foetal deaths in pregnancies lasting 7 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 7 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. 8.6 HIGH-RISK FERTILITY BEHAVIOUR Findings from scientific studies have confirmed a strong relationship between a child’s chance of dying and specific fertility behaviours. Typically, the probability of dying in early childhood is much greater for children born to mothers who are young or old, children born after a short birth interval, and 124 • Infant and Child Mortality children born to women who have had more than three births. Very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. Older women may experience age-related problems during pregnancy and delivery. In this analysis, a mother is considered to be too young if she is less than age 18 and too old if she is more than age 34 at the time of delivery. A short birth interval characterises a birth occurring within 24 months of a previous birth. The first column in Table 8.5 shows the percentages of births in the five years preceding the survey that fall into the various risk categories. Overall, 63 percent of births are in an avoidable risk category; 40 percent fall into a single high-risk category, and 23 percent are in a multiple high-risk category. Only 23 percent of births are not in any high-risk category. Table 8.5 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality, 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 2013 Births in the 5 years preceding the survey Percentage of currently married women1 Risk category Percentage of births Risk ratio Not in any high-risk category 22.6 1.00 13.7a Unavoidable risk category First-order births between ages 18 and 34 14.0 1.30 5.9 Single high-risk category Mother’s age <18 6.4 2.08 2.2 Mother’s age >34 1.2 1.11 3.9 Birth interval <24 months 7.1 1.56 9.6 Birth order >3 25.3 1.13 16.7 Subtotal 40.0 1.36 32.4 Multiple high-risk category Age <18 and birth interval <24 months2 0.6 2.16 0.5 Age >34 and birth interval <24 months 0.1 (0.26) 0.3 Age >34 and birth order >3 11.8 1.30 28.6 Age >34 and birth interval <24 months and birth order >3 2.2 2.79 5.8 Birth interval <24 months and birth order >3 8.5 2.38 12.7 Subtotal 23.4 1.85 47.9 In any avoidable high-risk category 63.3 1.54 80.4 Total 100.0 na 100.0 Number of births/women 31,828 na 27,830 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Figures in parentheses are based on 25-49 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 The risk ratios displayed in the second column of Table 8.5 denote the relationship between risk factors and mortality. In general, risk ratios are higher for children in a multiple high-risk category than for those in a single high-risk category. The combination of a short birth interval and a high birth order (above 3) results in a risk ratio that is twice as high as for births not in any high-risk category. Nine percent of births fall into this category. The combination of an older mother, a short birth interval, and a high birth order results in a risk ratio of almost three times higher; however, only 2 percent of births fall into this category. The other vulnerable births are those to women less than age 18 with a birth interval of less than 24 months. These children are more than twice as likely to die as children not in any high-risk category. Fortunately, less than 1 percent of births fall into this category. Infant and Child Mortality • 125 The last column of Table 8.5 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. The information in this column is purely hypothetical and does not take into consideration the protection provided by postpartum insusceptibility, prolonged abstinence, or family planning methods other than sterilisation. However, it provides insight into the potential magnitude of high-risk births. Overall, 80 percent of currently married women have the potential for a high-risk birth, with 32 percent falling into a single high-risk category and 48 percent falling into a multiple high-risk category. Reproductive Health • 127 REPRODUCTIVE HEALTH 9 health care system aiming to reduce pregnancy-related morbidity and mortality must focus on maternal and newborn health. Reproductive health care, the care a woman receives before and during pregnancy, at the time of delivery, and soon after delivery, is important for the survival and well-being of the mother and her child. It encompasses the health care dimensions of family planning and prenatal, natal, and postnatal care with the aim of reducing maternal morbidity and mortality (Franny, 2013). Nigeria has a reproductive health policy that provides a roadmap for all stakeholders working in this area. Also, the National Reproductive Health Working Group set up by the federal government plans, coordinates, and facilitates the implementation of reproductive health interventions in the country. The group’s members are drawn from government ministries and agencies, parastatal organisations, nongovernmental organisations, civil society organisations, regulatory bodies, professional bodies, and development partners. This body meets annually to review plans and strategies for improving reproductive health in the country. The Federal Ministry of Health is also implementing an integrated maternal, newborn, and child health strategy that emphasizes the continuum of care. The biannual Maternal, Newborn and Child Health Week is held in May and November of every year to highlight important maternal and child health issues at all levels of the health care system. To boost the proportion of skilled birth attendants, the government recruited additional midwives and community health extension workers (CHEWs) and supported training of CHEWs on modified lifesaving skills through the Subsidy Reinvestment and Empowerment Programme as well as the Midwives Service Scheme. The government is also looking toward developing a policy on task shifting as a measure to improve personnel deficits in some parts of the country and in underserved areas. This chapter presents findings from several areas of importance to reproductive health and women’s health, such as antenatal, delivery, and postnatal care and general access to health services. Information on antenatal, delivery, and postnatal care is of great value in identifying subgroups of women who do not use such services and is useful in planning ways to improve service delivery. Information on antenatal care (ANC) is shown according to the number of ANC visits made, the stage of pregnancy at the time of the first visit, the type of provider and the specific services offered during antenatal visits. A Key Findings • Sixty-one percent of women age 15-49 who had a live birth in the five years preceding the survey received antenatal care from a skilled provider (i.e., a doctor, nurse or midwife, or auxiliary nurse or midwife). • Fifty-one percent of women who had a live birth in the five years preceding the survey reported making at least four antenatal care visits during the pregnancy. • Sixty-three percent of women age 15-49 who had a live birth in the five years preceding the survey took iron tablets or syrup, and 14 percent took intestinal parasite drugs. • Fifty-three percent of women age 15-49 had their last birth protected against neonatal tetanus. • Thirty-six percent of births in Nigeria are delivered in a health facility. • Thirty-eight percent of deliveries are attended by a skilled birth assistant. 128 • Reproductive Health Similarly, delivery services are described according to place of delivery, the type of person assisting the delivery, and the rate of caesarean section births. The chapter includes information on postnatal care according to whether a woman delivered in a health facility or elsewhere, as well as information on timing of postnatal care after delivery and from whom care was received. This information helps identify population groups who are underserved by maternity care services. General information on access to health services and barriers to use of services by women is also presented. 9.1 ANTENATAL CARE The major objective of antenatal care is to ensure optimal health outcomes for the mother and her 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 for pregnant women. Table 9.1 and Figure 9.1 show the percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care 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. The results show that 61 percent of women had received antenatal care from a skilled provider, as compared with 58 percent in 2008. The mother’s age at birth is important for the quality of decisions she makes. Forty-six percent of mothers younger than age 20 did not receive antenatal care, which is an improvement from 2008, when 50 percent of women in this age group did not receive antenatal care. First-order births are more likely to receive ANC than births of higher orders. Urban women are more likely to receive antenatal care from a skilled provider than their rural counterparts (86 percent and 47 percent, respectively). Forty-seven percent of rural women age 15-49 did not receive antenatal care, as compared with only 11 percent of urban women. By zone, 9 in 10 women in the South East and South South received ANC from a skilled provider, compared with two in five women in the North West (41 percent). Women in Sokoto are least likely to receive ANC from a skilled provider (17 percent). The survey findings demonstrate the great importance of female education to health outcomes. Ninety-seven percent of women with more than a secondary education received antenatal care from a skilled provider, as compared with 36 percent of mothers with no education. Similarly, 95 percent of women in the highest wealth quintile received antenatal care from a skilled provider, compared with 25 percent in the lowest quintile. 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 2013 Antenatal care provider No ANC Total Percentage receiving antenatal care from a skilled provider1 Number of women Background characteristic Doctor Nurse/ midwife Auxiliary nurse/ midwife Community extension health worker Traditional birth attendant Other Missing Mother’s age at birth <20 14.0 30.8 3.0 4.5 0.7 0.3 0.7 46.1 100.0 47.8 2,813 20-34 27.0 33.1 2.9 3.2 0.9 0.4 0.9 31.5 100.0 63.0 13,877 35-49 27.2 31.6 2.2 3.2 0.9 0.4 1.0 33.3 100.0 61.0 3,777 Birth order 1 31.0 33.0 2.6 3.1 1.0 0.5 0.5 28.4 100.0 66.6 3,721 2-3 28.6 32.4 3.1 3.2 1.0 0.4 0.7 30.6 100.0 64.2 6,423 4-5 26.2 32.5 2.6 3.8 1.0 0.5 0.7 32.7 100.0 61.3 4,899 6+ 16.5 32.3 2.7 3.6 0.6 0.2 1.5 42.5 100.0 51.4 5,424 Continued… Reproductive Health • 129 Table 9.1—Continued Antenatal care provider No ANC Total Percentage receiving antenatal care from a skilled provider1 Number of women Background characteristic Doctor Nurse/ midwife Auxiliary nurse/ midwife Community extension health worker Traditional birth attendant Other Missing Residence Urban 44.4 38.8 2.8 1.0 1.3 0.3 0.7 10.6 100.0 86.0 7,278 Rural 14.7 29.0 2.8 4.7 0.7 0.4 1.0 46.7 100.0 46.5 13,189 Zone North Central 32.0 33.5 1.5 5.1 0.2 0.7 1.0 26.0 100.0 67.0 2,890 North East 9.7 32.9 6.7 8.5 0.0 0.3 1.1 40.8 100.0 49.3 3,434 North West 9.5 30.2 1.3 2.5 0.0 0.1 1.0 55.4 100.0 41.0 7,445 South East 39.7 46.6 4.3 1.3 1.8 1.2 0.9 4.2 100.0 90.6 1,719 South South 35.5 36.0 1.5 1.7 3.1 0.7 1.0 20.6 100.0 73.0 2,002 South West 60.8 26.5 3.1 0.7 2.7 0.4 0.1 5.7 100.0 90.4 2,977 State North Central FCT-Abuja 48.7 37.8 1.9 2.9 0.9 1.9 0.0 5.9 100.0 88.5 143 Benue 27.4 29.6 0.3 0.0 0.0 1.0 2.0 39.6 100.0 57.4 615 Kogi 59.1 28.5 0.0 3.1 0.0 1.0 2.9 5.4 100.0 87.5 283 Kwara 54.6 33.1 1.5 2.9 1.0 1.7 0.3 4.9 100.0 89.2 278 Nasarawa 44.9 15.3 3.0 5.6 0.0 0.2 0.5 30.5 100.0 63.2 309 Niger 15.8 41.6 2.6 11.2 0.3 0.2 0.3 28.2 100.0 59.9 916 Plateau 24.7 37.8 0.6 1.7 0.0 0.4 0.9 33.9 100.0 63.1 346 North East Adamawa 16.0 68.3 0.8 1.2 0.0 0.0 0.2 13.4 100.0 85.1 459 Bauchi 2.8 40.6 12.5 9.1 0.0 0.3 1.7 33.2 100.0 55.8 833 Borno 8.2 28.7 2.2 0.2 0.0 0.0 2.0 58.7 100.0 39.2 716 Gombe 24.2 6.6 27.5 17.7 0.5 0.6 0.6 22.5 100.0 58.2 361 Taraba 7.3 22.8 1.7 29.6 0.0 1.0 0.4 37.3 100.0 31.8 476 Yobe 9.2 24.0 0.0 0.5 0.0 0.0 0.7 65.6 100.0 33.2 588 North West Jigawa 9.1 38.7 1.9 2.0 0.0 0.2 0.9 47.2 100.0 49.7 973 Kaduna 27.1 27.5 0.0 0.1 0.1 0.0 1.0 44.2 100.0 54.6 1,051 Kano 10.4 52.3 1.6 0.0 0.0 0.1 0.3 35.4 100.0 64.3 1,907 Katsina 2.9 17.5 2.3 9.7 0.0 0.1 1.7 65.8 100.0 22.7 1,066 Kebbi 1.6 22.6 0.1 3.4 0.0 0.1 1.2 71.2 100.0 24.3 790 Sokoto 5.6 10.8 1.0 1.1 0.0 0.0 1.8 79.7 100.0 17.4 693 Zamfara 5.8 14.9 1.6 2.9 0.0 0.0 1.1 73.6 100.0 22.4 966 South East Abia 34.4 54.5 1.3 0.0 3.8 1.0 0.4 4.7 100.0 90.1 199 Anambra 38.9 48.0 1.5 1.4 2.0 2.1 1.8 4.3 100.0 88.4 379 Ebonyi 38.8 42.9 3.3 2.9 3.4 1.5 0.0 7.1 100.0 85.1 467 Enugu 41.1 46.1 8.4 0.5 0.0 0.7 0.0 3.2 100.0 95.6 355 Imo 43.6 45.7 6.5 0.3 0.3 0.1 2.6 0.9 100.0 95.9 319 South South Akwa Ibom 30.6 41.7 1.0 0.9 1.8 0.6 1.0 22.5 100.0 73.3 334 Bayelsa 25.0 22.4 0.3 0.1 0.0 0.0 0.5 51.7 100.0 47.7 153 Cross River 26.8 42.9 2.9 7.0 3.9 1.4 1.3 13.8 100.0 72.6 368 Delta 26.2 45.8 0.4 0.0 7.5 0.5 1.6 17.9 100.0 72.5 376 Edo 48.0 35.4 0.5 0.2 0.3 0.9 0.3 14.4 100.0 83.9 264 Rivers 48.7 24.3 2.5 0.7 2.4 0.6 0.7 20.0 100.0 75.5 508 South West Ekiti 53.3 29.8 3.7 9.7 0.0 1.3 0.0 2.3 100.0 86.8 139 Lagos 71.7 17.6 4.6 0.3 4.3 0.0 0.3 1.2 100.0 93.9 867 Ogun 68.8 25.6 0.4 0.2 2.2 0.4 0.0 2.3 100.0 94.8 495 Ondo 52.5 18.4 7.7 0.6 4.5 1.4 0.2 14.6 100.0 78.6 385 Osun 66.7 29.1 2.4 0.2 0.0 0.1 0.0 1.5 100.0 98.2 307 Oyo 46.8 39.2 1.2 0.1 1.9 0.1 0.0 10.6 100.0 87.2 783 Mother’s education No education 8.1 25.5 2.7 4.5 0.3 0.2 1.0 57.7 100.0 36.2 9,794 Primary 27.2 41.0 3.4 4.3 2.0 0.7 0.9 20.5 100.0 71.5 3,915 Secondary 43.8 40.8 2.9 1.4 1.4 0.5 0.7 8.4 100.0 87.6 5,475 More than secondary 71.4 25.0 0.9 0.7 0.2 0.1 0.5 1.1 100.0 97.3 1,283 Wealth quintile Lowest 4.4 18.1 2.1 4.6 0.2 0.3 0.9 69.4 100.0 24.6 4,699 Second 10.9 30.1 3.8 5.4 0.7 0.4 0.9 47.8 100.0 44.8 4,588 Middle 23.7 40.8 3.3 3.9 1.2 0.7 1.1 25.3 100.0 67.8 3,902 Fourth 36.0 46.5 2.7 1.8 1.5 0.6 0.7 10.3 100.0 85.2 3,674 Highest 61.5 31.1 1.9 0.5 1.1 0.1 0.7 3.1 100.0 94.5 3,604 Total 25.3 32.5 2.8 3.4 0.9 0.4 0.9 33.9 100.0 60.6 20,467 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. 130 • Reproductive Health Figure 9.1 Source of antenatal care Doctor 25% Nurse/midwife/ auxiliary nurse 35% Other 6% No ANC 34% NDHS 2013 9.1.1 Number and Timing of Antenatal Visits The antenatal care policy in Nigeria follows the WHO approach to promoting safe pregnancies, recommending at least four ANC visits for women without complications. This approach, called fo- cused antenatal care, emphasises quality of care during each visit instead of focusing on the number of visits. The recommended 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 should occur at 32 weeks, and the fourth visit should occur at 36 weeks. However, women with complications, special needs, or conditions beyond the scope of basic care may require additional visits. Early detection of problems during pregnancy leads to more timely treatment and referrals in the case of complications. This is particularly important in Ni- geria, a large country where physical barriers are a challenge to accessing care within the health system. Table 9.2 shows the percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care visits and timing of the first visit for the most recent live birth. Fifty-one percent of women who had a live birth in the five years preceding the survey reported visiting antenatal clinics at least four times during their pregnancy, an improvement over the figure in the 2008 NDHS (45 percent). Ten percent reported two or three antenatal visits during their last pregnancy. Thirty-four percent of women did not receive any antenatal care. The results show that only 18 percent of women had their first antenatal visit in the first trimester of pregnancy, which is not in compliance with the recommendation. Women in urban areas were more likely than those in rural areas to have their first ANC visit in the first trimester of pregnancy (23 percent versus 15 percent). The median duration of pregnancy at the first ANC visit is five months, the same figure observed in the 2008 NDHS. 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 2013 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 10.9 47.0 34.2 1 1.1 2.1 1.8 2-3 9.5 10.8 10.3 4+ 74.5 38.2 51.1 Don’t know/missing 4.0 1.9 2.7 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 10.9 47.0 34.2 <4 23.1 14.6 17.6 4-5 42.7 22.9 29.9 6-7 21.7 13.2 16.3 8+ 1.2 1.5 1.4 Don’t know/missing 0.3 0.7 0.6 Total 100.0 100.0 100.0 Number of women 7,278 13,189 20,467 Median months pregnant at first visit (for those with ANC) 5.0 5.0 5.0 Number of women with ANC 6,484 6,994 13,477 Reproductive Health • 131 9.1.2 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, along with screening for complications, should be a routine part of all antenatal care visits. To assess the quality of ANC services, 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 percentage of women who took iron tablets or syrup and intestinal parasite drugs during their most recent pregnancy in the five years preceding the survey. The table also shows the percentage of women who were informed about signs of pregnancy complications and who received selected routine services. 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 of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Nigeria 2013 Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Number of women with a live birth in the past five years Among women who received antenatal care for their most recent birth in the past five years, the percentage with selected services Number of women with ANC for their most recent birth Background characteristic Took iron tablets or syrup Took intestinal parasite drugs Informed of signs of pregnancy complications Blood pressure measured Urine sample taken Blood sample taken Mother’s age at birth <20 53.3 11.7 2,813 56.1 83.7 75.1 72.9 1,512 20-34 65.3 14.9 13,877 68.4 91.4 82.4 82.8 9,464 35-49 64.0 14.6 3,777 68.4 91.2 81.8 82.5 2,501 Birth order 1 68.2 14.9 3,721 68.1 90.2 83.2 82.7 2,660 2-3 66.0 15.0 6,423 70.1 91.0 83.2 83.1 4,441 4-5 64.9 14.1 4,899 68.3 91.3 81.8 82.5 3,287 6+ 55.6 13.5 5,424 60.3 89.0 77.1 77.7 3,089 Residence Urban 84.1 19.3 7,278 75.5 95.5 89.3 90.1 6,484 Rural 52.0 11.7 13,189 59.2 85.7 74.2 73.9 6,994 Zone North Central 71.4 15.7 2,890 68.2 94.2 90.9 89.3 2,130 North East 61.7 12.0 3,434 49.2 85.1 70.0 70.8 2,022 North West 43.9 13.0 7,445 57.4 85.3 76.0 75.8 3,302 South East 88.2 18.9 1,719 69.3 91.7 77.9 83.0 1,635 South South 69.4 18.8 2,002 70.0 91.0 84.5 84.4 1,583 South West 88.0 13.7 2,977 87.3 96.5 89.4 88.4 2,806 State North Central FCT-Abuja 89.4 12.8 143 86.1 95.7 87.7 83.1 135 Benue 54.5 16.9 615 69.1 92.5 87.9 85.6 368 Kogi 84.6 21.9 283 93.4 98.6 92.8 92.4 263 Kwara 96.1 22.9 278 89.8 98.0 96.8 96.3 264 Nasarawa 67.7 18.6 309 67.1 94.3 88.3 86.1 214 Niger 76.8 10.2 916 42.3 96.9 95.1 93.6 658 Plateau 52.6 15.7 346 77.8 78.9 78.6 77.6 228 North East Adamawa 84.9 17.0 459 55.0 76.7 64.4 70.5 397 Bauchi 66.6 15.2 833 53.5 92.7 71.7 72.7 555 Borno 39.4 1.8 716 19.0 94.3 74.9 63.7 293 Gombe 75.5 31.8 361 60.1 75.6 62.5 68.2 279 Taraba 62.7 7.1 476 46.7 79.6 72.8 70.1 299 Yobe 54.5 7.7 588 58.0 88.5 75.8 81.2 200 North West Jigawa 49.9 10.9 973 56.9 80.7 73.6 70.7 513 Kaduna 66.0 18.6 1,051 52.1 91.0 81.9 88.7 582 Kano 60.2 22.6 1,907 58.4 81.9 79.3 77.7 1,232 Katsina 32.8 15.6 1,066 91.1 86.4 78.1 74.7 364 Kebbi 21.4 3.8 790 15.8 90.4 55.0 58.8 222 Sokoto 19.6 2.5 693 61.3 94.0 84.1 83.8 141 Zamfara 29.5 2.5 966 50.8 87.1 62.0 58.6 249 Continued… 132 • Reproductive Health Table 9.3—Continued Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Number of women with a live birth in the past five years Among women who received antenatal care for their most recent birth in the past five years, the percentage with selected services Number of women with ANC for their most recent birth Background characteristic Took iron tablets or syrup Took intestinal parasite drugs Informed of signs of pregnancy complications Blood pressure measured Urine sample taken Blood sample taken South East Abia 84.7 26.0 199 79.7 94.0 90.0 91.8 189 Anambra 80.6 14.1 379 59.6 93.1 90.7 90.1 356 Ebonyi 88.1 27.5 467 64.1 89.5 60.6 67.6 434 Enugu 93.6 14.1 355 76.7 88.0 69.8 82.0 344 Imo 93.3 12.9 319 73.2 96.1 89.1 91.8 311 South South Akwa Ibom 62.2 26.1 334 86.3 91.6 88.4 87.5 257 Bayelsa 58.5 28.0 153 24.0 94.0 92.3 91.1 73 Cross River 81.9 23.0 368 90.2 90.1 72.4 76.3 317 Delta 60.8 13.9 376 53.7 86.3 81.4 81.5 303 Edo 75.2 7.5 264 85.6 95.1 88.7 86.1 226 Rivers 71.9 17.8 508 55.8 92.1 90.1 88.6 406 South West Ekiti 96.4 8.6 139 94.4 97.4 92.8 88.0 136 Lagos 91.1 18.1 867 93.5 97.7 87.8 87.3 855 Ogun 91.8 12.0 495 89.4 95.4 90.9 90.1 484 Ondo 81.4 6.3 385 74.2 88.6 79.0 73.9 328 Osun 98.5 23.6 307 99.3 99.4 96.8 97.2 302 Oyo 79.9 10.7 783 77.9 98.0 91.4 91.5 700 Education No education 42.9 9.0 9,794 51.1 83.6 71.9 70.4 4,118 Primary 74.0 16.8 3,915 66.7 89.7 77.8 79.0 3,094 Secondary 85.7 20.9 5,475 75.3 94.6 87.8 88.6 5,000 More than secondary 92.4 20.4 1,283 86.9 98.4 96.9 97.4 1,265 Wealth quintile Lowest 31.7 7.3 4,699 44.8 75.4 56.6 57.5 1,429 Second 50.5 11.7 4,588 55.0 82.0 67.3 67.0 2,379 Middle 71.3 15.5 3,902 61.9 90.4 81.3 80.1 2,901 Fourth 85.2 19.8 3,674 73.6 95.0 89.0 90.2 3,283 Highest 90.2 20.3 3,604 82.4 98.2 94.4 94.9 3,485 Total 63.4 14.4 20,467 67.0 90.5 81.5 81.7 13,477 Among women with a live birth in the past five years, 63 percent took iron tablets or syrup and 14 percent took intestinal parasite drugs. There were substantial variations in iron supplementation by background characteristics. Women age 20-34, women pregnant with their first child, urban women, women in the South West and South East zones, better educated women, and wealthier women were more likely than other women to have taken iron supplements during pregnancy. For example, 65 percent of women age 20-34 and 64 percent of women age 35-49 took iron supplements during their pregnancy, as compared with 53 percent of women less than age 20. Also, 84 percent of women in urban areas took iron supplements, compared with 52 percent in rural areas. Sixty-seven percent of women were informed of signs of pregnancy complications. In addition, 91 percent had their blood pressure measured, 82 percent gave a urine sample, and 82 percent provided a blood sample. The findings indicate that women at higher educational levels were more likely than their counterparts to use iron tablets or syrup and intestinal parasite drugs; they were also more likely to have their blood pressure measured and to provide urine and blood samples. Table 9.3 shows that 43 percent of women with no education used iron tablets or syrup, compared with 74 percent of women with a primary education, 86 percent of women with a secondary education, and 92 percent of women with more than a secondary education. The pattern is similar for use of intestinal parasite drugs and receipt of information on signs of pregnancy complications. Reproductive Health • 133 9.1.3 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 2013 NDHS, information was collected on the number of tetanus toxoid doses the mother received during the pregnancy for her most recent birth in the five years preceding the survey. If the mother did not receive at least two tetanus injections during the pregnancy, additional questions were asked about the number and timing of the injections that she may have received prior to that pregnancy. If a pregnant woman has not received any previous tetanus injections, she needs two doses of tetanus toxoid during pregnancy to be fully protected. However, if a woman was immunised before she became pregnant, she may require one or no tetanus toxoid injections during her pregnancy, depending on the number of injections she has received in the past and the timing of the last injection. Five tetanus toxoid doses are required to provide lifetime protection from neonatal tetanus. Table 9.4 shows tetanus toxoid injections among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage of women receiving two or more tetanus toxoid injections during the pregnancy for their last live birth, and the percentage whose last live birth was protected against neonatal tetanus. 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 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 2013 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 34.2 36.5 2,813 20-34 51.2 55.7 13,877 35-49 48.4 54.6 3,777 Birth order 1 53.3 54.6 3,721 2-3 52.0 56.8 6,423 4-5 49.4 54.2 4,899 6+ 39.7 45.7 5,424 Residence Urban 70.3 76.9 7,278 Rural 36.3 39.5 13,189 Zone North Central 53.8 56.8 2,890 North East 36.8 40.7 3,434 North West 27.1 32.9 7,445 South East 82.0 84.7 1,719 South South 68.6 73.0 2,002 South West 76.6 80.7 2,977 State North Central FCT-Abuja 59.7 72.8 143 Benue 40.3 43.4 615 Kogi 79.0 81.3 283 Kwara 80.4 83.4 278 Nasarawa 49.4 51.4 309 Niger 51.4 51.9 916 Plateau 44.0 50.6 346 North East Adamawa 58.8 66.5 459 Bauchi 32.1 32.7 833 Borno 28.6 32.4 716 Gombe 50.7 58.0 361 Taraba 41.1 47.9 476 Yobe 24.1 25.6 588 Continued… 134 • Reproductive Health Table 9.4—Continued Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers North West Jigawa 30.1 34.3 973 Kaduna 44.9 52.8 1,051 Kano 34.1 47.9 1,907 Katsina 23.8 25.3 1,066 Kebbi 14.4 14.4 790 Sokoto 12.6 13.9 693 Zamfara 15.5 17.5 966 South East Abia 88.7 91.7 199 Anambra 83.9 87.2 379 Ebonyi 70.3 72.1 467 Enugu 88.6 91.8 355 Imo 85.3 87.8 319 South South Akwa Ibom 62.4 67.5 334 Bayelsa 59.3 63.4 153 Cross River 67.2 73.2 368 Delta 67.7 70.8 376 Edo 69.8 74.4 264 Rivers 76.5 80.3 508 South West Ekiti 85.4 89.4 139 Lagos 81.7 85.5 867 Ogun 76.0 78.5 495 Ondo 60.9 70.4 385 Osun 92.5 94.1 307 Oyo 71.1 75.0 783 Education No education 25.4 28.8 9,794 Primary 57.6 63.9 3,915 Secondary 74.0 78.9 5,475 More than secondary 85.9 91.5 1,283 Wealth quintile Lowest 15.9 17.3 4,699 Second 33.0 36.9 4,588 Middle 54.5 59.6 3,902 Fourth 69.7 76.4 3,674 Highest 82.0 88.0 3,604 Total 48.4 52.8 20,467 1 Includes mothers with two injections during the pregnancy of their last birth or two or more injections (the last within 3 years of the last live birth), three or more injections (the last within 5 years of the last birth), four or more injections (the last within 10 years of the last live birth), or five or more injections at any time prior to the last birth. Nationally, 48 percent of women received two or more tetanus injections during their last pregnancy, and 53 percent had their last birth protected against neonatal tetanus. Women in urban areas (70 percent) were almost twice as likely as women in rural areas (36 percent) to have received two or more tetanus toxoid injections during their last pregnancy. Similarly, 77 percent of women in urban areas had their last births protected against neonatal tetanus, as compared with 40 percent of their rural counterparts. The proportion of women who received two or more tetanus toxoid injections during the pregnancy for their last live birth varies considerably across zones, ranging from a high of 82 percent in the South East to a low of 27 percent in the North West. Women with more than a secondary education (86 percent) and women who are in the fourth and highest wealth quintiles (70 percent and 82 percent, respectively) are more likely than other women to have received two or more injections during the pregnancy for their last live birth and to have had their last birth protected against neonatal tetanus. Reproductive Health • 135 9.2 DELIVERY 9.2.1 Place of Delivery Increasing the percentage of births delivered in health facilities is an important factor in reducing deaths arising from 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 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. Thirty-six percent of births in Nigeria are delivered in a health facility (as compared with 35 percent in 2008) (Figure 9.2). Twenty-three percent of deliveries occur in public sector facilities, and 13 percent occur in private sector facilities. Sixty-three percent of births are delivered at home. Women less than age 20 are more likely than women in other age groups to deliver at home (74 percent). The proportion of births occurring in health facilities decreases with increasing birth order, from a high of 48 percent for first births to a low of 22 percent for births of order six or above. 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 2013 Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector Mother’s age at birth <20 18.8 5.7 74.2 0.0 1.3 100.0 24.5 4,726 20-34 23.3 15.0 60.6 0.1 1.0 100.0 38.3 22,220 35-49 22.7 12.4 63.8 0.1 1.0 100.0 35.1 4,882 Birth order 1 30.0 17.8 51.0 0.1 1.2 100.0 47.8 6,285 2-3 23.3 16.7 58.9 0.1 1.0 100.0 40.0 10,311 4-5 22.1 11.7 65.1 0.2 0.9 100.0 33.8 7,441 6+ 16.0 6.4 76.4 0.1 1.1 100.0 22.4 7,791 Antenatal care visits1 None 2.8 1.5 95.1 0.1 0.5 100.0 4.3 6,990 1-3 21.3 6.9 71.7 0.2 0.0 100.0 28.2 2,474 4+ 37.7 22.9 39.3 0.1 0.0 100.0 60.6 10,457 Don’t know/missing 36.6 21.7 41.6 0.1 0.0 100.0 58.3 546 Residence Urban 35.1 26.5 37.4 0.1 0.8 100.0 61.7 11,126 Rural 15.8 6.1 76.9 0.1 1.1 100.0 21.9 20,702 Zone North Central 30.0 15.7 52.9 0.2 1.2 100.0 45.7 4,340 North East 18.4 1.2 79.3 0.1 1.0 100.0 19.5 5,578 North West 11.0 0.5 87.5 0.0 1.0 100.0 11.5 11,775 South East 33.9 44.2 19.9 0.3 1.6 100.0 78.1 2,840 South South 35.7 14.3 48.7 0.1 1.1 100.0 50.1 2,935 South West 35.4 39.6 24.2 0.2 0.5 100.0 75.0 4,360 State North Central FCT-Abuja 48.9 20.2 30.9 0.0 0.0 100.0 69.1 209 Benue 25.7 25.2 48.3 0.3 0.4 100.0 50.9 967 Kogi 51.7 27.2 18.8 0.2 2.0 100.0 78.9 401 Kwara 42.8 33.9 23.0 0.0 0.3 100.0 76.7 405 Nasarawa 29.2 10.9 59.0 0.6 0.3 100.0 40.1 460 Niger 23.3 2.0 72.3 0.0 2.4 100.0 25.3 1,394 Plateau 22.2 13.6 63.0 0.3 1.0 100.0 35.8 505 North East Adamawa 31.8 1.6 65.3 0.5 0.8 100.0 33.4 732 Bauchi 16.0 0.9 82.0 0.1 0.9 100.0 16.9 1,431 Borno 16.8 0.2 82.6 0.0 0.4 100.0 17.0 1,118 Gombe 26.4 1.2 71.4 0.1 0.9 100.0 27.6 595 Taraba 19.5 3.9 76.0 0.2 0.4 100.0 23.4 764 Yobe 7.5 0.1 90.0 0.0 2.4 100.0 7.6 938 Continued… 136 • Reproductive Health Table 9.5—Continued Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector North West Jigawa 6.6 0.2 91.4 0.0 1.9 100.0 6.7 1,594 Kaduna 29.1 3.3 67.5 0.0 0.1 100.0 32.4 1,439 Kano 12.6 0.3 86.5 0.0 0.6 100.0 12.9 3,024 Katsina 8.9 0.1 89.0 0.0 2.0 100.0 9.0 1,703 Kebbi 8.4 0.1 91.0 0.0 0.5 100.0 8.5 1,247 Sokoto 4.7 0.0 94.2 0.0 1.1 100.0 4.7 1,151 Zamfara 5.0 0.0 94.2 0.0 0.8 100.0 5.0 1,618 South East Abia 32.7 40.1 24.3 0.0 2.8 100.0 72.8 326 Anambra 24.9 59.8 11.3 0.1 3.9 100.0 84.6 657 Ebonyi 29.5 30.1 39.9 0.4 0.1 100.0 59.6 748 Enugu 36.5 49.0 13.1 0.7 0.7 100.0 85.5 558 Imo 48.8 42.1 7.5 0.4 1.2 100.0 90.9 552 South South Akwa Ibom 35.5 7.7 55.9 0.2 0.8 100.0 43.2 473 Bayelsa 25.3 3.1 70.9 0.0 0.7 100.0 28.4 233 Cross River 34.0 6.4 59.1 0.2 0.2 100.0 40.4 532 Delta 46.7 11.0 39.6 0.0 2.7 100.0 57.6 561 Edo 40.1 34.7 24.6 0.3 0.3 100.0 74.7 405 Rivers 29.7 19.2 49.6 0.0 1.4 100.0 49.0 730 South West Ekiti 60.7 25.6 12.9 0.4 0.4 100.0 86.3 200 Lagos 21.1 56.1 21.7 0.1 1.1 100.0 77.2 1,303 Ogun 30.7 44.0 24.8 0.0 0.5 100.0 74.7 736 Ondo 37.4 18.9 43.2 0.0 0.6 100.0 56.2 568 Osun 60.5 28.7 10.6 0.0 0.2 100.0 89.1 445 Oyo 39.9 34.8 24.7 0.6 0.0 100.0 74.7 1,108 Mother’s education No education 9.5 1.7 87.7 0.0 1.1 100.0 11.2 15,657 Primary 26.4 15.1 57.3 0.1 1.0 100.0 41.5 6,127 Secondary 38.2 27.7 32.9 0.2 1.0 100.0 65.9 8,211 More than secondary 50.7 40.6 7.8 0.2 0.7 100.0 91.3 1,834 Wealth quintile Lowest 4.6 1.2 93.1 0.1 1.0 100.0 5.8 7,496 Second 12.6 4.5 81.5 0.1 1.3 100.0 17.1 7,355 Middle 25.6 11.5 61.7 0.2 0.9 100.0 37.1 6,001 Fourth 38.5 18.2 42.1 0.1 1.0 100.0 56.8 5,656 Highest 41.1 38.8 19.1 0.0 0.9 100.0 79.9 5,320 Total 22.6 13.2 63.1 0.1 1.0 100.0 35.8 31,828 1 Includes only the most recent birth in the five years preceding the survey Women in rural areas are more likely to deliver at home (77 percent) than their urban counterparts (37 percent). The North West has the highest proportion of deliveries at home (88 percent), followed by the North East (79 percent); the South East has the lowest proportion of such deliveries (20 percent), followed closely by the South West (24 percent). Women with higher levels of educational attainment are more likely to deliver in a health facility than women with less or no education. For example, women with more than a secondary education (91 percent) are eight times as likely to deliver in a health facility as women with no education (11 percent). The proportion of births occurring in a health facility increases steadily with increasing wealth quintile, from 6 percent of births in the lowest quintile to 80 percent in the highest quintile. Figure 9.2 presents trends in the percentages of deliveries occurring at a health facility and at home over the past 10 years. The percentages have remained similar over the period. Reproductive Health • 137 Figure 9.2 Trends in place of delivery 33 66 35 62 36 63 Delivery at health facility Delivery at home Percentage 2003 NDHS 2008 NDHS 2013 NDHS 9.2.2 Reasons for Not Delivering in a Health Facility Table 9.6 presents information on most recent live births not delivered in a health facility according to specific reasons cited for not delivering in such a facility. Overall, 33 percent of mothers reported that they did not give birth at a health facility because the child was born suddenly and there was no time to reach the facility. Twenty-nine percent of women reported that they did not deliver in a health facility because they felt it was not necessary, while others reported distance from the facility (13 percent) or cost (8 percent) as the main hindering factor. In the case of sixth- and higher-order births, the reason most often cited was that it was not necessary to deliver at a health facility (31 percent). Reasons varied across zones. Cost was cited as the greatest impediment to delivery at a health facility in the South South zone (27 percent). Seven percent of mothers in the South West cited lack of trust for the provider or poor quality of service as their reason for not delivering in a health facility. The South West also had the greatest proportion of women whose husbands or family did not allow them to deliver in a health facility (12 percent). The North West had the highest proportion of mothers who said that delivery in a health facility was not necessary (37 percent). Twelve percent of mothers in the North West said that it is not customary to deliver in a health facility. One of the most cited reasons for not delivering in a health facility in all of the zones other than the North West and South South was that the child was born suddenly and there was no time to reach the facility. Forty-four percent of mothers in the North East cited this as a reason for delivering at home, along with 41 percent in the North Central zone, 37 percent in the South East, and 26 percent in the South West. This is particularly important because it may reflect the need for improvements in the quality of antenatal care received. It is during ANC visits that the expected date of delivery is typically determined. The mother is usually expected to deliver any moment from 38-42 weeks of gestation. Errors in estimating the expected date of delivery could lead to the baby being delivered supposedly unexpectedly. 138 • Reproductive Health Table 9.6 Reasons for not delivering in a health facility Among last live births not delivered in a health facility, percentage whose mothers cite specific reasons for not delivering in a health facility, according to background characteristics, Nigeria 2013 Background characteristic Cost too much Facility not open Too far/no transporta- tion Don’t trust facility/ poor- quality service No female provider at facility Husband/ family did not allow Not necessary Not customary Child born suddenly before going to facility Other Number of births Birth order 1 8.5 2.5 14.1 1.0 0.6 7.4 25.8 6.0 33.9 0.2 2,205 2-3 7.9 1.7 12.3 1.4 0.4 7.8 27.4 7.1 33.8 0.2 4,338 4-5 7.8 2.3 12.7 1.6 0.3 6.4 28.1 8.0 32.7 0.1 3,724 6+ 7.3 1.6 13.1 0.8 0.6 5.5 31.4 8.8 30.6 0.2 4,723 Residence Urban 8.1 1.0 7.3 2.8 0.4 5.2 26.1 5.9 42.9 0.4 2,923 Rural 7.7 2.1 14.3 0.8 0.5 7.1 29.2 8.2 30.0 0.1 12,067 Zone North Central 10.7 0.9 14.1 0.3 0.1 2.4 28.2 1.8 41.4 0.1 1,712 North East 8.3 3.9 17.5 0.7 0.3 5.2 16.5 3.8 43.5 0.2 3,391 North West 3.5 0.5 9.6 0.4 0.4 8.5 37.4 12.0 27.5 0.0 7,490 South East 15.4 2.6 18.0 3.6 1.1 4.2 14.7 2.5 36.8 1.1 397 South South 26.9 4.2 14.3 3.7 0.9 1.5 21.9 2.4 23.2 0.8 1,057 South West 9.7 5.0 16.5 6.8 0.7 11.9 16.3 6.4 26.2 0.4 942 State North Central FCT-Abuja 5.9 0.6 11.0 0.0 0.0 5.5 29.5 14.3 33.2 0.0 56 Benue 20.5 0.6 6.6 0.9 0.0 3.6 30.2 0.9 36.6 0.0 323 Kogi 12.2 0.8 6.7 0.0 0.0 0.4 15.8 0.0 63.1 1.1 56 Kwara 10.8 2.2 13.4 1.4 1.6 2.2 21.2 5.5 41.7 0.0 71 Nasarawa 7.8 0.6 5.9 0.0 0.0 6.5 24.9 2.9 51.4 0.0 192 Niger 2.4 0.1 21.7 0.0 0.0 0.7 28.8 0.3 45.9 0.1 734 Plateau 23.6 3.3 10.5 0.4 0.4 2.5 30.5 3.1 25.7 0.0 279 North East Adamawa 0.6 3.0 7.9 0.0 0.2 3.8 43.8 0.3 40.4 0.0 311 Bauchi 0.1 0.9 4.7 0.5 0.3 1.3 24.0 5.1 62.5 0.6 776 Borno 9.4 3.1 20.8 1.5 0.3 10.9 1.0 5.6 47.3 0.0 754 Gombe 3.0 1.3 6.0 0.4 1.0 0.5 11.9 1.0 74.5 0.3 280 Taraba 14.5 0.4 26.6 1.5 0.2 3.4 31.3 2.0 20.2 0.0 415 Yobe 16.3 10.1 29.1 0.3 0.4 6.8 7.9 4.0 25.1 0.0 856 North West Jigawa 6.2 0.4 16.3 0.2 0.1 4.0 38.3 7.3 27.1 0.3 986 Kaduna 0.9 1.1 15.6 0.3 0.0 6.2 28.4 2.1 45.4 0.0 860 Kano 4.5 0.0 10.0 0.2 0.0 3.0 63.4 1.7 17.2 0.0 1,710 Katsina 1.7 0.8 14.6 0.5 1.0 1.2 32.6 5.5 41.9 0.1 1,089 Kebbi 0.5 0.0 2.5 0.2 1.6 18.8 36.6 5.9 33.8 0.0 748 Sokoto 2.0 1.2 1.3 0.1 0.3 7.7 19.4 48.0 20.2 0.0 982 Zamfara 7.0 0.4 5.8 1.5 0.6 23.7 25.0 18.4 17.7 0.0 1,115 South East Abia 12.6 5.2 17.0 4.4 2.2 13.0 13.2 0.0 32.3 0.0 46 Anambra 29.8 3.2 26.8 4.3 0.0 5.3 8.5 0.0 13.2 8.9 49 Ebonyi 11.5 2.3 14.2 1.3 1.2 3.5 20.8 3.6 41.7 0.0 232 Enugu 18.6 3.6 24.8 4.1 2.0 0.0 0.0 5.1 41.8 0.0 35 Imo 20.8 0.0 25.1 15.6 0.0 0.0 0.0 0.0 38.4 0.0 36 South South Akwa Ibom 31.5 5.3 10.1 5.3 0.6 2.9 17.7 0.9 24.5 1.1 186 Bayelsa 17.5 9.4 18.1 3.0 1.3 1.2 37.3 1.1 10.5 0.6 153 Cross River 32.5 1.4 13.4 3.0 1.2 1.8 14.1 4.4 27.9 0.3 220 Delta 17.2 7.5 13.8 1.0 0.3 0.9 36.3 0.8 21.6 0.6 143 Edo 26.6 3.2 25.4 2.9 0.0 1.3 8.1 1.2 30.9 0.3 82 Rivers 29.9 1.5 12.7 5.2 1.4 1.0 19.0 4.0 24.0 1.5 274 South West Ekiti 18.7 23.8 2.4 2.0 0.0 5.5 16.8 0.0 30.7 0.0 18 Lagos 18.0 1.4 13.2 15.3 0.5 9.7 9.0 11.7 20.6 0.6 291 Ogun 10.8 1.3 20.4 1.4 0.0 16.1 12.2 1.2 36.6 0.0 169 Ondo 5.2 16.0 23.7 6.0 0.2 1.6 19.0 8.6 18.5 1.1 196 Osun 0.0 6.3 1.3 0.0 0.0 12.7 35.9 6.3 37.5 0.0 42 Oyo 3.3 1.2 15.5 2.4 2.1 20.6 22.8 2.3 29.9 0.0 227 Mother’s education No education 6.0 1.6 14.0 0.5 0.4 7.8 30.1 9.4 30.1 0.1 10,356 Primary 12.0 2.3 11.6 2.0 0.4 4.5 26.5 4.3 36.2 0.2 2,509 Secondary 12.0 2.8 9.3 3.5 0.6 3.9 24.4 3.6 39.4 0.6 2,015 More than secondary 2.8 3.8 7.8 2.4 0.0 4.1 20.0 4.4 53.9 0.8 111 Wealth quintile Lowest 6.7 2.0 18.3 0.7 0.6 7.8 28.2 9.7 25.9 0.0 5,471 Second 7.5 1.9 11.6 0.4 0.3 7.2 30.6 8.3 32.1 0.2 4,417 Middle 9.2 1.6 9.5 1.2 0.3 5.2 27.8 5.2 39.8 0.1 2,671 Fourth 9.1 2.2 6.6 2.6 0.3 4.7 28.7 4.5 40.7 0.5 1,682 Highest 9.2 1.8 7.3 6.4 0.5 5.2 23.0 6.6 39.3 0.7 750 Total 7.8 1.9 12.9 1.2 0.5 6.7 28.6 7.7 32.5 0.2 14,990 Reproductive Health • 139 9.2.3 Assistance during Delivery In addition to place of birth, assistance during childbirth is an important variable influencing the birth outcome and the mother’s and infant’s health. The skills and performance of the person providing assistance during delivery determine whether complications are properly managed and hygienic practices are observed. Table 9.7 shows the percent distribution of live births in the five years preceding the survey by the person providing assistance during delivery. Overall, 38 percent of all deliveries are assisted by a skilled provider, namely a doctor, nurse, or midwife. Traditional birth attendants assist 22 percent of all deliveries. Twenty-three percent of births are assisted by a relative or other person, and 13 percent are unassisted. About a quarter of mothers less than age 20 at the time of delivery, compared with 41 percent of those age 20-34, are assisted during delivery by a skilled provider. Birth order is inversely associated with the likelihood of a birth being assisted by a skilled provider. Half of first-order births are assisted by a skilled provider, as compared with a quarter of births of order six or higher. Table 9.7 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider, and percentage delivered via caesarean section, according to background characteristics, Nigeria 2013 Person providing assistance during delivery Percentage delivered by a skilled provider1 Percentage delivered by C- section Number of births Background characteristic Doctor Nurse/ midwife Auxiliary nurse/ midwife Community extension health worker Traditional birth attendant Relative/ other No one Don’t know/ missing Total Mother’s age at birth <20 5.1 17.8 2.3 3.4 29.3 30.7 9.8 1.7 100.0 25.2 1.0 4,726 20-34 11.2 26.8 3.1 2.1 20.7 21.7 13.0 1.4 100.0 41.1 2.1 22,220 35-49 10.9 24.0 2.4 2.3 21.2 19.5 18.4 1.2 100.0 37.3 2.7 4,882 Birth order 1 14.7 31.8 3.3 2.5 20.3 20.7 5.1 1.5 100.0 49.8 3.6 6,285 2-3 11.5 27.6 3.5 2.1 20.5 23.1 10.4 1.3 100.0 42.6 2.2 10,311 4-5 9.4 24.7 2.5 2.8 21.7 23.3 14.2 1.2 100.0 36.7 1.6 7,441 6+ 5.7 16.5 2.1 2.1 25.7 23.3 23.2 1.5 100.0 24.2 1.0 7,791 Antenatal care visits2 None 1.4 3.1 0.7 1.0 38.6 32.0 22.4 0.9 100.0 5.2 0.4 6,990 1-3 5.6 21.4 2.1 4.7 20.1 29.1 16.5 0.4 100.0 29.2 1.2 2,474 4+ 18.4 41.5 4.5 3.0 11.2 14.7 6.6 0.2 100.0 64.3 3.8 10,457 Don’t know/missing 18.3 43.7 5.9 3.0 11.1 10.6 7.4 0.0 100.0 67.8 4.9 546 Place of delivery Health facility 27.4 63.3 5.1 3.2 0.4 0.3 0.1 0.3 100.0 95.8 5.7 11,387 Elsewhere 0.7 3.7 1.7 1.9 34.6 35.8 21.1 0.6 100.0 6.1 0.0 20,115 Missing 0.1 2.8 0.0 0.3 1.0 2.1 1.4 92.3 100.0 2.9 0.0 326 Residence Urban 19.0 43.4 4.6 1.2 11.8 12.5 6.5 0.9 100.0 67.0 3.9 11,126 Rural 5.5 15.2 2.0 2.9 27.5 28.2 17.0 1.7 100.0 22.7 1.0 20,702 Zone North Central 12.4 32.2 1.9 6.0 3.6 35.4 6.5 2.0 100.0 46.5 2.3 4,340 North East 3.3 14.3 2.3 3.9 26.0 39.0 9.7 1.5 100.0 19.9 0.9 5,578 North West 3.5 8.5 0.3 0.8 34.0 23.6 27.8 1.4 100.0 12.3 0.6 11,775 South East 13.7 60.0 8.5 2.1 7.4 5.1 1.5 1.6 100.0 82.2 3.9 2,840 South South 13.7 37.6 4.0 2.0 29.7 9.6 1.8 1.5 100.0 55.4 4.1 2,935 South West 30.4 44.9 7.2 1.2 7.4 7.1 1.3 0.5 100.0 82.5 4.5 4,360 State North Central FCT-Abuja 29.3 39.7 1.2 6.0 4.6 15.2 4.0 0.0 100.0 70.2 6.3 209 Benue 14.7 36.0 0.9 0.9 4.5 36.4 6.0 0.6 100.0 51.6 2.1 967 Kogi 33.0 36.8 1.1 7.3 3.8 15.4 0.4 2.3 100.0 70.9 6.1 401 Kwara 10.0 66.8 2.8 2.3 3.6 13.1 1.0 0.4 100.0 79.6 4.3 405 Nasarawa 15.4 20.9 4.4 6.7 9.1 30.1 12.9 0.4 100.0 40.7 1.5 460 Niger 4.9 21.3 2.3 11.6 1.4 48.0 5.8 4.7 100.0 28.6 0.6 1,394 Plateau 4.7 30.5 0.6 1.5 2.3 45.9 13.5 1.0 100.0 35.8 1.7 505 Continued… 140 • Reproductive Health Table 9.7—Continued Person providing assistance during delivery Percentage delivered by a skilled provider1 Percentage delivered by C- section Number of births Background characteristic Doctor Nurse/ midwife Auxiliary nurse/ midwife Community extension health worker Traditional birth attendant Relative/ other No one Don’t know/ missing Total North East Adamawa 4.3 31.5 0.5 2.0 2.1 52.0 6.7 0.9 100.0 36.3 2.3 732 Bauchi 1.4 11.1 3.8 3.1 19.6 37.5 21.2 2.4 100.0 16.3 0.6 1,431 Borno 3.6 18.5 0.2 0.7 44.7 29.6 2.4 0.4 100.0 22.3 0.4 1,118 Gombe 10.9 5.4 10.3 3.6 12.4 41.3 15.2 0.9 100.0 26.6 1.2 595 Taraba 1.9 11.6 0.7 16.4 5.5 53.7 9.1 1.1 100.0 14.3 1.6 764 Yobe 1.3 8.7 0.2 0.2 57.4 29.2 0.2 2.9 100.0 10.2 0.3 938 North West Jigawa 1.7 5.6 0.3 0.8 31.2 35.0 23.1 2.3 100.0 7.6 0.9 1,594 Kaduna 14.9 20.5 0.1 0.2 24.9 23.6 15.6 0.2 100.0 35.5 1.4 1,439 Kano 3.4 10.0 0.3 0.2 23.7 22.5 39.0 1.0 100.0 13.7 0.5 3,024 Katsina 0.7 6.9 0.1 2.5 51.5 10.7 25.0 2.6 100.0 7.7 0.3 1,703 Kebbi 0.6 8.7 0.0 0.7 22.8 38.9 27.9 0.4 100.0 9.3 0.8 1,247 Sokoto 2.0 3.3 0.1 0.0 84.7 7.9 0.1 1.9 100.0 5.4 0.2 1,151 Zamfara 1.8 3.4 0.9 1.6 18.2 27.7 45.1 1.4 100.0 6.1 0.3 1,618 South East Abia 9.2 65.2 2.8 0.5 15.5 3.9 0.3 2.5 100.0 77.2 4.2 326 Anambra 17.9 65.2 4.4 3.4 3.6 1.7 0.0 3.7 100.0 87.6 5.1 657 Ebonyi 9.0 44.1 9.0 3.8 16.2 12.7 5.0 0.1 100.0 62.1 2.0 748 Enugu 13.9 62.1 15.6 1.3 2.0 3.8 0.5 0.8 100.0 91.5 3.4 558 Imo 17.6 70.0 8.9 0.1 0.7 0.9 0.5 1.3 100.0 96.5 5.1 552 South South Akwa Ibom 10.7 33.6 1.3 0.7 46.9 4.8 0.6 1.5 100.0 45.6 2.6 473 Bayelsa 10.2 19.8 2.1 0.0 65.6 1.6 0.1 0.7 100.0 32.1 1.0 233 Cross River 5.5 31.1 4.7 8.0 20.3 27.9 2.2 0.2 100.0 41.3 2.8 532 Delta 9.7 46.5 3.6 1.2 27.2 3.4 5.4 3.0 100.0 59.8 2.3 561 Edo 26.4 49.1 2.8 1.1 12.6 6.2 1.6 0.3 100.0 78.3 6.4 405 Rivers 19.0 37.6 6.8 0.3 25.6 8.4 0.3 2.1 100.0 63.4 7.1 730 South West Ekiti 21.2 55.9 7.7 6.8 4.0 3.6 0.5 0.4 100.0 84.7 6.5 200 Lagos 41.0 40.1 6.1 2.2 7.4 1.5 0.8 0.9 100.0 87.2 6.5 1,303 Ogun 46.4 35.8 2.5 0.3 5.6 8.6 0.2 0.5 100.0 84.7 1.9 736 Ondo 17.8 31.7 17.7 0.6 21.1 7.2 3.3 0.6 100.0 67.2 5.0 568 Osun 24.4 63.5 6.3 0.0 1.8 3.5 0.2 0.2 100.0 94.2 3.2 445 Oyo 18.0 54.0 6.3 0.3 4.3 14.7 2.3 0.0 100.0 78.3 3.8 1,108 Mother’s education No education 2.5 8.3 0.9 2.3 31.7 30.9 21.7 1.7 100.0 11.7 0.5 15,657 Primary 9.6 30.0 4.7 3.2 18.4 23.1 9.6 1.3 100.0 44.3 1.6 6,127 Secondary 18.9 47.2 5.6 2.0 10.8 11.3 3.1 1.1 100.0 71.7 3.3 8,211 More than secondary 39.7 51.7 1.8 0.8 2.2 2.8 0.4 0.6 100.0 93.2 11.1 1,834 Wealth quintile Lowest 1.4 3.8 0.5 1.7 33.4 32.3 25.5 1.4 100.0 5.7 0.5 7,496 Second 3.7 11.6 2.0 3.2 29.5 30.7 17.8 1.5 100.0 17.3 0.7 7,355 Middle 8.3 28.1 3.5 3.5 20.0 24.3 10.8 1.6 100.0 39.9 1.3 6,001 Fourth 12.5 44.3 5.2 2.2 14.6 14.5 5.1 1.5 100.0 62.1 2.2 5,656 Highest 31.4 49.6 4.3 0.9 5.7 5.4 1.8 0.9 100.0 85.3 6.7 5,320 Total 10.2 25.0 2.9 2.3 22.0 22.7 13.4 1.4 100.0 38.1 2.0 31,828 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. 2 Includes only the most recent birth in the five years preceding the survey Births in urban areas are much more likely to be assisted by a skilled health provider (67 percent) than births in rural areas (23 percent). Four in five births in the South West and South East are attended by a skilled health provider, as compared with 12 percent in the North West. Only 5 percent of births in Sokoto are attended by a skilled provider, and that state has the highest proportion of births attended by traditional birth attendants (85 percent). A mother’s level of education and wealth status affect the likelihood of her seeking assistance during delivery from a skilled provider. Twelve percent of women with no education were attended by a skilled provider, as compared with 93 percent of women with more than a secondary education. Similarly, births to women in the highest wealth quintile were almost 15 times as likely to be assisted by a skilled health provider as births to women in the lowest quintile (85 percent and 6 percent, respectively). Reproductive Health • 141 The proportion of births assisted by a skilled provider has remained relatively stagnant over the last 10 years (35 percent in 2003, 39 percent in 2008, and 38 percent in 2013). Table 9.7 shows that 2 percent of births are delivered via caesarean section. Delivery via caesarean section is highest among births to first-time mothers (4 percent), births to women with four or more antenatal visits (4 percent), births occurring in a health facility (6 percent), births to highly educated mothers (11 percent), and births to mothers in the highest wealth quintile (7 percent). Figure 9.3 presents the percent distribution of women who gave birth in a health facility in the five years preceding the survey by duration of stay in the facility and type of delivery. Among women who gave birth via caesarean section, 81 percent stayed at the hospital for more than three days, as compared with 10 percent of women who had a vaginal birth. The majority (41 percent) of women who had a vaginal birth in a health facility stayed for one or two days. Figure 9.3 Mother’s duration of stay in the health facility after giving birth 29 7 14 1 6 1 41 910 81 Vaginal birth Caesarean birth <6 hours 6-11 hours 12-23 hours 1-2 days 3+ days Percentage NDHS 2013 9.3 POSTNATAL CARE The postpartum period is particularly important for women, because during this period they may develop serious, life-threatening complications, especially in the interval immediately after delivery. There is evidence that a large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Postnatal care visits provide an ideal opportunity to educate a new mother on how to care for herself and her newborn baby. 9.3.1 Timing of First Postnatal Checkup for Mother 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 their last birth. If they reported receiving care, they were asked about the timing of the first postnatal checkup and the type of health provider performing the checkup. This information is presented according to background characteristics. Table 9.8 shows that in the two years preceding the survey, 40 percent of women received postnatal care for their last birth within the first two days following delivery. Thirty-one percent of women 142 • Reproductive Health received postnatal care within 4 hours of delivery, 5 percent received care within the first 4-23 hours, and 4 percent received care 1-2 days after delivery. Two percent of women received postnatal care on the third day after delivery or later. Overall, 58 percent of women had no postnatal checkup. Place of delivery also influenced the likelihood of receiving a postnatal checkup in the first two days. While 79 percent of those who delivered in a health facility had a checkup within the first two days, only 16 percent of those who delivered elsewhere had a checkup within that period. Those in rural areas were half as likely as their urban counterparts to have had a postnatal checkup within the first two days. Eighty-two percent of women in the North West had no postnatal checkup, as compared with 24 percent in the South West. Educational attainment is also a notable factor influencing the likelihood of seeking postnatal care. Women with no education (80 percent) are five times as likely as those with more than a secondary education (14 percent) to have received no postnatal checkup. Table 9.8 Timing of first postnatal checkup Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution of the mother’s first postnatal checkup for the last live birth by time after delivery, and the percentage of women with a live birth in the two years preceding the survey who received a postnatal checkup in the first two days after giving birth, according to background characteristics, Nigeria 2013 Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Background characteristic Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Mother’s age at birth <20 25.9 2.7 3.0 0.5 1.1 0.7 66.1 100.0 31.7 1,825 20-34 33.1 4.8 3.9 0.6 1.2 0.5 55.8 100.0 41.8 8,705 35-49 28.7 4.7 4.1 0.4 1.1 0.3 60.7 100.0 37.6 1,942 Birth order 1 39.2 5.8 5.2 0.8 1.6 1.1 46.4 100.0 50.3 2,537 2-3 35.0 4.8 4.0 0.6 1.5 0.4 53.6 100.0 43.9 4,032 4-5 29.5 4.2 3.4 0.7 1.2 0.5 60.6 100.0 37.1 2,812 6+ 21.9 3.2 2.6 0.3 0.5 0.2 71.3 100.0 27.7 3,092 Place of delivery2 Health facility 63.2 9.2 6.6 0.7 1.5 0.9 17.8 100.0 79.0 4,655 Elsewhere 12.5 1.7 2.1 0.5 1.0 0.3 82.0 100.0 16.2 7,796 Residence Urban 46.2 7.5 5.3 0.8 1.7 0.7 37.8 100.0 59.1 4,404 Rural 23.2 2.8 3.0 0.5 0.9 0.4 69.2 100.0 29.0 8,069 Zone North Central 41.9 3.7 2.1 0.6 1.7 0.6 49.6 100.0 47.6 1,692 North East 26.6 2.3 2.8 0.5 1.1 0.9 65.7 100.0 31.8 2,152 North West 14.7 1.2 1.1 0.2 0.9 0.2 81.7 100.0 17.0 4,554 South East 41.6 9.6 9.7 0.8 0.5 0.3 37.4 100.0 60.9 1,150 South South 43.5 7.4 9.3 1.0 1.5 1.2 36.0 100.0 60.3 1,191 South West 55.7 11.2 5.8 1.1 1.9 0.4 23.9 100.0 72.7 1,733 State North Central FCT-Abuja 69.2 8.7 1.7 0.2 2.5 1.8 15.8 100.0 79.6 75 Benue 31.1 5.8 2.6 0.6 0.0 0.6 59.3 100.0 39.4 374 Kogi 66.8 1.1 3.3 3.0 2.6 1.8 21.4 100.0 71.2 168 Kwara 55.8 3.6 4.3 0.1 10.6 0.3 25.2 100.0 63.7 161 Nasarawa 47.0 1.6 0.8 1.1 0.8 1.2 47.6 100.0 49.4 197 Niger 35.5 2.6 1.6 0.0 0.3 0.0 59.9 100.0 39.8 514 Plateau 31.0 4.7 0.6 0.3 0.8 0.0 62.5 100.0 36.3 204 North East Adamawa 30.8 1.7 1.5 0.2 2.4 0.7 62.7 100.0 34.0 289 Bauchi 36.0 1.0 1.6 0.4 0.5 2.5 58.0 100.0 38.6 573 Borno 15.6 1.8 2.7 0.3 0.6 0.9 78.1 100.0 20.1 408 Gombe 30.8 1.2 0.8 0.3 1.1 0.3 65.6 100.0 32.8 231 Taraba 23.5 7.2 3.8 1.0 1.0 0.0 63.6 100.0 34.5 300 Yobe 20.6 2.1 6.7 0.8 1.5 0.0 68.2 100.0 29.4 350 Continued… Reproductive Health • 143 Table 9.8—Continued Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Background characteristic Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing North West Jigawa 11.7 1.0 1.7 0.7 2.5 0.5 82.0 100.0 14.4 608 Kaduna 45.3 2.6 1.7 0.5 0.8 0.7 48.3 100.0 50.4 496 Kano 12.4 0.5 1.1 0.0 1.0 0.0 85.0 100.0 14.0 1,188 Katsina 11.6 0.1 0.7 0.1 0.7 0.0 86.8 100.0 12.4 688 Kebbi 5.5 0.9 1.2 0.0 0.4 0.0 92.0 100.0 7.6 479 Sokoto 5.7 0.4 0.3 0.0 0.5 0.6 92.4 100.0 6.5 444 Zamfara 14.3 3.2 1.2 0.2 0.4 0.2 80.4 100.0 18.7 652 South East Abia 47.9 8.2 12.5 1.2 0.7 0.4 29.1 100.0 68.5 135 Anambra 34.8 8.2 13.1 1.0 0.3 0.6 42.0 100.0 56.1 245 Ebonyi 43.7 7.6 4.0 0.4 0.0 0.6 43.7 100.0 55.3 313 Enugu 45.3 11.4 12.0 1.5 0.5 0.0 29.4 100.0 68.6 230 Imo 38.6 12.8 9.9 0.4 1.5 0.0 36.8 100.0 61.3 228 South South Akwa Ibom 30.0 7.4 27.4 2.0 3.9 0.9 28.5 100.0 64.7 202 Bayelsa 42.1 6.8 6.8 0.7 0.0 2.2 41.4 100.0 55.8 95 Cross River 54.6 6.3 7.4 0.5 0.2 0.3 30.7 100.0 68.3 221 Delta 45.8 7.0 2.0 0.0 0.0 0.0 45.2 100.0 54.8 220 Edo 62.9 9.1 4.4 0.6 1.1 2.1 19.7 100.0 76.5 168 Rivers 31.8 7.9 7.4 1.8 2.6 2.3 46.2 100.0 47.1 285 South West Ekiti 37.2 9.3 8.5 1.8 0.6 1.2 41.4 100.0 55.0 78 Lagos 65.5 15.5 2.9 2.0 3.0 0.3 10.8 100.0 83.9 519 Ogun 47.7 13.6 11.4 0.5 0.0 0.4 26.4 100.0 72.7 294 Ondo 36.6 9.5 11.0 0.2 1.1 0.4 41.1 100.0 57.2 225 Osun 64.0 19.8 3.6 2.5 4.9 0.0 5.1 100.0 87.4 189 Oyo 58.9 1.9 3.4 0.3 1.0 0.3 34.2 100.0 64.1 428 Education No education 15.7 1.4 1.5 0.2 0.7 0.4 80.1 100.0 18.7 5,940 Primary 35.2 5.0 4.7 0.5 1.4 0.3 52.9 100.0 44.9 2,253 Secondary 48.0 8.2 6.0 1.1 1.8 0.8 34.1 100.0 62.3 3,466 More than secondary 63.7 9.7 8.4 1.2 2.1 1.0 13.9 100.0 81.8 815 Wealth quintile Lowest 10.4 1.0 1.6 0.3 0.7 0.4 85.6 100.0 13.0 2,888 Second 19.5 1.8 1.9 0.2 0.8 0.3 75.4 100.0 23.3 2,842 Middle 33.7 5.2 3.9 0.4 1.1 0.5 55.3 100.0 42.7 2,360 Fourth 45.5 6.5 5.6 0.7 1.8 0.8 39.0 100.0 57.7 2,247 Highest 58.0 9.9 7.2 1.4 1.9 0.7 21.1 100.0 75.0 2,135 Total 31.4 4.5 3.8 0.6 1.2 0.5 58.1 100.0 39.6 12,473 1 Includes women who received a checkup after 41 days 2 Excludes 22 cases with missing information on place of delivery 9.3.2 Provider of First Postnatal Checkup for Mother The type of provider for the mother’s first postnatal checkup is a crucial determinant of the quality of the checkup. The ability to detect early warning signs in the mother and newborn and take appropriate actions (e.g., referral to a higher level of care) depends on the knowledge and skills of the provider. The federal government of Nigeria, through the Federal Ministry of Health, is providing training for skilled birth attendants on emergency obstetric and neonatal care and lifesaving skills to improve results for mothers and their babies during and after delivery. Table 9.9 shows the percent distribution of women age 15-49 who gave birth in the two years preceding the survey by the type of provider of the first postnatal health checkup in the two days after the most recent live birth, according to background characteristics. Sixty percent of women received no postnatal checkup in the first two days after birth. Thirty percent received a postnatal checkup from a doctor, nurse, or midwife, and 2 percent received a checkup from an auxiliary nurse or midwife. Mothers from urban areas, those who delivered in a health facility, and those in the South West and South East were more likely to have received a postnatal checkup from a skilled provider. The data also show that mothers at higher levels of educational attainment were more likely to have received a postnatal health checkup 144 • Reproductive Health from a skilled provider than mothers with no education. Wealth had an influence on whether women received postnatal checkups. Mothers in the highest wealth quintile were more likely than those in the lowest quintile to have received a postnatal checkup from a skilled provider (72 percent versus 5 percent). Table 9.9 Type of provider of first postnatal checkup for the mother Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal health check in the two days after the last live birth, according to background characteristics, Nigeria 2013 Type of health provider of mother’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of women Background characteristic Doctor/ nurse/ midwife Auxiliary nurse/ midwife Community extension health worker Traditional birth attendant Other Mother’s age at birth <20 19.2 2.3 3.5 5.6 1.2 68.3 100.0 1,825 20-34 32.3 2.2 2.3 4.0 1.0 58.2 100.0 8,705 35-49 29.2 1.5 2.3 3.5 1.0 62.4 100.0 1,942 Birth order 1 39.4 2.8 2.2 5.0 0.9 49.7 100.0 2,537 2-3 34.2 2.4 2.2 3.9 1.0 56.1 100.0 4,032 4-5 27.6 1.7 2.5 4.4 0.9 62.9 100.0 2,812 6+ 18.6 1.4 2.8 3.5 1.3 72.3 100.0 3,092 Place of delivery1 Health facility 72.7 3.5 2.4 0.1 0.3 21.0 100.0 4,655 Elsewhere 4.5 1.2 2.5 6.5 1.5 83.8 100.0 7,796 Residence Urban 52.3 3.3 1.1 2.2 0.2 40.9 100.0 4,404 Rural 17.7 1.4 3.2 5.2 1.5 71.0 100.0 8,069 Zone North Central 37.8 1.6 4.7 1.5 2.0 52.4 100.0 1,692 North East 16.0 2.8 3.7 6.9 2.5 68.2 100.0 2,152 North West 11.8 0.3 2.4 2.5 0.1 83.0 100.0 4,554 South East 53.8 4.5 0.9 1.3 0.4 39.1 100.0 1,150 South South 38.9 4.2 1.7 12.8 2.8 39.7 100.0 1,191 South West 65.2 3.3 0.6 3.5 0.1 27.3 100.0 1,733 State North Central FCT-Abuja 62.2 3.8 5.3 4.2 4.1 20.4 100.0 75 Benue 31.9 0.6 0.6 0.0 6.5 60.6 100.0 374 Kogi 61.1 0.0 5.1 3.3 1.7 28.8 100.0 168 Kwara 57.3 1.9 1.0 2.3 1.1 36.3 100.0 161 Nasarawa 35.6 4.7 5.6 3.5 0.0 50.6 100.0 197 Niger 28.7 1.7 9.0 0.4 0.0 60.2 100.0 514 Plateau 30.3 0.5 2.6 1.8 1.2 63.7 100.0 204 North East Adamawa 31.7 0.6 0.6 0.0 1.1 66.0 100.0 289 Bauchi 12.7 4.4 2.8 11.7 7.0 61.4 100.0 573 Borno 17.7 0.6 0.4 1.4 0.0 79.9 100.0 408 Gombe 15.9 12.3 2.3 1.4 0.9 67.2 100.0 231 Taraba 14.9 0.5 17.2 1.0 0.8 65.5 100.0 300 Yobe 7.3 0.0 0.7 19.8 1.7 70.6 100.0 350 North West Jigawa 9.7 0.2 1.7 2.5 0.3 85.6 100.0 608 Kaduna 35.6 0.3 0.0 13.9 0.6 49.6 100.0 496 Kano 13.0 0.6 0.0 0.4 0.0 86.0 100.0 1,188 Katsina 6.9 0.0 2.0 3.4 0.1 87.6 100.0 688 Kebbi 6.6 0.0 1.0 0.0 0.0 92.4 100.0 479 Sokoto 5.8 0.0 0.5 0.3 0.0 93.5 100.0 444 Zamfara 6.2 0.6 11.8 0.1 0.0 81.3 100.0 652 South East Abia 63.1 0.4 0.3 3.6 1.1 31.5 100.0 135 Anambra 55.1 0.0 0.7 0.3 0.0 43.9 100.0 245 Ebonyi 44.3 5.9 1.9 2.8 0.4 44.7 100.0 313 Enugu 55.5 11.6 0.9 0.0 0.6 31.4 100.0 230 Imo 58.1 2.9 0.0 0.4 0.0 38.7 100.0 228 South South Akwa Ibom 38.7 1.6 0.3 24.2 0.0 35.3 100.0 202 Bayelsa 24.7 3.2 0.0 27.9 0.0 44.2 100.0 95 Cross River 27.7 7.9 8.6 10.2 13.8 31.7 100.0 221 Delta 42.9 2.0 0.0 9.5 0.4 45.2 100.0 220 Edo 68.2 1.8 0.0 5.5 0.9 23.5 100.0 168 Rivers 32.0 6.8 0.0 8.3 0.0 52.9 100.0 285 Continued… Reproductive Health • 145 Table 9.9—Continued Type of health provider of mother’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of women Background characteristic Doctor/ nurse/ midwife Auxiliary nurse/ midwife Community extension health worker Traditional birth attendant Other South West Ekiti 51.0 2.1 1.9 0.0 0.0 45.0 100.0 78 Lagos 73.7 4.0 1.5 4.7 0.0 16.1 100.0 519 Ogun 68.5 0.6 0.0 3.5 0.0 27.3 100.0 294 Ondo 44.6 4.4 0.8 7.4 0.0 42.8 100.0 225 Osun 77.2 8.8 0.0 1.4 0.0 12.6 100.0 189 Oyo 60.5 1.5 0.0 1.7 0.4 35.9 100.0 428 Education No education 9.8 0.8 3.1 4.1 0.9 81.3 100.0 5,940 Primary 31.3 3.1 2.9 5.6 2.1 55.1 100.0 2,253 Secondary 52.1 3.8 1.5 4.1 0.8 37.7 100.0 3,466 More than secondary 78.6 1.5 0.8 0.6 0.2 18.2 100.0 815 Wealth quintile Lowest 4.4 0.5 2.7 4.1 1.3 87.0 100.0 2,888 Second 12.7 1.3 3.4 4.2 1.6 76.7 100.0 2,842 Middle 29.9 2.7 3.1 5.5 1.4 57.3 100.0 2,360 Fourth 46.7 3.6 1.8 4.9 0.7 42.3 100.0 2,247 Highest 69.5 2.9 0.7 1.8 0.0 25.0 100.0 2,135 Total 29.9 2.1 2.4 4.1 1.1 60.4 100.0 12,473 1 Excludes 22 cases with missing information on place of delivery 9.4 NEWBORN CARE Newborn care is essential to reduce neonatal health challenges and death. To identify, manage, and prevent complications, it is recommended that the mother and the newborn have at least three checkups within seven days after delivery (WHO and UNICEF, 2009), which is considered a critical period for neonates and mothers. As is the case for mothers, the timing of the first postnatal checkup for the newborn is crucial for early detection of complications after delivery. The earlier problems are discovered and managed, the better the outcomes. 9.4.1 Timing of First Postnatal Checkup for Newborn Table 9.10 shows the percent distribution of most recent births in the two years preceding the survey by time after birth of the first postnatal checkup, along with the percentage of newborns with a postnatal checkup in the first two days after birth, according to background characteristics. Overall, 14 percent of newborns received their first postnatal checkup within two days after birth. Among these newborns, 3 percent had a postnatal checkup less than one hour after birth, and 8 percent had a checkup between one and three hours after birth. In all, 11 percent of newborns had a postnatal checkup within 24 hours after birth. Eighty-four percent of newborns did not receive a postnatal checkup. Newborns delivered outside of a health facility were less likely to receive a postnatal checkup within the first two days after birth (6 percent) than newborns delivered in a health facility (28 percent). Similarly, postnatal checkups were less likely among births to mothers less than age 20, births of order six and above, births to rural women, and births in the North West zone than among births in the other categories. Ninety-four percent of newborns whose mothers had no education did not receive a postnatal checkup, as compared with 57 percent of newborns whose mothers had more than a secondary education. Newborns whose mothers were in the highest wealth quintile were more likely to receive a postnatal checkup than those whose mothers were in the lowest quintile. 146 • Reproductive Health Table 9.10 Timing of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by time after birth of first postnatal checkup, and the percentage of births with a postnatal checkup in the first two days after birth, according to background characteristics, Nigeria 2013 Time after birth of newborn’s first postnatal checkup No postnatal checkup1 Total Percentage of births with a postnatal checkup in the first two days after birth Number of births Background characteristic Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don’t know/ missing Mother’s age at birth <20 1.6 4.2 1.1 2.6 1.4 0.1 89.1 100.0 9.4 1,825 20-34 2.9 8.3 1.3 2.6 1.8 0.5 82.6 100.0 15.2 8,705 35-49 2.7 7.3 1.2 2.1 1.6 0.3 84.9 100.0 13.2 1,942 Birth order 1 2.9 10.0 1.6 2.9 2.5 0.3 79.8 100.0 17.4 2,537 2-3 3.8 8.9 1.6 2.8 1.5 0.4 81.1 100.0 17.1 4,032 4-5 2.5 6.5 1.1 2.8 2.1 0.3 84.8 100.0 12.9 2,812 6+ 1.2 4.6 0.6 1.7 1.1 0.6 90.2 100.0 8.3 3,092 Place of delivery2 Health facility 5.9 16.5 2.4 3.2 2.9 0.6 68.4 100.0 28.2 4,655 Elsewhere 0.7 2.2 0.5 2.1 1.0 0.2 93.1 100.0 5.6 7,796 Residence Urban 4.5 14.5 2.5 3.9 2.7 0.3 71.6 100.0 25.4 4,404 Rural 1.7 3.7 0.5 1.8 1.2 0.5 90.6 100.0 7.8 8,069 Zone North Central 2.0 6.2 0.6 2.1 3.2 0.6 85.4 100.0 10.9 1,692 North East 1.0 5.1 0.8 2.7 1.2 0.7 88.4 100.0 9.6 2,152 North West 1.4 3.4 0.1 1.4 1.0 0.1 92.5 100.0 6.4 4,554 South East 0.1 11.2 2.1 2.3 0.6 0.3 83.4 100.0 15.7 1,150 South South 4.1 8.0 1.1 5.2 2.2 0.5 78.8 100.0 18.4 1,191 South West 9.6 19.9 4.7 4.2 3.2 0.4 58.1 100.0 38.4 1,733 State North Central FCT-Abuja 10.1 25.5 6.5 1.7 3.7 4.7 47.8 100.0 45.3 75 Benue 0.0 4.1 0.0 0.9 0.9 0.5 93.6 100.0 5.0 374 Kogi 5.0 12.5 0.5 3.4 6.9 0.5 71.1 100.0 21.5 168 Kwara 1.0 3.2 0.9 6.8 13.2 0.0 74.9 100.0 11.9 161 Nasarawa 3.4 10.5 1.4 3.5 2.8 0.0 78.3 100.0 18.9 197 Niger 1.3 1.9 0.0 0.9 1.4 0.0 94.4 100.0 4.2 514 Plateau 0.9 6.4 0.5 1.0 1.2 1.8 88.2 100.0 8.9 204 North East Adamawa 0.3 9.2 0.3 0.6 2.0 0.0 87.6 100.0 10.5 289 Bauchi 0.9 5.7 1.9 5.0 0.4 2.2 84.0 100.0 13.5 573 Borno 1.6 1.4 0.6 2.7 1.9 0.0 91.8 100.0 6.3 408 Gombe 1.5 15.1 1.1 2.4 2.2 1.3 76.4 100.0 20.1 231 Taraba 0.3 1.4 0.5 1.6 1.4 0.2 94.8 100.0 3.7 300 Yobe 1.1 1.9 0.0 1.8 0.2 0.0 95.0 100.0 4.8 350 North West Jigawa 0.2 3.6 0.5 1.3 0.4 0.3 93.8 100.0 5.6 608 Kaduna 6.5 18.5 0.0 6.6 2.9 0.4 65.1 100.0 32.0 496 Kano 2.2 1.4 0.0 0.4 0.6 0.1 95.3 100.0 4.0 1,188 Katsina 0.2 0.8 0.0 1.4 0.7 0.1 96.8 100.0 2.4 688 Kebbi 0.0 0.7 0.0 0.7 0.1 0.0 98.4 100.0 1.5 479 Sokoto 0.8 0.4 0.0 0.0 0.2 0.0 98.6 100.0 1.2 444 Zamfara 0.0 2.0 0.4 0.9 2.6 0.2 93.9 100.0 3.3 652 South East Abia 0.0 10.0 1.0 2.5 1.2 0.3 85.0 100.0 13.4 135 Anambra 0.0 17.2 0.6 2.6 0.4 0.7 78.5 100.0 20.4 245 Ebonyi 0.0 11.6 1.1 1.3 1.2 0.3 84.6 100.0 13.9 313 Enugu 0.0 10.9 5.1 4.5 0.0 0.3 79.2 100.0 20.5 230 Imo 0.4 5.4 2.8 0.8 0.3 0.0 90.2 100.0 9.5 228 South South Akwa Ibom 1.0 9.4 2.3 11.2 3.6 1.3 71.2 100.0 24.0 202 Bayelsa 0.0 8.6 1.0 3.6 1.8 0.0 84.9 100.0 13.2 95 Cross River 7.0 12.1 0.6 4.6 4.7 0.4 70.6 100.0 24.3 221 Delta 13.9 4.3 1.4 1.1 0.6 0.0 78.7 100.0 20.6 220 Edo 0.6 7.1 1.0 1.9 0.8 1.2 87.4 100.0 10.6 168 Rivers 0.0 6.9 0.7 7.1 1.4 0.3 83.6 100.0 14.7 285 South West Ekiti 1.4 7.9 0.0 2.9 2.6 0.0 85.3 100.0 12.1 78 Lagos 7.5 39.2 6.6 4.3 4.6 0.4 37.5 100.0 57.9 519 Ogun 14.0 4.4 2.4 2.8 2.2 0.0 74.1 100.0 23.7 294 Ondo 0.4 6.2 2.6 6.6 4.2 0.3 79.7 100.0 15.8 225 Osun 0.8 35.4 12.5 7.2 2.6 0.0 41.5 100.0 56.0 189 Oyo 19.2 9.5 2.6 2.5 1.9 1.0 63.3 100.0 33.8 428 Continued… Reproductive Health • 147 Table 9.10—Continued Time after birth of newborn’s first postnatal checkup No postnatal checkup1 Total Percentage of births with a postnatal checkup in the first two days after birth Number of births Background characteristic Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don’t know/ missing Mother’s education No education 1.0 2.3 0.4 1.7 0.7 0.3 93.6 100.0 5.4 5,940 Primary 2.5 7.7 1.2 2.9 2.0 0.3 83.4 100.0 14.3 2,253 Secondary 4.7 13.0 2.1 3.0 2.7 0.5 74.0 100.0 22.9 3,466 More than secondary 7.0 21.5 3.7 5.7 4.5 0.8 56.7 100.0 38.2 815 Wealth quintile Lowest 0.1 1.5 0.4 1.1 0.4 0.4 96.1 100.0 3.0 2,888 Second 1.0 2.8 0.5 2.3 0.9 0.4 92.0 100.0 6.7 2,842 Middle 2.5 6.3 0.9 2.1 1.9 0.3 86.0 100.0 11.9 2,360 Fourth 4.2 11.6 1.5 3.5 2.7 0.3 76.3 100.0 20.7 2,247 Highest 6.9 19.0 3.6 4.3 3.3 0.5 62.4 100.0 33.9 2,135 Total 2.7 7.5 1.2 2.5 1.7 0.4 83.9 100.0 14.0 12,473 1 Includes newborns who received a checkup after the first week 2 Excludes 22 cases with missing information on place of delivery 9.4.2 Provider of First Postnatal Checkup for Newborn The type of provider of the first postnatal checkup for the newborn is crucial given that failure to detect complications could be potentially fatal in this important period. Again, the ability to detect such complications depends on the knowledge and skills of the provider undertaking the checkup. Table 9.11 shows the percent distribution of most recent births in the two years preceding the survey by type of provider of the newborn’s first postnatal health check during the two days after delivery, according to background characteristics. The findings show that 12 percent of newborns received postnatal care from a doctor, nurse, or midwife within the two days following birth. The distribution of newborns who received care from a skilled birth attendant by background characteristics is more or less similar to the pattern described for providers of mothers’ postnatal checkups. Table 9.11 Type of provider of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by type of provider of the newborn’s first postnatal health check during the two days after the last live birth, according to background characteristics, Nigeria 2013 Type of health provider of newborn’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of births Background characteristic Doctor/nurse/ midwife Auxiliary nurse/midwife Community extension health worker Traditional birth attendant Other Mother’s age at birth <20 6.1 0.5 0.4 2.2 0.2 90.6 100.0 1,825 20-34 12.4 0.8 0.3 1.6 0.1 84.8 100.0 8,705 35-49 11.1 0.4 0.3 1.4 0.0 86.8 100.0 1,942 Birth order 1 14.7 0.9 0.2 1.5 0.1 82.6 100.0 2,537 2-3 14.5 0.8 0.3 1.5 0.0 82.9 100.0 4,032 4-5 9.3 0.7 0.5 2.4 0.1 87.1 100.0 2,812 6+ 5.9 0.5 0.3 1.5 0.1 91.7 100.0 3,092 Place of delivery1 Health facility 26.6 1.3 0.2 0.0 0.0 71.8 100.0 4,655 Elsewhere 2.1 0.3 0.4 2.7 0.1 94.4 100.0 7,796 Residence Urban 22.8 1.3 0.3 0.9 0.1 74.6 100.0 4,404 Rural 4.9 0.4 0.3 2.1 0.1 92.2 100.0 8,069 Continued… 148 • Reproductive Health Table 9.11—Continued Type of health provider of newborn’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of births Background characteristic Doctor/nurse/ midwife Auxiliary nurse/midwife Community extension health worker Traditional birth attendant Other Zone North Central 9.6 0.3 0.4 0.5 0.1 89.1 100.0 1,692 North East 5.2 1.3 0.4 2.6 0.2 90.4 100.0 2,152 North West 4.3 0.1 0.1 1.8 0.0 93.6 100.0 4,554 South East 14.5 0.8 0.1 0.2 0.0 84.3 100.0 1,150 South South 11.8 1.9 0.8 3.9 0.1 81.6 100.0 1,191 South West 36.0 1.2 0.5 0.8 0.0 61.6 100.0 1,733 State North Central FCT-Abuja 37.9 2.1 2.0 3.4 0.0 54.7 100.0 75 Benue 5.0 0.0 0.0 0.0 0.0 95.0 100.0 374 Kogi 20.5 0.2 0.8 0.0 0.0 78.5 100.0 168 Kwara 11.5 0.5 0.0 0.0 0.0 88.1 100.0 161 Nasarawa 15.9 0.6 0.3 1.9 0.3 81.1 100.0 197 Niger 3.6 0.0 0.0 0.4 0.2 95.8 100.0 514 Plateau 6.4 0.4 1.4 0.2 0.4 91.1 100.0 204 North East Adamawa 10.0 0.0 0.0 0.0 0.5 89.5 100.0 289 Bauchi 4.9 1.0 0.4 7.2 0.0 86.5 100.0 573 Borno 3.7 0.8 0.0 1.3 0.6 93.7 100.0 408 Gombe 9.2 8.2 1.1 1.6 0.0 79.9 100.0 231 Taraba 2.1 0.1 1.2 0.1 0.1 96.3 100.0 300 Yobe 3.4 0.0 0.0 1.3 0.0 95.2 100.0 350 North West Jigawa 2.5 0.0 0.7 2.4 0.0 94.4 100.0 608 Kaduna 21.1 0.6 0.0 10.1 0.2 68.0 100.0 496 Kano 3.5 0.0 0.0 0.5 0.0 96.0 100.0 1,188 Katsina 1.4 0.0 0.1 0.9 0.0 97.6 100.0 688 Kebbi 1.0 0.0 0.0 0.4 0.0 98.5 100.0 479 Sokoto 1.2 0.0 0.0 0.0 0.0 98.8 100.0 444 Zamfara 2.5 0.0 0.0 0.8 0.0 96.7 100.0 652 South East Abia 12.7 0.4 0.0 0.3 0.0 86.6 100.0 135 Anambra 20.4 0.0 0.0 0.0 0.0 79.6 100.0 245 Ebonyi 11.3 1.6 0.4 0.6 0.0 86.1 100.0 313 Enugu 19.3 1.2 0.0 0.0 0.0 79.5 100.0 230 Imo 9.0 0.5 0.0 0.0 0.0 90.5 100.0 228 South South Akwa Ibom 15.3 0.5 0.0 8.2 0.0 76.0 100.0 202 Bayelsa 9.2 0.8 0.0 3.2 0.0 86.8 100.0 95 Cross River 9.0 5.6 4.2 5.0 0.5 75.7 100.0 221 Delta 17.1 0.5 0.0 3.1 0.0 79.4 100.0 220 Edo 8.0 0.0 0.0 2.6 0.0 89.4 100.0 168 Rivers 10.3 2.8 0.0 1.5 0.0 85.3 100.0 285 South West Ekiti 11.3 0.4 0.5 0.0 0.0 87.9 100.0 78 Lagos 53.1 1.7 1.7 1.5 0.0 42.1 100.0 519 Ogun 22.5 0.0 0.0 1.2 0.0 76.3 100.0 294 Ondo 15.1 0.5 0.0 0.2 0.0 84.2 100.0 225 Osun 52.0 3.9 0.0 0.0 0.0 44.0 100.0 189 Oyo 32.9 0.6 0.0 0.4 0.0 66.2 100.0 428 Mother’s education No education 2.9 0.2 0.2 2.1 0.1 94.6 100.0 5,940 Primary 11.0 1.3 0.4 1.5 0.2 85.7 100.0 2,253 Secondary 19.7 1.2 0.6 1.4 0.0 77.1 100.0 3,466 More than secondary 37.1 0.7 0.1 0.3 0.0 61.8 100.0 815 Wealth quintile Lowest 0.9 0.1 0.1 1.9 0.0 97.0 100.0 2,888 Second 3.7 0.3 0.3 2.2 0.1 93.3 100.0 2,842 Middle 9.0 0.6 0.3 1.9 0.1 88.1 100.0 2,360 Fourth 16.9 1.6 0.6 1.5 0.1 79.3 100.0 2,247 Highest 31.8 1.2 0.3 0.6 0.0 66.1 100.0 2,135 Total 11.2 0.7 0.3 1.7 0.1 86.0 100.0 12,473 1 Excludes 22 cases with missing information on place of delivery Reproductive Health • 149 9.4.3 Use of Clean Home Delivery Kits Infection prevention is a very important strategy in ensuring desirable outcomes during the delivery and postnatal periods. Neonatal tetanus is a common life-threatening complication after delivery, especially in rural areas where health facilities may be inaccessible. This condition can be caused by using contaminated instruments or applying contaminated substances to the umbilical stump after cutting. To combat infections, the federal government of Nigeria, through the Federal Ministry of Health, includes a clean home delivery kit known as the “Mama Kit” in the distribution of reproductive health supplies. Table 9.12 shows the percent distribution of most recent non-institutional live births in the two years preceding the survey by type of instrument used to cut the umbilical cord and the percentage of births where a newborn had something placed on the stump after the umbilical cord was cut, according to background characteristics. An instrument from a clean kit was used to cut the umbilical cord in 49 percent of non-institutional births, while in 43 percent of cases a new or boiled blade was used. The likelihood of use of an instrument from a clean delivery kit is about three times higher in the South West (73 percent) than in the North East (25 percent). Table 9.12 Use of clean home delivery kits and other instruments to cut the umbilical cord Percent distribution of non-institutional last live births in the two years preceding the survey, by type of instrument used to cut the umbilical cord and percentage who had something placed on stump after the umbilical cord was cut, according to background characteristics, Nigeria 2013 Non-institutional births with a clean delivery kit used Total Placed something on stump after cutting umbilical cord Number of non-insti- tutional last live births Background characteristic Instruments from a clean delivery kit New/boiled blade Used blade Knife Scissors Other Don’t know/ missing Residence Urban 61.0 29.5 1.3 0.2 1.5 0.0 6.5 100.0 45.4 2,678 Rural 45.7 47.1 2.8 0.5 0.6 0.4 2.8 100.0 33.9 10,140 Zone North Central 63.8 29.0 0.9 0.1 0.9 1.4 3.8 100.0 78.8 1,531 North East 24.8 69.0 1.1 1.2 0.6 0.3 3.0 100.0 33.5 2,729 North West 52.0 42.2 3.7 0.2 0.1 0.1 1.6 100.0 16.4 6,494 South East 65.2 14.0 2.5 1.0 3.1 0.0 14.1 100.0 67.1 369 South South 48.0 34.7 2.5 0.2 3.1 0.3 11.3 100.0 62.9 985 South West 73.2 14.3 0.2 0.8 3.5 0.3 7.8 100.0 84.2 709 State North Central FCT-Abuja 40.7 50.1 0.0 0.0 7.9 0.0 1.3 100.0 72.0 45 Benue 5.6 81.3 0.0 0.0 1.7 6.4 4.9 100.0 88.4 300 Kogi 48.4 34.2 6.0 0.0 1.1 0.0 10.4 100.0 85.7 59 Kwara 41.5 43.2 0.0 0.0 2.1 0.0 13.2 100.0 72.8 66 Nasarawa 62.6 31.8 0.9 0.3 1.3 0.0 3.2 100.0 83.6 177 Niger 97.1 0.5 0.0 0.0 0.0 0.0 2.4 100.0 83.0 665 Plateau 58.7 31.9 4.1 0.4 0.7 1.1 3.2 100.0 50.7 220 North East Adamawa 30.1 67.9 0.0 0.0 0.5 0.2 1.3 100.0 11.7 305 Bauchi 35.5 59.4 0.3 1.1 0.4 0.1 3.2 100.0 27.0 672 Borno 12.0 73.7 2.2 3.8 1.5 0.3 6.5 100.0 31.7 604 Gombe 61.6 33.7 2.1 0.0 0.8 0.0 1.8 100.0 41.2 259 Taraba 18.5 75.7 2.7 0.5 0.0 1.2 1.4 100.0 56.2 350 Yobe 9.2 88.8 0.2 0.0 0.0 0.3 1.4 100.0 37.6 538 North West Jigawa 44.5 49.6 1.7 0.9 0.3 0.1 2.9 100.0 32.5 891 Kaduna 67.8 30.5 0.8 0.0 0.0 0.0 0.8 100.0 59.4 708 Kano 65.4 33.6 0.2 0.4 0.0 0.0 0.5 100.0 10.2 1,648 Katsina 50.0 31.7 15.9 0.0 0.0 0.0 2.5 100.0 4.3 964 Kebbi 36.7 57.7 1.4 0.0 0.1 1.0 3.0 100.0 10.2 712 Sokoto 17.3 80.8 0.7 0.0 0.2 0.0 1.0 100.0 8.1 656 Zamfara 62.1 31.2 5.4 0.0 0.0 0.0 1.2 100.0 2.3 915 South East Abia 76.5 1.0 0.0 0.0 0.0 0.0 22.4 100.0 66.0 51 Anambra (51.9) (3.6) (10.5) (0.0) (11.4) (0.0) (22.5) 100.0 (83.9) 42 Ebonyi 69.2 23.5 1.0 1.9 1.3 0.0 3.2 100.0 64.9 190 Enugu 43.0 5.6 5.6 0.0 4.4 0.0 41.4 100.0 56.2 55 Imo * * * * * * * * * 32 Continued… 150 • Reproductive Health Table 9.12—Continued Non-institutional births with a clean delivery kit used Total Placed something on stump after cutting umbilical cord Number of non-insti- tutional last live births Background characteristic Instruments from a clean delivery kit New/boiled blade Used blade Knife Scissors Other Don’t know/ missing South South Akwa Ibom 65.9 16.4 0.0 0.0 0.8 0.0 16.9 100.0 75.9 188 Bayelsa 20.8 73.0 0.5 0.1 3.5 0.5 1.5 100.0 86.0 110 Cross River 24.2 58.8 5.3 0.3 1.5 0.0 10.0 100.0 65.0 219 Delta 35.5 37.2 5.0 0.6 7.3 1.4 12.9 100.0 42.7 148 Edo 83.2 7.3 0.0 0.0 1.5 0.0 8.0 100.0 58.9 69 Rivers 64.9 16.7 2.1 0.0 3.8 0.0 12.5 100.0 54.1 252 South West Ekiti (74.6) (5.5) (0.0) (0.0) (9.9) (0.0) (10.0) 100.0 (70.2) 19 Lagos 76.4 1.9 0.7 0.0 6.7 0.7 13.6 100.0 83.9 191 Ogun 69.5 18.4 0.0 0.0 3.2 0.0 8.9 100.0 87.5 117 Ondo 75.8 18.5 0.0 1.5 2.1 0.7 1.5 100.0 88.2 155 Osun (58.2) (31.3) (0.0) (0.0) (8.9) (0.0) (1.6) 100.0 (98.4) 36 Oyo 72.8 18.2 0.0 1.7 0.0 0.0 7.4 100.0 77.8 192 Mother’s education No education 46.2 47.6 2.9 0.5 0.4 0.3 2.0 100.0 27.7 8,624 Primary 48.6 40.9 2.1 0.3 1.5 0.5 6.0 100.0 49.9 2,237 Secondary 61.1 28.0 1.0 0.2 1.6 0.3 7.8 100.0 58.3 1,851 More than secondary 62.4 22.9 1.6 0.0 2.8 0.0 10.3 100.0 61.8 107 Wealth quintile Lowest 42.0 51.3 3.7 0.6 0.2 0.6 1.6 100.0 23.1 4,409 Second 45.8 47.0 2.8 0.6 0.6 0.2 2.9 100.0 31.6 3,752 Middle 52.0 40.0 1.5 0.3 1.1 0.2 5.0 100.0 49.1 2,426 Fourth 62.0 28.6 1.0 0.1 1.7 0.0 6.6 100.0 54.3 1,560 Highest 69.7 18.8 0.3 0.0 2.4 0.2 8.6 100.0 61.3 671 Total 48.9 43.4 2.5 0.5 0.8 0.3 3.6 100.0 36.3 12,818 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. In 36 percent of cases, something was placed on the stump of the umbilical cord after cutting. One-third of rural women (34 percent) reported placing a substance on the umbilical stump, as compared with 45 percent of their urban counterparts. The South West had the highest proportion of cases in which something was placed on the umbilical stump (84 percent). Interestingly, 62 percent of women with more than a secondary education reported placing something on the umbilical stump, compared with 28 percent of those with no education. The most common substances placed on the umbilical stump were oil and methylated spirit (Figure 9.4). Reproductive Health • 151 Figure 9.4 Type of substance applied on the umbilical stump 31 30 13 8 7 4 2 11 2 Percentage NDHS 2013 9.4.4 Newborn Care Practices The vulnerability of newborns requires specific evidence-based interventions to improve their chances of survival as well as normal growth and development. These interventions are in line with Millennium Development Goal 4. The federal government of Nigeria, through the Federal Ministry of Health, has developed newborn care programmes that focus on the areas outlined below (Federal Ministry of Health, 2007). a) Essential newborn care: This is an integrated package of newborn care at the primary health care level mainly focusing on skilled health workers. In addition to the essential care component, the intervention consists of the following programmes: Emergency Newborn Care, Helping Babies Breathe (for birth asphyxia), and Kangaroo Mothers’ Care (for low birth weight babies; to be initiated at the health facility and then continued at home). b) Community-based newborn care: In this programme, community health extension workers are trained in providing home-based newborn care and equipped with a kit for this assignment. c) Use of chlorhexidine for cord care: There is a new focus by the government of Nigeria on using chlorhexidine for cord care to prevent neonatal sepsis. Table 9.13 shows the percentage of most recent non-institutional live births in the two years preceding the survey in which the newborn was wiped before the placenta was delivered, along with the percentage of newborns placed on the mother’s belly or breast before the placenta was delivered, the percentage wrapped in cloth before the placenta was delivered, and the percent distribution by timing of first bath, according to background characteristics. Overall, 28 percent of newborns were wiped, 10 percent were placed on their mothers’ belly or breast, and 34 percent were wrapped in cloth before the placenta was delivered. In the South West, 9 percent of newborns were wiped before the placenta was delivered, as compared with 32 percent in the North East. Similarly, 3 percent of newborns in the South West were placed on the mothers’ belly or breast before the placenta was delivered, compared with 15 percent in the North East. 152 • Reproductive Health Table 9.13 Newborn care practices Percentage of non-institutional last live-born infants in the two years preceding the survey who were wiped before the placenta was delivered, the percentage placed on the mother’s belly/breast before the placenta was delivered, the percentage wrapped in cloth before the placenta was delivered, and the percent distribution by timing of first bath, according to background characteristics, Nigeria 2013 Wiped before the placenta was delivered Placed on belly/breast before placenta was delivered Wrapped in cloth before placenta was delivered Timing of first bath Number of births Background characteristic Within 1 hour 2-24 hours After 24 hours Don’t know/ missing Total Residence Urban 30.0 8.5 38.1 90.1 3.0 0.1 6.8 100.0 2,678 Rural 27.4 9.8 33.1 92.4 3.1 0.0 4.5 100.0 10,140 Zone North Central 27.2 12.9 29.4 92.8 1.3 0.0 5.8 100.0 1,531 North East 31.8 15.1 37.6 93.3 1.8 0.0 4.9 100.0 2,729 North West 30.6 8.1 37.9 95.4 1.6 0.0 3.0 100.0 6,494 South East 25.3 3.9 24.4 77.2 8.2 0.5 14.1 100.0 369 South South 16.3 5.1 19.2 69.1 17.7 0.2 13.0 100.0 985 South West 8.8 2.9 22.4 91.9 1.4 0.0 6.6 100.0 709 State North Central FCT-Abuja 33.8 13.2 36.0 96.8 1.2 0.0 2.0 100.0 45 Benue 15.7 3.9 25.7 92.8 3.0 0.0 4.2 100.0 300 Kogi 20.9 2.5 21.6 89.6 0.0 0.0 10.4 100.0 59 Kwara 11.2 8.7 9.5 88.0 0.0 0.0 12.0 100.0 66 Nasarawa 15.0 8.1 18.8 95.0 1.5 0.0 3.5 100.0 177 Niger 42.6 22.9 44.2 94.5 0.3 0.0 5.2 100.0 665 Plateau 11.2 3.0 4.8 87.6 2.8 0.0 9.7 100.0 220 North East Adamawa 20.1 6.5 18.2 96.8 1.2 0.0 1.9 100.0 305 Bauchi 42.8 28.7 45.7 90.9 0.6 0.0 8.5 100.0 672 Borno 19.7 2.0 26.9 92.3 0.8 0.0 6.9 100.0 604 Gombe 65.2 31.7 92.7 95.0 1.8 0.0 3.2 100.0 259 Taraba 24.3 9.7 30.0 96.0 1.4 0.0 2.6 100.0 350 Yobe 26.9 13.1 29.0 92.7 5.2 0.1 2.0 100.0 538 North West Jigawa 41.5 18.0 46.2 93.5 2.7 0.0 3.8 100.0 891 Kaduna 42.2 9.8 38.9 97.7 0.9 0.0 1.4 100.0 708 Kano 40.9 10.1 54.0 95.6 2.9 0.0 1.5 100.0 1,648 Katsina 53.5 7.0 60.0 94.9 0.2 0.0 5.0 100.0 964 Kebbi 12.0 4.5 32.5 94.2 3.3 0.0 2.4 100.0 712 Sokoto 5.0 3.7 8.1 95.1 0.0 0.0 4.9 100.0 656 Zamfara 1.1 0.2 2.3 96.9 0.4 0.0 2.8 100.0 915 South East Abia 41.0 10.0 45.3 46.0 31.6 0.0 22.4 100.0 51 Anambra 45.6 0.0 30.3 81.0 4.6 0.0 14.4 100.0 42 Ebonyi 12.9 3.3 12.0 92.0 3.2 0.0 4.8 100.0 190 Enugu 29.9 4.0 42.7 54.9 3.7 0.0 41.4 100.0 55 Imo 40.7 2.8 26.4 72.4 12.8 6.0 8.7 100.0 32 South South Akwa Ibom 18.5 5.7 21.4 50.2 30.4 0.7 18.6 100.0 188 Bayelsa 13.3 2.2 16.7 85.4 11.4 0.0 3.3 100.0 110 Cross River 20.7 1.9 18.8 71.3 19.5 0.0 9.2 100.0 219 Delta 7.6 6.2 26.6 79.8 5.3 0.0 14.8 100.0 148 Edo 7.7 11.6 8.3 82.1 2.5 0.0 15.4 100.0 69 Rivers 19.6 6.2 17.7 64.5 20.7 0.3 14.6 100.0 252 South West Ekiti 15.1 0.0 27.1 63.6 19.6 0.0 16.8 100.0 19 Lagos 11.4 1.5 19.1 91.0 2.1 0.0 6.9 100.0 191 Ogun 0.0 0.0 11.3 88.4 0.0 0.0 11.6 100.0 117 Ondo 8.0 9.1 27.1 95.5 1.3 0.0 3.2 100.0 155 Osun 10.1 0.0 19.7 96.9 1.5 0.0 1.6 100.0 36 Oyo 11.2 1.9 28.9 94.0 0.0 0.0 6.0 100.0 192 Mother’s education No education 29.3 9.9 35.8 94.4 1.8 0.0 3.7 100.0 8,624 Primary 25.7 9.7 31.0 89.4 3.8 0.0 6.7 100.0 2,237 Secondary 24.7 7.2 30.4 83.7 7.6 0.2 8.6 100.0 1,851 More than secondary 21.3 10.5 34.3 81.9 6.1 0.0 11.9 100.0 107 Wealth quintile Lowest 28.2 10.7 34.2 94.0 2.1 0.0 3.9 100.0 4,409 Second 27.2 8.8 34.0 93.6 2.5 0.1 3.9 100.0 3,752 Middle 28.5 9.1 33.3 89.6 3.8 0.0 6.5 100.0 2,426 Fourth 28.0 8.9 34.7 88.4 4.7 0.0 6.9 100.0 1,560 Highest 28.6 8.4 36.9 85.4 5.8 0.1 8.7 100.0 671 Total 28.0 9.5 34.1 91.9 3.0 0.0 5.0 100.0 12,818 Reproductive Health • 153 One of the important newborn care practices is related to thermal care, with the recommendation that bathing of a newborn be delayed. In Nigeria, 92 percent of babies are bathed within one hour of birth and 3 percent between 2 and 24 hours of birth. Five percent of mothers did not know the time interval between birth and when their baby was first bathed. Newborns in the South South are more likely to have delayed bathing than newborns in other zones. For instance, 69 percent of newborns in the South South are bathed within one hour of birth, while 77 percent of newborns in the South East and more than 90 percent of those in the other zones are bathed within an hour of birth. 9.5 PROBLEMS IN ACCESSING HEALTH CARE Common impediments to accessing health care in Nigeria include inadequate information, financial barriers, and lack of access to transport. These are important determinants of health interventions. Other possible challenges include the need to obtain permission before going to the health facility and the attitudes of health workers. Interventions targeted at eliminating barriers to accessing health care include health promotion activities, the Midwives Service Scheme, provision of free contraceptives, and distribution of “Mama Kits” to pregnant women. In the 2013 NDHS, women were asked whether or not each of the following factors would be a serious problem for them in seeking medical care: getting permission to go for treatment, getting money for advice or treatment, distance to a health facility, not wanting to go alone, and health workers’ attitudes. The majority of women (53 percent) reported that at least one of these problems would pose a barrier in seeking health care for themselves when they are sick (Table 9.14). Eleven percent reported that they had to seek permission before going for treatment, 42 percent had problems getting money to access health care, 29 percent complained of the distance to the facility, and 15 percent did not want to go alone. Another 17 percent reported that health workers’ attitudes impeded them from accessing health care. Women in rural areas were twice as likely as their urban counterparts to cite the need to get permission as a barrier to going to the health facility for treatment. Twenty percent of women in the North West cited the need to seek permission as a barrier, as compared with 4 percent in the North Central zone. Twenty-three percent of women in the North West and 11 percent each in the North Central and South West zones cited health workers’ attitudes as their reason for not going to the health facility for treatment. Twenty-one percent of women with no education cited health workers’ attitudes as a barrier, as compared with 12 percent of women with more than a secondary education. Table 9.14 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, according to background characteristics, Nigeria 2013 Problems in accessing health care Background characteristic Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone Attitude of health worker At least one problem accessing health care Number of women Age 15-19 13.6 41.8 28.9 20.4 16.9 54.4 7,820 20-34 10.9 41.3 27.8 13.1 16.4 52.4 19,369 35-49 10.2 43.4 30.5 13.1 16.6 54.2 11,760 Number of living children 0 10.4 38.9 24.3 16.5 16.5 49.8 11,750 1-2 10.7 41.4 28.8 13.3 15.5 52.7 9,737 3-4 11.2 42.7 29.6 13.4 16.7 54.0 8,876 5+ 13.0 46.4 34.2 14.7 17.6 58.1 8,585 Marital status Never married 9.1 40.3 22.3 16.1 15.8 50.0 9,326 Married or living together 12.3 42.0 31.3 14.3 17.0 54.1 27,830 Divorced/separated/widowed 5.9 52.4 24.9 10.3 13.1 58.8 1,793 Continued… 154 • Reproductive Health Table 9.14—Continued Problems in accessing health care Background characteristic Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone Attitude of health worker At least one problem accessing health care Number of women Employed in last 12 months Not employed 15.0 44.5 30.5 17.2 17.5 55.3 14,260 Employed for cash 9.0 39.6 27.2 12.5 15.9 50.9 22,333 Employed not for cash 9.7 51.6 34.5 19.3 16.1 64.6 2,255 Missing 11.1 33.8 32.1 12.3 16.3 54.5 100 Residence Urban 7.2 31.9 15.6 9.1 15.0 41.7 16,414 Rural 14.2 49.4 38.5 18.6 17.7 61.7 22,534 Zone North Central 4.3 46.6 27.3 13.3 11.3 56.0 5,572 North East 12.3 44.8 35.3 16.2 14.9 58.1 5,766 North West 19.9 40.1 35.0 19.8 23.0 55.4 11,877 South East 9.2 56.4 33.5 17.7 19.3 64.0 4,476 South South 5.6 46.6 25.6 9.9 13.6 54.0 4,942 South West 5.9 25.6 11.9 5.9 10.8 34.5 6,314 State North Central FCT-Abuja 3.9 24.6 12.4 5.9 6.1 31.5 315 Benue 7.2 49.4 25.0 20.7 9.9 64.4 1,240 Kogi 1.8 36.2 14.3 2.0 12.6 41.6 704 Kwara 0.7 27.2 11.5 0.4 7.6 37.1 596 Nasarawa 4.4 40.4 23.3 8.1 7.0 47.6 594 Niger 3.7 56.7 41.8 18.7 15.9 65.4 1,462 Plateau 6.3 63.5 37.9 19.0 11.7 70.8 662 North East Adamawa 12.4 52.8 17.4 14.3 10.9 64.6 828 Bauchi 11.0 46.3 34.9 17.8 26.4 59.7 1,161 Borno 10.8 28.3 32.7 10.3 6.4 43.1 1,412 Gombe 2.4 37.4 18.7 5.3 6.3 43.2 550 Taraba 9.5 64.0 38.5 10.8 3.5 70.0 844 Yobe 23.8 47.3 61.3 35.7 32.0 70.6 971 North West Jigawa 16.2 41.1 30.6 19.2 21.4 54.9 1,353 Kaduna 14.1 31.4 24.6 14.5 13.5 44.3 2,136 Kano 18.1 37.4 38.7 22.3 35.7 64.8 3,189 Katsina 16.6 62.1 46.8 15.8 8.6 70.4 1,525 Kebbi 34.5 56.3 43.6 29.8 36.1 66.0 1,244 Sokoto 30.8 33.7 42.2 23.2 20.5 49.8 1,098 Zamfara 18.2 24.4 20.0 15.6 15.9 29.1 1,332 South East Abia 16.1 73.5 63.3 28.2 36.3 78.5 518 Anambra 6.4 42.5 22.6 14.4 19.1 48.5 1,052 Ebonyi 8.9 51.4 36.8 22.9 15.7 63.1 1,122 Enugu 8.5 67.9 37.2 17.6 18.5 71.2 951 Imo 9.8 56.9 19.9 8.5 14.7 67.4 833 South South Akwa Ibom 7.6 49.5 22.5 8.6 13.9 54.7 864 Bayelsa 8.5 53.1 47.9 29.7 19.5 65.3 364 Cross River 2.8 55.0 25.0 8.3 17.7 64.9 703 Delta 3.0 33.4 17.1 4.0 6.7 37.4 993 Edo 12.5 56.6 26.0 12.5 19.1 63.2 742 Rivers 3.1 42.6 27.8 9.0 11.6 51.9 1,276 South West Ekiti 8.0 27.5 10.7 6.4 5.6 31.3 326 Lagos 3.5 25.7 5.6 3.3 5.9 30.9 1,964 Ogun 0.5 7.9 2.5 0.2 0.6 9.5 883 Ondo 5.4 48.5 25.7 11.1 4.4 62.2 808 Osun 0.7 17.2 4.6 0.2 9.0 24.0 765 Oyo 14.3 27.2 22.0 12.5 28.0 44.6 1,568 Education No education 18.3 48.4 42.5 21.0 20.9 63.2 14,729 Primary 8.9 48.3 28.8 13.2 15.4 57.7 6,734 Secondary 7.0 37.5 18.8 10.8 13.6 46.7 13,927 More than secondary 2.7 21.9 11.7 5.3 11.9 30.1 3,558 Wealth quintile Lowest 20.1 52.4 53.1 28.4 24.8 69.2 7,132 Second 16.1 52.0 40.0 19.3 18.0 64.6 7,428 Middle 10.5 48.1 27.5 12.5 14.5 58.3 7,486 Fourth 7.3 37.4 18.0 8.7 13.9 45.9 7,992 Highest 4.2 24.6 10.9 6.6 12.8 33.6 8,910 Total 11.2 42.0 28.8 14.6 16.5 53.3 38,948 Child Health • 155 CHILD HEALTH 10 his chapter presents findings on several areas of importance relating to child health, including neonatal birth weight, childhood vaccination coverage, and prevalence and treatment of acute respiratory infections (ARIs) and fever. Information is also presented on the prevalence and treatment of diarrhoea, feeding practices during diarrhoea, knowledge of oral rehydration salt (ORS) packets, and disposal of children’s stools. Interventions such as immunisation and early treatment of common childhood illnesses have been shown to be the most cost-effective ways of preventing many under-5 deaths and reducing the duration and severity of childhood illnesses. Nigeria is currently implementing many such interventions, including the Expanded Programme on Immunisation, the Polio Eradication Initiative and National Emergency Action Plan, Integrated Community Case Management of Childhood Illnesses in Nigeria, and the Integrated Maternal Newborn and Child Health Strategy (National Primary Health Care Development Agency [NPHCDA], 2012). The information on child health presented in this chapter pertains only to children born during the five years preceding the survey unless otherwise specified. Information on birth weight or size at birth is important for the design and implementation of programmes aimed at reducing neonatal and infant mortality. Vaccination coverage information focuses on the 12- to 23-month age group (i.e., the typical age by which children should have received all basic vaccinations). Data on differences in vaccination coverage between subgroups of the population aid in programme planning. Data on treatment practices and contact with health services among children ill with the three most important childhood illnesses help in the assessment of national programmes aimed at reducing the mortality impact of these illnesses. Information is provided on the prevalence and treatment of ARIs, including treatment with antibiotics, and T Key Findings • One in every four children age 12-23 months (25 percent) were fully vaccinated at the time of the survey, a 9 percent increase from the figure reported in the 2008 NDHS and nearly twice the figure reported in 2003. • Thirty-eight percent of children age 12-23 months received the third dose of DPT at any time before the survey, a 9 percent increase from the figure reported in 2008 and an 81 percent increase from 2003. • Fifty-four percent of children age 12-23 months received the third dose of polio vaccine. That proportion was 39 percent in 2008 and 29 percent in 2003. • Two percent of children under age 5 showed symptoms of acute respiratory infection in the two weeks before the survey; for 35 percent of these children, advice or treatment was sought from a health care facility or provider. • Thirteen percent of children under age 5 had a fever in the two weeks before the survey; for 32 percent of these children, advice or treatment was sought from a health care facility or provider. • Ten percent of children under age 5 had diarrhoea, and 2 percent had diarrhoea with blood, in the two weeks before the survey. • Knowledge of oral rehydration salt packets or pre-packaged liquids is high (80 percent) among Nigerian mothers age 15-49 with a live birth in the five years preceding the survey. 156 • Child Health the prevalence of fever and its treatment with antimalarial drugs and antibiotics. Data on the treatment of diarrhoeal disease with oral rehydration therapy and increased fluids aid in assessing programmes that recommend such treatments. Because sanitary practices can help prevent diarrhoeal disease, information is also provided on disposal of children’s faecal matter. 10.1 CHILD’S SIZE AND WEIGHT AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to the risk of childhood illnesses and the child’s chances of survival. Children who weigh less than 2.5 kilograms at birth, or children reported to be “very small” or “smaller than average,” have a higher than average risk of early childhood death. The 2013 NDHS Woman’s Questionnaire recorded birth weight, if available from written records or the mother’s recall, for all births in the five years preceding the survey. Because birth weight may not be known for many babies, particularly babies delivered at home and not weighed at birth, the mother’s estimate of the baby’s size at birth was also obtained. Although subjective, mothers’ estimates can be a useful proxy for the weight of the child. Table 10.1 presents information on children’s size and weight at birth according to background characteristics. The table shows that birth weight was reported for only 16 percent of children born in the five years preceding the survey. This is not surprising because the majority of births (63 percent, as reported in Chapter 9) did not take place in a health facility, and children are less likely to be weighed at birth in a non-institutional setting. Of the children whose birth weights are known, 8 percent weighed less than 2.5 kilograms. Low birth weight is most common among children of the youngest mothers (less than age 20) (15 percent) and children of birth order six and above (11 percent). The birth weight of a child varies by geopolitical zone. The North West zone has the highest proportion (27 percent) of children reported as weighing less than 2.5 kg at birth, while the South West zone has the lowest (3 percent). More than a third (36 percent) of children whose birth weights are known in Kaduna weighed less than 2.5 kg at birth. As noted, a mother’s subjective assessment of the size of the baby at birth—in the absence of birth weight—may be useful. Mothers reported 4 percent of all live births in the five years preceding the survey to be very small and 11 percent as smaller than average. Children of mothers with no education and children born to mothers in the lowest wealth quintile were the most likely to be reported as very small. Table 10.1 Child’s size and weight at birth Percent distribution of live births in the five years preceding the survey by mother’s estimate of baby’s size at birth, percentage of live births in the five years preceding the survey that have a reported birth weight, and among live births in the five years preceding the survey with a reported birth weight, percentage less than 2.5 kg, according to background characteristics, Nigeria 2013 Percent distribution of all live births by size of child at birth Percentage of all births that have a reported birth weight1 Number of births Births with a reported birth weight1 Background characteristic Very small Smaller than average Average or larger Don’t know/ missing Total Percentage less than 2.5 kg Number of births Mother’s age at birth <20 5.9 12.2 79.5 2.4 100.0 6.1 4,726 14.8 290 20-34 4.1 10.1 84.0 1.8 100.0 19.0 22,220 7.7 4,212 35-49 4.6 10.5 83.2 1.7 100.0 14.7 4,882 8.0 719 Birth order 1 4.9 10.8 82.2 2.1 100.0 23.4 6,285 8.9 1,470 2-3 4.1 10.2 84.0 1.8 100.0 20.0 10,311 6.3 2,063 4-5 4.0 10.4 83.8 1.8 100.0 15.2 7,441 8.9 1,135 6+ 5.0 10.7 82.4 1.8 100.0 7.1 7,791 11.4 552 Mother’s smoking status Smokes cigarettes/tobacco 1.0 10.6 84.4 4.0 100.0 24.1 57 * 14 Does not smoke 4.5 10.5 83.2 1.9 100.0 16.4 31,665 8.1 5,184 Missing 0.0 5.4 92.1 2.4 100.0 20.5 107 * 22 Residence Urban 3.4 8.8 86.2 1.6 100.0 34.3 11,126 7.6 3,818 Rural 5.0 11.4 81.6 2.0 100.0 6.8 20,702 9.6 1,402 Continued… Child Health • 157 Table 10.1—Continued Percent distribution of all live births by size of child at birth Percentage of all births that have a reported birth weight1 Number of births Births with a reported birth weight1 Background characteristic Very small Smaller than average Average or larger Don’t know/ missing Total Percentage less than 2.5 kg Number of births Zone North Central 2.6 6.7 88.9 1.8 100.0 12.3 4,340 7.5 534 North East 8.0 13.2 76.9 1.8 100.0 5.4 5,578 13.6 302 North West 5.3 11.9 80.7 2.1 100.0 4.2 11,775 27.2 489 South East 2.8 8.9 85.7 2.5 100.0 46.4 2,840 4.3 1,317 South South 2.5 9.4 86.2 1.9 100.0 27.2 2,935 11.6 798 South West 1.7 8.6 88.6 1.1 100.0 40.8 4,360 3.4 1,780 State North Central FCT-Abuja 4.7 14.5 74.9 5.9 100.0 43.2 209 5.1 90 Benue 2.5 7.1 90.3 0.1 100.0 5.5 967 3.6 53 Kogi 1.5 5.1 90.8 2.6 100.0 30.1 401 7.2 121 Kwara 0.3 8.7 90.1 0.9 100.0 25.6 405 2.0 104 Nasarawa 5.1 9.9 84.7 0.3 100.0 5.3 460 (21.0) 24 Niger 0.5 1.9 94.8 2.8 100.0 6.8 1,394 14.2 94 Plateau 8.6 12.8 76.7 1.8 100.0 9.3 505 9.0 47 North East Adamawa 3.8 8.3 86.1 1.8 100.0 14.5 732 20.0 106 Bauchi 4.0 17.6 76.3 2.1 100.0 1.9 1,431 (9.0) 27 Borno 16.6 13.8 68.0 1.5 100.0 5.4 1,118 (10.9) 61 Gombe 3.1 10.6 85.1 1.2 100.0 3.6 595 (12.9) 22 Taraba 3.9 17.1 77.7 1.3 100.0 9.8 764 9.6 75 Yobe 13.8 8.3 75.2 2.6 100.0 1.3 938 * 12 North West Jigawa 5.0 13.2 78.3 3.5 100.0 0.8 1,594 * 13 Kaduna 2.5 15.0 81.3 1.2 100.0 22.4 1,439 36.1 322 Kano 9.6 10.0 78.4 2.0 100.0 3.4 3,024 3.2 103 Katsina 1.6 9.1 86.8 2.5 100.0 1.2 1,703 * 21 Kebbi 10.7 24.9 63.1 1.3 100.0 0.5 1,247 * 6 Sokoto 0.3 2.2 94.7 2.9 100.0 1.8 1,151 (0.0) 20 Zamfara 3.4 11.4 84.0 1.2 100.0 0.3 1,618 * 5 South East Abia 1.4 7.2 85.2 6.3 100.0 56.5 326 2.1 184 Anambra 5.8 3.2 85.5 5.4 100.0 67.3 657 2.1 442 Ebonyi 1.7 12.4 85.8 0.0 100.0 16.9 748 7.7 127 Enugu 2.9 11.7 84.1 1.3 100.0 46.6 558 7.2 260 Imo 1.4 9.3 87.8 1.5 100.0 55.1 552 4.9 304 South South Akwa Ibom 4.1 5.7 87.3 2.9 100.0 18.4 473 9.5 87 Bayelsa 5.4 10.5 83.2 0.9 100.0 11.6 233 11.5 27 Cross River 1.0 11.3 87.4 0.2 100.0 13.4 532 12.7 71 Delta 1.2 4.9 90.8 3.1 100.0 33.9 561 7.7 190 Edo 2.7 11.6 84.9 0.9 100.0 46.6 405 8.6 189 Rivers 2.7 12.1 82.9 2.3 100.0 31.9 730 17.5 233 South West Ekiti 1.3 5.2 90.9 2.6 100.0 41.2 200 6.8 82 Lagos 1.3 6.2 90.9 1.5 100.0 54.4 1,303 3.8 709 Ogun 1.8 6.4 90.5 1.3 100.0 34.4 736 4.1 253 Ondo 2.3 7.0 90.1 0.6 100.0 11.7 568 7.9 66 Osun 0.5 3.2 95.6 0.6 100.0 75.2 445 0.7 334 Oyo 2.4 16.3 80.8 0.6 100.0 30.1 1,108 3.1 333 Mother’s education No education 5.9 12.3 79.6 2.1 100.0 1.9 15,657 15.2 292 Primary 3.6 9.8 84.9 1.7 100.0 12.7 6,127 8.0 779 Secondary 2.8 8.5 87.1 1.6 100.0 34.6 8,211 8.4 2,840 More than secondary 2.0 6.0 90.2 1.7 100.0 71.4 1,834 6.1 1,310 Wealth quintile Lowest 6.5 14.1 77.5 2.0 100.0 0.5 7,496 (13.5) 39 Second 5.5 11.4 81.2 1.9 100.0 3.1 7,355 17.3 229 Middle 4.2 9.3 84.7 1.8 100.0 10.3 6,001 9.1 619 Fourth 3.2 8.7 86.2 1.9 100.0 25.7 5,656 8.7 1,452 Highest 1.8 7.4 89.1 1.7 100.0 54.1 5,320 6.8 2,881 Total 4.4 10.5 83.2 1.9 100.0 16.4 31,828 8.1 5,220 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 Based on either a written record or the mother’s recall 158 • Child Health 10.2 VACCINATION COVERAGE Immunisation coverage is one of the indicators used to monitor progress toward the achievement of Millennium Development Goal (MDG) 4 and the reduction of child morbidity and mortality, as it is one of the most cost-effective public health interventions for reaching these goals. In the five years preceding the survey, Nigeria introduced several child survival initiatives and expanded existing ones, with a particular focus on polio eradication and strengthening routine immunisation. Several supplemental vaccination campaigns were also conducted to rapidly increase the coverage of specific vaccines and to pre-empt or respond to disease outbreaks. These included campaigns targeting maternal and newborn tetanus, measles, yellow fever, and cerebrospinal meningitis (NPHCDA, 2012). In May 2006, Nigeria began to implement polio vaccination campaigns (Immunisation Plus Days). In 2012 alone, for example, Nigeria conducted two national and five subnational polio immunisation campaigns (NPHCDA, 2012). In May 2012, Nigeria began the phased replacement of the diphtheria, pertussis, and tetanus (DPT) vaccine with the pentavalent vaccine, which contains more antigens (DPT, Haemophilus influenzae type B, and hepatitis B).1 The Nigeria Expanded Programme on Immunisation mirrors the international recommendations of the World Health Organization. A child is considered fully vaccinated if she or he has received BCG vaccination against tuberculosis; three doses of vaccine to prevent diphtheria, pertussis, and tetanus; at least three doses of polio vaccine; and one dose of measles vaccine. These vaccines should be received during the first year of life. The 2013 NDHS collected information on vaccination coverage in two ways: from vaccination cards shown to the interviewer and from mothers’ verbal reports. If the cards were available, the interviewer copied the vaccination dates directly onto the questionnaire. When there was no vaccination card for the child or if a vaccine had not been recorded on the card as being given, the respondent was asked to recall the vaccines given to her child. Table 10.2 and Figure 10.1 show the percentage of children age 12-23 months who have received the various vaccinations by source of information (vaccination card or mother’s report). This is the youngest cohort of children who have reached the age by which they should be fully vaccinated. The table shows the proportion of children age 12-23 months who were immunised at any age up to the time of the survey, as well as the proportion who were vaccinated by age 12 months, the age at which vaccination coverage should be complete. Overall, 25 percent of children age 12-23 months were fully vaccinated at the time of the survey. This represents a 9 percent increase from the figure reported in the 2008 NDHS and is nearly double the figure reported in 2003. Twenty-one percent of eligible children received no vaccination at all. While this figure represents a 28 percent improvement over that recorded in the 2008 NDHS, it still represents a significant risk for not achieving MDG 4. As for coverage of specific vaccines among children age 12-23 months, 51 percent had received the BCG vaccine, and 42 percent had received the measles vaccine. While 51 percent received the first dose of the DPT vaccine, only 38 percent went on to receive the third dose, reflecting a dropout rate of 25 percent. Although only 47 percent of children received the recommended polio 0 dose at birth, 77 percent received the first dose, 70 percent received the second dose, and 54 percent received the third dose. The wide difference in DPT and OPV coverage is accounted for by the national and subnational immunisation day campaigns during which the polio vaccine is administered. Overall, only 21 percent of children age 12- 23 months had received all of the recommended vaccinations before their first birthday. 1 Phase I (May 2012) covered 13 states (Adamawa, Akwa Ibom, Anambra, Bauchi, Edo, Ekiti, Enugu, Jigawa, Kaduna, Kwara, Lagos, Plateau, and Rivers) and the Federal Capital Territory-Abuja. Phase II (May 2013) covered an additional 12 states, and Phase III (May 2014) will cover 11 states. Because the 2013 NDHS fieldwork spanned from February to June 2013, only some states were covered by pentavalent vaccinations. Child Health • 159 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 2013 Source of information BCG DPT1 Polio2 Measles All basic vaccina- tions3 No vaccina- tions Number of children 1 2 3 0 1 2 3 Vaccinated at any time before survey Vaccination card 27.0 26.7 24.8 22.2 26.2 26.8 25.1 22.7 21.1 19.0 0.0 1,650 Mother’s report 24.1 23.9 20.7 16.0 20.7 49.7 44.9 30.8 21.0 6.3 20.7 4,250 Either source 51.2 50.6 45.6 38.2 46.8 76.5 69.9 53.6 42.1 25.3 20.7 5,900 Vaccinated by 12 months of age4 50.3 49.6 44.2 36.2 46.5 75.0 67.8 51.2 35.1 21.4 22.1 5,900 1 Includes pentavalent 2 Polio 0 is the polio vaccination given at birth. 3 BCG, measles, and 3 doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 4 For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccination. Figure 10.1 Percentage of children age 12-23 months with specific vaccinations 51 51 46 38 47 77 70 54 42 25 21 Percentage vaccinated at any time before the survey NDHS 2013Note: Based on vaccination cards and mother’s reports 10.2.1 Vaccination Coverage by Background Characteristics Table 10.3 presents vaccination coverage among children age 12-23 months by background characteristics. Children of birth order six and higher are less likely to receive all basic vaccinations (16 percent) than first-born children (34 percent). Urban children are nearly three times more likely than rural children to receive all basic vaccinations (43 percent versus 16 percent). Children whose mothers have more than a secondary education are more likely to be fully immunised than those born to mothers with no education (64 percent and 7 percent, respectively). Similarly, 58 percent of children in the highest wealth quintile are fully immunised, as compared with 4 percent of children in the lowest wealth quintile. There is wide variation among the geopolitical zones and states in full vaccination coverage. Fifty-two percent of children in the South East and South South zones are fully immunised, compared with 10 percent in the North West. Among the states, full vaccination is highest in Imo (62 percent) and lowest in Sokoto (1 percent). 160 • Child Health 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, by background characteristics, Nigeria 2013 Background characteristic BCG DPT1 Polio2 Measles All basic vaccina- tions3 No vaccina- tions Percent- age with a vaccina- tion card seen Number of children 1 2 3 0 1 2 3 Sex Male 52.9 52.4 47.0 39.4 48.2 76.8 70.7 53.4 43.1 25.7 20.0 29.0 3,066 Female 49.3 48.6 44.1 37.0 45.3 76.2 69.1 53.8 41.0 24.9 21.4 26.9 2,834 Birth order 1 61.6 61.4 56.8 49.5 55.4 79.1 73.1 55.4 53.0 34.2 18.8 35.2 1,188 2-3 55.4 54.6 49.5 41.8 49.5 77.5 70.5 53.2 43.7 27.4 19.8 30.3 1,848 4-5 50.8 50.4 45.7 36.7 46.8 75.7 69.3 54.0 41.6 25.0 21.0 28.9 1,445 6+ 37.3 36.5 30.9 25.8 36.1 73.8 67.2 52.1 31.3 15.5 23.1 17.9 1,419 Residence Urban 76.3 73.8 69.8 62.2 70.0 83.3 77.9 58.2 61.9 42.5 13.5 44.0 2,113 Rural 37.1 37.6 32.0 24.9 33.9 72.7 65.5 51.0 31.0 15.8 24.7 19.0 3,787 Zone North Central 62.7 62.0 55.0 43.9 57.0 79.1 68.9 45.5 48.1 26.9 17.3 33.3 812 North East 35.1 34.7 28.4 20.6 27.7 51.5 44.4 34.8 26.8 14.2 45.3 20.3 1,023 North West 21.7 22.2 18.1 13.9 26.4 77.2 71.8 61.1 22.3 9.6 20.8 8.5 2,100 South East 90.4 88.9 86.7 80.7 82.9 90.6 87.2 62.3 72.2 51.7 7.2 57.1 550 South South 84.7 84.5 79.1 69.8 65.8 88.6 82.3 64.5 74.0 52.0 9.4 49.0 591 South West 84.5 81.5 76.3 65.5 74.9 85.1 77.4 52.1 62.5 40.9 10.3 47.3 823 State North Central FCT-Abuja 81.6 83.9 75.3 69.1 77.0 91.8 86.0 77.5 69.6 60.9 7.3 65.5 38 Benue 54.8 55.6 45.0 29.0 45.5 76.1 60.6 41.8 42.7 20.0 19.2 23.5 187 Kogi 85.4 87.1 82.7 75.9 85.0 83.1 78.0 40.0 75.2 35.6 12.9 43.6 83 Kwara 79.0 73.5 69.0 65.1 72.9 77.6 70.9 52.0 56.9 42.9 19.1 47.4 69 Nasarawa 62.3 60.1 42.6 34.1 45.9 65.2 42.2 25.8 45.4 20.1 29.8 23.1 90 Niger 51.8 52.7 48.8 37.3 51.5 87.1 81.0 53.3 38.9 23.0 10.9 29.9 253 Plateau 68.4 62.4 60.5 46.3 60.8 68.6 61.6 37.1 46.6 23.6 25.7 39.4 91 North East Adamawa 79.0 80.3 67.5 49.7 62.5 79.7 71.9 60.8 68.7 40.4 13.3 49.9 133 Bauchi 26.3 25.4 18.9 12.5 15.9 51.9 43.4 33.4 20.3 6.1 44.3 14.9 265 Borno 17.7 19.5 16.9 12.4 16.2 25.9 21.3 15.3 17.3 9.7 71.0 7.4 226 Gombe 44.3 44.4 41.3 36.0 39.3 46.2 39.4 27.3 36.1 22.4 51.9 33.6 98 Taraba 45.0 44.1 32.7 21.4 41.6 86.9 73.9 57.5 27.4 14.4 9.7 24.6 143 Yobe 22.9 18.8 15.7 11.0 15.0 34.8 32.6 27.2 10.0 6.9 65.2 10.7 158 North West Jigawa 20.4 20.9 12.7 7.0 23.2 67.2 59.3 49.1 10.9 3.6 29.9 9.6 314 Kaduna 57.9 60.5 56.9 43.7 55.0 67.1 60.5 44.3 56.4 35.3 28.9 30.0 219 Kano 27.5 26.2 22.3 18.9 28.3 75.9 70.8 57.9 25.3 13.2 22.3 8.4 530 Katsina 21.9 23.3 17.9 14.6 25.7 94.1 88.7 81.3 42.9 8.7 4.9 5.0 326 Kebbi 5.2 4.9 4.2 2.8 38.5 92.8 90.0 80.5 3.2 2.8 5.8 2.2 220 Sokoto 3.6 3.3 2.9 2.6 10.6 75.0 70.9 63.2 3.6 1.4 24.1 1.6 204 Zamfara 10.5 12.2 8.1 5.6 7.6 69.1 63.7 53.9 7.9 2.1 28.6 5.0 289 South East Abia 86.1 93.4 90.8 79.8 87.9 92.5 84.3 60.5 73.1 49.8 5.4 61.4 64 Anambra 87.1 85.5 82.1 78.5 77.7 91.0 88.4 57.9 75.0 51.6 9.0 50.1 128 Ebonyi 91.4 88.7 86.6 80.3 88.0 89.2 86.4 68.6 61.7 51.1 8.1 63.5 137 Enugu 89.7 88.2 87.6 81.8 80.7 90.9 87.5 50.3 78.4 45.0 8.6 50.6 122 Imo 97.2 91.8 89.2 83.1 81.9 90.3 88.3 75.4 75.1 62.4 2.8 62.6 98 South South Akwa Ibom 87.5 89.5 85.0 65.3 69.6 92.3 86.8 59.7 75.2 48.0 7.2 53.8 102 Bayelsa 77.4 79.1 73.0 67.7 47.8 79.5 76.4 56.0 73.0 51.5 19.4 32.7 49 Cross River 87.3 86.8 80.9 76.1 69.6 91.9 86.5 66.0 77.1 52.5 6.1 56.6 98 Delta 73.6 73.2 70.8 62.2 54.4 76.6 71.8 60.6 60.4 50.7 19.2 42.9 106 Edo 93.4 91.5 85.7 79.6 75.9 94.4 82.7 64.1 76.5 52.2 1.8 57.2 89 Rivers 86.0 85.1 77.7 69.2 68.8 91.9 85.4 72.6 79.7 55.5 7.4 45.3 148 South West Ekiti 97.3 97.6 88.1 79.0 82.6 96.2 90.5 60.9 85.7 49.4 0.0 65.2 33 Lagos 93.3 90.2 86.6 77.4 86.5 91.2 85.8 65.0 75.8 53.9 4.2 55.7 252 Ogun 82.6 77.5 68.1 56.9 73.0 78.1 68.5 33.9 51.0 24.4 12.3 32.8 149 Ondo 72.7 70.3 68.7 62.5 63.0 85.1 78.0 60.2 60.7 47.2 14.9 43.1 90 Osun 93.5 92.2 89.6 82.8 85.5 91.3 88.0 65.8 75.2 55.3 5.8 60.7 98 Oyo 73.8 70.6 64.4 47.7 60.6 77.9 65.9 37.7 45.2 25.8 18.3 39.8 201 Mother’s education No education 20.7 20.8 16.9 12.0 22.4 66.2 59.8 48.4 18.0 6.9 31.8 10.0 2,807 Primary 63.2 61.7 52.6 40.0 52.4 78.0 68.8 48.9 47.9 26.3 16.2 31.4 1,062 Secondary 84.3 83.4 78.1 69.9 74.1 88.5 82.6 61.7 68.2 46.6 9.1 48.8 1,608 More than secondary 96.9 95.3 94.4 87.1 91.1 95.7 91.8 69.0 88.2 64.1 2.4 59.3 423 Wealth quintile Lowest 14.0 14.2 10.9 7.0 15.4 61.2 54.8 45.0 13.2 3.6 37.1 5.9 1,350 Second 31.4 32.4 26.4 18.5 29.9 73.8 65.0 51.7 26.6 11.5 23.6 16.3 1,330 Middle 57.3 56.6 49.5 39.7 49.4 77.0 69.8 50.5 43.9 24.0 19.9 29.5 1,100 Fourth 75.8 74.0 68.5 60.0 66.9 83.5 78.2 56.4 60.6 39.3 12.2 40.4 1,060 Highest 92.3 90.0 86.7 79.5 85.3 91.9 87.4 67.4 77.9 57.7 5.4 56.7 1,060 Total 51.2 50.6 45.6 38.2 46.8 76.5 69.9 53.6 42.1 25.3 20.7 28.0 5,900 1 Includes pentavalent 2 Polio 0 is the polio vaccination given at birth. 3 BCG, measles, and 3 doses each of DPT and polio vaccine (excluding polio vaccine given at birth) Child Health • 161 10.2.2 Trends in Vaccination Coverage Table 10.4 presents data on immunisation coverage trends from the 2003, 2008, and 2013 NDHS surveys. Immunisation coverage in Nigeria has improved over the past 10 years. The proportion of children age 12-23 months who received all basic vaccines almost doubled from 13 percent in 2003 to 25 percent in 2013. While this improvement is appreciable, it still falls far short of the increase needed to achieve the MDG target of more than 90 percent by 2015 (Federal Republic of Nigeria, 2010a). The proportion of children who received none of the six basic vaccinations declined marginally by 6 percentage points from the 2003 level (Figure 10.2). There has been a sustained increase in the proportion of children receiving each of the specific vaccines between 2003 and 2013; the increase is most marked for the polio vaccine, with coverage increasing from 29 percent to 54 percent. The smallest increase in coverage is that for the BCG vaccine, from 48 percent in 2003 to 51 percent in 2013. Table 10.4 Trends in vaccination coverage 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), 2003 NDHS, 2008 NDHS, and 2013 NDHS Source of information BCG DPT1 Polio2 Measles All basic vaccina- tions3 No vaccina- tions Number of children 1 2 3 0 1 2 3 2003 NDHS 48.3 42.6 31.7 21.4 27.8 67.2 52.3 29.4 35.9 12.9 26.5 999 2008 NDHS 49.7 52.0 44.7 35.4 36.7 67.8 57.2 38.7 41.4 22.7 28.7 4,945 2013 NDHS 51.2 50.6 45.6 38.2 46.8 76.5 69.9 53.6 42.1 25.4 20.7 5,900 1 Includes pentavalent 2 Polio 0 is the polio vaccination given at birth. 3 BCG, measles, and 3 doses each of DPT and polio vaccine (excluding polio vaccine given at birth) Figure 10.2 Trends in vaccination coverage among children age 12-23 months, 2003-2013 48 21 29 36 13 27 50 35 39 41 23 29 51 38 54 42 25 21 BCG DPT 3 Polio 3 Measles All basic vaccinations No vaccinations 2003 NDHS 2008 NDHS 2013 NDHS Percentage 10.3 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality in Nigeria and throughout the world. Pneumonia is the most serious outcome of ARI in young children. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths caused by pneumonia. The prevalence of ARI symptoms was estimated by asking mothers whether their children under age 5 had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These data are subjective (i.e., based on the mother’s perception of illness) and not validated by a medical examination. 162 • Child Health Table 10.5 shows the percentage of children under age 5 who experienced symptoms of ARI in the two weeks preceding the survey. Two percent of children showed ARI symptoms during this period. Advice or treatment was sought from a health facility or provider for only about a third (35 percent) of children with ARI symptoms, while 37 percent received antibiotics for their illness. ARI symptoms were reported most frequently in children age 12-23 months, children whose mothers smoked cigarettes or tobacco, children in rural areas and the North East, and children whose families were in the lower wealth quintiles. Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age 5, 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 the percentage who received antibiotics as treatment, according to background characteristics, Nigeria 2013 Among children under age 5: Among children under age 5 with symptoms of ARI: 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 1.5 2,989 (28.2) (34.2) 44 6-11 2.9 3,263 33.5 39.7 93 12-23 3.1 5,900 30.5 35.3 184 24-35 2.1 5,490 44.6 36.6 115 36-47 1.0 5,722 31.9 32.6 59 48-59 1.2 5,586 35.8 40.0 69 Sex Male 1.9 14,509 36.2 35.9 279 Female 2.0 14,440 32.8 37.0 286 Mother’s smoking status3 Smokes cigarettes/tobacco 9.8 52 * * 5 Does not smoke 1.9 28,796 34.6 36.4 558 Cooking fuel4 Electricity or gas 1.3 467 * * 6 Kerosene 0.9 5,094 (51.6) (43.8) 43 Coal/lignite 0.5 117 * * 1 Charcoal 1.5 957 * * 15 Wood/straw5 2.2 22,256 31.8 34.4 500 Animal dung (2.7) 35 * * 1 Residence Urban 1.5 10,403 46.6 44.2 154 Rural 2.2 18,547 30.0 33.6 411 Zone North Central 2.1 4,019 28.5 23.8 83 North East 5.1 5,034 32.7 37.2 257 North West 0.9 10,485 40.5 31.5 91 South East 2.1 2,585 29.9 28.9 53 South South 1.7 2,742 32.1 55.7 48 South West 0.8 4,084 * * 33 Mother’s education No education 2.0 13,945 31.2 34.5 277 Primary 2.1 5,563 27.5 37.1 115 Secondary 2.0 7,697 42.1 38.2 151 More than secondary 1.2 1,744 * * 22 Wealth quintile Lowest 2.1 6,636 26.8 36.5 140 Second 2.9 6,483 27.7 25.2 189 Middle 2.1 5,534 40.7 42.5 114 Fourth 1.4 5,243 36.9 49.9 72 Highest 1.0 5,053 (63.7) (45.9) 50 Total 2.0 28,950 34.5 36.5 565 Note: State-level disaggregation is not shown due to the small number of cases. 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 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related and/or by difficult breathing that is chest-related) are considered a proxy for pneumonia. 2 Excludes pharmacy, chemist/PMS, shop, traditional practitioner, market, and other 3 Excludes children for whom the mother’s smoking status is missing 4 Excludes 12 children who live in households where no food is cooked and 11 children for whom information on the cooking fuel used in the household is missing 5 Includes grass, shrubs, and crop residues Child Health • 163 As a result of differences in the definition of a health facility/provider between the 2008 and 2013 NDHS surveys, the results from these two surveys regarding treatment of ARI cannot be directly compared. The 2013 NDHS excluded pharmacy, chemist/PMS, shop, and traditional practitioner from the definition of a health facility or provider, while the 2008 NDHS included chemist/PMS in the definition. The 2008 NDHS data were rerun to match the 2013 NDHS definition, and the results showed a 9 percent increase in the proportion of children under age 5 for whom advice or treatment was sought from a health facility or provider (from 32 percent in 2008 to 35 percent in 2013) (Figure 10.3). 10.4 FEVER Fever is a major manifestation of malaria and other acute infections in children. Malaria and fever contribute to high levels of malnutrition 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. Since malaria is a major cause of death in infancy and childhood in many developing countries, the presumptive treatment of fever with antimalarial medication is advocated in countries such as Nigeria where malaria is endemic. Information relating to the prevention and treatment of malaria is discussed in greater detail in Chapter 12 of this report. Table 10.6 shows the percentage of children under age 5 with a fever during the two weeks preceding the survey and the percentage receiving various treatments, by selected background characteristics. Among children under age 5, 13 percent had a fever in the two weeks preceding the survey. Advice or treatment was sought from a health facility or provider for 32 percent of these children; 33 percent took antimalarial drugs, and a quarter took antibiotics. The prevalence of fever varied by age of the child; it was highest in children age 12-23 months and lowest in children younger than age 6 months. There was little variation in the prevalence of fever by sex of the child, place of residence, or mother’s education. Although the proportion of children under age 5 with a fever was similar in rural and urban areas (12-13 percent), children in rural areas were less likely than those in urban areas to receive care and treatment (29 percent versus 37 percent). Children of mothers with little or no education and those born to families in the lower wealth quintiles were also less likely to receive care and treatment. The prevalence of fever was highest among children in the lowest wealth quintile and lowest among children in the highest quintile (14 percent and 10 percent, respectively). Also, fever prevalence varied from 7 percent in the North Central and South West zones to 21 percent in the North East. Care must be taken in comparing the results from the 2008 and 2013 NDHS surveys regarding the practice of seeking advice and treatment for fever because the 2008 NDHS included chemist/PMS in the health facility/provider category while the 2013 survey excluded pharmacy, chemist/PMS, shop, and traditional practitioner. The 2008 NDHS data were rerun to facilitate such a comparison. The results indicate that while there was a slight decline in the prevalence of fever from 16 percent in 2008 to 13 percent in 2013, there was also an 11 percent decrease in the proportion of children under age 5 for whom advice or treatment was sought from a health facility or provider (Figure 10.3). The proportion of children who took antimalarial drugs remained unchanged at 33 percent, while the proportion who took antibiotics for their illness rose sharply from 18 percent in 2008 to 26 percent in 2013. 164 • Child Health Table 10.6 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey, and among children with fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who received antibiotics as treatment, by background characteristics, Nigeria 2013 Among children under age 5: Among children under age 5 with fever: 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 antimalarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 6.8 2,989 33.3 21.6 28.5 203 6-11 17.0 3,263 35.5 33.7 29.1 556 12-23 17.5 5,900 31.8 33.3 26.9 1,034 24-35 13.4 5,490 31.4 33.6 24.0 736 36-47 10.3 5,722 31.1 35.5 24.2 591 48-59 9.2 5,586 26.3 30.4 23.1 512 Sex Male 12.9 14,509 31.8 33.2 26.0 1,867 Female 12.2 14,440 31.1 32.3 25.4 1,766 Residence Urban 12.1 10,403 36.5 39.9 29.3 1,262 Rural 12.8 18,547 28.8 28.9 23.9 2,370 Zone North Central 7.4 4,019 38.6 50.7 15.7 297 North East 20.8 5,034 27.0 25.0 26.5 1,045 North West 9.9 10,485 34.1 29.0 22.8 1,034 South East 19.3 2,585 23.9 29.9 28.2 498 South South 16.8 2,742 28.2 39.8 31.4 460 South West 7.3 4,084 48.6 48.6 30.6 297 State North Central FCT-Abuja 7.6 196 (47.6) (29.0) (10.5) 15 Benue 3.7 878 * * * 33 Kogi 3.4 378 * * * 13 Kwara 4.3 377 (50.8) (58.9) (19.1) 16 Nasarawa 9.8 421 47.8 65.0 42.3 41 Niger 9.3 1,303 38.4 69.5 6.1 121 Plateau 12.5 464 35.5 25.5 20.1 58 North East Adamawa 13.2 661 37.2 16.9 26.0 87 Bauchi 25.3 1,243 33.3 19.3 37.1 315 Borno 10.7 1,064 27.7 39.7 31.9 114 Gombe 18.5 529 34.6 38.4 20.5 98 Taraba 21.1 690 22.5 23.4 21.4 146 Yobe 33.7 848 16.4 24.1 17.4 286 North West Jigawa 18.9 1,380 41.5 31.6 19.7 260 Kaduna 12.2 1,375 12.4 17.4 17.1 168 Kano 9.1 2,717 37.5 29.2 30.2 248 Katsina 6.3 1,549 27.5 39.2 19.4 98 Kebbi 9.0 1,094 39.7 45.0 5.3 98 Sokoto 6.2 1,005 35.0 20.5 32.9 62 Zamfara 7.3 1,365 42.9 21.0 36.3 100 South East Abia 11.2 297 (33.0) (28.1) (18.0) 33 Anambra 11.4 608 11.8 18.9 18.9 69 Ebonyi 25.1 663 19.1 21.6 43.6 166 Enugu 24.3 514 29.0 25.8 16.9 125 Imo 20.7 502 30.5 56.2 26.6 104 South South Akwa Ibom 18.8 439 21.1 18.9 37.0 83 Bayelsa 3.9 220 (29.6) (62.9) (47.4) 9 Cross River 25.6 499 21.0 27.1 29.8 128 Delta 5.2 520 (20.0) (33.7) (18.3) 27 Edo 5.9 387 (49.1) (52.0) (2.0) 23 Rivers 28.3 676 34.6 55.5 34.8 192 South West Ekiti 6.4 188 (48.7) (43.4) (31.2) 12 Lagos 9.2 1,220 41.8 54.5 30.3 112 Ogun 2.1 689 * * * 15 Ondo 9.6 520 63.6 38.5 46.9 50 Osun 6.9 427 (66.1) (83.7) (12.8) 30 Oyo 7.6 1,040 48.9 36.9 28.5 79 Continued… Child Health • 165 Table 10.6—Continued Among children under age 5: Among children under age 5 with fever: 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 antimalarial drugs Percentage who took antibiotic drugs Number of children Mother’s education No education 12.3 13,945 27.9 26.3 22.8 1,718 Primary 12.8 5,563 29.3 31.8 27.2 714 Secondary 12.8 7,697 34.2 41.1 28.4 982 More than secondary 12.5 1,744 54.3 48.8 32.3 219 Wealth quintile Lowest 13.6 6,636 25.2 22.1 22.7 899 Second 12.9 6,483 29.1 26.4 22.3 837 Middle 13.7 5,534 30.0 35.0 28.8 756 Fourth 11.7 5,243 35.1 41.6 28.3 614 Highest 10.4 5,053 43.6 47.5 29.0 526 Total 12.5 28,950 31.5 32.7 25.7 3,632 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 Excludes pharmacy, chemist/PMS, shop, traditional practitioner, market, and other Figure 10.3 Percentage of children with symptoms of ARI, fever, and diarrhoea for whom treatment was sought from a health facility or provider 32 36 32 35 32 29 Sypmtoms of ARI Fever Diarrhoea Percentage 2008 NDHS 2013 NDHS Note: Excludes pharmacy, chemist/PMS, shop, traditional practitioner, market, and other. The 2008 NDHS data have been rerun for comparision and might be different from the report. 10.5 DIARRHOEAL DISEASE Diarrhoea remains a leading cause of childhood morbidity and mortality in developing countries. Dehydration caused by diarrhoea is a major cause of illness and death among young children, even though the condition can be easily treated with oral rehydration therapy (ORT). Exposure to diarrhoea-causing pathogens is frequently related to the consumption of contaminated water and to unhygienic practices in food preparation and disposal of excreta. The combination of high cause-specific mortality and the existence of an effective remedy makes diarrhoea and its treatment a priority concern for health services. In the 2013 NDHS, mothers were asked whether any of their children under age 5 had diarrhoea at any time during the two-week period preceding the survey. The validity of this indicator is affected by the mother’s perception of diarrhoea as an illness and her capacity to recall the events. Moreover, the 166 • Child Health prevalence of diarrhoea varies seasonally. Thus, information on diarrhoea should be interpreted with caution. If the child had experienced diarrhoea, the mother was asked about actions she took to treat the illness and feeding practices during the diarrhoeal episode. The mother was also asked if there was blood in the child’s stools, which is indicative of dysentery or other specific diseases and needs to be treated somewhat differently than diarrhoea without blood. In addition, questions were asked regarding knowledge of oral rehydration salt (ORS) packets or pre-packaged liquids for treatment of diarrhoea and disposal of children’s stools. 10.5.1 Prevalence of Diarrhoea Table 10.7 shows that 10 percent of children under age 5 were reported to have had diarrhoea in the two-week period before the survey, and 2 percent had diarrhoea with blood. Diarrhoea was most common among children age 12–23 months (17 percent) and least common among those age 48-59 months (5 percent). Diarrhoea with blood was also most common in children age 12-23 months. Children of mothers with no education were twice as likely as children of mothers with more than a secondary education to have had diarrhoea. There was also a direct relationship between family wealth and diarrhoea prevalence, with children from wealthier households being less likely to have diarrhoea. Diarrhoea prevalence was highest in Yobe (35 percent) and lowest in Bayelsa, Edo, and Ogun (2 percent each). Table 10.7 Prevalence of diarrhoea Percentage of children under age 5 who had diarrhoea in the two weeks preceding the survey, by background characteristics, Nigeria 2013 Diarrhoea in the two weeks preceding the survey Number of children Background characteristic All diarrhoea Diarrhoea with blood Age in months <6 5.7 0.7 2,989 6-11 16.4 1.3 3,263 12-23 16.7 3.0 5,900 24-35 11.1 1.9 5,490 36-47 6.8 1.3 5,722 48-59 5.0 0.9 5,586 Sex Male 10.2 1.5 14,509 Female 10.3 1.7 14,440 Source of drinking water1 Improved 9.5 1.4 16,515 Not improved 11.2 2.0 12,381 Toilet facility2 Improved, not shared 10.1 1.3 9,172 Shared3 9.3 1.0 5,551 Non-improved 10.7 2.1 14,141 Residence Urban 9.2 0.8 10,403 Rural 10.8 2.1 18,547 Zone North Central 7.3 1.7 4,019 North East 21.1 3.6 5,034 North West 9.2 1.3 10,485 South East 10.3 0.7 2,585 South South 4.5 1.5 2,742 South West 6.3 0.5 4,084 State North Central FCT-Abuja 5.6 0.7 196 Benue 9.5 2.7 878 Kogi 3.3 0.6 378 Kwara 5.3 0.1 377 Nasarawa 8.3 2.5 421 Niger 8.2 2.2 1,303 Plateau 5.6 0.7 464 Continued… Child Health • 167 Table 10.7—Continued Diarrhoea in the two weeks preceding the survey Number of children Background characteristic All diarrhoea Diarrhoea with blood State (continued) North East Adamawa 16.6 2.3 661 Bauchi 25.7 6.2 1,243 Borno 10.8 0.5 1,064 Gombe 16.7 4.4 529 Taraba 19.7 2.7 690 Yobe 34.6 5.0 848 North West Jigawa 14.8 3.5 1,380 Kaduna 13.5 1.0 1,375 Kano 6.5 0.8 2,717 Katsina 7.7 0.9 1,549 Kebbi 13.6 1.4 1,094 Sokoto 4.6 0.8 1,005 Zamfara 6.0 1.4 1,365 South East Abia 2.5 0.0 297 Anambra 5.7 0.3 608 Ebonyi 13.2 0.7 663 Enugu 14.7 1.9 514 Imo 12.2 0.4 502 South South Akwa Ibom 5.5 1.6 439 Bayelsa 1.8 0.1 220 Cross River 8.0 4.3 499 Delta 2.8 0.6 520 Edo 2.0 0.2 387 Rivers 5.0 1.1 676 South West Ekiti 6.6 0.4 188 Lagos 7.5 0.6 1,220 Ogun 1.9 0.3 689 Ondo 5.5 0.5 520 Osun 4.1 0.2 427 Oyo 9.2 0.7 1,040 Mother’s education No education 11.7 2.2 13,945 Primary 9.9 1.7 5,563 Secondary 8.8 0.8 7,697 More than secondary 5.6 0.5 1,744 Wealth quintile Lowest 12.5 2.3 6,636 Second 11.9 2.4 6,483 Middle 9.9 1.7 5,534 Fourth 8.6 0.7 5,243 Highest 7.2 0.5 5,053 Total 10.2 1.6 28,950 1 See Table 2.1 for definition of categories. Excludes children with missing information on source of drinking water. 2 See Table 2.2 for definition of categories. Excludes children with missing information on type of toilet facility. 3 Facilities that would be considered improved if they were not shared by two or more households 10.5.2 Treatment of Diarrhoea Table 10.8 shows the percentage of children under age 5 with diarrhoea in the two weeks before the survey who were taken to a health facility or provider for advice or treatment, the percentage who received ORT, and the percentage who were given other treatments, by background characteristics. Overall, 29 percent of children under age 5 with diarrhoea were taken for advice or treatment at a health facility or provider. Children age 6-11 months were more likely than children in other age groups to be taken to a health facility or provider for treatment (33 percent). Urban children were more likely to have been taken for advice or treatment than rural children (35 percent versus 26 percent). Children with bloody diarrhoea, children of better educated mothers, and children in families in the highest wealth quintile were more likely than other children to be taken to a health facility or provider for treatment. For example, 24 percent of children of mothers with no education were taken to a health facility or provider for treatment of 168 • Child Health diarrhoea, as compared with 64 percent of children of mothers with more than a secondary education. Mothers in the North Central zone were more likely than those in other zones to seek advice or treatment from a health facility or provider. A simple and effective response to dehydration caused by diarrhoea is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy. ORT may include the use of a solution prepared from commercially produced packets of oral rehydration salts; a recommended home fluid (RHF), usually a homemade mixture prepared from sugar, salt, and water; any kind of thin, nutritious fluid such as rice water, coconut milk, or watery soup; or simply increased fluid intake. Ten Table 10.8 Diarrhoea treatment Among children under age 5 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 given other treatments, by background characteristics, Nigeria 2013 Percent- age of children with diarrhoea for whom advice or treatment was sought from a health facility or provider1 Oral rehydration therapy (ORT) Increased fluids ORT or increased fluids Other treatments Missing No treat- ment Number of children with diar- rhoea Background characteristic Fluid from ORS packets or pre- packaged liquid Recom- mended home fluids (RHF) Either ORS or RHF Anti- biotic drugs Anti- motility drugs Zinc supple- ments Intra- venous solution Home remedy/ other Age in months <6 23.5 20.7 4.1 23.6 11.5 33.2 25.9 2.1 0.5 0.3 29.8 0.7 34.2 171 6-11 33.3 37.1 9.9 41.6 7.3 44.3 36.2 2.6 2.7 0.1 33.6 0.6 19.7 537 12-23 31.2 36.3 10.5 41.2 10.6 47.0 33.2 2.8 1.9 0.4 35.7 0.8 20.7 984 24-35 24.4 30.8 8.2 34.5 9.3 40.8 34.2 3.1 2.8 0.4 34.4 1.3 22.0 609 36-47 29.4 32.1 12.3 37.7 10.7 45.7 37.0 1.3 3.8 0.0 33.1 0.9 17.6 387 48-59 25.0 34.3 10.0 37.9 15.2 47.4 38.5 2.1 1.1 0.3 37.0 1.6 16.3 279 Sex Male 28.4 31.8 10.1 36.3 10.4 42.7 34.7 2.9 2.5 0.3 36.5 0.9 20.5 1,482 Female 29.4 35.6 9.4 39.9 10.0 45.9 34.3 2.2 2.2 0.3 32.5 1.0 21.0 1,484 Type of diarrhoea Non-bloody 27.6 34.1 9.1 38.3 8.6 43.4 33.3 2.7 2.1 0.3 32.9 0.7 22.6 2,322 Bloody 36.4 33.5 13.6 39.8 15.0 49.8 40.7 2.2 3.3 0.2 42.0 1.2 12.4 470 Missing 26.3 29.1 8.7 31.7 18.6 41.3 33.6 1.2 3.1 0.9 35.2 3.3 19.1 174 Residence Urban 35.0 44.7 12.0 49.4 8.4 53.2 45.0 3.3 2.5 0.3 26.0 0.9 15.6 958 Rural 26.0 28.4 8.7 32.7 11.1 40.1 29.5 2.2 2.2 0.3 38.5 1.0 23.2 2,008 Zone North Central 42.0 41.7 11.5 46.8 12.6 52.7 40.0 3.2 6.1 0.6 37.1 0.3 12.0 295 North East 24.4 28.5 6.0 30.6 17.7 42.9 32.6 3.1 0.8 0.4 40.0 1.6 19.8 1,061 North West 28.7 33.7 9.5 37.4 4.0 39.4 30.5 1.3 3.1 0.0 31.8 0.4 28.4 961 South East 27.5 37.0 13.0 44.9 4.9 47.4 37.6 3.2 3.8 0.0 28.5 0.0 17.7 266 South South 31.3 31.7 16.3 45.0 14.1 49.6 47.9 1.4 0.4 2.2 30.0 1.5 13.6 124 South West 33.8 43.6 17.3 51.5 3.3 52.6 41.3 3.9 0.8 0.0 27.4 1.5 12.8 259 Mother’s education No education 24.3 28.6 6.9 31.5 9.7 38.3 29.9 2.3 2.1 0.2 38.5 1.3 24.4 1,638 Primary 32.2 32.0 14.0 39.1 13.0 46.2 36.5 2.5 2.6 0.4 34.9 0.2 17.7 553 Secondary 32.4 42.9 13.1 48.9 8.8 52.9 42.2 3.2 2.5 0.4 26.5 0.4 16.1 677 More than secondary 64.0 65.3 10.1 69.1 12.8 73.8 47.8 0.8 3.8 0.0 20.8 2.0 9.8 98 Wealth quintile Lowest 19.1 20.4 4.9 23.2 10.6 31.4 23.8 1.9 1.5 0.4 42.7 1.2 26.6 832 Second 28.0 30.3 9.4 34.7 10.5 41.9 29.6 2.6 2.2 0.2 36.8 1.3 23.4 774 Middle 31.5 38.4 13.6 45.4 11.1 51.0 39.1 2.1 3.5 0.3 34.2 0.6 16.6 549 Fourth 38.0 42.8 10.8 46.4 9.7 50.5 48.9 3.5 2.4 0.0 25.9 0.5 16.5 450 Highest 38.3 53.0 14.3 58.4 8.0 61.2 44.7 3.4 2.7 0.7 21.8 0.8 13.4 362 Total 28.9 33.7 9.7 38.1 10.2 44.3 34.5 2.5 2.3 0.3 34.5 1.0 20.8 2,966 Note: ORT includes fluid prepared from oral rehydration salt (ORS) packets, pre-packaged ORS fluid, and recommended home fluids (RHF). State-level disaggregation is not shown due to the small number of cases. 1 Excludes pharmacy, chemist/PMS, shop, traditional practitioner, market, and other Child Health • 169 percent of children with diarrhoea were given increased fluids, 35 percent were given antibiotic drugs, and 21 percent received no treatment of any kind. Children age 6-11 months (42 percent), children residing in urban areas (49 percent), children living in the South West zone (52 percent), children of mothers with more than a secondary education (69 percent), and children from families in the higher wealth quintiles (58 percent) were most likely to receive ORT. To allow a comparison of diarrhoea treatment trends between 2008 and 2013, the data from the 2008 NDHS were rerun to reflect the same definition of health facility/provider (i.e., excluding pharmacy, chemist/PMS, shop, and traditional practitioner). The results indicate that while there was a slight decline in mothers’ health-seeking behaviour for children with diarrhoea from 32 percent in 2008 to 29 percent in 2013 (Figure 10.3), there was a 7 percentage point increase in the proportion of children given either ORS or RHF during episodes of diarrhoea and an 8 percentage point decline in the proportion of children who received no treatment of any kind when they had diarrhoea. Zinc supplementation has been shown to reduce the severity and shorten the duration of diarrhoea in children. UNICEF and WHO recommend zinc supplementation for all children who have diarrhoea, and this recommendation is being actively promoted in Nigeria. The proportion of children with diarrhoea in the two weeks preceding the survey who received zinc supplementation increased from less than 1 percent in 2008 to just over 2 percent in 2013. This small increase falls far short of the UNICEF and WHO recommendation (UNICEF/WHO, 2009). 10.5.3 Feeding Practices during Diarrhoea Mothers are encouraged to continue feeding and increase the amount of fluids given to their children when they suffer from diarrhoea. These practices help to reduce dehydration and minimise the adverse consequences of diarrhoea on the child’s nutritional status. Mothers interviewed in the 2013 NDHS were specifically asked whether they gave their child with diarrhoea less, the same amount, or more fluids and food than usual during the illness. Table 10.9 shows the percentage distribution of children under age 5 who had diarrhoea in the two weeks preceding the survey by feeding practices, according to background characteristics. Ten percent of children with diarrhoea were given more fluids than usual, as recommended. One-third of children (34 percent) were given the same amount of fluids as usual, 29 percent were given somewhat less fluids, and 22 percent were given much less than usual. Four percent of children received no fluids at all when they had diarrhoea. Two percent of children were given more food than usual when they had diarrhoea, one- third were fed the same amount, and a third were given somewhat less food than usual. Four percent were given no food at all. Overall, less than one-third (29 percent) of children under age 5 continued feeding and were given ORT and/or increased fluids when they had diarrhoea. Although this is a slight improvement from the 25 percent recorded in the 2008 NDHS, these findings still suggest that a large proportion of mothers continue to engage in the dangerous practice of restricting fluids and food intake when their children have diarrhoea. 17 0 • C hi ld H ea lth Ta bl e 10 .9 F ee di ng p ra ct ic es d ur in g di ar rh oe a P er ce nt d is tri bu tio n of c hi ld re n un de r a ge 5 w ho h ad d ia rr ho ea in th e tw o w ee ks p re ce di ng th e su rv ey b y am ou nt o f l iq ui ds a nd fo od o ffe re d co m pa re d w ith n or m al p ra ct ic e, th e pe rc en ta ge o f c hi ld 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 is od e, a nd th e pe rc en ta ge o f c hi ld re n w ho c on tin ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s du rin g th e ep is od e of d ia rrh oe a, b y ba ck gr ou nd c ha ra ct er is tic s, N ig er ia 2 01 3 A m ou nt o f l iq ui ds g iv en A m ou nt o f f oo d gi ve n P er ce nt - ag e gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g1 P er ce nt - ag e w ho co nt in ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s1 N um be r o f ch ild re n w ith di ar rh oe a B ac kg ro un d ch ar ac te ris tic M or e S am e as us ua l S om ew ha t le ss M uc h le ss N on e D on ’t kn ow / m is si ng To ta l M or e S am e as us ua l S om ew 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 is si ng To ta l A ge in m on th s <6 11 .5 48 .6 19 .4 17 .0 3. 5 0. 0 10 0. 0 3. 9 37 .7 16 .4 13 .3 1. 1 26 .3 1. 3 10 0. 0 4. 2 17 .7 17 1 6- 11 7. 3 34 .5 30 .1 24 .9 3. 0 0. 2 10 0. 0 1. 4 31 .7 30 .5 23 .6 6. 2 5. 8 0. 9 10 0. 0 3. 5 28 .0 53 7 12 -2 3 10 .6 34 .3 28 .8 22 .9 2. 3 1. 1 10 0. 0 2. 6 30 .9 35 .1 24 .7 4. 3 1. 9 0. 4 10 0. 0 6. 7 32 .6 98 4 24 -3 5 9. 3 34 .8 29 .5 19 .0 5. 5 1. 9 10 0. 0 2. 0 36 .1 32 .7 24 .4 2. 7 0. 7 1. 4 10 0. 0 4. 9 27 .7 60 9 36 -4 7 10 .7 30 .4 30 .7 19 .9 6. 7 1. 6 10 0. 0 0. 8 34 .3 36 .7 23 .8 3. 1 0. 0 1. 2 10 0. 0 6. 1 31 .7 38 7 48 -5 9 15 .2 29 .2 25 .5 25 .1 3. 7 1. 3 10 0. 0 4. 5 29 .5 30 .8 32 .5 1. 8 0. 3 0. 6 10 0. 0 7. 9 26 .7 27 9 Se x M al e 10 .4 33 .6 29 .1 21 .2 4. 3 1. 4 10 0. 0 2. 0 33 .5 32 .2 24 .3 4. 3 2. 7 1. 0 10 0. 0 5. 9 29 .0 1, 48 2 Fe m al e 10 .0 35 .0 28 .1 22 .7 3. 4 0. 9 10 0. 0 2. 6 32 .2 32 .8 24 .5 3. 2 4. 0 0. 7 10 0. 0 5. 3 29 .5 1, 48 4 Ty pe o f d ia rr ho ea N on -b lo od y 8. 6 37 .1 29 .5 20 .4 3. 5 0. 9 10 0. 0 2. 3 34 .7 32 .6 22 .7 3. 2 3. 8 0. 7 10 0. 0 4. 9 29 .3 2, 32 2 B lo od y 15 .0 21 .3 25 .7 31 .0 6. 9 0. 0 10 0. 0 3. 3 24 .0 31 .0 32 .5 6. 7 1. 9 0. 6 10 0. 0 8. 7 29 .4 47 0 M is si n g 18 .6 32 .1 24 .3 17 .8 0. 7 6. 5 10 0. 0 0. 0 31 .1 35 .8 25 .5 2. 7 0. 8 4. 0 10 0. 0 7. 2 27 .8 17 4 R es id en ce U rb an 8. 4 43 .0 29 .2 14 .7 3. 4 1. 3 10 0. 0 2. 9 40 .6 34 .6 15 .6 2. 9 2. 4 0. 9 10 0. 0 4. 7 39 .8 95 8 R ur al 11 .1 30 .2 28 .3 25 .4 4. 1 1. 0 10 0. 0 2. 0 29 .1 31 .5 28 .6 4. 1 3. 8 0. 9 10 0. 0 6. 1 24 .2 2, 00 8 Zo ne N or th C en tra l 12 .6 37 .6 26 .3 23 .2 0. 0 0. 3 10 0. 0 7. 0 35 .1 30 .4 26 .1 0. 3 0. 7 0. 3 10 0. 0 10 .1 37 .4 29 5 N or th E as t 17 .7 32 .9 21 .5 22 .1 4. 7 1. 0 10 0. 0 1. 7 30 .1 26 .9 29 .6 4. 5 6. 0 1. 1 10 0. 0 7. 8 23 .1 1, 06 1 N or th W es t 4. 0 26 .0 37 .3 26 .9 4. 0 1. 8 10 0. 0 1. 6 27 .0 38 .4 26 .2 3. 9 2. 1 0. 9 10 0. 0 3. 2 26 .8 96 1 S ou th E as t 4. 9 37 .7 33 .6 15 .8 7. 2 0. 7 10 0. 0 2. 4 43 .2 33 .1 16 .8 2. 5 1. 3 0. 7 10 0. 0 3. 1 35 .0 26 6 S ou th S ou th 14 .1 39 .8 27 .7 16 .9 1. 4 0. 0 10 0. 0 3. 0 35 .1 44 .3 11 .4 6. 1 0. 0 0. 0 10 0. 0 5. 8 36 .7 12 4 S ou th W es t 3. 3 60 .8 23 .1 9. 7 2. 1 1. 1 10 0. 0 1. 2 51 .5 29 .6 8. 5 4. 2 3. 9 1. 1 10 0. 0 3. 3 44 .3 25 9 M ot he r’s e du ca tio n N o ed uc at io n 9. 7 27 .9 29 .0 26 .9 4. 8 1. 7 10 0. 0 1. 5 27 .5 31 .3 30 .3 4. 3 3. 9 1. 2 10 0. 0 4. 7 22 .7 1, 63 8 P rim ar y 13 .0 40 .6 29 .1 14 .8 2. 1 0. 4 10 0. 0 4. 1 40 .1 34 .1 15 .5 3. 2 2. 7 0. 3 10 0. 0 9. 2 34 .1 55 3 S ec on da ry 8. 8 43 .0 27 .7 16 .9 3. 2 0. 3 10 0. 0 2. 5 38 .7 33 .6 18 .7 3. 2 2. 9 0. 4 10 0. 0 4. 7 36 .9 67 7 M or e th an s ec on da ry 12 .8 45 .1 24 .3 13 .6 2. 1 2. 0 10 0. 0 2. 7 40 .2 36 .4 16 .5 2. 2 0. 0 2. 0 10 0. 0 7. 8 58 .5 98 W ea lth q ui nt ile Lo w es t 10 .6 26 .6 28 .3 29 .1 4. 1 1. 2 10 0. 0 0. 7 25 .1 31 .9 31 .7 4. 8 4. 6 1. 2 10 0. 0 4. 8 16 .4 83 2 S ec on d 10 .5 29 .4 29 .2 24 .4 4. 5 2. 1 10 0. 0 1. 7 29 .6 31 .9 27 .3 4. 4 4. 0 1. 0 10 0. 0 6. 1 25 .9 77 4 M id dl e 11 .1 38 .6 27 .2 18 .7 4. 1 0. 4 10 0. 0 4. 8 34 .3 33 .9 23 .2 2. 2 1. 3 0. 2 10 0. 0 8. 3 34 .7 54 9 Fo ur th 9. 7 43 .1 29 .7 14 .6 2. 8 0. 0 10 0. 0 3. 4 38 .4 35 .3 16 .5 2. 9 3. 0 0. 6 10 0. 0 5. 2 37 .5 45 0 H i g he st 8. 0 44 .8 28 .8 14 .1 2. 8 1. 4 10 0. 0 2. 1 48 .3 29 .5 13 .1 3. 4 2. 5 1. 1 10 0. 0 3. 1 47 .2 36 2 To ta l 10 .2 34 .3 28 .6 21 .9 3. 9 1. 1 10 0. 0 2. 3 32 .8 32 .5 24 .4 3. 7 3. 3 0. 9 10 0. 0 5. 6 29 .2 2, 96 6 N ot e: It is re co m m en de d th at c hi ld re n be g iv en m or e liq ui ds to d rin k du rin g di ar rh oe a an d th at fo od n ot b e re du ce d. S ta te -le ve l d is ag gr eg at io n is n ot s ho w n du e to th e sm al l n um be r o f c as es . 1 C on tin ue d 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, th e sa m 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 is od e. 170 • Child Health Child Health • 171 10.6 KNOWLEDGE OF ORS PACKETS To ascertain respondents’ knowledge of ORS in Nigeria, mothers were asked whether they knew about ORS packets. Table 10.10 presents information on the proportion of mothers with a live birth in the five years preceding the survey who had heard about ORS packets. Overall, 80 percent of mothers had heard about ORS packets, an increase from the figure of 66 percent reported in 2008. Knowledge was highest among mothers age 35-49 (83 percent) and lowest among the youngest mothers (69 percent). Urban mothers (89 percent), mothers in the South East (91 percent), mothers with more than a secondary education (91 percent), and mothers in the highest wealth quintile (89 percent) were most knowledgeable about ORS packets. 10.7 STOOL DISPOSAL The proper disposal of children’s faeces is important in preventing the spread of disease. Diarrhoea and other diseases can be caused by direct contact or by animal contact with human faeces. Table 10.11 presents information on disposal of children’s stools. Fifty-nine percent of children’s stools are disposed of safely; 5 percent of children use a toilet or latrine, 52 percent of children’s stools are rinsed into the toilet or latrine, and 2 percent are buried. In contrast, the stools of a quarter of children are thrown into the garbage, while 7 percent are left in the open and 2 percent are thrown in a river or riverbank. There are marked differences in disposal of children’s stools according to background characteristics. A higher proportion of urban children’s stools than rural children’s stools are disposed of safely (69 percent and 54 percent, respectively). Regional differentials in safe disposal also are substantial. For example, in the North West zone, 78 percent of children’s stools are disposed of safely, as compared with 28 percent in the North Central zone. There has been a marginal increase in safe stool disposal over the past five years, from 57 percent in the 2008 NDHS to 59 percent in 2013. Table 10.10 Knowledge of ORS packets or pre-packaged liquids Percentage of women age 15-49 with a live 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 2013 Background characteristic Percentage of women who know about ORS packets or ORS pre- packaged liquids Number of women Age 15-19 69.2 1,323 20-24 75.8 4,009 25-34 80.4 9,623 35-49 82.9 5,513 Residence Urban 88.6 7,278 Rural 74.5 13,189 Zone North Central 68.7 2,890 North East 82.5 3,434 North West 80.3 7,445 South East 90.7 1,719 South South 70.2 2,002 South West 84.1 2,977 State North Central FCT-Abuja 91.7 143 Benue 39.0 615 Kogi 66.2 283 Kwara 87.4 278 Nasarawa 81.1 309 Niger 82.4 916 Plateau 51.4 346 North East Adamawa 94.7 459 Bauchi 77.0 833 Borno 81.6 716 Gombe 92.4 361 Taraba 85.7 476 Yobe 73.1 588 North West Jigawa 71.8 973 Kaduna 91.1 1,051 Kano 90.0 1,907 Katsina 85.3 1,066 Kebbi 52.1 790 Sokoto 71.1 693 Zamfara 82.4 966 South East Abia 92.0 199 Anambra 90.3 379 Ebonyi 93.6 467 Enugu 86.1 355 Imo 91.2 319 South South Akwa Ibom 86.7 334 Bayelsa 71.3 153 Cross River 80.7 368 Delta 79.3 376 Edo 56.2 264 Rivers 52.0 508 South West Ekiti 94.8 139 Lagos 92.3 867 Ogun 84.0 495 Ondo 61.9 385 Osun 92.8 307 Oyo 80.8 783 Education No education 75.6 9,794 Primary 78.9 3,915 Secondary 84.2 5,475 More than secondary 90.9 1,283 Wealth quintile Lowest 70.4 4,699 Second 75.5 4,588 Middle 79.4 3,902 Fourth 86.6 3,674 Highest 89.2 3,604 Total 79.5 20,467 ORS = Oral rehydration salts 172 • Child Health Table 10.11 Disposal of children’s stools Percent distribution of youngest children under age 5 living with their 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 2013 Manner of disposal of children’s stools Total Percentage of children whose stools are disposed of safely1 Number of children Background characteristic Child used toilet or latrine Put/rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Left in the open River/river- banks Other Missing Age in months <6 2.0 48.8 1.8 7.8 28.9 5.9 1.6 0.2 2.9 100.0 52.6 2,930 6-11 1.9 54.0 1.9 5.1 26.3 5.7 1.8 0.1 3.3 100.0 57.9 3,212 12-23 2.9 53.7 2.0 3.9 24.8 7.3 1.6 0.1 3.6 100.0 58.6 5,606 24-35 5.0 54.6 2.4 3.2 22.0 7.4 1.4 0.0 3.9 100.0 62.1 3,824 36-47 12.0 49.1 2.1 2.5 20.4 7.3 2.1 0.1 4.4 100.0 63.2 2,233 48-59 20.8 44.2 1.6 3.1 16.6 7.2 1.8 0.3 4.4 100.0 66.6 1,483 Toilet facility2 Improved, not shared 7.9 71.0 0.9 2.7 10.8 2.8 0.3 0.1 3.5 100.0 79.8 6,043 Shared3 5.2 65.7 0.4 5.0 18.7 1.6 0.2 0.2 3.1 100.0 71.3 3,815 Non-improved or shared 4.0 34.0 3.4 5.2 34.7 11.5 3.2 0.1 4.0 100.0 41.4 9,376 Residence Urban 6.3 61.5 1.0 4.4 19.9 2.9 1.3 0.1 2.6 100.0 68.8 6,930 Rural 4.9 46.6 2.6 4.3 26.3 9.0 1.9 0.1 4.2 100.0 54.2 12,357 Zone North Central 4.5 19.4 4.2 5.4 55.4 6.5 0.5 0.1 4.0 100.0 28.1 2,739 North East 7.2 56.6 1.5 2.9 22.8 4.5 0.1 0.2 4.1 100.0 65.3 3,233 North West 5.5 71.6 1.0 2.5 6.3 8.7 0.3 0.1 4.1 100.0 78.1 7,030 South East 4.6 40.6 0.8 8.6 31.0 11.3 0.3 0.1 2.7 100.0 46.0 1,621 South South 6.2 32.3 2.7 6.8 30.6 4.6 12.0 0.0 4.9 100.0 41.1 1,853 South West 4.2 48.5 3.5 5.6 30.6 4.0 2.2 0.1 1.3 100.0 56.2 2,811 State FCT-Abuja 5.4 48.6 1.3 4.3 33.2 4.7 0.0 0.2 2.2 100.0 55.4 137 Benue 1.2 14.8 2.0 13.7 61.5 2.1 0.0 0.0 4.7 100.0 18.0 556 Kogi 1.4 13.7 0.0 3.9 76.7 1.3 2.0 0.0 1.0 100.0 15.1 266 Kwara 4.3 43.9 0.0 0.8 46.9 1.8 0.0 0.0 2.3 100.0 48.2 268 Nasarawa 3.4 24.8 21.7 1.8 33.2 14.2 0.0 0.3 0.5 100.0 49.9 290 Niger 7.7 12.8 0.4 0.3 65.5 5.7 0.0 0.0 7.6 100.0 20.9 892 Plateau 4.6 13.0 10.5 14.0 36.4 18.2 2.4 0.4 0.5 100.0 28.1 331 North East Adamawa 6.0 57.2 0.5 3.1 28.8 2.7 0.1 0.3 1.2 100.0 63.7 434 Bauchi 1.3 68.8 2.1 2.1 14.6 8.2 0.2 0.3 2.3 100.0 72.2 772 Borno 19.1 67.3 0.0 1.3 2.5 2.5 0.4 0.0 6.9 100.0 86.5 688 Gombe 2.9 76.5 0.4 10.0 7.9 1.3 0.0 0.0 1.0 100.0 79.8 332 Taraba 7.9 31.8 0.7 4.8 46.9 3.3 0.0 0.3 4.3 100.0 40.4 446 Yobe 3.6 34.1 4.6 0.0 44.2 6.2 0.0 0.0 7.2 100.0 42.3 560 North West Jigawa 4.1 55.5 0.3 2.7 11.7 21.9 0.0 0.0 3.8 100.0 59.8 901 Kaduna 3.9 76.4 0.3 5.6 8.7 2.2 0.1 0.3 2.5 100.0 80.5 1,014 Kano 3.7 89.0 0.5 0.2 1.1 2.9 0.0 0.1 2.5 100.0 93.2 1,799 Katsina 20.5 70.1 0.2 0.1 4.0 0.0 0.0 0.0 5.1 100.0 90.8 1,011 Kebbi 0.9 71.1 0.2 0.4 0.7 22.7 2.0 0.2 1.8 100.0 72.2 747 Sokoto 4.3 33.6 8.2 12.2 26.2 2.2 0.1 0.1 13.1 100.0 46.1 658 Zamfara 0.0 77.3 0.0 0.5 1.2 16.9 0.1 0.1 3.8 100.0 77.3 900 South East Abia 6.8 57.8 0.0 2.2 30.2 0.3 0.0 0.0 2.7 100.0 64.6 186 Anambra 1.6 53.6 0.5 21.1 16.9 0.6 1.2 0.6 4.0 100.0 55.6 361 Ebonyi 6.4 21.9 0.2 9.3 54.1 5.2 0.0 0.0 3.0 100.0 28.4 431 Enugu 5.1 23.8 2.2 2.9 35.0 28.1 0.0 0.0 3.0 100.0 31.1 339 Imo 3.4 60.1 0.9 3.1 11.0 20.8 0.0 0.0 0.6 100.0 64.5 304 South South Akwa Ibom 8.0 61.8 0.4 13.0 12.5 0.2 0.0 0.0 4.1 100.0 70.1 309 Bayelsa 0.9 10.4 0.3 1.9 16.1 1.8 61.0 0.0 7.6 100.0 11.6 139 Cross River 5.2 23.4 0.5 7.2 56.7 4.3 0.3 0.0 2.3 100.0 29.1 339 Delta 7.1 28.9 5.6 5.3 24.3 2.6 22.2 0.0 4.1 100.0 41.6 353 Edo 1.8 46.0 0.9 3.4 38.0 1.6 1.1 0.0 7.3 100.0 48.7 256 Rivers 9.0 20.6 5.2 6.7 28.4 12.0 12.1 0.0 5.9 100.0 34.8 458 South West Ekiti 2.6 42.8 0.5 9.7 36.9 7.3 0.0 0.0 0.3 100.0 45.9 131 Lagos 6.4 56.7 0.0 1.3 32.7 0.2 1.3 0.0 1.5 100.0 63.1 815 Ogun 0.0 69.9 0.0 1.3 23.5 3.9 0.0 0.0 1.5 100.0 69.9 475 Ondo 11.0 25.2 0.6 12.8 32.2 2.6 13.4 0.0 2.1 100.0 36.8 354 Osun 2.3 47.9 0.1 4.6 38.5 4.8 0.9 0.9 0.0 100.0 50.4 301 Oyo 2.5 38.0 13.1 9.3 27.8 8.0 0.0 0.0 1.4 100.0 53.5 735 Continued… Child Health • 173 Table 10.11—Continued Manner of disposal of children’s stools Total Percentage of children whose stools are disposed of safely1 Number of children Background characteristic Child used toilet or latrine Put/rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Left in the open River/river banks Other Missing Mother’s education No education 5.6 55.3 2.2 3.1 19.3 8.9 0.7 0.1 4.6 100.0 63.2 9,221 Primary 4.3 44.7 2.3 5.1 31.1 6.3 3.5 0.1 2.5 100.0 51.3 3,684 Secondary 4.8 50.0 1.8 6.1 27.2 4.6 2.3 0.1 3.2 100.0 56.6 5,168 More than secondary 10.2 56.1 0.8 4.3 24.4 1.7 0.6 0.1 1.8 100.0 67.1 1,214 Wealth quintile Lowest 4.9 49.2 2.7 4.2 21.3 13.0 0.3 0.1 4.5 100.0 56.7 4,406 Second 4.8 50.3 2.3 4.6 23.9 8.1 1.9 0.1 4.0 100.0 57.4 4,287 Middle 5.2 43.9 2.7 3.6 31.7 6.2 2.7 0.0 3.9 100.0 51.7 3,678 Fourth 4.6 54.5 1.7 5.0 24.6 3.4 2.7 0.2 3.4 100.0 60.8 3,490 Highest 8.1 63.6 0.6 4.5 18.6 1.4 1.0 0.1 2.1 100.0 72.3 3,428 Total 5.4 51.9 2.0 4.3 24.0 6.8 1.7 0.1 3.7 100.0 59.4 19,288 1 Children’s stools are considered to be disposed of safely if the child used a toilet or latrine, if the faecal matter was put/rinsed into a toilet or latrine, or if it was buried. 2 See Table 2.2 for definition of categories. Excludes 54 cases with missing information on type of toilet facility. 3 Facilities that would be considered improved if they were not shared by two or more households Nutrition of Children and Women • 175 NUTRITION OF CHILDREN AND WOMEN 11 ood nutrition is a prerequisite for the national development of countries and for the well-being of individuals. Although problems related to poor nutrition affect the entire population, women and children are especially vulnerable because of their unique physiology and socioeconomic characteristics. Adequate nutrition is essential to children’s growth and development. The period from conception to age 2 is especially important for optimal physical, mental, and cognitive growth, health, and development. However, this period is often marked by protein-energy and micronutrient deficiencies that interfere with optimal growth. Illnesses such as diarrhoea and acute respiratory infections are also common among children. A woman’s nutritional status has important implications for her health as well as for the health of her children. Among women, malnutrition results in reduced productivity, increased susceptibility to infections, slow recovery from illness, and a heightened risk of adverse pregnancy outcomes. For example, a woman with poor nutritional status, as indicated by a low body mass index (BMI), short stature, anaemia, or other micronutrient deficiencies, has a greater risk of obstructed labour, of having a baby with a low birth weight, of producing low-quality breast milk, of death due to postpartum haemorrhage, and of morbidity for both herself and her baby. This chapter reviews the nutritional status of children and women in Nigeria. Specific issues discussed include child nutrition based on anthropometric measurements, infant and young child feeding practices, and micronutrient intake among children and women. 11.1 NUTRITIONAL STATUS OF CHILDREN The nutritional status of children under age 5 is an important measure of children’s health. The anthropometric data on height and weight collected in the 2013 NDHS permit the measurement and G Key Findings • Thirty-seven percent of children under age 5 are stunted, 18 percent are wasted, and 29 percent are underweight. • The proportion of stunted children has declined since 2008 (from 41 percent to 37 percent). • Ninety-eight percent of children were reported to have been breastfed at some time. • Seventeen percent of children less than age 6 months are exclusively breastfed. The median duration of exclusive breastfeeding (0.5 months) has remained unchanged since 2008. • Complementary foods are not introduced in a timely fashion for all children. Only 67 percent of breastfed children age 6-9 months received complementary foods. • Overall, only 10 percent of children age 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices. • Eleven percent of women are undernourished (BMI <18.5), and 25 percent are overweight or obese (BMI ≥25.0). 176 • Nutrition of Children and Women 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. 11.1.1 Measurement of Nutritional Status among Young Children The 2013 NDHS collected data on the nutritional status of children by measuring the height and weight of all children under age 5 in selected households. These data allow the calculation of three indices: height-for-age, weight-for-height, and weight-for-age. Indicators of the nutritional status of children were calculated using growth standards published by the World Health Organization in 2006. These growth standards were generated through data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). The findings of that study, which sampled 8,440 children in six countries (Brazil, Ghana, India, Norway, Oman, and the United States), illustrated 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, or feeding practices. The WHO growth standards replaced the previously used NCHS/CDC/WHO (U.S. National Center for Health Statistics/U.S. Centers for Disease Control and Prevention/World Health Organization) reference standards. It should be noted that the WHO child growth standards are not comparable to the previously used NCHS/CDC/WHO standards. Several changes are evident when the WHO standards rather than the previous standards are used (WHO, 2006). For example, the level of stunting is higher, and the level of underweight is substantially higher during the first half of infancy (0-6 months) and decreases thereafter. The three nutritional status indices are expressed in standard deviation units from the Multicentre Growth Reference Study median. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits in children. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the WHO reference population are considered short for their age (stunted), or chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the reference median are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is 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 height or length and describes current nutritional status. Children with Z-scores below minus two standard deviations (-2 SD) from the reference population median are considered thin (wasted) or 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 with a weight-for-height index below minus three standard deviations (-3 SD) from the reference median are considered severely wasted. The weight-for-height index also provides data on overweight and obesity. Children above two standard deviations (+2 SD) from the reference median are considered overweight or obese. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute malnutrition (wasting) and chronic malnutrition (stunting), but it does not distinguish between the two. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the reference population median are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the reference median are considered severely underweight. Z-score means are also calculated as summary statistics representing the nutritional status of children in a population. These mean scores describe the nutritional status of the entire population without the use of a cutoff. A mean Z-score of less than 0 (i.e., a negative mean value for stunting, wasting, or Nutrition of Children and Women • 177 underweight) suggests that the distribution of an index has shifted downward and that most if not all children in the population suffer from undernutrition relative to the reference population. 11.1.2 Data Collection Measurements of height and weight were obtained for children born in the five years preceding the survey (i.e., born in January 2008 or later) in all of the selected households. Each team of interviewers carried a scale and measuring board. Measurements were made using lightweight SECA scales (with digital screens) designed and manufactured under the authority of the United Nations Children’s Fund (UNICEF). The measuring boards employed were specially made by Shorr Productions for use in survey settings. Children under age 2 were measured lying down on the board (recumbent length), and standing height was measured for all other children. Every effort was made to successfully carry out the measurements of the eligible women and children. A total of 30,050 children under age 5 (unweighted) in the 2013 NDHS subsample households were eligible for anthropometric measurements. Given the law and order situation of the country during the fieldwork, it was very challenging to carry the instruments to the field in some of the northern states. There was an overall 4 percent nonresponse rate for children with respect to height and weight measurements. Eighty-eight percent of the measurements carried out for children were valid. The following analysis focuses on the 26,190 children for whom valid and complete information on date of birth, height (in centimetres), and weight (in kilograms) is available. 11.1.3 Measures of Child Nutritional Status Height-for-age Table 11.1 presents the nutritional status of children under age 5 by various background characteristics. Nationally, 37 percent of children under age 5 are stunted, and 21 percent are severely stunted. Analysis by age groups shows that stunting increases with age, peaking at 46 percent among children age 24-35 months (Figure 11.1). Severe stunting shows a similar pattern, with the highest proportion of severe stunting in children age 24-35 months (27 percent). Stunting is higher in male children (39 percent) than in female children (35 percent). Stunting is higher among children with a preceding birth interval of less than 24 months (41 percent) than among children who were first births and children with a preceding birth interval of 24-47 months or 48 months or more. Nearly one half of children (46 percent) whose perceived size at birth (as reported by the mother) was very small or small are stunted. Mothers’ nutritional status, as measured by their body mass index, also has an impact on the level of stunting in their children. Children whose mothers are thin (BMI less than 18.5) have the highest levels of stunting (48 percent), while those whose mothers are overweight or obese (BMI of 25 or above) have the lowest levels (25 percent). Children in rural areas are more likely to be stunted (43 percent) than those in urban areas (26 percent), and the pattern is similar for severe stunting (26 percent in rural areas and 13 percent in urban areas). The North West has the highest proportion of children who are stunted (55 percent), followed by the North East (42 percent) and North Central (29 percent). At the state level, Kebbi has the highest proportion of stunted children (61 percent), while Enugu has the lowest proportion (12 percent). Mother’s level of education generally has an inverse relationship with stunting; stunting ranges from a low of 13 percent among children whose mothers have a higher education to 50 percent among those whose mothers have no education. A similar inverse relationship is observed between household wealth and stunting. Children in the poorest households are three times as likely to be stunted (54 percent) as children in the wealthiest households (18 percent). 178 • Nutrition of Children and Women Table 11.1 Nutritional status of children Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for- height, and weight-for-age, by background characteristics, Nigeria 2013 Height-for-age1 Weight-for-height Weight-for-age Number of children Background characteristic Percent- age below -3 SD Percent- age below -2 SD2 Mean Z- score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z- score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z- score (SD) Age in months <6 7.8 15.7 -0.0 11.8 24.8 7.2 -0.8 7.4 17.0 2.5 -0.7 2,433 6-8 12.1 22.6 -0.5 11.4 25.3 3.9 -1.1 12.9 29.2 0.9 -1.2 1,489 9-11 16.9 28.7 -0.9 11.1 27.3 4.1 -1.1 13.0 31.2 0.7 -1.3 1,394 12-17 20.6 35.3 -1.3 11.0 25.7 2.2 -1.1 14.6 32.1 0.7 -1.4 2,955 18-23 24.1 41.0 -1.6 8.3 18.9 3.1 -0.7 13.2 29.2 1.4 -1.3 2,210 24-35 27.4 45.7 -1.8 8.8 15.7 3.9 -0.5 14.7 32.4 1.3 -1.3 4,961 36-47 25.3 42.8 -1.7 8.1 14.2 3.7 -0.5 12.2 29.4 0.7 -1.3 5,386 48-59 19.7 37.3 -1.6 5.1 11.8 4.0 -0.4 7.2 27.1 0.9 -1.2 5,361 Sex Male 22.6 38.6 -1.5 9.3 18.9 3.7 -0.7 12.4 30.2 0.9 -1.3 13,045 Female 19.6 35.0 -1.3 8.0 17.2 4.2 -0.6 10.8 27.3 1.2 -1.2 13,144 Birth interval in months3 First birth4 18.7 33.3 -1.2 8.1 17.1 3.8 -0.7 9.8 25.8 1.3 -1.2 4,670 <24 24.6 41.4 -1.6 8.5 17.8 4.2 -0.6 13.6 31.8 1.1 -1.3 4,312 24-47 21.8 38.0 -1.4 9.3 19.1 3.9 -0.7 12.1 29.8 0.9 -1.3 11,792 48+ 17.6 31.8 -1.1 9.1 18.7 3.9 -0.7 10.9 26.5 1.4 -1.2 3,671 Size at birth3 Very small 29.3 45.6 -1.7 15.7 28.7 5.1 -1.0 23.7 43.3 1.7 -1.7 948 Small 26.9 44.3 -1.7 11.0 21.9 4.5 -0.8 15.9 36.8 1.3 -1.6 2,426 Average or larger 20.0 35.4 -1.3 8.4 17.6 3.8 -0.6 10.8 27.3 1.0 -1.2 20,727 Missing 20.9 41.3 -1.7 6.2 14.5 3.4 -0.5 10.8 29.5 1.1 -1.3 334 Mother’s interview status Interviewed 21.1 36.8 -1.4 8.9 18.5 3.9 -0.7 11.8 28.9 1.1 -1.3 24,444 Not interviewed but in household 21.4 34.7 -1.4 5.4 11.6 7.5 -0.3 9.6 24.2 1.6 -1.0 315 Not interviewed and not in the household5 21.6 38.1 -1.5 5.3 11.9 3.9 -0.4 9.8 26.6 1.3 -1.1 1,431 Mother’s nutritional status6 Thin (BMI <18.5) 29.7 47.6 -1.9 9.7 23.6 3.2 -1.0 17.9 42.7 0.8 -1.8 1,763 Normal (BMI 18.5-24.9) 22.4 38.6 -1.4 9.4 19.7 3.7 -0.7 12.4 30.7 0.9 -1.4 13,131 Overweight/obese (BMI ≥25) 13.5 25.4 -0.9 7.0 14.7 4.1 -0.5 7.4 19.6 1.6 -0.9 4,885 Residence Urban 13.0 26.0 -0.9 8.4 17.6 3.2 -0.7 8.8 22.9 1.3 -1.0 9,725 Rural 25.9 43.2 -1.6 8.8 18.3 4.4 -0.6 13.3 32.2 1.0 -1.4 16,465 Zone North Central 14.3 29.3 -1.1 4.3 11.7 3.6 -0.4 6.1 18.5 1.3 -0.9 3,764 North East 23.6 42.3 -1.5 9.3 19.5 4.1 -0.7 11.1 30.8 1.3 -1.3 4,286 North West 36.2 54.8 -2.2 15.3 27.1 5.3 -0.9 22.6 47.4 0.5 -1.9 9,049 South East 5.8 16.0 -0.5 4.4 11.9 2.6 -0.5 2.5 11.4 0.9 -0.6 2,455 South South 8.3 18.3 -0.5 3.6 11.1 4.5 -0.4 3.4 12.8 2.4 -0.6 2,619 South West 8.5 22.2 -0.9 3.0 10.0 1.6 -0.5 3.8 14.9 1.2 -0.8 4,016 State North Central FCT-Abuja 9.0 20.6 -0.6 5.0 13.8 3.8 -0.4 3.4 12.6 2.3 -0.6 184 Benue 10.4 22.6 -0.8 1.4 7.8 2.7 -0.2 3.5 11.3 0.8 -0.6 838 Kogi 10.7 23.1 -0.8 2.8 9.5 1.6 -0.4 2.9 14.6 1.3 -0.8 362 Kwara 10.1 27.1 -1.2 1.4 6.5 4.2 -0.2 3.3 13.8 1.1 -0.9 383 Nasarawa 19.9 34.5 -1.3 3.5 9.8 6.5 -0.2 5.7 20.9 1.4 -0.9 398 Niger 16.9 34.2 -1.2 8.0 17.7 2.8 -0.8 10.6 26.0 1.4 -1.3 1,183 Plateau 18.5 35.8 -1.3 4.4 10.5 5.9 -0.2 5.5 19.9 1.8 -0.9 416 North East Adamawa 12.7 34.3 -1.3 5.2 14.5 1.9 -0.6 7.8 23.1 0.3 -1.2 645 Bauchi 30.9 50.8 -1.9 8.6 23.3 1.2 -0.9 15.9 40.6 0.2 -1.7 1,024 Borno 13.7 26.8 -0.4 17.9 28.2 5.2 -1.0 7.6 23.3 2.9 -0.9 760 Gombe 27.2 47.5 -1.8 5.9 14.2 3.3 -0.6 11.9 32.0 0.6 -1.4 473 Taraba 23.8 43.4 -1.6 2.4 7.9 3.2 -0.2 6.8 24.5 1.1 -1.1 675 Yobe 31.1 49.3 -1.8 13.3 23.6 10.7 -0.5 14.6 36.6 2.6 -1.4 709 North West Jigawa 41.5 59.0 -2.2 7.8 17.0 5.0 -0.6 18.3 44.1 1.1 -1.7 1,147 Kaduna 41.7 56.6 -2.4 27.6 41.7 5.6 -1.4 36.9 57.6 0.4 -2.3 1,054 Kano 31.1 48.3 -1.9 25.1 39.7 2.5 -1.6 29.0 58.0 0.5 -2.2 2,372 Katsina 38.0 58.5 -2.2 12.0 24.3 5.5 -0.8 20.8 46.0 0.5 -1.9 1,358 Kebbi 42.7 60.6 -2.5 9.4 18.1 11.6 -0.3 17.5 39.0 0.4 -1.6 889 Sokoto 30.8 51.6 -2.1 8.8 19.3 6.8 -0.6 12.3 37.7 0.4 -1.6 929 Zamfara 33.5 55.9 -2.2 6.1 16.2 4.5 -0.5 15.7 37.0 0.2 -1.6 1,301 Continued… Nutrition of Children and Women • 179 Table 11.1—Continued Height-for-age1 Weight-for-height Weight-for-age Number of children Background characteristic Percent- age below -3 SD Percent- age below -2 SD2 Mean Z- score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z- score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z- score (SD) South East Abia 6.2 17.3 -0.6 4.8 11.0 1.2 -0.6 2.3 11.6 0.7 -0.7 299 Anambra 9.2 18.4 -0.4 9.2 17.3 7.4 -0.4 4.0 14.1 0.9 -0.6 498 Ebonyi 6.1 16.2 -0.6 3.2 10.5 1.2 -0.5 3.0 12.4 0.7 -0.7 671 Enugu 2.5 11.7 -0.3 2.0 8.9 1.6 -0.4 1.1 7.1 1.9 -0.4 495 Imo 4.7 16.9 -0.5 3.5 11.8 1.3 -0.6 2.0 11.6 0.2 -0.7 493 South South Akwa Ibom 10.9 22.4 -0.8 2.7 10.5 2.7 -0.5 4.5 15.1 0.9 -0.8 424 Bayelsa 8.8 20.5 -0.5 1.3 5.2 3.2 -0.2 1.4 10.0 1.4 -0.5 217 Cross River 8.5 21.7 -0.8 3.1 9.8 1.1 -0.5 3.9 14.8 0.6 -0.8 514 Delta 8.6 14.9 -0.4 7.2 17.0 3.8 -0.6 4.3 15.4 0.6 -0.7 493 Edo 6.8 15.8 -0.5 3.6 10.5 8.9 -0.2 3.1 7.6 3.3 -0.5 349 Rivers 6.8 16.1 -0.2 2.8 10.5 7.1 -0.4 2.4 11.4 6.3 -0.4 622 South West Ekiti 7.3 19.2 -0.8 2.3 8.3 1.3 -0.3 2.9 10.4 0.6 -0.6 188 Lagos 6.3 17.0 -0.4 3.8 11.3 1.7 -0.6 3.0 12.9 1.8 -0.6 1,141 Ogun 9.9 23.8 -1.0 4.6 10.0 1.3 -0.6 4.5 18.3 0.4 -1.0 677 Ondo 10.4 24.0 -1.1 1.7 6.6 2.3 -0.4 2.9 13.4 0.5 -0.9 523 Osun 7.9 20.5 -0.7 3.3 11.1 3.0 -0.4 2.2 11.5 3.2 -0.7 429 Oyo 9.6 27.2 -1.2 1.9 10.1 0.9 -0.5 5.4 17.7 0.7 -1.0 1,059 Mother’s education7 No education 31.1 49.7 -1.9 11.9 22.7 5.0 -0.8 17.3 39.7 0.9 -1.6 11,534 Primary 17.1 33.1 -1.3 6.7 16.0 3.3 -0.6 9.4 24.4 1.0 -1.2 4,971 Secondary 10.1 22.6 -0.8 6.2 14.3 2.6 -0.6 5.8 17.7 1.2 -0.9 6,736 More than secondary 6.4 13.3 -0.3 4.6 11.0 4.0 -0.4 3.6 10.0 2.5 -0.5 1,515 Wealth quintile Lowest 33.8 53.8 -2.0 10.5 21.9 4.9 -0.7 17.3 41.9 0.7 -1.7 5,684 Second 28.5 46.1 -1.8 10.2 19.7 4.7 -0.7 15.6 34.8 1.0 -1.5 5,758 Middle 19.3 35.1 -1.3 8.5 16.8 3.9 -0.6 10.3 25.7 1.0 -1.2 5,073 Fourth 12.2 26.3 -1.0 7.6 16.7 2.8 -0.7 7.9 22.1 0.9 -1.1 4,970 Highest 7.9 18.0 -0.6 5.9 13.9 3.2 -0.6 5.4 15.6 1.9 -0.7 4,704 Total 21.1 36.8 -1.4 8.7 18.0 4.0 -0.7 11.6 28.7 1.1 -1.3 26,190 Note: Table is based on children who stayed in the household on 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. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. 1 Recumbent length is measured for children under age 2 and in the few cases when the age of the child is unknown and the child is less than 85 cm; standing height is measured for all other children. 2 Includes children who are below -3 standard deviations (SD) from the WHO child growth standards population median 3 Excludes children whose mothers were not interviewed 4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 5 Includes children whose mothers are deceased 6 Excludes children whose mothers were not weighed and measured, children whose mothers were not interviewed, and children whose mothers are pregnant or gave birth within the preceding 2 months. Mother’s nutritional status in terms of BMI (body mass index) is presented in Table 11.8. 7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. Excludes 3 cases with missing information on mother’s education. Weight-for-height Table 11.1 also shows the nutritional status of children less than age 5 as measured by weight-for- height. Overall, 18 percent of children in Nigeria are wasted. Disaggregation of wasting by child’s age shows that wasting is highest (27 percent) among children age 9-11 months and lowest (12 percent) among children age 48-59 months. Male children are more likely to be wasted (19 percent) than female children (17 percent). As expected, the data show a linear relationship between wasting and perceived size of the baby at birth. Wasting is higher (29 percent) among children who were reported to be very small at birth than among those whose perceived size at birth was small, average, or large. Twenty-four percent of children born to mothers who are thin (BMI less than 18.5) are wasted, as compared with 15 percent of those born to mothers who are overweight or obese (BMI of 25 or above). An equal proportion of children in urban and rural areas are wasted (18 percent each). Wasting is generally high in the North West (27 percent) and North East (20 percent) and is lowest in the South West (10 percent). In general, there is an inverse relationship between mother’s level of education and wasting, with the lowest proportion of wasting among children of mothers with a higher education (11 percent) and the 180 • Nutrition of Children and Women highest proportion among children of mothers with no education (23 percent). There is a similar inverse relationship between household wealth and wasting. Four percent of Nigerian children are overweight. Weight-for-age As shown in Table 11.1, 29 percent of children under age 5 are underweight (weight-for-age below -2 SD), and 12 percent are severely underweight. The proportion of underweight children is highest (32 percent) among those age 12-17 months and those age 24-35 months. Male children are more likely to be underweight (30 percent) than female children (27 percent). Similar to wasting, underweight shows a strong relationship with perceived size of the baby at birth. Children reported to be very small or small at birth are much more likely to be underweight (43 percent and 37 percent, respectively) than children reported to be average or large at birth (27 percent). Children born to mothers who are thin (BMI less than 18.5) are more likely to be underweight (43 percent) than children born to mothers who are overweight or obese (20 percent). Rural children are more likely to be underweight (32 percent) than urban children (23 percent). Fifty-eight percent of children in Kano and Kaduna are underweight, as compared with only 7 percent in Enugu and 8 percent in Edo. Figure 11.1 Nutritional status of children by age 0 5 10 15 20 25 30 35 40 45 50 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Percent Age (months) Stunted Wasted Underweight 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. NDHS 2013 As with wasting and stunting, mother’s education is associated with underweight. Children born to mothers with no education (40 percent) are four times as likely to be underweight as children born to mothers with a higher education (10 percent). A similar inverse relationship is observed between household wealth and percentage of underweight children: children in the poorest households are almost three times more likely to be underweight (42 percent) than children in the wealthiest households (16 percent). 11.1.4 Trends in Children’s Nutritional Status Trends in the nutritional status of children for the period 2008 to 2013 are shown in Figure 11.2. For the purpose of assessing trends, the data from the 2003 NDHS were recalculated using the WHO child growth standards adopted in 2006. One of the Millennium Development Goal 4 targets is to reduce the proportion of underweight children under age 5 to 20 percent by 2015 (Federal Republic of Nigeria, 2010a). Nutrition of Children and Women • 181 Figure 11.2 Trends in nutritional status of children under age 5, 2003-2013 42 11 24 6 41 14 23 9 37 18 29 4 Stunting (height-for-age) Wasting (weight-for-height) Underweight (weight-for-age) Overweight Percent 2003 NDHS 2008 NDHS 2013 NDHS Note: The data for all three surveys are based on the WHO child growth standards adopted in 2006. In general, the nutritional status of children in Nigeria has gradually improved over the last decade. The proportion of children who are stunted declined from 41 percent in 2008 to 37 percent in 2013. However, the extent of wasting has worsened, indicating a more recent nutritional deficiency among children in the country. 11.2 BREASTFEEDING AND COMPLEMENTARY FEEDING Feeding practices play a critical role in child development. Poor feeding practices can adversely impact the health and nutritional status of children, which in turn has direct consequences for their mental and physical development. Duration and intensity of breastfeeding also affect a mother’s period of postpartum infertility and, hence, the length of the birth interval and fertility levels. 11.2.1 Initiation of Breastfeeding Early initiation of breastfeeding is important for both the mother and the child. Early suckling stimulates the release of prolactin, which helps in the production of milk, and oxytocin, which is responsible for the ejection of milk. It also stimulates contraction of the uterus after childbirth and reduces postpartum blood loss. The first liquid to come from the breast, known as colostrum, is produced in the first few days after delivery. Colostrum is highly nutritious and contains antibodies that provide natural immunity to the infant. It is recommended that children be fed colostrum immediately after birth (within one hour) and that they continue to be exclusively breastfed even if the regular breast milk has not yet started to flow. Table 11.2 shows the percentage of last-born children born in the two years preceding the survey according to whether they were ever breastfed, when they began breastfeeding, and whether they were fed anything other than breast milk prior to the commencement of breastfeeding. Ninety-eight percent of children were reported to have been breastfed at some time. Differences in the proportion of children ever breastfed by background characteristics are minor. One of the goals of the 2008 national infant and young child feeding (IYCF) strategy was to increase the percentage of newborns who are breastfed. The Saving Newborn Lives program reports that Nigeria has one of the poorest exclusive breastfeeding rates in Africa. Efforts are being made to help mothers by increasing community awareness about the benefits of early and exclusive breastfeeding and addressing harmful practices, such as discarding colostrum that may prevent optimal infant feeding (Federal Ministry of Health, 2011). However, the 2013 NDHS results show that only a third of children were breastfed within one hour of birth. Seventy-four percent of children were breastfed within one day of birth. 182 • Nutrition of Children and Women Table 11.2 Initial breastfeeding Among last-born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth, and among last-born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, Nigeria 2013 Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Background characteristic Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 97.4 33.0 73.3 6,287 58.7 6,124 Female 98.3 33.3 74.1 6,185 58.4 6,083 Assistance at delivery Health professional3 97.5 39.2 80.1 5,288 44.4 5,157 Traditional birth attendant 98.6 31.5 69.5 2,756 69.1 2,718 Other 97.9 29.5 70.9 2,734 67.1 2,678 No one 98.5 23.1 65.4 1,640 71.7 1,616 Missing 69.0 18.7 51.7 56 (74.4) 38 Place of delivery4 Health facility 97.4 40.1 80.5 4,655 43.3 4,535 At home 98.3 29.1 69.8 7,781 67.6 7,652 Other * * * 15 * 15 Residence Urban 97.7 40.1 83.0 4,404 48.2 4,304 Rural 97.9 29.4 68.6 8,069 64.2 7,902 Zone North Central 98.2 46.7 77.6 1,692 49.3 1,662 North East 98.0 37.9 67.1 2,152 73.0 2,109 North West 98.3 25.7 69.7 4,554 68.3 4,475 South East 97.4 32.6 75.7 1,150 53.4 1,120 South South 96.8 42.5 77.5 1,191 46.5 1,153 South West 97.4 27.7 84.7 1,733 35.5 1,687 State North Central FCT-Abuja 98.9 51.3 85.5 75 51.7 74 Benue 98.2 47.7 90.1 374 36.7 367 Kogi 98.4 73.6 94.1 168 44.1 165 Kwara 98.8 71.4 94.9 161 40.5 159 Nasarawa 97.1 40.9 75.4 197 40.1 191 Niger 98.9 31.2 54.6 514 69.7 508 Plateau 96.6 45.8 84.7 204 39.4 197 North East Adamawa 97.7 33.3 66.5 289 63.8 282 Bauchi 97.5 31.7 62.7 573 87.9 558 Borno 99.7 67.8 79.4 408 58.0 407 Gombe 97.1 48.2 70.3 231 79.1 225 Taraba 98.0 14.4 79.6 300 50.9 294 Yobe 97.8 30.6 47.8 350 88.9 342 North West Jigawa 98.0 13.7 57.5 608 68.8 596 Kaduna 98.2 35.6 92.4 496 63.2 487 Kano 97.6 40.9 69.0 1,188 78.2 1,160 Katsina 99.3 18.2 82.6 688 71.2 683 Kebbi 97.9 8.3 77.4 479 45.5 469 Sokoto 99.5 40.8 67.4 444 91.2 442 Zamfara 98.0 12.3 47.1 652 51.7 639 South East Abia 96.7 63.9 86.8 135 40.7 131 Anambra 97.0 39.7 77.3 245 52.0 237 Ebonyi 96.5 17.3 76.0 313 46.8 302 Enugu 98.9 24.6 64.9 230 63.3 227 Imo 97.6 35.2 77.8 228 61.2 222 South South Akwa Ibom 97.7 43.7 69.3 202 32.3 198 Bayelsa 97.2 27.4 60.4 95 73.9 92 Cross River 99.1 32.8 85.6 221 55.5 219 Delta 95.1 47.2 83.7 220 47.5 210 Edo 97.1 54.8 83.0 168 37.4 163 Rivers 95.6 43.4 74.5 285 44.8 272 Continued… Nutrition of Children and Women • 183 Table 11.2—Continued Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Background characteristic Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last-born children ever breastfed South West Ekiti 95.6 21.2 78.8 78 14.8 75 Lagos 96.8 20.0 79.5 519 43.4 502 Ogun 97.3 30.8 83.3 294 28.0 286 Ondo 95.7 38.1 81.5 225 40.1 215 Osun 98.9 28.0 91.9 189 25.0 187 Oyo 98.6 30.4 91.6 428 37.3 422 Mother’s education No education 98.3 28.7 66.3 5,940 71.1 5,837 Primary 97.0 35.0 79.7 2,253 53.0 2,186 Secondary 97.8 37.5 80.9 3,466 45.9 3,390 More than secondary 97.3 42.7 80.7 815 35.9 793 Wealth quintile Lowest 97.9 22.4 59.6 2,888 73.8 2,828 Second 98.2 29.9 71.0 2,842 62.7 2,791 Middle 97.8 36.2 79.0 2,360 56.3 2,307 Fourth 97.7 41.5 81.8 2,247 52.5 2,195 Highest 97.6 40.2 81.9 2,135 41.1 2,084 Total 97.9 33.2 73.7 12,473 58.6 12,206 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children were living or dead at the time of the interview. 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 Includes children who started breastfeeding within 1 hour of birth 2 Children given something other than breast milk during the first 3 days of life 3 Doctor, nurse/midwife, or auxiliary midwife 4 Excludes 5 cases with missing information on place of delivery The government has introduced Maternal Newborn Child Health Week along with other interventions designed to encourage exclusive breastfeeding for the first six months of life, early initiation of breastfeeding with colostrum, timely and appropriate complementary feeding practices, and adequate micronutrient intake (particularly twice-a-year vitamin A, iron, iodine, and zinc supplementation and deworming for children above age 12 months). These key nutrition-specific interventions will be scaled up in health facilities across the nation (National Primary Healthcare Development Agency, 2012). The prevalence of early initiation of breastfeeding (within one hour) varies according to specific background characteristics, including area of residence (40 percent in urban areas and 29 percent in rural areas). There are also zonal differences, with the highest proportion in the North Central zone (47 percent) and the lowest in the North West (26 percent). Early initiation of breastfeeding differs according to place of delivery as well (40 percent among children born in a health facility and 29 percent among those delivered at home). Last-born children of mothers with a higher education are more likely to be breastfed within an hour of birth and within the first day than other children. Women from the higher wealth quintiles are more likely to start breastfeeding within an hour of birth than women from the lowest quintile. The practice of providing a prelacteal feed is discouraged because it limits the frequency of suckling by the infant and exposes the baby to the risk of infection. The data show that 59 percent of newborns were given something other than breast milk (prelacteal feed) during the first three days of life. There are differences among children who are given a prelacteal feed by place of birth (43 percent for those born in a health facility and 68 percent for those born at home). Prelacteal feeding is more common among newborns whose mothers have no education (71 percent) than among newborns whose mothers have a higher education (36 percent). Prelacteal feeding is most common (74 percent) among children in the lowest wealth quintile and least prevalent among those in the highest quintile (41 percent). 184 • Nutrition of Children and Women Although discouraged, the practice of giving a prelacteal feed has increased from 56 percent in 20081 to 59 percent in 2013. Some mothers lack antenatal counselling, and some have obstetric complications necessitating that they introduce prelacteal feeding (Federal Ministry of Health, 2005). 11.2.2 Breastfeeding Status by Age UNICEF and WHO recommend that children be exclusively breastfed (no other liquid, solid food, or plain water) during the first six months of life (WHO/UNICEF, 2002; Pan American Health Organization [PAHO]/WHO, 2003). Also, recent evidence suggests that suboptimal breastfeeding can increase the risk of mortality for children in the first two years of life (Black et al., 2013). Nigeria’s national nutrition strategy promotes exclusive breastfeeding through age 6 months (National Planning Commission, 2012) and, thereafter, the introduction of semisolid or solid foods along with continued breast milk until the child is at least age 2. Introducing breast milk substitutes to infants before age 6 months can displace exclusive breastfeeding. Substitutes such as formula, other kinds of milk, and porridge are often inadequate in nutrients and calories. Furthermore, possible contamination of these substitutes exposes infants to the risk of illness. After six months, a child requires adequate complementary foods for normal growth. Lack of appropriate complementary feeding may lead to undernutrition and frequent illness, which in turn may lead to death. However, even with complementary feeding, children should continue to be breastfed for two years or more. The 2013 NDHS used a 24-hour recall method to collect data on infant and young child feeding for all last-born children under age 2 living with their mothers. Table 11.3 shows the percentage of youngest children under age 2 by breastfeeding status and the percentage using a bottle with a nipple, according to age in months. Although only 17 percent of children under age 6 months are exclusively breastfed, this is an improvement from the 2008 NDHS, when the figure was 13 percent. As can be seen in Figure 11.3 and Table 11.3, supplementing breast milk with water, other liquids, or foods starts at an early age in Nigeria. More than half of children received water in addition to breast milk in the first three months of life. Furthermore, contrary to the recommendation of exclusive breastfeeding, 47 percent of children under age 6 months were given plain water, 5 percent received other milk, and 23 percent were fed complementary foods in addition to breast milk. Table 11.3 also shows complementary feeding practices among breastfeeding children of different ages. Contrary to recommendations, 9 percent of children age 0-1 month, 16 percent of children age 2-3 months, and 38 percent of children age 4-5 months are given complementary foods in addition to breast milk. Although children age 6-8 months should receive solid/semisolid foods, Table 11.3 shows that only 64 percent received complementary feeding the day or night preceding the survey in addition to breast milk. The data show that 16 percent of infants less than age 6 months are fed using a bottle with a nipple. 1 The data for the 2008 NDHS were rerun to allow a comparison of this indicator. In 2008, this information was derived for children born in the five years preceding the survey, whereas in 2013 it was calculated for last-born children in the two years preceding the survey. Nutrition of Children and Women • 185 Table 11.3 Breastfeeding status by age Percent distribution of youngest children under age 2 who are living with their mother by breastfeeding status and the percentage currently breastfeeding, and the percentage of all children under age 2 using a bottle with a nipple, according to age in months, Nigeria 2013 Not breast- feeding Breastfeeding status Total Percentage currently breast- feeding Number of youngest children under age 2 living with their mother Percentage using a bottle with a nipple Number of all children under age 2 Age in months Exclusively breastfed Breast- feeding and consuming plain water only Breast- feeding and consuming non-milk liquids1 Breast- feeding and consuming other milk Breast- feeding and consuming comple- mentary foods 0-1 2.9 26.1 54.7 5.1 2.5 8.7 100.0 97.1 776 15.9 802 2-3 4.6 18.9 51.2 4.0 5.8 15.5 100.0 95.4 1,029 15.5 1,046 4-5 4.3 10.0 36.7 4.9 5.7 38.3 100.0 95.7 1,125 16.7 1,141 6-8 4.5 3.3 20.1 4.1 4.3 63.6 100.0 95.5 1,657 17.4 1,682 9-11 9.1 0.9 6.8 2.5 1.7 78.9 100.0 90.9 1,555 15.6 1,581 12-17 21.5 0.5 3.7 1.5 0.2 72.6 100.0 78.6 3,312 10.9 3,411 18-23 58.1 0.2 1.4 0.5 0.2 39.6 100.0 41.9 2,294 6.6 2,489 0-3 3.9 22.0 52.7 4.5 4.4 12.6 100.0 96.1 1,805 15.6 1,848 0-5 4.1 17.4 46.6 4.6 4.9 22.5 100.0 95.9 2,930 16.1 2,989 6-9 5.2 2.9 17.0 3.8 3.9 67.1 100.0 94.8 2,201 16.8 2,235 12-15 16.0 0.6 4.0 1.7 0.3 77.6 100.0 84.0 2,378 11.9 2,439 12-23 36.4 0.4 2.7 1.1 0.2 59.1 100.0 63.6 5,606 9.1 5,900 20-23 64.7 0.1 1.1 0.6 0.2 33.2 100.0 35.3 1,465 6.3 1,621 Note: Breastfeeding status refers to a “24-hour” period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semisolids) are hierarchical and mutually exclusive, and their percentages sum to 100 percent. Thus, children who receive breast milk and non-milk liquids and who do not receive other milk and 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 Non-milk liquids include juice, juice drinks, clear broth, or other liquids. Figure 11.3 Infant feeding practices by age 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months Not breastfeeding Breast milk and complementary foods Breast milk and other milk Breast milk and non-milk liquids/juice Breast milk and plain water only Exclusively breastfed NDHS 2013 186 • Nutrition of Children and Women Figure 11.4 shows the 2013 NDHS results for key IYCF breastfeeding practices among children under age 2 who are living with their mothers. Seventeen percent of children under age 6 months are exclusively breastfed, while only 10 percent are exclusively breastfed up to 4-5 months. Eighty-four percent continue breastfeeding at age 1, and 35 percent continue to breastfeed until age 2. Sixty-seven percent of children start receiving complementary foods at the appropriate age of 6-8 months. Fifty-two percent of children age 0-23 months are breastfed appropriately for their age (i.e., exclusive breastfeeding for children age 0-5 months and continued breastfeeding along with complementary foods for children age 6-23 months). Sixty-nine percent of children are predominantly breastfed (breast milk and only plain water or non-milk liquids such as juice, clear broth, and other liquids); 13 percent of children under age 2 are bottle fed. Figure 11.4 IYCF indicators on breastfeeding status 17 10 84 67 35 52 69 13 Exclusive breastfeeding under age 6 months Exclusive breastfeeding at age 4-5 months Continued breastfeeding at 1 year Introduction of solid, semisolid, or soft foods (6-8 months) Continued breastfeeding at 2 years Age-appropriate breastfeeding (0-23 months) Predominant breastfeeding (0-5 months) Bottle feeding (0-23 months) Percentage of children NDHS 2013 11.2.3 Duration of Breastfeeding Table 11.4 provides information on the median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey by selected background characteristics. The median duration of any breastfeeding in Nigeria is 18.3 months. Median duration of breastfeeding is higher among children residing in rural areas (19.5 months), children of mothers with no education (21.0 months), and those in the lowest wealth quintile (21.4 months). The median duration of breastfeeding is highest in the North West (21.0 months) and lowest in the South East (14.1 months). The mean duration of any breastfeeding for all children is 18.2 months. Table 11.4 also shows that the median duration of exclusive breastfeeding is 0.5 months, which indicates that 50 percent of infants do not exclusively breastfeed for even a month. The median duration of breastfeeding has remained the same in the last five years. However, the median duration of predominant breastfeeding is slightly higher than in 2008 (4.4 months versus 3.0 months). Nutrition of Children and Women • 187 Table 11.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the 3 years preceding the survey, by background characteristics, Nigeria 2013 Median duration (months) of breastfeeding among children born in the past three years1 Background characteristic Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 18.1 0.5 4.0 Female 18.5 0.5 4.6 Residence Urban 16.5 0.6 4.5 Rural 19.5 0.5 4.3 Zone North Central 18.2 0.5 3.4 North East 20.1 0.5 5.1 North West 21.0 0.4 5.0 South East 14.1 0.6 3.0 South South 14.5 0.6 2.6 South West 16.1 0.9 4.7 Mother’s education No education 21.0 0.4 4.7 Primary 17.8 0.5 4.1 Secondary 15.6 0.6 4.1 More than secondary 14.5 1.5 3.8 Wealth quintile Lowest 21.4 0.4 4.9 Second 20.0 0.5 4.5 Middle 17.7 0.5 3.9 Fourth 17.1 0.6 4.0 Highest 15.0 1.1 4.4 Total 18.3 0.5 4.4 Mean for all children 18.2 1.8 5.8 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. State- level disaggregation is not shown because of the small number of cases. 1 It is assumed that non-last-born children and last-born children not currently living with their mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water and/or non-milk liquids only 11.2.4 Types of Complementary Foods It is recommended that complementary foods (solid or semisolid foods fed to infants in addition to breast milk) be started at age 6 months. The reason is that, at this age, breast milk alone is no longer sufficient to maintain the child’s recommended daily nutritional requirements and enhance growth. Children are fed small quantities of solid and semisolid foods while continuing to breastfeed up to age 2 or beyond. The amount of food is increased gradually from 6 to 23 months, the period of transition to eating the regular family diet. This period is characterised by an increase in the prevalence of malnutrition because of poor feeding practices and infections. Table 11.5 shows the percentage of youngest children under age 2 who are living with their mother by types of foods consumed in the day or night preceding the interview, according to breastfeeding status and age. The data show that, contrary to WHO recommendations, the practice of feeding children liquids other than milk and giving them solid or semisolid foods starts early in life. Nine percent of breastfeeding children have received a liquid (not plain water) other than infant formula or other types of milk by age 2-3 months. Sixteen percent of breastfeeding children have received some kind of solid or semisolid food by age 2-3 months, and this proportion increases to 40 percent by age 4-5 months. 188 • Nutrition of Children and Women Overall, 85 percent of breastfed children age 6-23 months received solid or semisolid complementary foods in addition to breast milk. These complementary foods included fortified baby foods (5 percent), foods made from grains (64 percent), fruits and vegetables rich in vitamin A (31 percent), other fruits and vegetables (12 percent), and food made from roots and tubers (13 percent). Children were also fed protein-rich foods such as legumes and nuts (20 percent); meat, fish, and poultry (23 percent); and eggs (11 percent). Fifteen percent of children were given cheese, yogurt, and other milk products. In addition, 10 percent of children in this age group were given other milk, and 38 percent were given other liquids. Use of infant formula was minimal (5 percent). Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age 2 who are living with their mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Nigeria 2013 Liquids Solid or semisolid foods Any solid or semi- solid food Number of children 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 Eggs Cheese, yogurt, other milk products BREASTFEEDING CHILDREN 0-1 2.0 2.4 8.7 0.6 1.8 1.1 0.2 0.3 0.4 0.3 0.0 4.9 9.0 754 2-3 5.2 3.8 9.2 0.5 4.8 2.7 0.8 1.7 1.0 1.4 1.2 4.1 16.3 981 4-5 6.8 6.7 19.2 4.3 16.3 4.4 1.7 2.2 3.2 3.2 2.2 9.1 40.1 1,076 6-8 8.8 11.4 30.1 6.4 38.1 13.2 5.9 5.9 10.8 11.8 7.4 8.8 66.6 1,582 9-11 6.4 12.9 40.4 6.5 63.7 27.5 11.0 13.0 20.5 23.9 13.2 11.8 86.9 1,413 12-17 2.9 7.9 40.4 3.5 75.5 38.7 14.2 15.1 24.7 27.7 11.6 19.1 92.4 2,601 18-23 2.2 9.0 42.4 3.3 77.6 42.7 13.9 19.1 24.4 25.7 9.1 18.9 94.5 961 6-23 4.9 10.0 38.2 4.8 64.2 30.7 11.5 13.0 20.4 22.7 10.5 15.0 85.3 6,556 Total 4.9 8.4 30.6 4.0 47.5 22.4 8.3 9.6 14.8 16.5 7.8 12.4 66.7 9,368 NONBREASTFEEDING CHILDREN 0-1 * * * * * * * * * * * * * 23 2-3 2.6 2.0 6.8 0.0 1.9 0.9 0.0 0.0 0.0 0.0 0.0 0.0 12.8 48 4-5 13.8 6.6 19.7 7.7 13.2 1.9 5.8 2.7 8.7 3.8 5.0 6.1 36.3 49 6-8 9.8 8.5 45.3 6.4 37.9 12.8 6.1 8.4 21.4 14.2 7.2 14.7 72.1 75 9-11 11.5 23.0 39.9 9.3 62.9 33.8 16.2 19.6 26.7 38.1 16.9 15.8 85.4 142 12-17 8.8 24.5 56.4 9.3 79.3 46.1 22.8 26.1 32.9 49.9 26.6 19.0 94.5 710 18-23 4.8 16.7 49.4 5.5 82.5 47.5 23.3 29.2 33.6 50.9 26.0 17.0 98.0 1,333 6-23 6.6 19.3 50.8 7.0 78.8 45.1 22.1 26.9 32.5 48.5 25.0 17.5 95.2 2,260 Total 6.6 18.6 48.9 6.8 75.1 42.9 21.1 25.6 31.1 46.2 23.8 16.7 91.4 2,379 Note: Breastfeeding status and food consumed refer to a “24-hour” period (yesterday and last night). 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 Does not include plain water 3 Includes fortified baby food 4 Includes pumpkin, carrots, squash, red sweet potatoes, dark green leafy vegetables, ripe mangoes, paw paw, papayas, palm nuts, and other locally grown fruits and vegetables that are rich in vitamin A Ninety-five percent of nonbreastfeeding children age 6-23 months received solid or semisolid foods, as compared with 85 percent of breastfeeding children. Consumption of different types of food was also higher among nonbreastfeeding children than among breastfeeding children. 11.3 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Appropriate IYCF practices include timely initiation of feeding solid or semisolid foods at age 6 months and increasing the amount and variety of foods and frequency of feeding as the child gets older while maintaining frequent breastfeeding (WHO, 2008). Guidelines have been established for IYCF practices among children age 0-23 months (PAHO/WHO, 2003; WHO, 2005, 2008). Although breastfeeding is recommended for infants up to age 2, some infants have stopped breastfeeding before reaching age 2 because, for example, their mother is HIV positive or has died; guidelines on feeding this group of children have also been developed (WHO, 2005). Nutrition of Children and Women • 189 Appropriate nutrition includes feeding children age 6-23 months a variety of foods a desired number of times to ensure that their nutrient and caloric requirements are met. Minimum dietary diversity refers to feeding the child food from at least four food groups, a cutoff selected because of its association with better-quality diets for both breastfed and nonbreastfed children. Studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients (WHO and UNICEF, 1998). Therefore, it is recommended that meat, poultry, fish, and eggs be eaten daily or as often as possible. Fruits and vegetables rich in vitamin A should be consumed daily to achieve the proven health benefits associated with vitamin A (Allen and Gillespie, 2001). Children’s diets should include an adequate fat content, because fat provides essential fatty acids, facilitates absorption of fat-soluble vitamins (such as vitamin A), and enhances dietary energy density. It is highly likely that children consuming foods from at least four groups are consuming at least one animal source of food and at least one fruit or vegetable in addition to a staple food (grains, roots, or tubers) (WHO, 2008). These four food groups should come from the following seven categories: grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry, liver/organ meat); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Minimum dietary diversity scores may be reported separately for breastfed and nonbreastfed children. However, diversity scores for breastfed and nonbreastfed children should not be directly compared, because breast milk is not counted in any of the above-stated food groups. The recommended numbers of feedings are as follows: • Breastfed children age 6-23 months should receive animal-source foods and vitamin-A rich fruits and vegetables daily (PAHO/WHO, 2003). Breastfed infants age 6-8 months should be fed meals of complementary foods two to three times per day, with one to two snacks as desired; breastfed children age 9-23 months should be fed meals three to four times per day, with one to two snacks. • Nonbreastfed children age 6-23 months should receive milk products at least twice a day 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 acceptable number for nonbreastfed children. Nonbreastfed children should be fed meals four to five times per day, with one to two snacks as desired (WHO, 2005). Meal frequency is considered a proxy for energy intake from foods other than breast milk; therefore, the feeding frequency indicator for nonbreastfed children includes both milk feeds and solid/semisolid feeds (WHO, 2008). These minimum feeding frequencies are based on the energy needs estimated from age-specific total daily energy requirements. Infants with low breast milk intake would need to be fed more frequently. However, overly frequent feeding may lead to displacement of breast milk (PAHO/WHO, 2003). Table 11.6 and Figure 11.5 show IYCF practices according to breastfeeding status. The IYCF recommendations for children age 6-23 months take into account feeding practices that meet minimum standards with respect to: • Food diversity (the number of food groups consumed) • Feeding frequency (the number of times the child is fed) • Consumption of breast milk or other types of milk or milk products Table 11.6 shows that only about one in five children age 6-23 months (breastfed and nonbreastfed) receive the appropriately diverse diet; 58 percent of children are fed the recommended number of times with solid or semisolid foods, and 79 percent are given breast milk or other milk products. Only 10 percent of children are fed in compliance with the IYCF recommendations of consuming breast milk or other milk products, having the minimum dietary diversity, and having the minimum meal frequency. 190 • Nutrition of Children and Women 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 feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night preceding the survey, by background characteristics, Nigeria 2013 Among breastfed children 6-23 months, percentage fed: Among nonbreastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: Background characteristic 4+ food groups1 Minimum meal frequency2 Both 4+ food groups and minimum meal frequency Number of breastfed children 6-23 months Milk or milk products3 4+ food groups1 Minimum meal frequency4 With 3 IYCF practices5 Number of non- breastfed children 6-23 months Breast milk, milk, or milk products6 4+ food groups1 Minimum meal frequency7 With 3 IYCF practices Number of all children 6-23 months Age in months 6-8 6.6 57.2 6.0 1,582 17.0 3.7 28.1 1.5 75 96.2 6.5 55.9 5.8 1,657 9-11 16.2 55.8 11.7 1,413 22.4 25.2 44.8 6.3 142 92.9 17.0 54.8 11.2 1,555 12-17 18.1 64.4 14.0 2,601 20.9 35.5 52.1 8.7 710 83.1 21.8 61.8 12.9 3,312 18-23 15.7 66.8 12.6 961 13.3 34.3 48.6 6.4 1,333 49.6 26.5 56.2 9.0 2,294 Sex Male 13.2 62.0 10.2 3,256 16.6 32.3 49.6 7.3 1,191 77.7 18.3 58.7 9.4 4,448 Female 15.9 60.4 12.6 3,300 16.2 34.0 47.9 6.5 1,069 79.5 20.4 57.3 11.1 4,370 Residence Urban 21.2 58.8 15.9 2,096 22.1 42.4 53.1 9.6 1,078 73.5 28.4 56.8 13.8 3,173 Rural 11.4 62.3 9.2 4,461 11.3 24.7 44.9 4.5 1,183 81.4 14.2 58.7 8.2 5,645 Zone North Central 14.1 55.0 9.2 864 13.5 30.4 34.7 5.6 321 76.6 18.5 49.5 8.2 1,185 North East 15.3 65.1 13.3 1,191 8.8 28.9 56.9 1.8 314 81.0 18.1 63.4 10.9 1,505 North West 11.0 66.1 9.7 2,798 10.6 19.2 53.5 2.2 448 87.7 12.1 64.4 8.6 3,246 South East 28.2 56.7 18.6 454 30.4 55.3 54.8 18.2 357 69.4 40.1 55.9 18.5 811 South South 25.2 62.1 19.8 474 24.9 43.4 56.5 13.0 368 67.2 33.2 59.7 16.8 842 South West 12.5 46.1 7.6 776 11.8 26.0 37.7 2.4 453 67.5 17.5 43.0 5.6 1,229 State North Central FCT-Abuja 35.9 73.3 27.8 34 43.8 51.4 72.1 21.2 22 77.9 42.0 72.8 25.2 55 Benue 16.9 61.3 16.7 160 6.5 38.2 38.2 5.0 94 65.4 24.8 52.7 12.4 255 Kogi 22.8 49.9 12.9 106 (26.7) (49.8) (56.3) (24.2) 27 85.0 28.3 51.2 15.2 133 Kwara 21.5 18.1 3.9 82 (15.6) (47.8) (4.2) (2.9) 30 77.4 28.5 14.4 3.6 112 Nasarawa 15.6 63.7 13.8 110 (11.6) (25.7) (29.3) (3.8) 29 81.5 17.7 56.5 11.7 139 Niger 4.8 63.7 1.8 264 11.1 6.7 30.6 0.0 79 79.4 5.2 56.0 1.4 343 Plateau 10.3 42.7 6.0 109 8.7 24.2 26.6 0.0 39 75.9 13.9 38.5 4.4 148 North East Adamawa 11.0 77.9 9.9 146 5.3 27.6 77.8 1.7 56 73.9 15.6 77.9 7.6 202 Bauchi 9.7 63.4 9.0 311 3.8 28.8 41.8 0.0 74 81.4 13.4 59.2 7.2 386 Borno 16.6 48.0 12.9 230 (14.3) (31.8) (53.3) (1.7) 79 78.1 20.5 49.4 10.0 308 Gombe 39.7 76.9 38.2 134 (1.5) (47.4) (69.4) (0.0) 27 83.7 41.0 75.7 31.9 160 Taraba 12.9 55.8 11.1 159 7.0 15.6 37.9 1.7 42 80.4 13.5 52.1 9.1 201 Yobe 11.2 77.0 8.6 212 (19.9) (26.8) (76.5) (7.7) 36 88.4 13.4 76.9 8.5 247 North West Jigawa 13.0 56.1 9.7 368 23.8 28.8 50.7 7.3 64 88.8 15.3 55.3 9.3 432 Kaduna 17.2 89.5 16.9 318 (24.2) (24.0) (79.4) (2.2) 68 86.7 18.4 87.8 14.3 385 Kano 11.7 63.3 10.9 732 5.0 16.8 60.5 1.1 83 90.3 12.2 63.0 9.9 815 Katsina 6.9 71.8 5.7 403 6.4 11.6 59.4 1.9 80 84.5 7.7 69.8 5.1 483 Kebbi 19.7 64.3 18.3 292 (5.1) (26.3) (37.3) (2.5) 53 85.5 20.7 60.1 15.9 344 Sokoto 8.4 75.4 8.1 263 2.4 14.5 31.5 0.0 49 84.6 9.4 68.5 6.8 312 Zamfara 2.7 52.0 1.1 421 (5.4) (13.5) (39.4) (0.0) 54 89.2 4.0 50.6 1.0 475 South East Abia 27.2 24.4 11.5 49 32.6 46.6 44.3 20.9 43 68.5 36.3 33.7 15.9 92 Anambra 30.5 42.3 18.4 84 41.1 70.5 54.8 30.8 92 69.1 51.5 48.9 24.9 176 Ebonyi 24.3 83.8 22.3 139 16.9 42.5 69.6 13.2 69 72.4 30.3 79.1 19.3 208 Enugu 42.3 43.8 23.5 96 30.8 61.7 37.5 18.2 70 70.8 50.5 41.1 21.2 167 Imo 17.1 59.6 11.7 86 28.4 47.9 62.7 6.8 82 65.0 32.1 61.1 9.3 168 South South Akwa Ibom 15.2 44.3 7.1 86 16.0 37.8 26.3 9.6 56 66.9 24.1 37.2 8.1 142 Bayelsa 23.5 73.9 22.4 37 21.0 27.4 63.3 4.7 27 66.2 25.2 69.4 14.8 64 Cross River 33.9 75.1 28.9 95 7.5 35.6 54.5 3.2 55 66.2 34.5 67.6 19.5 150 Delta 8.2 51.5 7.1 81 21.8 22.6 64.2 5.4 77 61.9 15.2 57.7 6.3 157 Edo 14.3 62.8 8.0 79 25.1 24.7 47.0 5.7 41 74.7 17.8 57.5 7.2 120 Rivers 49.6 69.0 41.6 96 40.6 74.9 69.1 29.3 112 68.0 63.2 69.0 34.9 209 South West Ekiti 13.8 32.0 1.6 34 10.1 32.6 18.9 2.6 20 66.5 20.8 27.1 2.0 54 Lagos 10.7 42.0 4.1 210 21.7 20.0 50.7 1.9 155 66.7 14.7 45.7 3.2 365 Ogun 4.3 29.9 0.0 128 5.5 13.4 22.6 0.0 84 62.6 7.9 27.0 0.0 212 Ondo 19.1 62.5 16.9 105 0.0 46.7 31.7 0.0 46 69.7 27.4 53.2 11.8 150 Osun 27.9 84.2 26.0 91 22.5 61.6 72.9 14.8 49 73.1 39.6 80.3 22.1 140 Oyo 9.2 37.8 3.9 209 2.1 17.8 19.4 0.0 100 68.4 12.0 31.9 2.6 309 Continued… Nutrition of Children and Women • 191 Table 11.6—Continued Among breastfed children 6-23 months, percentage fed: Among non-breastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: Background characteristic 4+ food groups1 Minimum meal frequency2 Both 4+ food groups and minimum meal frequency Number of breastfed children 6-23 months Milk or milk products3 4+ food groups1 Minimum meal frequency4 With 3 IYCF practices5 Number of non- breastfed children 6-23 months Breast milk, milk, or milk products6 4+ food groups1 Minimum meal frequency7 With 3 IYCF practices Number of all children 6-23 months Mother’s education No education 9.8 62.7 7.9 3,494 7.7 18.7 46.4 1.3 670 85.1 11.2 60.1 6.9 4,165 Primary 18.3 63.1 14.4 1,144 8.0 27.7 41.8 2.8 427 75.0 20.8 57.3 11.3 1,570 Secondary 20.3 57.9 15.8 1,586 21.4 41.4 51.1 9.4 890 71.7 27.9 55.5 13.5 2,477 More than secondary 24.5 53.8 16.0 333 34.8 50.0 58.5 19.1 273 70.6 36.0 55.9 17.4 606 Wealth quintile Lowest 7.9 62.2 6.6 1,732 10.3 18.6 48.8 2.7 286 87.3 9.4 60.3 6.0 2,018 Second 11.0 64.5 9.2 1,591 4.8 20.4 40.8 1.2 352 82.7 12.7 60.2 7.8 1,943 Middle 16.9 63.2 12.7 1,215 8.7 26.2 42.2 4.8 473 74.4 19.5 57.3 10.5 1,688 Fourth 21.5 58.5 17.1 1,111 17.6 38.0 51.5 5.9 497 74.5 26.6 56.3 13.7 1,609 Highest 22.1 53.8 15.6 909 30.1 47.7 56.0 14.3 652 70.8 32.8 54.7 15.0 1,561 Total 14.6 61.2 11.4 6,558 16.4 33.1 48.8 6.9 2,260 78.6 19.3 58.0 10.2 8,818 Note: Figures in parentheses are based on 25-49 unweighted cases. 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 and fortified baby food from grains; c. vitamin A-rich fruits and vegetables (and red palm oil); d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts. 2 For breastfed children, minimum meal frequency is receiving solid or semisolid food at least twice a day for infants age 6-8 months and at least 3 times a day for children age 9- 23 months. 3 Includes 2 or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 4 For nonbreastfed children age 6-23 months, minimum meal frequency is receiving solid or semisolid food or milk feeds at least 4 times a day. 5 Nonbreastfed children age 6-23 months are considered to be fed with a minimum standard of 3 IYCF practices if they receive other milk or milk products at least twice a day, receive the minimum meal frequency, and receive solid or semisolid foods from at least 4 food groups not including the milk or milk products food group. 6 Breastfeeding, or not breastfeeding and receiving 2 or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 7 Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in notes 2 and 4. The proportion of children age 6-23 months who are fed according to all three IYCF recommendations varies slightly between boys (9 percent) and girls (11 percent); there are also differences across other background characteristics. Children living in urban areas (14 percent) are more likely to be fed according to the recommendations than their rural counterparts (8 percent). Children in the South East (19 percent) and South South (17 percent) are more likely to be fed according to all three IYCF recommendations. None of the children residing in Ogun and only 1 percent in Zamfara are fed according to the IYCF recommendations. The highest prevalence of compliance with IYCF practices is observed in Rivers, and the proportion there (35 percent) is almost three times the national average. There is a positive relationship between infant and child feeding practices and mother’s education and wealth. Nonbreastfed children are more likely than breastfed children to consume a diverse diet, while higher proportions of breastfed children are fed in accordance with minimum frequency guidelines. Overall, breastfed children are more likely to be fed in compliance with minimum acceptable dietary recommendations (Figure 11.5). 192 • Nutrition of Children and Women Figure 11.5 IYCF indicators on minimum acceptable diet 15 61 11 33 49 7 19 58 10 IYCF 5: Minimum dietary diversity IYCF 6: Minimum meal frequency IYCF 7: Minimum acceptable diet Percent Among breastfed children Among nonbreastfed children Among all children 6-23 months NDHS 2013 11.4 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is a major contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, food fortification, and direct supplementation. The 2013 NDHS collected information on consumption of foods rich in vitamin A and iron and the status of children receiving vitamin A capsules, iron supplements, and deworming medication during national campaigns. Table 11.7 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey, and among all children 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 who were given deworming medication in the six months preceding the survey by background characteristics, Nigeria 2013 Among youngest children age 6-23 months living with their mother: Among all children age 6-59 months: Background characteristic Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supplements in last 6 months Percentage given iron supplements in last 7 days Percentage given deworming medication in last 6 months3 Number of children Age in months 6-8 23.9 15.9 1,657 31.7 3.9 7.0 1,682 9-11 44.2 30.4 1,555 40.6 5.9 14.1 1,581 12-17 58.3 37.7 3,312 44.4 6.1 17.8 3,411 18-23 67.2 47.0 2,294 45.3 5.8 23.2 2,489 24-35 na na na 42.5 6.3 22.2 5,490 36-47 na na na 40.2 5.6 21.5 5,722 48-59 na na na 40.6 5.3 21.5 5,586 Sex Male 51.7 35.0 4,448 41.5 5.7 20.6 13,023 Female 51.6 34.4 4,370 41.1 5.6 19.2 12,938 Breastfeeding status Breastfeeding 44.6 27.1 6,558 36.8 5.0 12.6 7,184 Not breastfeeding 72.3 56.9 2,247 43.0 5.9 22.7 18,347 Missing * * 13 42.3 7.4 23.7 430 Mother’s age at birth 15-19 43.3 23.8 674 29.4 2.9 12.2 1,124 20-29 51.3 35.2 4,496 39.6 5.3 18.2 12,284 30-39 54.0 37.2 2,997 45.3 6.2 23.3 9,895 40-49 51.7 31.6 652 39.4 6.6 18.6 2,657 Residence Urban 58.9 48.5 3,173 53.2 7.2 28.4 9,360 Rural 47.6 27.0 5,645 34.6 4.8 15.2 16,600 Continued… Nutrition of Children and Women • 193 Table 11.7—Continued Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Background characteristic Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supplements in last 6 months Percentage given iron supplements in last 7 days Percentage given deworming medication in last 6 months3 Number of children Zone North Central 53.2 39.5 1,185 44.6 10.6 17.2 3,586 North East 55.9 29.6 1,505 31.1 5.2 12.1 4,493 North West 42.8 20.2 3,246 26.1 1.7 9.0 9,448 South East 66.1 54.9 811 56.7 13.2 41.9 2,311 South South 63.8 57.7 842 64.8 5.0 44.5 2,457 South West 50.3 45.8 1,229 64.4 7.3 30.2 3,665 State North Central FCT-Abuja 72.5 62.5 55 48.4 2.3 34.4 180 Benue 75.8 64.4 255 35.4 1.1 5.1 782 Kogi 60.3 52.0 133 73.9 7.3 29.6 347 Kwara 62.6 55.3 112 71.8 3.2 27.5 336 Nasarawa 52.4 35.0 139 52.2 30.2 21.4 374 Niger 38.0 17.2 343 33.4 16.7 16.3 1,146 Plateau 29.7 20.8 148 37.6 6.5 12.4 419 North East Adamawa 55.5 36.2 202 75.8 5.9 25.6 591 Bauchi 61.9 18.7 386 36.3 13.0 13.2 1,095 Borno 51.1 35.7 308 16.2 1.7 3.5 971 Gombe 73.0 46.7 160 21.0 4.1 9.8 476 Taraba 68.2 36.8 201 31.6 0.8 19.5 608 Yobe 31.6 16.8 247 13.8 1.8 6.3 752 North West Jigawa 38.8 23.4 432 17.7 2.5 6.7 1,251 Kaduna 56.6 47.2 385 37.3 4.0 6.1 1,286 Kano 43.7 10.6 815 5.4 1.0 1.0 2,418 Katsina 43.5 9.9 483 77.1 2.7 45.2 1,382 Kebbi 50.7 37.8 344 10.7 0.2 1.4 985 Sokoto 48.1 27.1 312 17.9 0.2 2.3 901 Zamfara 24.1 4.8 475 24.5 1.1 0.5 1,225 South East Abia 65.3 51.7 92 65.9 5.8 45.5 264 Anambra 72.9 63.9 176 34.1 14.2 31.9 547 Ebonyi 62.0 50.0 208 55.1 15.8 31.3 587 Enugu 74.4 62.1 167 64.6 21.5 38.7 458 Imo 56.3 46.2 168 72.4 4.7 69.0 455 South South Akwa Ibom 49.3 39.9 142 60.2 9.8 30.7 392 Bayelsa 75.0 70.7 64 52.9 11.7 30.1 196 Cross River 66.3 55.6 150 83.4 1.2 43.4 439 Delta 52.9 50.8 157 63.9 8.7 36.3 471 Edo 51.7 46.7 120 53.7 2.3 28.7 344 Rivers 83.6 78.9 209 65.4 1.4 73.5 616 South West Ekiti 37.2 35.8 54 84.8 14.0 40.8 166 Lagos 54.4 49.8 365 74.1 4.7 51.6 1,103 Ogun 26.7 22.1 212 57.4 2.8 10.2 621 Ondo 58.2 53.5 150 39.3 7.7 21.3 465 Osun 65.2 63.9 140 84.8 13.8 45.6 381 Oyo 53.5 47.0 309 58.1 9.3 14.3 929 Mother’s education No education 43.6 19.7 4,165 24.9 3.8 9.4 12,493 Primary 55.7 40.6 1,570 47.3 6.9 20.4 5,024 Secondary 60.2 50.7 2,477 59.1 7.5 33.6 6,877 More than secondary 61.6 57.2 606 74.6 9.1 42.5 1,565 Wealth quintile Lowest 41.7 15.5 2,018 20.9 2.6 7.9 5,932 Second 47.7 24.9 1,943 30.9 3.9 11.8 5,780 Middle 53.0 37.7 1,688 42.8 7.0 18.8 4,975 Fourth 57.2 47.0 1,609 53.0 7.9 27.7 4,708 Highest 62.3 55.9 1,561 67.3 8.1 39.1 4,565 Total 51.6 34.7 8,818 41.3 5.7 19.9 25,960 Note: Information on vitamin A is based on both mother’s recall and the immunization card (where available). Information on iron supplements and deworming medication is based on the mother’s recall. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mango, papaya, and other locally grown fruits and vegetables that are rich in vitamin A, and red palm nuts 2 Includes meat (and organ meat), fish, poultry, and eggs. 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 194 • Nutrition of Children and Women Vitamin A is an essential micronutrient for the immune system that 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 the severity of diseases, such as measles and diarrhoeal diseases in children, and slow recovery from illness. Vitamin A is found in breast milk, other milk, liver, eggs, fish, butter, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Table 11.7 shows that 52 percent of children age 6-23 months consumed foods rich in vitamin A the day or night preceding the survey. The proportion of children consuming vitamin A-rich foods increases with age. Nonbreastfeeding children (72 percent) are more likely to consume foods rich in vitamin A than breastfeeding children (45 percent). Also, urban children are more likely to consume vitamin A-rich foods (59 percent) than children in rural areas (48 percent). Children in the North West zone are least likely to receive vitamin A-rich foods (43 percent). Among the states, children residing in Rivers are most likely to consume vitamin A-rich foods (84 percent), and children in Zamfara (24 percent) are least likely to do so. Mother’s education has a positive relationship with consumption of vitamin A-rich foods; 44 percent of children whose mothers have no education consume vitamin A-rich foods, as compared with 62 percent of children whose mothers have a higher education. Children born to families in the highest wealth quintile are more likely than children born to families in the lowest quintile to consume vitamin A-rich foods (62 percent versus 42 percent). Iron is essential for red blood cell formation and cognitive development, and low iron intake can contribute to anaemia. Iron requirements are greatest at age 6-23 months, when growth is extremely rapid. The results of the 2013 NDHS (Table 11.7) show that 35 percent of children age 6-23 months consumed foods rich in iron in the 24 hours prior to the survey. Consumption of iron-rich foods is highest among children age 18-23 months (47 percent), children in urban areas (49 percent), children in Rivers (79 percent), and children in the highest wealth quintile (56 percent). Children whose mothers have a higher education (57 percent) are more likely to consume iron-rich foods than those whose mothers have no education (20 percent). Periodic dosing (usually every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD. In Nigeria, campaigns are in place for semiannual mass supplementation with vitamin A capsules. The 2013 NDHS collected data on vitamin A supplements for children under age 5. Table 11.7 shows that 41 percent of children age 6-59 months were given vitamin A supplements in the six months before the survey. Children age 18-23 months (45 percent), those living in urban areas (53 percent), and those born to women age 30-39 (45 percent) are more likely to receive vitamin A supplementation. There are substantial differences in the proportion of children receiving vitamin A supplements by geographical area, with the highest coverage in the South South (65 percent) and the lowest in the North West (26 percent). Mother’s education and wealth have a marked impact on use of vitamin A supplementation. Children of mothers with a higher education are more likely than children of mothers with no education to receive vitamin A supplementation (75 percent and 25 percent, respectively). Similarly, children in the highest wealth quintile are more than three times as likely as children in the lowest quintile to receive supplementation (67 percent and 21 percent, respectively). As a means of assessing iron supplementation coverage, mothers were asked if their children under age 5 had received an iron tablet or syrup or iron sprinkles in the seven days prior to the survey. Table 11.7 shows that, overall, only 6 percent of children age 6-59 months received iron supplementation. Certain types of intestinal parasites can cause anaemia. Periodic deworming for organisms such as helminthes can improve children’s micronutrient status. Table 11.7 shows that 20 percent of children age 6-59 months received deworming medication in the six months before the survey. Children in urban areas (28 percent) were more likely than children in rural areas (15 percent) to receive deworming medication. Nutrition of Children and Women • 195 Likelihood of receiving deworming medication increased with child’s age, with the highest proportion among children age 18-23 months (23 percent). Seventy-four percent of children in Rivers received deworming medication, as compared with less than 1 percent in Zamfara. Children of mothers age 30-39, children of mothers with a higher education, and children residing in households in the highest wealth quintile were most likely to receive deworming medication. 11.5 NUTRITIONAL STATUS OF WOMEN The nutritional status of women was assessed with two anthropometric indices: height and body mass index. To derive these indices, the 2013 NDHS took height and weight measurements among women age 15-49 in every household that was selected for an interview. Women who were pregnant and women who had given birth in the two months preceding the survey were excluded from the analysis. Short stature is associated with poor socioeconomic conditions and inadequate nutrition during childhood and adolescence. In a woman, short stature is a risk factor for poor birth outcomes and obstetric complications. For example, short stature is associated with small pelvic size, which increases the likelihood of difficulty during delivery and the risk of bearing low birth weight babies. A woman is considered to be at risk if her height is below 145 cm. According to Table 11.8, only 2 percent of women are shorter than 145 cm. Women in rural areas are slightly more likely to be below 145 cm than women in urban areas. Women in Kano are most likely to be short (7 percent). There is no correlation between likelihood of short stature and education or wealth quintile. BMI (expressed as the ratio of weight in kilograms to the square of height in metres [kg/m2]) is used to measure thinness or obesity. A BMI below 18.5 kg/m2 indicates thinness or acute undernutrition, and a BMI of 25.0 kg/m2 or above indicates overweight or obesity. A BMI below 16 kg/m2 indicates severe undernutrition and is associated with increased mortality. Low pre-pregnancy BMI, as with short stature, is associated with poor birth outcomes and obstetric complications. Table 11.8 shows that the mean BMI among women age 15-49 is 23.0 kg/m2. Mean BMI generally increases with age. Urban women have a mean BMI of 23.9 kg/m2, while the mean among rural women is 22.3 kg/m2. There are only small differences among women living in the different zones, although women in the North West have the lowest mean BMI (21.9 kg/m2). Mean BMI is lower among women with no education (21.9 kg/m2) than among those with a primary or higher education (23.3 kg/m2 and 25.4 kg/m2, respectively). Mean BMI shows a steady increase with increasing wealth, from 21.3 kg/m2 among women in the lowest wealth quintile to 24.9 kg/m2 among those in the highest quintile. Eleven percent of women of reproductive age are thin or undernourished (BMI less than 18.5 kg/m2). The proportions of mild thinness (17.0-18.4 kg/m2) and moderate and severe thinness (less than 17 kg/m2) are 8 percent and 4 percent, respectively. Twenty-three percent of women age 15-19 are thin, as compared with 7 percent of women age 30-39 and 6 percent of women age 40-49. Rural women are more likely to be thin (13 percent) than urban women (10 percent). Women in Gombe and Bauchi (23 percent each) are more likely to be thin than women in other states. As also indicated in the 2008 NDHS, obesity is a public health problem in Nigeria. Seventeen percent of women are overweight (BMI of 25-29 kg/m2), and 8 percent are obese (BMI of 30 kg/m2 or above). Variations in overweight or obesity among women are apparent by background characteristics. The prevalence of overweight and obesity among women of reproductive age increases with age and is higher in urban areas (33 percent) than rural areas (18 percent). In addition, 42 percent of women in the highest wealth quintile are overweight or obese, as compared with only 10 percent of women in the lowest quintile. Overweight or obesity is most prevalent in Lagos (44 percent) and the Federal Capital Territory- Abuja (43 percent). 196 • Nutrition of Children and Women Table 11.8 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Nigeria 2013 Height Body mass index1 Mean BMI Normal Thin Overweight/obese Number of women Background characteristic Percentage below 145 cm Number of women 18.5-24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moderate- ly and severely thin) ≥25.0 (total overweight or obese) 25.0-29.9 (over- weight) ≥30.0 (obese) Age 15-19 5.2 7,643 20.6 70.9 23.1 13.8 9.3 6.1 4.9 1.1 6,955 20-29 1.4 13,705 22.4 70.4 10.7 7.4 3.3 18.9 14.5 4.4 10,925 30-39 0.8 10,043 24.3 57.8 6.6 4.7 1.9 35.6 23.7 11.8 8,349 40-49 1.0 6,928 24.7 53.5 6.4 4.5 1.9 40.1 26.2 13.9 6,587 Residence Urban 1.6 16,139 23.9 57.4 9.6 6.3 3.3 33.0 21.7 11.4 14,313 Rural 2.2 22,181 22.3 69.0 12.8 8.4 4.4 18.2 13.7 4.5 18,502 Zone North Central 1.7 5,512 23.2 67.5 7.2 5.3 1.9 25.3 17.7 7.6 4,748 North East 1.4 5,587 22.2 65.5 15.9 10.3 5.5 18.7 13.4 5.3 4,659 North West 3.0 11,716 21.9 68.4 16.0 9.4 6.6 15.6 12.0 3.6 9,522 South East 0.7 4,391 23.8 62.8 7.0 5.3 1.7 30.2 20.8 9.5 3,965 South South 2.7 4,858 23.9 59.9 7.4 5.2 2.3 32.7 22.4 10.3 4,352 South West 1.0 6,255 23.9 55.7 9.8 7.1 2.7 34.5 22.1 12.4 5,569 State North Central FCT-Abuja 0.8 311 25.0 52.2 4.9 3.6 1.3 42.9 26.3 16.6 281 Benue 2.6 1,231 22.5 73.6 8.0 5.5 2.5 18.4 14.8 3.7 1,042 Kogi 0.6 694 23.5 63.3 9.3 7.6 1.7 27.4 16.8 10.6 621 Kwara 1.6 596 23.6 58.1 10.7 8.1 2.6 31.2 19.3 11.9 546 Nasarawa 2.0 581 23.2 72.3 4.9 3.8 1.2 22.8 16.4 6.4 503 Niger 1.4 1,453 23.0 69.8 6.5 4.7 1.9 23.7 18.1 5.6 1,192 Plateau 1.9 647 23.6 68.4 4.7 3.6 1.1 26.9 18.8 8.1 562 North East Adamawa 1.2 819 22.7 62.6 14.5 9.9 4.6 22.9 15.1 7.8 665 Bauchi 2.2 1,119 21.1 63.5 23.1 13.9 9.1 13.4 9.9 3.5 888 Borno 0.6 1,327 22.2 68.3 15.3 10.3 5.0 16.4 11.2 5.2 1,148 Gombe 1.7 536 21.5 60.6 23.4 13.8 9.6 16.0 11.0 5.0 440 Taraba 1.8 835 23.0 67.2 9.1 6.0 3.0 23.7 17.3 6.4 722 Yobe 0.9 950 22.5 67.0 11.8 8.6 3.1 21.2 16.8 4.3 796 North West Jigawa 2.1 1,326 21.9 66.3 20.7 14.1 6.6 13.0 7.5 5.5 1,096 Kaduna 0.6 2,086 22.8 67.0 10.1 6.8 3.3 22.9 16.3 6.5 1,628 Kano 7.4 3,148 21.7 64.6 18.7 8.6 10.1 16.7 13.7 2.9 2,662 Katsina 1.4 1,511 21.4 74.9 15.2 11.3 3.8 10.0 7.3 2.7 1,197 Kebbi 0.5 1,238 22.3 71.7 11.1 8.0 3.2 17.2 14.3 2.8 991 Sokoto 2.1 1,086 21.2 67.8 19.3 10.2 9.1 13.0 11.2 1.8 885 Zamfara 2.1 1,323 21.4 72.8 15.8 8.9 7.0 11.4 9.4 2.0 1,061 South East Abia 1.2 514 23.7 63.0 6.8 5.2 1.6 30.1 21.1 9.1 465 Anambra 0.3 1,009 24.7 60.6 3.2 2.2 1.0 36.2 26.5 9.7 926 Ebonyi 1.3 1,108 22.0 69.9 12.8 10.2 2.6 17.4 13.3 4.1 984 Enugu 0.3 931 24.0 61.4 5.4 4.5 0.9 33.2 22.1 11.1 843 Imo 0.7 829 24.6 57.5 6.0 3.7 2.3 36.5 21.9 14.7 747 South South Akwa Ibom 1.7 845 23.6 59.6 8.2 5.5 2.7 32.2 22.9 9.3 785 Bayelsa 0.3 358 23.9 62.8 5.7 4.2 1.5 31.5 21.7 9.8 310 Cross River 1.6 701 23.3 62.7 8.7 7.2 1.5 28.6 20.7 8.0 622 Delta 5.3 972 23.4 65.5 7.4 4.9 2.5 27.1 20.0 7.1 857 Edo 2.3 725 24.0 58.7 8.0 5.4 2.7 33.3 22.3 11.0 667 Rivers 2.9 1,258 24.7 54.0 6.4 4.2 2.2 39.6 25.1 14.5 1,111 South West Ekiti 1.7 326 23.7 63.3 7.3 6.2 1.1 29.4 18.9 10.5 297 Lagos 0.6 1,927 25.2 48.2 7.5 5.6 1.9 44.3 26.1 18.2 1,750 Ogun 1.3 873 23.8 53.2 11.8 8.6 3.2 35.0 23.6 11.3 763 Ondo 0.7 805 23.6 61.1 8.3 6.3 2.0 30.6 20.6 10.0 719 Osun 2.0 762 23.3 62.8 9.2 7.1 2.0 28.1 19.3 8.8 697 Oyo 0.8 1,562 22.9 58.5 13.5 9.0 4.5 28.0 19.2 8.8 1,343 Education No education 1.9 14,458 21.9 69.8 14.6 9.3 5.3 15.6 12.0 3.6 11,781 Primary 2.4 6,634 23.3 60.5 10.4 6.8 3.6 29.1 20.3 8.9 5,653 Secondary 2.1 13,706 23.1 63.5 10.8 7.2 3.6 25.7 17.7 8.0 12,196 More than secondary 0.3 3,521 25.4 49.7 4.1 3.1 1.0 46.2 28.7 17.5 3,185 Wealth quintile Lowest 2.1 7,008 21.3 72.3 17.5 11.1 6.4 10.1 8.3 1.9 5,654 Second 2.8 7,297 21.8 71.8 13.8 8.7 5.2 14.4 11.5 2.9 6,013 Middle 2.2 7,358 22.5 67.3 11.7 8.0 3.7 20.9 15.8 5.1 6,356 Fourth 1.6 7,905 23.5 60.2 10.0 6.8 3.1 29.9 21.0 8.8 6,927 Highest 1.2 8,751 24.9 52.2 6.3 4.2 2.1 41.5 25.6 15.9 7,865 Total 1.9 38,319 23.0 63.9 11.4 7.5 3.9 24.7 17.2 7.5 32,815 Note: Body mass index 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 Nutrition of Children and Women • 197 Figure 11.6 presents trends in women’s nutritional status since 2003. There has been a slight decline over time in undernutrition and an increase in the prevalence of overweight among women of reproductive age. Figure 11.6 Trends in nutritional status of women 15 21 12 22 11 25 Undernutrition (chronic energy deficiency) Overnutrition (overweight/obese) 2003 NDHS 2008 NDHS 2013 NDHS Percent 11.6 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects the mother and infant against anaemia, which is considered a major cause of perinatal and maternal mortality. Anaemia also results in an increased risk of premature delivery and low birth weight. Finally, iodine deficiency is related to a number of adverse pregnancy outcomes including abortion, foetal brain damage and congenital malformation, stillbirth, and prenatal death. In Nigeria, micronutrient deficiency among pregnant and lactating mothers is a common public health problem. Thus, the 2013 NDHS collected data on the use of vitamin A and iron-folic acid supplements among women age 15-49 with a child born in the past five years, as well as the use of deworming medication during the last pregnancy. A single dose of vitamin A is typically given to women within 45 days of childbirth, aimed at increasing the mother’s vitamin A level and the content of the vitamin in her breast milk for the benefit of her child. Because of the risk of teratogenesis (abnormal development of the foetus) resulting from high doses of vitamin A during pregnancy, the supplement should not be given to pregnant women. Table 11.9 includes measures that are useful in assessing micronutrient intake by women during pregnancy and the two months after delivery (postpartum period). The findings show that 29 percent of women received a vitamin A dose during the postpartum period, a higher proportion than in 2008 (25 percent). There is substantial variation across geographical areas, with the highest proportion in the South West (58 percent) and the lowest in the North East (9 percent). The proportion of women receiving postpartum vitamin A also differs by urban and rural residence (45 percent and 21 percent, respectively). Women with a higher education are more likely than those with no education to receive a postpartum vitamin A supplement (64 percent and 13 percent, respectively). The coverage of postpartum vitamin A supplementation increases with increasing wealth, from 9 percent in the lowest quintile to 59 percent in the highest quintile. 198 • Nutrition of Children and Women Table 11.9 Micronutrient intake among mothers Among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child, the percent distribution by number of days they took iron tablets or syrup during the pregnancy of the last child, and the percentage who took deworming medication during the pregnancy of the last child, by background characteristics, Nigeria 2013 Percentage who received vitamin A dose postpartum1 Number of days women took iron tablets or syrup during pregnancy of last birth Percentage of women who took deworming medication during pregnancy of last birth Number of women Background characteristic None <60 60-89 90+ Don’t know/ missing Total Age 15-19 17.9 48.0 27.3 7.4 13.2 4.0 100.0 10.7 1,323 20-29 27.7 35.9 32.0 7.6 19.2 5.4 100.0 14.7 9,384 30-39 33.7 32.6 29.5 8.2 24.0 5.6 100.0 14.8 7,420 40-49 28.2 38.6 29.7 7.1 19.0 5.6 100.0 13.7 2,340 Residence Urban 44.6 15.0 31.2 12.1 34.1 7.6 100.0 19.3 7,278 Rural 20.8 47.3 30.1 5.3 13.0 4.2 100.0 11.7 13,189 Zone North Central 37.4 27.4 46.2 5.1 15.7 5.6 100.0 15.7 2,890 North East 9.0 37.9 23.1 8.3 25.7 5.0 100.0 12.0 3,434 North West 15.9 55.6 29.6 5.5 5.8 3.5 100.0 13.0 7,445 South East 42.4 10.4 31.3 13.3 38.3 6.6 100.0 18.9 1,719 South South 48.0 28.4 26.6 5.9 26.2 12.8 100.0 18.8 2,002 South West 58.0 11.8 28.2 13.1 42.0 5.0 100.0 13.7 2,977 State North Central FCT-Abuja 50.2 10.3 11.8 4.5 69.7 3.8 100.0 12.8 143 Benue 37.5 43.7 47.1 2.9 3.6 2.7 100.0 16.9 615 Kogi 65.2 13.6 13.5 13.1 47.1 12.7 100.0 21.9 283 Kwara 69.0 3.8 16.3 13.5 57.9 8.4 100.0 22.9 278 Nasarawa 40.8 31.8 61.2 2.3 1.8 3.0 100.0 18.6 309 Niger 19.8 23.2 66.5 3.6 2.5 4.2 100.0 10.2 916 Plateau 27.7 42.6 42.7 2.8 2.4 9.5 100.0 15.7 346 North East Adamawa 13.4 15.0 10.3 11.0 61.8 1.8 100.0 17.0 459 Bauchi 6.5 33.0 27.9 10.0 26.1 3.0 100.0 15.2 833 Borno 7.0 59.9 11.7 3.1 15.3 10.1 100.0 1.8 716 Gombe 14.7 24.0 36.7 9.9 26.1 3.4 100.0 31.8 361 Taraba 13.5 37.3 22.4 10.2 22.9 7.2 100.0 7.1 476 Yobe 4.6 44.8 32.3 7.7 11.8 3.4 100.0 7.7 588 North West Jigawa 12.5 49.4 36.9 4.6 5.2 3.9 100.0 10.9 973 Kaduna 34.6 33.5 31.6 11.7 21.1 2.1 100.0 18.6 1,051 Kano 6.5 39.6 50.9 6.2 2.3 0.9 100.0 22.6 1,907 Katsina 27.4 66.5 11.7 5.4 5.6 10.8 100.0 15.6 1,066 Kebbi 4.2 77.5 16.1 0.2 0.0 6.3 100.0 3.8 790 Sokoto 1.9 80.2 9.8 5.3 4.3 0.4 100.0 2.5 693 Zamfara 24.4 70.0 23.1 3.1 2.5 1.2 100.0 2.5 966 South East Abia 53.7 14.6 44.3 12.7 24.5 3.9 100.0 26.0 199 Anambra 37.4 15.1 30.9 5.9 28.8 19.2 100.0 14.1 379 Ebonyi 35.9 11.5 37.1 21.7 25.4 4.2 100.0 27.5 467 Enugu 37.7 6.4 16.3 12.0 64.7 0.6 100.0 14.1 355 Imo 56.2 5.2 31.9 11.6 47.8 3.5 100.0 12.9 319 South South Akwa Ibom 48.2 36.8 49.8 3.2 3.5 6.7 100.0 26.1 334 Bayelsa 29.5 41.0 32.4 6.7 15.4 4.6 100.0 28.0 153 Cross River 66.6 16.8 34.6 7.0 24.1 17.5 100.0 23.0 368 Delta 40.3 38.0 7.4 4.6 45.6 4.4 100.0 13.9 376 Edo 50.3 20.4 35.7 5.5 18.0 20.4 100.0 7.5 264 Rivers 44.5 24.4 13.4 8.0 36.0 18.2 100.0 17.8 508 South West Ekiti 50.8 3.6 30.4 11.7 33.6 20.7 100.0 8.6 139 Lagos 80.9 8.5 14.0 15.0 56.2 6.3 100.0 18.1 867 Ogun 51.6 8.2 53.6 12.8 24.4 1.0 100.0 12.0 495 Ondo 46.9 17.8 15.4 13.4 51.7 1.7 100.0 6.3 385 Osun 55.6 1.5 24.8 20.4 53.0 0.3 100.0 23.6 307 Oyo 44.4 20.1 35.0 8.3 30.0 6.7 100.0 10.7 783 Education No education 12.5 56.6 27.8 4.3 7.8 3.5 100.0 9.0 9,794 Primary 33.2 25.0 36.1 9.3 23.1 6.6 100.0 16.8 3,915 Secondary 48.4 13.3 32.8 12.0 34.6 7.3 100.0 20.9 5,475 More than secondary 64.0 6.3 24.5 10.9 50.2 8.2 100.0 20.4 1,283 Wealth quintile Lowest 9.1 67.7 21.2 3.6 5.3 2.2 100.0 7.3 4,699 Second 16.6 48.7 30.5 5.6 11.1 4.1 100.0 11.7 4,588 Middle 29.9 27.7 38.8 7.6 19.6 6.3 100.0 15.5 3,902 Fourth 41.4 14.0 37.3 11.5 29.7 7.6 100.0 19.8 3,674 Highest 58.8 8.7 26.9 12.1 44.1 8.2 100.0 20.3 3,604 Total 29.3 35.8 30.5 7.7 20.5 5.4 100.0 14.4 20,467 1 In the first two months after delivery of last birth Nutrition of Children and Women • 199 Nutritional deficiencies such as anaemia are often exacerbated during pregnancy because of the additional nutrient demands associated with foetal growth. Iron status can be enhanced by including iron supplements in food consumed by women, improving women’s diets, and controlling intestinal parasites. Iron supplementation is necessary for pregnant women because their needs are usually too high to be met solely by food intake. According to Table 11.9, 21 percent of women took iron tablets daily for 90 or more days during their last pregnancy. Eight percent took iron supplements for 60 to 89 days, and 31 percent took supplements for less than 60 days. Thirty-six percent of pregnant women did not take iron supplements at all. The proportion of women taking daily iron supplements for 90 or more days differs substantially between urban and rural areas (34 percent and 13 percent, respectively). Seventy percent of pregnant women in the Federal Capital Territory-Abuja took iron supplements daily for 90 or more days, while none of the women in Kebbi did so. Women with a higher education are more likely to take iron tablets for 90 days or more (50 percent) than women with no education (8 percent). Women in the highest wealth quintile are much more likely than those in the lowest quintile to take iron tablets for 90 or more days (44 percent versus 5 percent). Infections caused by helminthes (intestinal parasites) are one of the factors contributing to anaemia among pregnant women. Deworming during pregnancy is a cost-effective intervention against intestinal worms that allows better absorption of nutrients and iron, thus reducing the prevalence of anaemia. Table 11.9 shows that 14 percent of women took deworming medication during their last pregnancy. Urban women were more likely than rural women to take deworming medication during pregnancy (19 percent and 12 percent, respectively). Also, women in the South East and South South (19 percent each) were more likely than women in the North East (12 percent) to take deworming medication. Women with no education and those in the lowest wealth quintile were less likely than other women to take deworming medication during their pregnancy. Malaria • 201 MALARIA 12 alaria is endemic in Nigeria, with year-round transmission. Rates of transmission are slightly lower in the Sahel regions and the high mountain area of the plateau. Plasmodium falciparum is the predominant parasite species, mainly transmitted by Anopheles gambiae S.S., An. funestus, and An. arabiensis. Prior to 2010, available data were insufficient to clearly micro-stratify the country’s malaria epidemiological profile. However, the 2010 Nigeria Malaria Indicators Survey revealed that malaria parasite prevalence is still high, with an average prevalence of 42 percent among children under age 5 and zonal variations ranging from 28 percent in the South East to 50 percent in the South West (National Population Commission, National Malaria Control Programme, and ICF International, 2012). Malaria remains an important cause of morbidity and mortality in Nigeria. Nigeria accounted for 32 percent of the global estimate of 655,000 malaria deaths in 2010 (World Health Organization, 2012). An estimated 97 percent of the country’s approximate population of 160 million residents are at risk of malaria. Children under age 5 and pregnant women are the groups most vulnerable to illness and death from malaria infection in Nigeria. In addition to the direct health impact of malaria, there are also severe M Key Findings • Fifty-five percent of households have at least one mosquito net, 50 percent have at least one insecticide-treated mosquito net (ITN), and 48 percent have at least one long-lasting insecticidal net. • Two percent of households reported that they had received indoor residual spraying (IRS) during the past 12 months. • Fifty percent of households have at least one ITN and/or have had IRS in the last 12 months. • Twenty-three percent of households have at least one ITN for every two people and/or have had IRS in the last 12 months. • Overall, 36 percent of households have access to an insecticide-treated net. • Twenty-four percent of the household population in households with at least one ITN slept under an ITN the night before the survey, and 18 percent of children under age 5 slept under a mosquito net. • Among households with at least one ITN, 28 percent of children under age 5 slept under an ITN. • Overall, 18 percent of pregnant women slept under some type of mosquito net the night before the survey. • Among pregnant women living in households that possess an ITN, 3 in 10 slept under an ITN the night before the survey. • Twenty-three percent of women who had their last birth in the two years preceding the survey received intermittent preventive treatment during their pregnancy; that is, they took two or more doses of sulphadoxine- pyrimethamine (SP)/Fansidar and received at least one dose during an antenatal care visit. • While advice or treatment was sought for 70 percent of children with a fever, only 4 percent had artemisinin-based combination therapy (ACT) the same or next day. • Chloroquine and SP continue to be the most common antimalarial drugs taken by children (31 percent each), while 18 percent receive ACT. 202 • Malaria social and economic burdens on communities and the country as a whole, with about 480 billion Naira lost to malaria annually in the form of treatment costs, prevention efforts, loss of work time, and so forth (Sach, 2001, as cited by Federal Ministry of Health [FMoH], 2012). The National Malaria Control Strategic Plan (NMCSP) addresses national health and development priorities including the Roll Back Malaria goals and the Millennium Development Goals. The NMCSP includes the following priorities: reducing malaria-related mortality, reducing malaria parasite prevalence in children under age 5, increasing possession and use of insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs), introducing and scaling up indoor residual spraying (IRS), increasing the use of diagnostic tests for fever patients, improving efforts related to appropriate and timely treatment of malaria, and increasing coverage of intermittent preventive treatment (IPT) of malaria during pregnancy. The NMCSP outlined specific targets to be achieved by 2010 and sustained through 2013 (FMoH, 2009). The 2009-2013 NMCSP addressed malaria control through three core interventions: prevention of malaria transmission through an integrated vector management strategy, prompt diagnosis and adequate treatment of clinical cases at all levels and in all sectors of health care, and prevention and treatment of malaria in pregnancy. Through the NMCSP, approximately 60 million LLINs (with a massive influx of resources from donors) were distributed in an effort to achieve universal access and universal coverage (FMoH, 2009). Moreover, a new 2014-2020 national strategic plan for malaria control has been developed in Nigeria that includes massive scaling up of interventions. It is expected that such massive deployment of effective interventions will change the epidemiological profile of malaria in the country (FMoH, 2013b). 12.1 MOSQUITO NETS The use of ITNs is currently considered the most cost-effective method of malaria prevention in highly endemic areas. The use of ITNs or LLINs is the main method of malaria prevention employed in Nigeria. Free LLINs are distributed through mass campaigns, public health facilities, faith-based organisations, nongovernmental organisations (NGOs), retail commercial outlets, and maternal and child health weeks with the goal of achieving universal access. 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). All households in the 2013 NDHS were asked whether they possess a mosquito net and, if so, how many. Table 12.1 shows the percentage of households with any mosquito net, insecticide-treated mosquito net, or long-lasting insecticidal net, by background characteristics. Possession of ITNs among surveyed households measures access to effective personal protection from malaria parasite-carrying mosquitoes. Malaria • 203 Table 12.1 Household possession of mosquito nets Percentage of households with at least one mosquito net (treated or untreated), insecticide-treated net (ITN), and long-lasting insecticidal net (LLIN); average number of nets, ITNs, and LLINs per household; and percentage of households with at least one net, ITN, and LLIN per two persons who stayed in the household the night before the survey, by background characteristics, Nigeria 2013 Percentage of households with at least one mosquito net Average number of nets per household Number of households Percentage of households with at least one net for every two persons who stayed in the household the night before the survey1 Number of households with at least one person who stayed in the household the night before the survey Background characteristic Any mosquito net Insecticide- treated mosquito net (ITN)2 Long- lasting insecticidal net (LLIN) Any mosquito net Insecticide- treated mosquito net (ITN)2 Long- lasting insecticidal net (LLIN) Any mosquito net Insecticide- treated mosquito net (ITN)2 Long- lasting insecticidal net (LLIN) Residence Urban 48.2 42.1 39.8 0.9 0.8 0.7 16,609 21.8 18.9 17.7 16,576 Rural 60.7 55.2 54.3 1.2 1.1 1.1 21,913 27.0 24.6 24.1 21,881 Zone North Central 54.4 49.6 48.9 1.1 1.0 1.0 5,942 24.9 22.8 22.5 5,918 North East 64.9 60.9 60.6 1.4 1.3 1.3 5,115 28.7 26.0 25.8 5,114 North West 57.7 49.2 49.0 1.2 1.0 1.0 9,992 20.5 17.7 17.7 9,986 South East 63.8 57.1 55.1 1.2 1.0 1.0 4,687 33.9 30.3 29.0 4,686 South South 46.6 42.7 40.1 0.9 0.8 0.7 5,239 23.1 21.2 19.9 5,234 South West 47.2 42.3 38.7 0.8 0.7 0.6 7,546 23.1 20.4 18.6 7,520 State North Central FCT-Abuja 37.4 27.4 25.0 0.7 0.5 0.4 361 16.6 12.1 11.0 361 Benue 74.6 73.2 73.0 1.6 1.5 1.5 1,365 41.5 40.7 40.5 1,351 Kogi 29.4 25.5 23.8 0.5 0.4 0.4 876 14.1 12.1 11.6 876 Kwara 54.2 34.0 33.1 0.9 0.6 0.6 617 21.5 12.8 12.4 616 Nasarawa 58.6 52.7 52.0 1.2 1.1 1.1 550 24.3 21.6 21.4 546 Niger 50.9 49.4 49.4 1.0 1.0 1.0 1,504 18.6 18.2 18.2 1,500 Plateau 59.7 57.2 56.9 1.2 1.1 1.1 669 28.0 26.6 26.5 667 North East Adamawa 74.8 72.8 72.8 1.7 1.7 1.7 726 36.7 35.2 35.2 725 Bauchi 70.2 68.8 68.8 1.6 1.5 1.5 932 24.9 23.7 23.7 932 Borno 58.0 50.2 49.4 1.1 0.9 0.9 1,560 31.2 25.6 25.0 1,560 Gombe 74.5 71.2 71.2 1.7 1.6 1.6 464 28.5 27.2 27.2 464 Taraba 62.0 59.4 59.3 1.2 1.2 1.2 634 22.5 21.3 21.2 634 Yobe 59.7 56.9 56.6 1.2 1.2 1.2 799 25.9 24.3 24.2 799 North West Jigawa 75.3 57.7 56.9 1.7 1.3 1.2 1,152 32.2 23.9 23.8 1,151 Kaduna 35.3 24.9 24.4 0.6 0.4 0.4 1,915 13.1 9.2 9.0 1,913 Kano 47.2 33.8 33.6 0.8 0.6 0.6 2,606 11.9 9.3 9.2 2,606 Katsina 67.9 67.3 67.2 1.4 1.4 1.4 1,257 24.0 23.7 23.7 1,255 Kebbi 64.2 60.3 60.3 1.3 1.2 1.2 1,069 21.8 20.5 20.5 1,069 Sokoto 58.7 56.0 56.0 1.3 1.2 1.2 898 21.1 20.2 20.2 897 Zamfara 84.2 82.3 82.3 1.9 1.8 1.8 1,096 35.5 34.6 34.6 1,096 South East Abia 60.0 59.6 59.3 1.1 1.1 1.1 644 35.4 34.9 34.7 644 Anambra 55.1 47.2 45.4 0.9 0.8 0.7 1,050 23.4 18.9 17.7 1,049 Ebonyi 60.2 57.7 57.4 1.2 1.1 1.1 978 28.7 27.3 27.2 978 Enugu 65.4 46.5 43.7 1.3 0.9 0.8 920 34.9 25.2 23.8 920 Imo 76.3 73.7 69.6 1.5 1.4 1.3 1,096 46.9 45.3 42.6 1,096 South South Akwa Ibom 45.6 43.6 42.8 0.8 0.8 0.8 892 19.8 19.2 18.7 891 Bayelsa 48.9 46.7 45.5 1.0 0.9 0.9 322 20.6 19.9 19.2 322 Cross River 66.5 57.9 56.3 1.2 1.0 1.0 848 34.9 29.6 29.0 847 Delta 42.1 38.7 34.2 0.7 0.7 0.6 946 21.2 19.3 17.6 945 Edo 62.0 61.0 54.1 1.2 1.2 1.1 702 28.6 28.0 24.3 700 Rivers 31.2 27.0 25.7 0.6 0.5 0.5 1,529 17.7 15.9 15.2 1,529 South West Ekiti 46.9 43.3 42.2 0.8 0.7 0.7 376 21.6 19.5 18.8 375 Lagos 57.6 48.0 42.9 1.0 0.8 0.7 2,240 29.1 23.3 20.6 2,225 Ogun 38.0 37.8 37.8 0.6 0.6 0.6 1,355 18.6 18.6 18.6 1,353 Ondo 64.9 58.4 52.0 1.2 1.1 1.0 920 36.6 32.6 28.7 918 Osun 24.8 23.1 17.6 0.4 0.4 0.3 853 9.4 9.0 7.3 850 Oyo 42.9 39.1 36.8 0.7 0.7 0.6 1,802 19.0 17.5 16.2 1,799 Wealth quintile Lowest 60.7 55.1 55.0 1.3 1.1 1.1 6,245 23.0 20.8 20.8 6,241 Second 60.7 54.6 53.8 1.2 1.1 1.1 7,166 25.7 23.1 22.8 7,159 Middle 58.6 52.5 51.3 1.1 1.0 1.0 7,894 28.5 25.7 25.2 7,871 Fourth 50.9 45.8 43.6 0.9 0.9 0.8 8,310 23.5 21.2 20.1 8,296 Highest 48.4 42.5 39.8 0.9 0.8 0.7 8,907 23.1 19.9 18.4 8,889 Total 55.3 49.5 48.0 1.1 1.0 0.9 38,522 24.8 22.1 21.4 38,457 1 De facto household members 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN) or (2) a pretreated net obtained within the past 12 months. 204 • Malaria The 2013 NDHS results indicate that 55 percent of households in Nigeria possess at least one mosquito net (treated or untreated), 50 percent possess at least one ITN, and 48 percent possess at least one LLIN. On average, each household possesses one mosquito net of any type. The majority of mosquito nets in Nigeria are LLINs. Twenty-five percent of households had at least one net for every two persons who stayed in the household the night before the survey; 22 percent had at least one ITN, and 21 percent had at least one LLIN. More rural households (61 percent) than urban households (48 percent) possess any mosquito net. Similarly, possession of ITNs (55 percent versus 42 percent) and LLINs (54 percent versus 40 percent) is greater in rural than urban areas. Possession of mosquito nets varies by zone as well. The percentage of households that own any mosquito net in the northern zones ranges from 54 percent in the North Central zone to 65 percent in the North East, while the percentage in the Southern zones ranges from 47 percent in the South South and South West to 64 percent in the South East. Possession of any type of mosquito net is highest among households in the North East and lowest in the South West. Among the states, possession of any mosquito net varies markedly. In six states—Kogi, Kaduna, Rivers, Osun, Ogun, and FCT-Abuja— less than 40 percent of households possess any mosquito net, while in the remaining 31 states more than 40 percent possess a mosquito net, with the highest proportion in Zamfara (84 percent). Possession of ITNs and LLINs shows similar variations across states. Possession of any type of mosquito net decreases with increasing wealth quintile. 12.2 INDOOR RESIDUAL SPRAYING Indoor residual spraying (IRS) is another component of efforts to control malaria transmission in Nigeria. To obtain information on coverage of indoor residual spraying, all households interviewed in the 2013 NDHS were asked whether the interior walls of their dwelling had been sprayed against mosquitoes during the 12-month period before the survey and, if so, who had sprayed the dwelling. Part of the new strategy in the fight against malaria is to increase IRS coverage in Nigeria.1 Households are considered to be covered if they own at least one ITN and/or the dwelling has been sprayed at any time in the past 12 months. Table 12.2 indicates that only 2 percent of households reported having been sprayed in the past 12 months. However, 50 percent of households are covered through having at least one ITN and/or having had IRS in the past 12 months. Twenty-three percent of households have at least one ITN for every two persons and/or have had IRS in the last 12 months. Slightly more rural households (2 percent) than urban households (1 percent) reported that someone has come into their dwelling to spray the interior walls against mosquitoes. The states with the highest percentages of IRS are Jigawa (15 percent), Yobe (10 percent), and Nasarawa (6 percent). 1 The goal is for at least 80 percent of the targeted population to use appropriate preventive measures by 2020. One of the core technical strategies is to expand universal access to insecticide-treated materials. This will involve sustained mass distribution of long-lasting insecticidal nets, significantly scaling up indoor residual spraying, and expanding larval source management (larviciding and environmental management). There will also be support for intermittent preventive therapy and seasonal malaria chemoprevention. Malaria • 205 Table 12.2 Indoor residual spraying against mosquitoes Percentage of households in which someone has come into the dwelling to spray the interior walls against mosquitoes (IRS) in the past 12 months, the percentage of households with at least one ITN and/or IRS in the past 12 months, and the percentage of households with at least one ITN for every two persons and/or IRS in the past 12 months, by background characteristics, Nigeria 2013 Background characteristic Percentage of households with IRS1 in the past 12 months Percentage of households with at least one ITN2 and/or IRS in the past 12 months Percentage of households with at least one ITN2 for every two persons and/or IRS in the past 12 months Number of households Residence Urban 2.4 43.0 20.6 16,609 Rural 1.1 55.6 25.3 21,913 Zone North Central 1.1 50.1 23.5 5,942 North East 2.4 61.2 27.5 5,115 North West 2.4 50.1 19.6 9,992 South East 1.0 57.5 31.0 4,687 South South 1.4 43.5 22.2 5,239 South West 1.4 42.7 21.2 7,546 State North Central FCT-Abuja 3.9 29.5 15.3 361 Benue 0.0 73.2 40.2 1,365 Kogi 0.6 25.9 12.8 876 Kwara 0.0 34.0 12.8 617 Nasarawa 6.3 56.0 26.2 550 Niger 0.4 49.4 18.5 1,504 Plateau 0.6 57.3 26.9 669 North East Adamawa 0.1 72.8 35.3 726 Bauchi 2.8 69.3 25.6 932 Borno 0.2 50.2 25.8 1,560 Gombe 2.9 71.7 29.2 464 Taraba 0.1 59.4 21.3 634 Yobe 9.9 58.0 29.9 799 North West Jigawa 15.4 63.1 35.4 1,152 Kaduna 0.4 25.2 9.6 1,915 Kano 0.2 33.8 9.5 2,606 Katsina 0.0 67.3 23.6 1,257 Kebbi 0.3 60.3 20.6 1,069 Sokoto 5.0 58.3 24.4 898 Zamfara 0.0 82.3 34.7 1,096 South East Abia 4.3 61.0 38.4 644 Anambra 0.4 47.2 19.1 1,050 Ebonyi 0.3 57.9 27.5 978 Enugu 0.2 46.6 25.3 920 Imo 0.8 74.0 45.9 1,096 South South Akwa Ibom 0.7 43.8 19.5 892 Bayelsa 0.8 46.7 20.0 322 Cross River 0.5 57.9 29.7 848 Delta 3.3 41.1 22.5 946 Edo 0.6 61.2 28.4 702 Rivers 1.7 28.0 17.1 1,529 South West Ekiti 0.7 43.4 20.0 376 Lagos 4.4 49.6 26.0 2,240 Ogun 0.0 37.8 18.6 1,355 Ondo 0.2 58.5 32.7 920 Osun 0.0 23.1 8.9 853 Oyo 0.0 39.1 17.5 1,802 Wealth quintile Lowest 1.2 55.4 21.7 6,245 Second 1.2 55.0 24.0 7,166 Middle 1.6 53.2 26.9 7,894 Fourth 2.0 46.4 22.7 8,310 Highest 2.1 43.3 21.3 8,907 Total 1.7 50.1 23.3 38,522 1 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation. 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN) or (2) a pretreated net obtained within the past 12 months. 206 • Malaria Among households with IRS, 69 percent reported that government workers or government- sponsored programmes sprayed their dwelling (Table 12.3). Ten percent of households with IRS reported that a private company sprayed the dwelling’s interior walls against mosquitoes, while 3 percent reported that NGOs provided this service. In both rural (78 percent) and urban (63 percent) areas, government workers or government-sponsored programmes are reported as the main provider of IRS. Thirteen percent of urban households reported that a private company sprayed their interior walls, as compared with 5 percent of rural households, while 3 percent of urban households and 4 percent of rural households reported that an NGO sprayed their dwelling. Reports of government workers or programmes as the primary source of IRS ranged from a high of 87 percent of households in the North West to a low of 44 percent of households in the South West. Also, households in the lower wealth quintiles were more likely to have been sprayed by government workers or programmes than households in the higher wealth quintiles. Twenty-six percent of households in the highest wealth quintile reported that a private company sprayed their dwelling. Table 12.3 Source of IRS Among households in which someone has come into the dwelling to spray interior walls against mosquitoes in the past 12 months, percentage who received the spraying from various organisations, Nigeria 2013 Background characteristic Government worker/ programme Private company Non- governmental organisation (NGO) Other Don’t know/ missing Number of households sprayed in past 12 months Residence Urban 63.2 12.7 2.6 6.9 6.5 515 Rural 78.0 5.3 4.0 1.7 2.2 281 Zone North Central 52.6 9.9 4.3 8.2 10.7 97 North East 77.5 0.8 6.8 1.1 6.0 146 North West 87.2 0.0 1.2 0.0 3.4 270 South East 74.2 20.8 3.0 0.0 0.0 47 South South 50.7 28.9 5.8 7.9 3.3 86 South West 44.4 23.4 0.8 16.1 5.4 150 Wealth quintile Lowest 83.5 0.7 1.8 0.0 4.1 86 Second 78.7 0.2 3.4 0.0 4.5 108 Middle 83.8 1.9 3.1 0.7 4.1 147 Fourth 79.4 4.4 3.6 1.6 4.9 194 Highest 42.6 26.1 3.0 13.8 6.0 262 Total 68.5 10.1 3.1 5.1 5.0 796 12.3 ACCESS TO AN INSECTICIDE-TREATED NET (ITN) The 2013 NDHS asked about access to mosquito nets among household members during the night before the survey. Access to an ITN on the night before the survey is taken as typical net usage. The proportion of the household population sleeping under an ITN is a key indicator of the effectiveness of the malaria programme in Nigeria. Table 12.4 shows that, overall, 36 percent of the de facto population who stayed in the household the night before the survey could sleep under an ITN if each net were used by a maximum of two people. Access to an ITN varies according to the number of people who stayed in the household the night before the survey. Forty-five percent of households with four people had access to an ITN. Similarly, 43 percent each of households with two people and households with three people had access to an ITN. Malaria • 207 Table 12.4 Access to an insecticide-treated net (ITN) Percent distribution of the de facto household population by number of ITNs the household owns, according to number of persons who stayed in the household the night before the survey, Nigeria 2013 Number of persons who stayed in the household the night before the survey Total Number of ITNs 1 2 3 4 5 6 7 8+ 0 68.8 57.1 50.0 46.1 45.3 44.5 42.4 41.2 45.5 1 21.5 21.4 19.8 18.3 14.9 13.6 12.3 7.4 13.4 2 8.6 19.4 25.6 28.5 30.7 28.9 28.8 21.9 25.3 3 1.0 1.9 4.2 6.5 8.3 11.2 14.5 21.5 12.5 4 0.0 0.2 0.3 0.5 0.5 1.3 1.4 3.6 1.7 5 0.0 0.0 0.1 0.1 0.1 0.3 0.5 1.1 0.5 6 0.0 0.0 0.0 0.0 0.2 0.2 0.2 2.5 0.9 7+ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.8 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 6,173 9,354 15,956 20,561 23,924 23,722 19,114 57,771 176,574 Percent with access to an ITN1 31.2 42.9 43.4 44.7 39.6 36.8 34.4 29.1 36.1 1 Percentage of the de facto household population that could sleep under an ITN if each ITN in the household were used by up to two people Figure 12.1 shows the percentage of the de facto household population with access to an ITN, by background characteristics. A higher percentage of rural than urban households have access to an ITN (39 percent and 31 percent, respectively). In three zones—the North Central (37 percent), North East (43 percent), and South East (42 percent)—the percentage of the household population with access to an ITN is higher than the national average (36 percent). There is no clear pattern between household wealth and access to an ITN. Figure 12.1 Percentage of the de facto population with access to an ITN in the household, by background characteristics, 2013 36 31 39 37 43 33 42 33 33 37 39 38 34 33 TOTAL RESIDENCE Urban Rural ZONE North Central North East North West South East South South South West WEALTH QUINTILE Lowest Second Middle Fourth Highest Percent NDHS 2013 208 • Malaria 12.4 USE OF MOSQUITO NETS BY PERSONS IN THE HOUSEHOLD The 2013 NDHS asked about use of mosquito nets by household members during the night before the survey. Table 12.5 shows that 14 percent of the de facto household population slept under any mosquito net the night before the survey; 13 percent slept under an ITN, and 13 percent slept under an LLIN. It is interesting to note that only 24 percent of the population in households with at least one ITN slept under an ITN the night before the survey. However, since use of mosquito nets is seasonal, this result should be assessed with caution. Net usage on the night before the survey may not be representative of the pattern of use during periods of high malaria transmission. The percentage of the household population that slept under any net varies by age. For example, 11 percent of children age 5-14 slept under a net, as compared with 18 percent of children less than age 5. Table 12.5 Use of mosquito nets by persons in the household Percentage of the de facto household population that slept the night before the survey under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months, and among the de facto household population in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Nigeria 2013 Household population Household population in households with at least one ITN1 Background characteristic Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number Percentage who slept under an ITN1 the night before the survey Number Age (in years)3 <5 18.2 16.6 16.1 17.9 30,327 28.4 17,664 5-14 10.9 9.8 9.5 11.4 50,337 17.5 28,249 15-34 13.5 12.2 11.9 13.6 51,969 23.7 26,865 35-39 16.2 14.7 14.3 16.2 23,686 27.0 12,896 50+ 16.8 15.1 14.5 16.3 20,211 28.9 10,540 Sex4 Male 13.1 11.9 11.5 13.4 87,034 22.0 46,808 Female 15.5 14.0 13.6 15.3 89,529 25.4 49,419 Residence Urban 13.9 12.6 12.0 14.7 70,439 26.6 33,346 Rural 14.6 13.2 12.9 14.2 106,135 22.2 62,890 Zone North Central 14.9 13.4 13.2 14.5 26,922 24.5 14,753 North East 10.7 10.1 10.1 12.0 26,898 15.6 17,513 North West 12.3 10.8 10.7 12.6 56,241 20.5 29,678 South East 19.8 17.9 17.2 18.8 18,960 29.8 11,352 South South 16.3 14.7 14.0 16.2 20,159 30.5 9,722 South West 16.1 14.8 13.8 15.8 27,394 30.7 13,219 State North Central FCT-Abuja 15.8 12.1 11.2 16.3 1,352 36.2 453 Benue 23.6 23.3 23.2 23.3 5,949 30.1 4,603 Kogi 9.1 7.6 7.0 7.9 3,186 25.3 950 Kwara 19.0 11.8 11.4 11.8 2,640 30.4 1,022 Nasarawa 12.9 11.4 11.3 16.3 2,867 18.9 1,726 Niger 9.3 9.0 9.0 9.7 7,791 16.9 4,175 Plateau 15.8 15.4 15.2 16.0 3,137 26.5 1,823 North East Adamawa 11.0 10.8 10.8 10.9 3,763 14.2 2,854 Bauchi 5.7 5.6 5.6 9.0 5,701 7.7 4,140 Borno 9.6 8.6 8.6 9.1 6,423 15.2 3,639 Gombe 11.9 11.0 11.0 13.1 2,787 15.0 2,049 Taraba 11.9 11.3 11.2 11.5 3,618 18.6 2,192 Yobe 16.4 16.0 16.0 20.4 4,606 28.0 2,639 Continued… Malaria • 209 Table 12.5—Continued Household population Household population in households with at least one ITN1 Background characteristic Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number Percentage who slept under an ITN1 the night before the survey Number North West Jigawa 25.5 19.9 19.6 31.0 6,448 32.4 3,969 Kaduna 4.9 3.9 3.7 4.3 9,078 14.1 2,493 Kano 7.1 5.3 5.2 5.5 15,677 14.4 5,765 Katsina 21.2 21.0 20.9 21.0 7,423 30.3 5,155 Kebbi 19.5 18.8 18.8 18.9 6,314 30.2 3,932 Sokoto 8.9 8.5 8.5 12.8 5,086 13.9 3,106 Zamfara 7.8 7.2 7.2 7.2 6,215 8.5 5,256 South East Abia 19.0 18.7 18.4 24.8 2,337 29.9 1,461 Anambra 11.5 9.8 9.5 10.0 4,338 18.7 2,272 Ebonyi 23.5 23.1 23.0 23.2 4,476 38.3 2,695 Enugu 20.4 14.7 13.9 14.8 3,894 31.1 1,834 Imo 24.5 23.6 21.9 24.1 3,916 29.9 3,091 South South Akwa Ibom 15.3 14.4 14.1 15.1 3,649 29.3 1,786 Bayelsa 20.6 19.2 18.6 19.9 1,520 37.2 786 Cross River 29.1 25.1 24.3 25.3 3,268 41.4 1,984 Delta 9.4 7.6 6.9 11.5 3,800 17.7 1,623 Edo 15.9 15.6 13.7 16.3 2,997 23.3 2,007 Rivers 12.7 11.7 11.4 13.4 4,924 37.5 1,536 South West Ekiti 17.8 16.6 16.1 17.3 1,375 33.9 675 Lagos 14.8 13.1 12.2 16.3 8,157 24.3 4,416 Ogun 17.0 17.0 17.0 17.0 4,113 37.2 1,882 Ondo 25.6 22.1 19.6 22.3 3,522 35.0 2,225 Osun 4.7 4.4 3.6 4.4 3,223 16.0 885 Oyo 17.3 16.2 15.2 16.2 7,003 36.2 3,136 Wealth quintile Lowest 10.3 9.4 9.4 10.3 35,222 16.4 20,252 Second 16.3 14.6 14.4 15.6 35,167 25.1 20,477 Middle 17.7 16.0 15.6 17.5 35,356 28.0 20,180 Fourth 14.0 12.7 12.1 14.7 35,410 24.4 18,397 Highest 13.2 12.0 11.3 13.9 35,418 25.0 16,930 Total 14.3 12.9 12.6 14.4 176,574 23.7 96,236 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN) or (2) a pretreated net obtained within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation. 3 Excludes 45 cases with missing information on age 4 Excludes 11 cases with missing information on sex Among zones, the percentage of the household population that slept under any mosquito net ranged from 11 percent in the North East to 20 percent in the South East. The use of mosquito nets varied among the states. Ten percent or less of the household population in 10 states—Kogi, Niger, Adamawa, Kaduna, Kano, Delta, Sokoto, Bauchi, Zamfara, and Osun—slept under any type of mosquito net the night before the survey. The percentages of the household population that slept under any net the night before the survey were highest in Cross River (29 percent), Ondo and Jigawa (26 percent each), and Imo (25 percent). Similar state patterns were observed for the proportion of the household population that slept under an ITN or LLIN and for the proportion that slept under ITN and/or had their dwelling sprayed in the last 12 months. Although mosquito net use varies according to wealth, there is no distinct pattern. The proportion of the household population that slept under any mosquito net the night before the survey rises from a low of 10 percent in the lowest wealth quintile to a high of 18 percent in the middle quintile before decreasing to 14 percent in the fourth quintile and 13 percent in the highest quintile. Similar variations were seen for the proportion of the household population that slept under an ITN or LLIN and the proportion that slept under an ITN or had their dwelling sprayed in the last 12 months. 210 • Malaria Figure 12.2 shows that 50 percent of households have at least one ITN. One in five households have at least one ITN for every two persons who stayed in the household the night before the survey. Thirty-six percent of the household population had access to an ITN, and 13 percent slept under an ITN. Figure 12.2 Ownership of, access to, and use of ITNs 50 22 36 13 Percent of households with at least one ITN Percent of households with at least one ITN for every two persons who stayed in the household the night before the interview Percent of the household population with access to an ITN within their household Percent of the household population who slept under an ITN Percent NDHS 2013 12.5 USE OF EXISTING ITNS Table 12.6 shows that 35 percent of the ITNs reported as owned by households were used by someone in the household the night before the survey. The percentage of use of existing ITNs is lower in rural areas than in urban areas (33 percent and 38 percent, respectively). A comparison by zones shows that the percentage of use is higher in all southern zones than in the northern zones. The South South has the highest usage (41 percent), while the North East has the lowest (24 percent). The South East and South West have equal proportions of use (39 percent). Use of existing ITNs varies among the states as well. FCT-Abuja has the highest usage (54 percent) and Bauchi the lowest (12 percent). By wealth, the proportion of net usage is highest in the middle wealth quintile (41 percent) and lowest in the lowest wealth quintile (25 percent). Malaria • 211 Table 12.6 Use of existing ITNs Percentage of insecticide-treated nets (ITNs) that were used by anyone the night before the survey, by background characteristics, Nigeria 2013 Background characteristic Percentage of existing ITNs1 used the night before the survey Number of ITNs1 Residence Urban 38.2 12,546 Rural 32.8 24,065 Zone North Central 37.6 5,773 North East 23.8 6,493 North West 33.1 10,057 South East 38.9 4,899 South South 40.8 4,040 South West 39.1 5,349 State North Central FCT-Abuja 54.4 173 Benue 37.1 2,083 Kogi 41.5 389 Kwara 52.3 349 Nasarawa 33.2 604 Niger 34.0 1,431 Plateau 37.1 744 North East Adamawa 18.8 1,211 Bauchi 12.4 1,434 Borno 21.6 1,441 Gombe 26.7 738 Taraba 29.5 732 Yobe 44.6 937 North West Jigawa 47.1 1,448 Kaduna 23.3 855 Kano 27.1 1,586 Katsina 50.1 1,761 Kebbi 45.9 1,336 Sokoto 25.2 1,069 Zamfara 12.7 2,003 South East Abia 36.7 694 Anambra 28.6 789 Ebonyi 50.9 1,075 Enugu 40.4 806 Imo 36.1 1,534 South South Akwa Ibom 47.0 687 Bayelsa 50.1 294 Cross River 53.0 856 Delta 23.8 633 Edo 33.1 838 Rivers 40.2 733 South West Ekiti 48.7 259 Lagos 30.3 1,807 Ogun 45.5 758 Ondo 43.8 1,004 Osun 19.8 329 Oyo 47.5 1,192 Wealth quintile Lowest 25.3 7,134 Second 36.2 7,688 Middle 40.6 8,019 Fourth 35.7 7,067 Highest 34.9 6,703 Total 34.7 36,610 1 An insecticide-treated net (ITN) is (1) a factory- treated net that does not require any further treatment (LLIN) or (2) a pretreated net obtained within the past 12 months. 212 • Malaria 12.6 USE OF MOSQUITO NETS BY CHILDREN UNDER AGE 5 The use of mosquito nets by vulnerable groups in highly endemic communities is one of the major indicators in the 2014-2020 national malaria strategic plan (FMoH, 2013b). Table 12.7 presents data on the extent to which children under age 5 slept under various types of nets on the night before the interview. Overall, 18 percent of children slept under any net, 17 percent slept under an ITN, and 16 percent slept under an LLIN. The likelihood of sleeping under any net decreases with increasing age, from 21 percent among children younger than age 1 to 15 percent among children age 4. Children in urban areas are more likely to sleep under a net than children in rural areas (20 percent and 17 percent, respectively). Table 12.7 Use of mosquito nets by children Percentage of children under age 5 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide- treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months, and among children under age 5 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Nigeria 2013 Children under age 5 in all households Children under age 5 in households with at least one ITN1 Background characteristic Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number of children Percentage who slept under an ITN1 the night before the survey Number of children Age (in years) <1 20.8 18.9 18.3 20.1 6,372 32.0 3,757 1 19.6 17.9 17.4 19.1 6,060 30.4 3,568 2 19.2 17.4 17.0 18.8 5,737 29.8 3,358 3 16.2 14.9 14.4 16.4 6,137 26.0 3,512 4 15.2 13.7 13.3 15.0 6,021 23.7 3,469 Sex3 Male 18.0 16.3 15.9 17.8 15,275 27.9 8,961 Female 18.5 16.8 16.3 18.0 15,049 29.1 8,702 Residence Urban 19.9 18.1 17.3 20.0 10,979 34.9 5,699 Rural 17.3 15.7 15.4 16.7 19,348 25.4 11,965 Zone North Central 18.9 16.9 16.7 18.0 4,177 29.3 2,411 North East 12.6 12.1 12.1 13.6 5,237 17.5 3,609 North West 16.6 14.8 14.7 16.4 10,994 26.1 6,239 South East 26.5 24.2 23.3 25.6 2,739 38.9 1,701 South South 20.9 19.0 17.8 20.1 2,915 37.6 1,474 South West 21.2 19.6 18.2 20.4 4,264 37.5 2,229 State North Central FCT-Abuja 25.0 20.7 18.9 25.4 202 47.9 87 Benue 29.5 29.4 29.4 29.4 897 36.5 722 Kogi 12.7 9.9 9.4 9.9 400 29.8 133 Kwara 31.3 17.9 17.1 17.9 403 44.5 162 Nasarawa 15.9 14.5 14.5 18.3 446 22.9 283 Niger 10.5 10.3 10.3 11.4 1,342 18.4 751 Plateau 18.1 18.0 18.0 18.6 487 32.1 273 North East Adamawa 12.9 12.6 12.6 12.7 701 15.8 560 Bauchi 6.9 6.8 6.8 9.1 1,259 9.0 952 Borno 11.3 10.7 10.7 11.1 1,110 17.0 699 Gombe 12.8 11.7 11.7 13.5 559 16.0 408 Taraba 15.5 14.5 14.5 14.6 712 23.6 436 Yobe 19.7 19.1 19.1 22.9 896 30.9 554 North West Jigawa 29.8 24.4 24.0 33.4 1,430 38.9 895 Kaduna 7.1 5.0 4.9 5.5 1,441 17.7 404 Kano 9.1 7.3 7.2 7.5 2,860 17.9 1,163 Katsina 29.0 28.9 28.6 28.9 1,617 40.8 1,146 Kebbi 24.7 23.5 23.5 23.5 1,173 37.5 736 Sokoto 13.3 12.3 12.3 14.7 1,061 19.5 672 Zamfara 10.0 9.1 9.1 9.1 1,413 10.6 1,223 Continued… Malaria • 213 Table 12.7—Continued Children under age 5 in all households Children under age 5 in households with at least one ITN1 Background characteristic Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number of children Percentage who slept under an ITN1 the night before the survey Number of children South East Abia 23.5 23.5 23.4 33.6 315 34.1 218 Anambra 15.9 14.1 13.8 14.6 630 26.9 330 Ebonyi 31.0 30.7 30.5 30.9 727 50.2 444 Enugu 29.0 21.2 20.4 21.4 540 41.2 278 Imo 32.4 30.7 27.8 30.9 527 37.4 432 South South Akwa Ibom 16.5 14.9 14.5 15.2 478 31.0 229 Bayelsa 25.8 24.2 23.7 25.0 235 44.3 128 Cross River 33.6 29.2 27.7 29.4 534 46.9 332 Delta 12.3 9.7 8.6 12.8 553 23.8 225 Edo 22.9 22.9 20.7 23.2 407 30.8 303 Rivers 18.0 17.5 16.1 18.9 709 48.4 256 South West Ekiti 22.9 20.8 20.8 22.1 199 39.4 105 Lagos 21.5 19.4 18.0 22.0 1,254 31.5 770 Ogun 20.0 20.0 20.0 20.0 711 42.6 333 Ondo 29.3 25.2 21.6 25.2 544 41.9 328 Osun 8.4 7.8 5.7 7.8 456 25.7 138 Oyo 22.7 21.6 20.5 21.6 1,100 42.8 556 Wealth quintile Lowest 12.6 11.8 11.8 12.7 6,927 19.8 4,146 Second 19.5 17.4 17.2 18.1 6,818 28.4 4,164 Middle 21.9 19.8 19.3 21.5 5,812 33.0 3,495 Fourth 18.4 17.0 16.3 19.2 5,547 30.7 3,076 Highest 19.6 17.7 16.7 19.1 5,222 33.2 2,783 Total 18.2 16.6 16.1 17.9 30,327 28.4 17,664 Note: Table is based on children who stayed in the household the night before the interview. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN) or (2) a pretreated net obtained within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation. 3 Excludes 2 cases with missing information on sex Net usage among children living in households with an ITN was lowest in the North East (13 percent) and highest in the South East (27 percent). The percentage of children under age 5 who slept under any net was lowest in Bauchi and Kaduna (7 percent each) and highest in Cross River (34 percent). By wealth quintile, children’s use of mosquito nets varied from 13 percent in the lowest quintile to 22 percent in the middle quintile. 12.7 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 2013 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 are presented in Table 12.8. Table 12.8 shows that 18 percent of pregnant women slept under a mosquito net the night before the survey, an appreciable increase from the 2008 NDHS figure of 12 percent. In addition, 16 percent of women slept under an ITN, as compared with only 4 percent in 2008. Similarly, 16 percent of women slept under an LLIN the night before the survey. Use of all three types of nets is slightly higher in urban areas than in rural areas, which is a reversal of the trend observed in the 2008 NDHS. The urban-rural difference in net usage among pregnant women is smaller than in 2008. 214 • Malaria Table 12.8 Use of mosquito nets by pregnant women Percentages of pregnant women age 15-49 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide- treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months, and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Nigeria 2013 Among pregnant women age 15-49 in all households Among pregnant women age 15-49 in households with at least one ITN1 Background characteristic Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number of women Percentage who slept under an ITN1 the night before the survey Number of women Residence Urban 18.4 17.1 16.3 18.1 1,565 36.0 741 Rural 17.4 16.0 15.8 16.8 3,151 27.3 1,848 Zone North Central 17.0 15.7 15.5 16.5 644 28.3 358 North East 14.3 13.2 13.2 13.9 795 19.8 532 North West 17.4 15.9 15.7 16.9 1,930 29.4 1,043 South East 24.1 23.2 22.7 24.3 347 40.2 200 South South 17.6 16.4 15.1 17.5 424 37.6 185 South West 21.0 18.9 17.7 19.3 576 40.0 272 State North Central FCT-Abuja 22.4 14.2 12.7 15.5 26 (39.8) 9 Benue 21.4 21.4 21.4 21.4 160 26.8 128 Kogi 11.5 8.5 7.5 8.5 66 (21.8) 26 Kwara 22.1 14.8 14.8 14.8 44 (37.0) 17 Nasarawa 15.3 14.3 13.3 19.5 62 24.0 37 Niger 14.0 14.0 14.0 14.0 217 29.7 102 Plateau 17.5 17.5 17.5 19.8 69 31.3 39 North East Adamawa 13.1 13.1 13.1 13.1 128 16.8 99 Bauchi 9.2 8.3 8.3 10.6 188 11.2 139 Borno 15.9 13.8 13.8 13.8 181 23.2 108 Gombe 17.6 16.5 16.5 16.8 77 23.6 54 Taraba 13.1 11.7 11.7 11.7 91 20.4 52 Yobe 19.7 18.7 18.7 19.6 131 30.8 80 North West Jigawa 29.8 26.1 26.1 32.5 203 41.6 128 Kaduna 6.3 5.0 5.0 5.2 457 18.2 125 Kano 11.1 8.8 8.1 9.0 405 20.8 171 Katsina 36.2 36.2 35.7 36.2 264 53.4 179 Kebbi 29.5 28.8 28.8 28.8 213 42.0 146 Sokoto 9.7 9.1 9.1 11.9 158 14.0 102 Zamfara 12.1 10.6 10.6 10.6 230 12.7 192 South East Abia 18.9 18.9 18.9 29.2 38 (33.6) 22 Anambra 13.8 13.8 13.8 13.8 63 (30.2) 29 Ebonyi 34.5 34.5 34.5 34.5 100 60.4 57 Enugu 24.0 20.0 20.0 20.0 77 (36.0) 43 Imo 21.2 21.2 18.6 21.2 68 29.3 49 South South Akwa Ibom 15.2 15.2 15.2 18.5 45 (32.2) 21 Bayelsa 21.9 18.7 18.7 19.7 42 48.4 16 Cross River 37.8 34.7 33.3 34.7 61 (54.3) 39 Delta 10.8 9.9 7.3 11.8 107 (20.1) 52 Edo 16.8 16.8 13.4 16.8 47 (25.7) 31 Rivers 13.0 12.3 12.3 13.0 122 * 25 South West Ekiti 29.4 27.9 26.4 27.9 23 (44.9) 14 Lagos 16.8 14.3 12.5 16.0 142 25.6 80 Ogun 19.8 19.8 19.8 19.8 96 (43.9) 43 Ondo 28.0 22.5 19.2 22.5 74 (41.5) 40 Osun 2.0 1.1 1.1 1.1 53 * 8 Oyo 26.3 24.2 23.4 24.2 188 53.2 86 Education No education 17.2 15.8 15.6 16.7 2,310 27.6 1,321 Primary 20.8 19.0 18.5 19.9 846 34.9 461 Secondary 17.4 16.0 15.2 16.9 1,273 31.0 656 More than secondary 15.2 15.1 14.6 15.7 287 28.7 151 Wealth quintile Lowest 13.7 12.9 12.9 13.2 1,156 22.6 658 Second 18.0 17.1 16.9 17.8 1,117 29.7 643 Middle 23.7 20.9 20.5 22.3 866 35.5 511 Fourth 19.9 18.1 17.2 19.6 821 35.5 418 Highest 14.5 13.6 12.8 14.3 757 28.6 360 Total 17.8 16.4 16.0 17.2 4,716 29.8 2,589 Note: Table is based on women who stayed in the household the night before the interview. 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 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN) or (2) a pretreated net obtained within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation. Malaria • 215 Use of any type of mosquito net is generally higher in the southern zones of the country than in the northern zones. Proportions range from 14 percent in the North East to 24 percent in the South East. The results also show that use of mosquito nets by pregnant women varies by education and wealth quintile. Pregnant women with a primary education are most likely to use mosquito nets (21 percent), while pregnant women with more than a secondary education are least likely to do so (15 percent). Thirty percent of pregnant women in households with at least one ITN slept under an ITN on the night before the survey. Among pregnant women in households with at least one ITN, 36 percent in urban areas and 27 percent in rural areas slept under an ITN in the night before the survey. The proportion of pregnant women sleeping under a net the night before the survey was higher in the southern zones than the northern zones. The use of mosquito nets by pregnant women varies by state. Osun has the lowest proportion (2 percent), followed by Kaduna (6 percent), while Cross River has the highest (38 percent) proportion of pregnant women sleeping under any net the night before the survey. 12.8 PROPHYLACTIC USE OF ANTIMALARIAL 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; Fansidar, Amalar, and Maloxine are some of the most common. IPT is offered through the focused antenatal care strategy. In accordance with the national protocol, SP is given free of charge to pregnant women through antenatal care (ANC) services at public health facilities and NGO facilities. Using an approach of directly observed therapy, one dose each of SP is given during the second and third trimesters. A third dose is recommended for pregnant women who are HIV positive. However, recent recommendations stress the importance of three doses of SP during pregnancy for all women. Table 12.9 shows information on malaria prevention for pregnant women through prophylactic antimalarial drug use and IPT. According to the 2013 NDHS, 23 percent of women received an antimalarial drug for prevention of malaria during the pregnancy for their last live birth in the two years preceding the survey, an improvement from the 8 percent figure reported in 2008 (Figure 12.3). Thirty-one percent of women in urban areas and 18 percent in rural areas took antimalarial drugs during pregnancy for prevention of malaria, as compared with 13 percent and 6 percent, respectively, in 2008. The survey also collected information on the number of SP doses taken by pregnant women. Overall, 15 percent of pregnant women reported receiving the recommended two doses of SP, with at least one dose administered during an ANC visit. This is an improvement over the 5 percent figure reported in the 2008 NDHS. A higher proportion of women in urban areas than rural areas received two or more doses of SP (19 percent and 12 percent, respectively). Among the zones, the proportion was highest in the South East (18 percent) and lowest in the South South (10 percent). Pregnant women with a secondary or more than a secondary education and those in the fourth wealth quintile were more likely to receive IPT during an ANC visit than other women. 216 • Malaria Table 12.9 Use of intermittent preventive treatment by women during pregnancy Percentage of women age 15-49 with a live birth in the two years preceding the survey who, during the pregnancy preceding the last birth, received any SP/Fansidar during an ANC visit and who took at least two doses of SP/Fansidar and received at least one dose during an ANC visit, by background characteristics, Nigeria 2013 Background characteristic Percentage who received any SP/Fansidar during an ANC visit Percentage who took 2+ doses of SP/Fansidar and received at least one during ANC visit Percentage who took 3+ doses of SP/Fansidar and received at least one during ANC visit Number of women with a live birth in the two years preceding the survey Residence Urban 31.3 19.4 6.3 4,404 Rural 17.8 12.0 5.5 8,069 Zone North Central 20.8 16.9 10.7 1,692 North East 22.5 12.2 4.8 2,152 North West 24.7 16.7 4.5 4,554 South East 24.0 18.3 9.6 1,150 South South 15.3 10.1 3.8 1,191 South West 23.0 10.5 4.3 1,733 State North Central FCT-Abuja 28.1 16.6 1.9 75 Benue 0.8 0.6 0.4 374 Kogi 32.9 24.8 13.6 168 Kwara 24.3 11.4 1.8 161 Nasarawa 16.5 11.2 4.9 197 Niger 35.3 34.5 26.7 514 Plateau 9.7 5.5 2.5 204 North East Adamawa 27.0 22.3 11.5 289 Bauchi 32.7 14.3 5.5 573 Borno 13.9 6.7 1.9 408 Gombe 32.0 19.7 4.7 231 Taraba 10.2 6.0 2.0 300 Yobe 16.7 7.4 3.7 350 North West Jigawa 24.6 18.7 9.3 608 Kaduna 26.4 15.5 4.4 496 Kano 53.2 36.1 7.5 1,188 Katsina 13.2 8.4 1.9 688 Kebbi 5.0 3.8 1.7 479 Sokoto 7.4 4.7 0.7 444 Zamfara 9.7 6.6 2.2 652 South East Abia 27.8 21.7 17.8 135 Anambra 4.7 3.6 1.8 245 Ebonyi 39.4 32.1 11.7 313 Enugu 20.6 15.0 9.7 230 Imo 24.8 16.6 10.1 228 South South Akwa Ibom 11.6 7.3 2.9 202 Bayelsa 10.2 5.1 2.2 95 Cross River 23.9 18.2 12.5 221 Delta 29.0 19.7 2.2 220 Edo 3.2 1.6 1.2 168 Rivers 9.5 5.0 1.2 285 South West Ekiti 19.4 5.2 0.5 78 Lagos 26.2 10.0 3.0 519 Ogun 31.9 28.3 12.7 294 Ondo 10.7 4.1 2.7 225 Osun 43.9 10.8 3.9 189 Oyo 11.0 3.0 1.9 428 Education No education 17.6 11.7 4.7 5,940 Primary 24.5 15.5 6.6 2,253 Secondary 26.9 17.7 6.8 3,466 More than secondary 35.2 20.2 7.5 815 Wealth quintile Lowest 11.2 6.3 2.5 2,888 Second 18.2 11.9 4.4 2,842 Middle 24.8 17.7 9.1 2,360 Fourth 32.2 22.6 7.9 2,247 Highest 31.2 17.5 6.2 2,135 Total 22.6 14.6 5.8 12,473 Malaria • 217 The results by states show that only 1 percent of pregnant women in Benue received two or more doses of SP with at least one during an ANC visit, while approximately one-third of women in Kano (36 percent), Niger (35 percent), and Ebonyi (32 percent) received two or more doses. Table 12.9 also includes information on the new malaria indicator for pregnant women, that is, three or more SP doses with at least one dose administered during an ANC visit. Six percent of women received three or more SP doses during pregnancy. There was no variation according to urban-rural residence; however, Niger had the highest proportion of women who received three or more doses (27 percent). Figure 12.3 Trends in the percentage of women taking 2+ doses of SP and at least one dose during ANC 1 na 8 5 23 15 Received any SP during an ANC visit Received 2+ doses of SP and at least one during ANC Percent 2003 NDHS 2008 NDHS 2013 NDHS 12.9 PREVALENCE AND PROMPT TREATMENT OF FEVER IN CHILDREN UNDER AGE 5 Following a period of continuous increases in the resistance of Plasmodium falciparum to the commonly used antimalarial medicines, the artemisinin-based combination therapy (ACT) was introduced in 2005 with artemether-lumefantrine as the first-line treatment for uncomplicated malaria and artesunate plus amodiaquine (co-packaged) as an alternative (FMoH, 2011b). As programmatic deployment of ACT will be scaled up to include persons above age 5 over the period of the strategic plan, a policy to improve diagnosis of malaria cases through parasitological confirmation by microscopy or rapid diagnostic tests has been put in place (FMoH, 2011b). 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 caregivers in the 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 2013 NDHS, mothers were asked whether their children under age 5 had had a 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. 218 • Malaria Table 12.10 shows the percentage of children under age 5 with a fever in the two weeks preceding the survey and, among children with fever, the percentage who took antimalarial 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 2013 NDHS indicate that 13 percent of children under age 5 had a fever during the two weeks preceding the interview. Children age 12-23 months were most likely to have had a fever in the past two weeks (18 percent), while children age 48-59 months were least likely (9 percent). There was little variation by sex or urban-rural residence in the prevalence of fever during the two weeks preceding the survey. The prevalence was lowest in the South West and North Central (7 percent each) and highest in the North East (21 percent). The prevalence of fever was similar among children of all women irrespective of education or wealth. Table 12.10 Prevalence, diagnosis, and prompt treatment of children with fever Percentage of children under age 5 with a fever in the two weeks preceding the survey, and among children under age 5 with fever, the percentage for whom advice or treatment was sought, the percentage who had blood taken from a finger or heel, the percentage who took any artemisinin-based combination therapy (ACT), the percentage who took ACT the same or next day following the onset of fever, the percentage who took antimalarial drugs, and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, Nigeria 2013 Among children under age 5: Among children under age 5 with fever: Background characteristic Percentage with fever in the two weeks preceding the survey Number of children Percentage for whom advice or treatment was sought1 Percentage who had blood taken from a finger or heel for testing Percentage who took any ACT Percentage who took any ACT the same or next day Percentage who took antimalarial drugs Percentage who took antimalarial drugs the same or next day Number of children Age (in months) <12 12.1 6,252 71.3 8.1 6.3 4.1 30.4 20.6 759 12-23 17.5 5,900 70.8 12.6 6.4 4.5 33.3 21.6 1,034 24-35 13.4 5,490 71.1 10.4 5.6 4.9 33.6 24.5 736 36-47 10.3 5,722 68.2 12.2 5.7 3.7 35.5 26.1 591 48-59 9.2 5,586 68.1 12.4 5.6 3.7 30.4 23.0 512 Sex Male 12.9 14,509 71.3 11.4 6.9 4.5 33.2 22.2 1,867 Female 12.2 14,440 68.9 10.8 5.0 4.0 32.3 23.7 1,766 Residence Urban 12.1 10,403 71.9 11.9 7.6 5.9 39.9 29.7 1,262 Rural 12.8 18,547 69.2 10.7 5.1 3.4 28.9 19.3 2,370 Zone North Central 7.4 4,019 65.3 29.0 11.7 10.3 50.7 43.9 297 North East 20.8 5,034 74.0 8.7 3.7 2.0 25.0 14.9 1,045 North West 9.9 10,485 63.6 6.7 5.3 3.5 29.0 19.3 1,034 South East 19.3 2,585 71.0 9.3 4.9 3.7 29.9 21.1 498 South South 16.8 2,742 78.6 15.0 10.7 8.6 39.8 27.6 460 South West 7.3 4,084 69.6 13.9 5.3 3.0 48.6 38.3 297 State North Central FCT-Abuja 7.6 196 (73.7) (9.6) (16.2) (16.2) (29.0) (27.3) 15 Benue 3.7 878 * * * * * * 33 Kogi 3.4 378 * * * * * * 13 Kwara 4.3 377 (78.2) (28.0) (6.0) (3.0) (58.9) (48.6) 16 Nasarawa 9.8 421 83.9 32.7 27.4 23.7 65.0 56.0 41 Niger 9.3 1,303 66.3 35.3 14.7 14.0 69.5 64.5 121 Plateau 12.5 464 58.1 25.6 1.8 1.8 25.5 15.8 58 North East Adamawa 13.2 661 81.1 7.2 2.4 1.9 16.9 10.7 87 Bauchi 25.3 1,243 75.6 10.1 1.4 0.4 19.3 10.5 315 Borno 10.7 1,064 62.7 1.4 0.0 0.0 39.7 16.6 114 Gombe 18.5 529 83.9 10.0 4.3 3.1 38.4 35.4 98 Taraba 21.1 690 69.6 15.7 1.6 1.6 23.4 17.6 146 Yobe 33.7 848 73.4 6.5 8.9 4.3 24.1 11.8 286 North West Jigawa 18.9 1,380 65.7 13.1 6.6 4.9 31.6 22.7 260 Kaduna 12.2 1,375 48.7 4.2 1.9 1.1 17.4 16.2 168 Kano 9.1 2,717 70.3 3.3 2.1 1.4 29.2 18.9 248 Katsina 6.3 1,549 53.3 6.6 8.5 4.6 39.2 21.9 98 Kebbi 9.0 1,094 70.5 11.6 14.8 7.4 45.0 26.4 98 Sokoto 6.2 1,005 62.6 3.0 8.2 8.2 20.5 17.8 62 Zamfara 7.3 1,365 70.8 0.9 1.0 1.0 21.0 8.0 100 Continued… Malaria • 219 Table 12.10—Continued Among children under age 5: Among children under age 5 with fever: Background characteristic Percentage with fever in the two weeks preceding the survey Number of children Percentage for whom advice or treatment was sought1 Percentage who had blood taken from a finger or heel for testing Percentage who took any ACT Percentage who took any ACT the same or next day Percentage who took antimalarial drugs Percentage who took antimalarial drugs the same or next day Number of children South East Abia 11.2 297 (69.2) (15.4) (0.0) (0.0) (28.1) (2.6) 33 Anambra 11.4 608 54.6 16.5 10.4 7.4 18.9 14.8 69 Ebonyi 25.1 663 75.8 1.1 4.4 3.1 21.6 14.8 166 Enugu 24.3 514 69.4 14.1 2.8 2.8 25.8 16.8 125 Imo 20.7 502 77.0 10.0 6.0 4.6 56.2 46.6 104 South South Akwa Ibom 18.8 439 81.9 8.9 4.5 1.9 18.9 12.0 83 Bayelsa 3.9 220 (78.1) (5.0) (8.3) (0.0) (62.9) (50.5) 9 Cross River 25.6 499 79.9 11.7 2.3 0.7 27.1 8.8 128 Delta 5.2 520 (46.2) (2.7) (8.5) (8.5) (33.7) (33.7) 27 Edo 5.9 387 (77.4) (37.7) (7.3) (7.3) (52.0) (31.6) 23 Rivers 28.3 676 81.1 19.3 19.7 17.2 55.5 44.6 192 South West Ekiti 6.4 188 (62.7) (0.0) (10.7) (6.3) (43.4) (28.4) 12 Lagos 9.2 1,220 69.8 12.4 9.7 4.6 54.5 43.9 112 Ogun 2.1 689 * * * * * * 15 Ondo 9.6 520 73.3 10.5 0.0 0.0 38.5 24.7 50 Osun 6.9 427 (72.7) (8.2) (12.6) (9.6) (83.7) (72.9) 30 Oyo 7.6 1,040 76.1 23.9 0.0 0.0 36.9 28.3 79 Mother’s education No education 12.3 13,945 66.6 8.2 4.1 2.4 26.3 16.4 1,718 Primary 12.8 5,563 70.6 10.7 6.0 3.8 31.8 21.1 714 Secondary 12.8 7,697 75.2 13.3 8.4 7.0 41.1 32.6 982 More than secondary 12.5 1,744 74.0 25.3 10.2 7.8 48.8 36.3 219 Wealth quintile Lowest 13.6 6,636 64.4 6.4 3.6 2.4 22.1 12.6 899 Second 12.9 6,483 69.3 10.0 3.9 1.9 26.4 16.5 837 Middle 13.7 5,534 73.5 12.3 6.0 4.9 35.0 26.5 756 Fourth 11.7 5,243 74.1 12.8 8.3 5.8 41.6 30.4 614 Highest 10.4 5,053 71.9 17.4 10.4 8.4 47.5 36.8 526 Total 12.5 28,950 70.1 11.1 6.0 4.2 32.7 22.9 3,632 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 Excludes market and traditional practitioner Prompt treatment of fever is one indicator used to measure the quality of case management. Advice or treatment was sought for 70 percent of children under age 5 with a fever, while 11 percent had blood taken from a finger or heel for testing. The proportion for whom advice or treatment was sought was highest among children less than age 1 and lowest among those age 48-59 months. Blood was less often taken from younger children (less than age 12 months) (8 percent). The proportion of children who had blood taken was highest in the North Central zone (29 percent). Overall, only 6 percent of children under age 5 with a fever took any ACT, and only 4 percent took it on the same or next day. ACT was mostly given in the North Central and South South zones (12 percent and 11 percent, respectively). It was mostly taken by children whose mothers had more than a secondary education (10 percent) and those in the highest wealth quintile (10 percent). Thirty-three percent of children under age 5 with a fever took antimalarial drugs, and 23 percent of children took antimalarial drugs on the same or next day. Treatment of malaria varies by zone, with children in the North Central zone (51 percent) more likely than children in other zones to receive antimalarial drugs. Use of antimalarial drugs increases with mother’s level of education and wealth quintile, similar to the pattern reported in the 2008 NDHS. 220 • Malaria 12.10 SOURCE OF ADVICE OR TREATMENT FOR CHILDREN WITH FEVER The 2013 NDHS included questions on source of advice or treatment for children with fever. Table 12.11 shows the proportion of children under age 5 with a fever in the two weeks preceding the survey for whom advice or treatment was sought from different sources. Advice or treatment was sought from the public sector for 26 percent of children, with government hospitals accounting for 12 percent of this total. Advice or treatment was sought from the private sector for 42 percent of children, primarily from a chemist/PMS (34 percent). For 8 percent of children, advice or treatment was sought from other sources such as shops, traditional practitioners, and markets. Among children with fever for whom advice or treatment was sought, 35 percent received advice or treatment from any public sector source, including a government hospital (16 percent) or government health centre (14 percent). Fifty-seven percent received advice or treatment from any private sector source, with chemists/PMS playing an important role (46 percent). 12.11 TYPE AND TIMING OF ANTIMALARIAL DRUGS In the 2013 NDHS, mothers with children under age 5 who had a fever in the two weeks preceding the survey and were treated with antimalarial drugs were asked about the types of drugs used to treat the fever. Table 12.12 shows specific types of antimalarial drugs given to children. The use of ACT is the recommended first-line treatment for uncomplicated malaria in Nigeria. Eighteen percent of children were reported to have received any ACT. Despite the fact that both chloroquine and SP are no longer recommended as first-line drugs for malaria treatment, they remain the most commonly reported antimalarial drugs given to children with fever (31 percent each). Six percent of children received amodiaquine, 2 percent received quinine, and 22 percent were reported to have received other antimalarial drugs. Although use of ACT for malaria treatment increased from 2 percent in 2008 to 18 percent in 2013, this figure remains below the national target (at least 80 percent by 2010, as specified in the national malaria strategic plan). Use of any antimalarial drug, including ACT, is similar in all age groups. However, more male than female children receive ACT. There is no marked variation in the pattern of use of antimalarial drugs between urban and rural areas. Children in the South South (27 percent) and North Central (23 percent) zones were more likely to be treated with ACT than children in other zones. Mother’s educational status and wealth influenced use of ACT for malaria treatment. For example, 21 percent of children whose mothers had more than a secondary education were treated with ACT, as compared with 16 percent of children whose mothers did not have any education. Twenty-two percent of children in the highest wealth quintile were given ACT for treatment of malaria, while 15 percent in the second quintile and 17 percent each in the lowest and middle quintiles were treated with ACT. Similarly, use of SP and chloroquine for treatment of malaria was associated with both educational status and wealth quintile. The results show that 37 percent and 36 percent of children whose mothers have no education were given SP and chloroquine, respectively, as compared with 29 percent and 21 percent of children whose mothers have more than a secondary education. Thirty-six Table 12.11 Source of advice or treatment for children with fever Percentage of children under age 5 with a fever in the two weeks preceding the survey for whom advice or treatment was sought from specific sources, and among children under age 5 with fever in the two weeks preceding the survey for whom advice or treatment was sought, the percentage for whom advice or treatment was sought from specific sources, by background characteristics, Nigeria 2013 Percentage for whom advice or treatment was sought from each source: Background characteristic Among children with fever Among children with fever for whom advice or treatment was sought Any public sector source 25.7 34.8 Government hospital 12.0 16.2 Government health centre 10.3 13.9 Government health post 2.7 3.7 Mobile clinic 0.3 0.4 Fieldworker 0.5 0.7 Other public 0.1 0.2 Any private sector source 42.0 56.8 Private hospital/clinic 4.8 6.6 Pharmacy 2.8 3.8 Private doctor 0.3 0.4 Mobile clinic 0.4 0.5 Fieldworker 0.2 0.3 Chemist/PMS 33.7 45.6 Other private medical sector 0.2 0.3 Any other source 7.5 10.1 Shop 2.4 3.2 Traditional practitioner 3.7 4.9 Market 1.0 1.4 Other 0.6 0.9 Number of children 3,632 2,685 Malaria • 221 percent of children in the lowest wealth quintile received SP, compared with 28 percent in the highest wealth quintile while 36 percent of children in the lowest quintile and 21 percent in the highest quintile were given chloroquine. Table 12.12 Type of antimalarial drugs used Among children under age 5 with a fever in the two weeks preceding the survey who took any antimalarial medication, the percentage who took specific antimalarial drugs, by background characteristics, Nigeria 2013 Percentage of children who took drug: Number of children with fever who took antimalarial drug Background characteristic Any ACT Quinine SP/Fansidar Chloroquine Amodiaquine Other anti- malarial Age (in months) <12 20.6 4.3 25.0 38.0 4.5 19.0 231 12-23 19.0 1.4 30.1 28.0 8.7 23.0 345 24-35 16.8 0.5 34.4 28.0 3.7 23.2 247 36-47 16.0 2.1 31.7 31.2 6.9 20.7 210 48-59 18.4 1.5 32.6 30.9 4.8 21.1 156 Sex Male 20.9 1.9 30.8 30.4 6.4 20.6 619 Female 15.4 2.0 30.4 31.4 5.6 22.7 570 Residence Urban 19.1 1.6 28.6 25.1 4.5 28.5 504 Rural 17.7 2.2 32.1 35.1 7.1 16.5 685 Zone North Central 23.1 1.7 34.1 31.1 27.0 8.0 151 North East 14.7 1.5 32.6 40.6 2.8 14.2 261 North West 18.2 2.3 40.4 36.5 4.0 11.9 300 South East 16.3 5.3 28.6 23.8 3.2 29.6 149 South South 26.8 1.0 21.0 18.9 0.5 33.6 183 South West 10.9 0.0 17.4 24.1 3.9 45.6 145 Mother’s education No education 15.5 2.2 37.2 35.5 8.9 11.6 452 Primary 18.9 1.0 19.8 39.5 4.8 22.0 227 Secondary 20.3 1.8 29.6 23.6 4.4 28.4 404 More than secondary 20.8 3.0 29.4 20.5 2.7 37.6 107 Wealth quintile Lowest 16.5 0.8 35.5 35.8 2.9 14.8 199 Second 15.0 4.3 31.4 36.1 6.2 19.0 221 Middle 17.2 1.6 32.8 35.2 10.6 15.1 264 Fourth 20.1 1.9 26.7 28.0 6.3 22.9 255 Highest 21.9 1.1 27.8 20.7 3.2 34.9 250 Total 18.3 1.9 30.6 30.9 6.0 21.6 1,189 Note: State-level disaggregation is not shown due to the small number of cases. ACT = Artemisinin-based combination therapy HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 223 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 igeria, with an estimated population of 160 million (National Population Commission, 2014), is second to South Africa in the number of people living with HIV/AIDS worldwide, representing 9 percent of the global burden of the disease. Since 1991, the country has employed a sentinel surveillance system among pregnant women age 15-49 attending antenatal care to track HIV prevalence. Surveillance results show that HIV prevalence has declined over the years, from 5.8 percent in 2001 to 4.6 percent in 2008 and 4.1 percent in 2010. In 2010, across the country’s states, HIV prevalence ranged from 1.0 percent in Kebbi to 12.6 percent in Benue (Federal Ministry of Health [FMoH], 2011c). New HIV infections in the country are fuelled by low perceptions of personal risk, multiple and concurrent sexual partnerships, intense transactional and intra-generational sex, ineffective and inefficient treatment services for sexually transmitted infections (STIs), and inadequate access to and poor quality of N Key Findings • Ninety-three percent of women and 96 percent of men age 15-49 have heard of AIDS. • HIV awareness is almost universal among urban women and men (97 percent and 98 percent, respectively), while awareness among rural women and men is lower (89 percent and 93 percent, respectively). • Seventy-eight percent of women and 85 percent of men know that limiting sexual intercourse to one uninfected partner who has no other partners can reduce the chances of contracting HIV. • Twenty-six percent of women and 37 percent of men have comprehensive knowledge about AIDS. That is, they know that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting HIV, they know that a healthy-looking person can have the AIDS virus, and they reject the two most common local misconceptions about HIV transmission or prevention. • Overall, 49 percent of women and 45 percent of men know that HIV can be transmitted by breastfeeding and that the risk of mother-to-child transmission can be reduced if the mother takes special drugs during pregnancy. • Twelve percent of women and 13 percent of men express accepting attitudes in four situations: they would care for a family member with HIV or AIDS in their own home, they would buy fresh vegetables from a shopkeeper with HIV, they would allow an HIV-positive female teacher to continue teaching, and they would not want to keep secret the HIV- positive status of a family member. • One percent of women and 13 percent of men had two or more sexual partners during the 12 months preceding the survey. Among respondents who had two or more partners in the past 12 months, 29 percent of women and 20 percent of men reported that they used a condom during their most recent sexual intercourse. • Eight percent of women and 4 percent of men reported that they had a sexually transmitted infection (STI) or symptoms of an STI in the 12 months preceding the survey. 224 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour health care services. Entrenched gender inequalities and inequities, chronic and debilitating poverty, and the persistence of HIV/AIDS-related stigma and discrimination are other contributing factors (National Agency for the Control of AIDS, 2010). To further strengthen its coordination of the multisectoral response, the federal government transformed the National Action Committee on AIDS into an agency, the National Agency for the Control of AIDS, in July 2007. For the purpose of sustaining and improving the effectiveness and coordination of the national HIV response, states have taken the same step of transforming smaller committees and bodies into agencies. Nationally, HIV and AIDS programmes have received a boost through the efforts of the government and the support of development partners, which has led to a scale up of prevention, care, and treatment programmes aimed at combating the disease. Also, the monitoring and evaluation system has been strengthened, and there have been increases in the amount of HIV research conducted. The fight against HIV will depend on well-articulated prevention programmes addressing issues such as HIV- and AIDS-related knowledge among the general population, social stigmatisation, risk behaviour modification, access to quality STI treatment services, provision and uptake of HIV counselling and testing, and access to care and antiretroviral therapy (ART), including prevention and treatment of opportunistic infections. The principal objective of this chapter is to present detailed information on these issues, as recorded in the 2013 NDHS, at the national, zonal, and state levels according to selected demographic and socioeconomic characteristics of the population. 13.1 HIV AND AIDS KNOWLEDGE, TRANSMISSION, AND PREVENTION METHODS 13.1.1 Awareness of HIV and AIDS The 2013 NDHS respondents were asked whether they had heard of AIDS. Those who reported having heard of AIDS were asked a number of questions about whether and how HIV can be prevented. Table 13.1 shows the percentage of women and men age 15-49 who have heard of AIDS, by background characteristics. In Nigeria, 93 percent of women and 96 percent of men have heard of AIDS. There are minor differences in awareness according to background characteristics. Women and men who have never been married but have had sex are more likely than those who have never had sex to have knowledge of AIDS. Awareness about AIDS is almost universal among urban women and men (97 percent and 98 percent, respectively), while awareness among rural women and men is slightly lower (89 percent and 93 percent, respectively). Women and men in the South East show the highest level of AIDS awareness (99 percent each), while women in the North Central and North East zones exhibit the lowest awareness (84 percent and 88 percent, respectively). Since 2008, the percentage of women and men age 15-49 who have heard of AIDS has increased by 4 and 2 percentage points, respectively. This increase in awareness can be attributed to the intensive HIV and AIDS prevention programmes administered through nongovernmental organisations (NGOs). HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 225 Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Nigeria 2013 Women Men Background characteristic Has heard of AIDS Number of respondents Has heard of AIDS Number of respondents Age 15-24 91.4 14,576 92.1 6,511 15-19 89.5 7,820 89.3 3,619 20-24 93.5 6,757 95.5 2,892 25-29 92.6 7,145 97.3 2,757 30-39 94.2 10,185 97.5 4,589 40-49 92.8 7,042 97.7 3,501 Marital status Never married 94.3 9,326 93.7 8,378 Ever had sex 97.8 3,732 98.5 3,461 Never had sex 91.9 5,593 90.3 4,918 Married/living together 91.8 27,830 97.1 8,723 Divorced/separated/widowed 95.5 1,793 99.4 258 Residence Urban 97.3 16,414 98.3 7,611 Rural 89.2 22,534 93.3 9,748 Zone North Central 83.5 5,572 93.8 2,685 North East 88.1 5,766 94.1 2,515 North West 95.4 11,877 95.3 5,185 South East 99.0 4,476 98.7 1,686 South South 94.3 4,942 97.5 2,445 South West 93.6 6,314 95.1 2,843 State North Central FCT-Abuja 90.4 315 94.0 175 Benue 99.7 1,240 100.0 616 Kogi 88.0 704 96.1 333 Kwara 92.5 596 99.2 274 Nasarawa 82.5 594 86.6 282 Niger 64.0 1,462 90.0 701 Plateau 80.6 662 88.9 302 North East Adamawa 89.7 828 97.8 358 Bauchi 87.2 1,161 94.9 512 Borno 80.4 1,412 95.5 676 Gombe 79.4 550 93.9 255 Taraba 95.6 844 93.2 325 Yobe 97.1 971 88.3 390 North West Jigawa 93.5 1,353 97.2 510 Kaduna 95.8 2,136 97.5 1,033 Kano 99.7 3,189 96.0 1,592 Katsina 99.7 1,525 99.6 596 Kebbi 75.9 1,244 80.2 551 Sokoto 99.1 1,098 95.4 424 Zamfara 96.9 1,332 97.5 479 South East Abia 98.6 518 99.2 229 Anambra 99.6 1,052 99.2 446 Ebonyi 98.3 1,122 98.5 368 Enugu 99.5 951 98.7 320 Imo 98.9 833 98.1 323 South South Akwa Ibom 95.9 864 97.6 451 Bayelsa 90.0 364 100.0 187 Cross River 96.5 703 97.5 310 Delta 92.4 993 99.5 473 Edo 96.1 742 99.6 365 Rivers 93.6 1,276 93.9 658 South West Ekiti 99.4 326 100.0 148 Lagos 98.1 1,964 98.2 948 Ogun 97.1 883 90.6 358 Ondo 88.1 808 88.2 404 Osun 99.7 765 99.5 356 Oyo 84.6 1,568 93.7 629 Education No education 85.7 14,729 88.6 3,685 Primary 93.1 6,734 94.9 2,907 Secondary 97.8 13,927 97.5 8,281 More than secondary 99.6 3,558 99.5 2,486 Wealth quintile Lowest 85.3 7,132 88.6 2,862 Second 89.3 7,428 93.1 2,992 Middle 91.6 7,486 96.4 3,338 Fourth 96.2 7,992 97.8 3,835 Highest 98.8 8,910 98.9 4,332 Total 92.6 38,948 95.5 17,359 226 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour 13.1.2 Knowledge of HIV Prevention Methods HIV is mainly transmitted through heterosexual contact. Nigeria’s national HIV prevention programme has sought to promote behaviour change strategies that focus on sexual abstinence, mutually faithful monogamy between HIV-negative partners, and condom use as the primary ways of avoiding HIV infection among sexually active women and men. In the 2013 NDHS, to ascertain whether programmes have effectively communicated these prevention messages, women and men 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 58 percent of women and 74 percent of men know that consistent and correct use of condoms can reduce the spread of HIV. Seventy-eight percent of women and 85 percent of men know that limiting sexual intercourse to one uninfected partner who has no other partners can reduce the chances of contracting HIV, and 54 percent of women and 70 percent of men know that using condoms and limiting sexual intercourse to one uninfected partner can reduce the risk of HIV infection. 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 the AIDS virus by using condoms every time they have sexual intercourse and by having one sex partner who is not infected and has no other partners, by background characteristics, Nigeria 2013 Women Men Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of men Age 15-24 55.8 75.4 52.2 14,576 70.0 79.0 65.7 6,511 15-19 51.6 71.4 47.7 7,820 63.9 73.2 59.1 3,619 20-24 60.6 80.0 57.3 6,757 77.5 86.1 74.1 2,892 25-29 60.2 79.5 56.8 7,145 76.4 87.9 72.6 2,757 30-39 61.2 81.1 58.1 10,185 77.4 88.3 74.0 4,589 40-49 54.9 77.1 51.6 7,042 74.7 88.1 72.0 3,501 Marital status Never married 62.8 78.6 58.7 9,326 74.0 82.2 69.8 8,378 Ever had sex 75.4 87.0 71.2 3,732 85.3 90.9 80.7 3,461 Never had sex 54.4 73.1 50.4 5,593 66.0 76.1 62.1 4,918 Married/living together 55.7 77.5 52.5 27,830 73.7 86.9 70.6 8,723 Divorced/separated/ widowed 65.8 82.3 62.4 1,793 80.1 89.6 75.6 258 Residence Urban 67.9 85.2 64.1 16,414 81.2 89.1 77.2 7,611 Rural 50.5 72.7 47.4 22,534 68.2 81.3 64.8 9,748 Zone North Central 60.7 73.4 58.2 5,572 66.1 82.1 61.6 2,685 North East 48.6 71.8 45.8 5,766 71.5 83.8 68.8 2,515 North West 48.9 79.6 46.5 11,877 70.5 83.5 68.4 5,185 South East 61.2 82.7 56.4 4,476 79.4 90.3 75.7 1,686 South South 68.8 79.0 63.9 4,942 85.9 90.4 81.6 2,445 South West 69.6 80.4 65.2 6,314 76.0 81.9 70.2 2,843 State North Central FCT-Abuja 65.2 78.2 63.2 315 54.5 86.5 51.7 175 Benue 81.1 92.6 78.1 1,240 74.3 88.3 68.2 616 Kogi 65.9 82.9 64.7 704 80.3 91.9 77.3 333 Kwara 73.5 85.7 71.0 596 77.6 81.9 71.0 274 Nasarawa 52.0 63.7 49.0 594 70.7 78.5 66.4 282 Niger 42.1 54.6 40.9 1,462 52.0 76.0 49.8 701 Plateau 52.2 64.3 46.7 662 58.7 73.6 51.3 302 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 227 Table 13.2—Continued Women Men Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of men North East Adamawa 62.3 84.6 60.5 828 88.5 96.2 87.4 358 Bauchi 37.5 69.8 35.7 1,161 77.0 94.6 77.0 512 Borno 44.9 68.2 43.5 1,412 63.5 70.2 57.5 676 Gombe 43.7 66.3 40.1 550 56.3 83.7 52.1 255 Taraba 72.8 80.2 71.2 844 86.6 91.0 85.2 325 Yobe 37.3 64.4 29.6 971 60.2 75.5 57.7 390 North West Jigawa 47.1 77.7 44.4 1,353 63.7 79.2 59.7 510 Kaduna 66.5 88.4 64.8 2,136 83.5 91.6 82.3 1,033 Kano 48.2 82.4 44.5 3,189 89.7 93.7 88.8 1,592 Katsina 56.2 91.6 53.2 1,525 69.8 89.5 68.3 596 Kebbi 28.1 50.9 25.1 1,244 27.9 64.9 26.5 551 Sokoto 62.6 92.7 61.5 1,098 77.4 88.6 75.7 424 Zamfara 24.3 63.0 23.8 1,332 29.5 46.0 21.2 479 South East Abia 48.4 55.7 40.1 518 89.7 91.2 84.6 229 Anambra 48.1 80.4 42.5 1,052 68.3 88.3 65.0 446 Ebonyi 61.7 87.6 58.4 1,122 85.4 90.3 81.4 368 Enugu 77.3 93.3 74.1 951 91.3 95.0 88.5 320 Imo 66.4 83.7 61.3 833 68.9 88.1 65.2 323 South South Akwa Ibom 52.7 69.6 48.4 864 87.7 94.2 85.8 451 Bayelsa 43.3 69.1 38.6 364 96.0 97.4 94.2 187 Cross River 77.1 88.9 74.5 703 77.5 90.2 75.1 310 Delta 70.7 70.2 60.8 993 84.9 96.4 82.3 473 Edo 73.0 81.3 67.2 742 86.0 89.2 79.2 365 Rivers 78.4 88.4 76.4 1,276 86.4 82.3 79.0 658 South West Ekiti 65.3 82.5 59.7 326 52.0 94.6 51.4 148 Lagos 76.1 86.8 71.8 1,964 83.0 84.3 78.3 948 Ogun 76.3 82.6 71.4 883 73.7 85.6 70.8 358 Ondo 39.7 59.2 33.2 808 53.3 59.2 39.8 404 Osun 91.1 94.5 89.1 765 89.9 86.7 82.2 356 Oyo 63.6 74.8 59.3 1,568 79.3 84.9 74.7 629 Education No education 40.3 68.2 37.5 14,729 55.1 71.7 52.0 3,685 Primary 60.1 78.9 56.8 6,734 72.8 84.6 69.2 2,907 Secondary 69.7 84.5 65.4 13,927 78.9 87.6 74.7 8,281 More than secondary 80.2 91.3 76.9 3,558 86.5 94.2 83.8 2,486 Wealth quintile Lowest 35.8 65.5 32.9 7,132 53.7 71.0 51.3 2,862 Second 49.0 73.2 46.1 7,428 67.7 80.4 63.5 2,992 Middle 59.2 77.3 55.9 7,486 76.8 87.2 72.8 3,338 Fourth 66.7 83.1 62.8 7,992 80.9 88.4 76.6 3,835 Highest 73.9 87.9 69.9 8,910 83.1 91.4 79.9 4,332 Total 57.8 78.0 54.4 38,948 73.9 84.7 70.3 17,359 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners Table 13.2 also shows that women who are unmarried and never had sex and those who are currently married are least likely to know that using condoms and limiting sexual intercourse to one HIV- negative partner reduces the risk of HIV transmission (50 percent and 53 percent, respectively). On the other hand, 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 (71 percent). Men show the same pattern; awareness of HIV prevention is lowest among men who are unmarried and have never had sexual intercourse (62 percent) and highest among men who have never been married but have had sexual intercourse (81 percent). As expected, women and men in urban areas are more likely to be knowledgeable about HIV prevention methods than their counterparts in rural areas. Knowledge of HIV prevention varies by zone. It is highest among women in the South West and South South (65 percent and 64 percent, respectively) and 228 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour highest among men in the South South and South East (82 percent and 76 percent, respectively). Knowledge of HIV prevention methods increases with increasing education and wealth. 13.1.3 Rejection of Misconceptions about HIV/AIDS As part of the effort to assess HIV and AIDS knowledge, the 2013 NDHS collected 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 can be transmitted through mosquito bites, touching someone who has AIDS, or sharing food with a person who has HIV or AIDS. Comprehensive knowledge is defined as knowing that consistent condom use 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: that HIV can be transmitted by mosquito bites and by supernatural means. Tables 13.3.1 and 13.3.2 show that 67 percent of women and 75 percent of men agree that a healthy-looking person can have HIV, 67 percent of women and 66 percent of men know that the AIDS virus cannot be transmitted by mosquito bites, and 64 percent of women and 66 percent of men say that the AIDS virus cannot be transmitted by supernatural means. Seventy-five percent of women and 78 percent of men correctly believe that a person cannot contract HIV by sharing food with someone who has AIDS. Table 13.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of the AIDS virus, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Nigeria 2013 Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about AIDS2 Number of women Background characteristic A healthy-looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 64.4 64.9 62.2 74.1 36.5 24.2 14,576 15-19 61.8 63.5 60.4 72.0 35.3 22.4 7,820 20-24 67.5 66.7 64.3 76.4 37.8 26.4 6,757 25-29 68.1 67.8 64.9 76.1 39.8 28.4 7,145 30-39 69.8 68.3 64.8 77.0 39.9 28.4 10,185 40-49 65.3 66.6 63.5 74.4 37.2 24.6 7,042 Marital status Never married 67.7 69.2 63.2 79.5 38.3 27.0 9,326 Ever had sex 72.7 73.0 62.5 84.7 37.8 30.2 3,732 Never had sex 64.4 66.7 63.7 76.0 38.6 24.9 5,593 Married/living together 66.2 65.7 63.9 73.7 38.1 25.8 27,830 Divorced/separated/ widowed 69.2 67.0 62.0 77.4 37.3 27.5 1,793 Residence Urban 73.1 74.6 69.9 84.7 44.6 32.7 16,414 Rural 62.0 60.8 59.1 68.4 33.3 21.4 22,534 Zone North Central 66.7 53.9 51.6 63.5 32.0 25.8 5,572 North East 67.5 61.1 61.8 68.8 42.8 29.6 5,766 North West 66.3 75.4 71.9 78.0 44.0 25.9 11,877 South East 42.1 73.4 65.8 86.7 19.6 12.5 4,476 South South 77.3 65.2 50.6 76.5 37.0 27.9 4,942 South West 75.7 62.6 69.0 77.2 42.2 32.1 6,314 State North Central FCT-Abuja 78.6 73.5 63.5 77.5 51.2 41.9 315 Benue 75.2 51.8 51.4 75.0 26.5 24.5 1,240 Kogi 70.8 65.1 66.8 67.8 45.7 36.8 704 Kwara 76.2 69.2 81.9 76.3 54.8 48.1 596 Nasarawa 77.3 43.9 31.7 61.8 20.3 10.5 594 Niger 47.7 48.8 38.6 43.6 24.6 20.1 1,462 Plateau 64.5 43.3 49.5 64.7 25.0 15.4 662 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 229 Table 13.3.1—Continued Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about AIDS2 Number of women Background characteristic A healthy-looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS North East Adamawa 77.6 59.7 71.0 77.0 47.6 36.0 828 Bauchi 56.3 28.2 40.9 46.1 17.0 11.7 1,161 Borno 70.7 74.8 70.5 77.4 60.0 38.0 1,412 Gombe 64.5 55.5 58.6 68.9 42.4 26.9 550 Taraba 86.7 73.2 57.9 73.4 52.3 47.7 844 Yobe 52.6 74.3 71.7 72.5 36.1 19.2 971 North West Jigawa 63.8 60.6 63.6 65.9 36.0 20.4 1,353 Kaduna 66.3 81.1 42.9 77.0 27.2 23.2 2,136 Kano 70.9 83.5 84.2 85.9 56.8 29.2 3,189 Katsina 60.4 78.6 92.5 93.2 45.8 27.4 1,525 Kebbi 28.8 53.5 54.2 55.1 12.5 7.6 1,244 Sokoto 83.3 91.6 91.5 92.6 77.4 52.2 1,098 Zamfara 85.8 65.4 74.2 65.4 47.9 21.5 1,332 South East Abia 14.3 83.6 81.2 82.8 9.1 1.5 518 Anambra 40.1 82.2 57.2 90.9 18.6 10.9 1,052 Ebonyi 49.8 57.4 57.5 77.4 20.2 14.0 1,122 Enugu 45.2 76.8 76.3 93.4 23.6 16.3 951 Imo 47.9 73.9 66.4 88.9 21.8 15.0 833 South South Akwa Ibom 78.3 59.8 49.8 77.3 35.8 20.8 864 Bayelsa 84.8 77.1 55.1 82.3 46.6 19.1 364 Cross River 79.9 59.6 46.4 80.0 29.2 25.3 703 Delta 74.5 74.3 61.2 73.5 47.3 35.5 993 Edo 74.1 57.1 52.7 76.8 34.4 29.8 742 Rivers 77.2 66.2 42.8 74.6 32.9 29.6 1,276 South West Ekiti 82.0 70.9 69.9 81.2 51.4 33.4 326 Lagos 80.6 62.5 74.8 86.7 42.4 34.5 1,964 Ogun 82.9 77.8 72.1 77.9 53.8 45.1 883 Ondo 63.5 51.9 53.5 64.0 29.5 9.8 808 Osun 86.5 71.3 80.1 84.4 55.2 49.3 765 Oyo 65.2 53.9 62.2 67.2 33.8 24.4 1,568 Education No education 57.5 60.9 60.1 64.8 34.6 19.8 14,729 Primary 65.6 60.3 58.4 71.6 31.9 22.5 6,734 Secondary 72.7 71.1 66.0 83.2 39.8 29.2 13,927 More than secondary 83.1 84.8 78.8 94.0 58.0 47.7 3,558 Wealth quintile Lowest 54.1 57.6 59.0 62.2 31.1 16.1 7,132 Second 60.5 60.2 59.4 68.0 32.8 20.4 7,428 Middle 65.1 62.7 58.9 72.4 33.5 23.4 7,486 Fourth 71.5 71.5 67.1 81.1 41.9 30.7 7,992 Highest 79.0 78.0 71.7 88.9 48.5 37.3 8,910 Total 66.7 66.6 63.6 75.3 38.1 26.2 38,948 1 Two most common local misconceptions: the AIDS virus can be transmitted by mosquito bites and the AIDS virus can be transmitted by supernatural means. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the 2 most common local misconceptions about AIDS transmission or prevention. The results in Tables 13.3.1 and 13.3.2 show that 38 percent of women and 46 percent of men know about the two most common misconceptions regarding HIV and AIDS (i.e., HIV can be transmitted by mosquito bites and by supernatural means) and that a healthy-looking person can have HIV. The tables also show that 26 percent of women and 37 percent of men have comprehensive knowledge about AIDS; that is, they know that using condoms and limiting sexual intercourse to one HIV-negative partner are HIV prevention methods, they know that a healthy-looking person can have HIV, and they reject the two most common local misconceptions about HIV. 230 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Comprehensive knowledge is highest among never-married women and men who are sexually active. Respondents in urban areas are more likely than those in rural areas to have comprehensive knowledge of HIV. Comprehensive knowledge among women is highest in the South West (32 percent), while comprehensive knowledge among men is highest in the North West (46 percent). Comprehensive knowledge about HIV increases with increasing education and wealth. Table 13.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of the AIDS virus, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Nigeria 2013 Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about AIDS2 Number of men Background characteristic A healthy-looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 69.8 61.6 61.6 73.4 40.8 33.5 6,511 15-19 65.3 58.7 56.4 68.9 36.8 29.3 3,619 20-24 75.6 65.3 68.3 79.2 45.9 38.6 2,892 25-29 77.1 68.4 67.2 81.1 46.7 38.6 2,757 30-39 80.0 68.2 68.4 79.5 48.0 39.9 4,589 40-49 77.8 69.3 71.9 80.7 49.7 40.4 3,501 Marital status Never married 74.0 65.8 63.9 77.3 44.6 37.3 8,378 Ever had sex 80.9 68.4 67.2 83.5 45.8 39.0 3,461 Never had sex 69.1 64.0 61.6 72.9 43.7 36.1 4,918 Married/living together 76.5 66.2 68.8 78.2 46.5 37.6 8,723 Divorced/separated/ widowed 75.7 62.1 63.3 76.9 39.2 31.4 258 Residence Urban 79.6 74.0 72.6 85.3 51.5 44.0 7,611 Rural 71.9 59.8 61.5 71.9 40.7 32.2 9,748 Zone North Central 62.9 52.4 49.2 71.1 25.1 19.6 2,685 North East 76.3 61.5 70.9 73.1 46.6 38.6 2,515 North West 77.3 77.7 70.0 81.7 57.8 46.1 5,185 South East 73.5 70.9 66.2 87.5 43.3 36.9 1,686 South South 84.9 67.9 63.6 76.8 47.2 43.0 2,445 South West 75.0 56.7 74.6 75.9 41.0 32.6 2,843 State North Central FCT-Abuja 49.8 82.7 76.8 88.6 32.9 26.1 175 Benue 70.5 50.7 51.9 77.4 25.4 18.6 616 Kogi 53.7 59.8 52.7 84.0 28.6 25.6 333 Kwara 85.7 45.3 56.5 70.6 27.4 21.4 274 Nasarawa 76.8 46.6 43.7 69.0 28.2 23.0 282 Niger 49.6 46.5 36.1 55.4 17.2 13.5 701 Plateau 62.9 55.4 52.5 72.8 29.5 20.1 302 North East Adamawa 83.4 50.9 78.7 74.7 43.6 40.8 358 Bauchi 88.4 47.4 68.7 70.9 42.0 35.5 512 Borno 71.6 74.2 73.2 79.6 53.8 42.4 676 Gombe 84.2 57.0 78.1 75.6 48.5 26.0 255 Taraba 84.3 76.6 70.0 78.4 61.5 59.2 325 Yobe 50.6 58.1 58.5 57.3 29.1 25.4 390 North West Jigawa 85.8 56.4 73.7 76.6 44.0 28.0 510 Kaduna 56.9 86.9 45.4 83.7 37.9 33.2 1,033 Kano 93.8 92.3 85.6 93.7 82.1 77.5 1,592 Katsina 78.1 81.0 82.8 80.6 65.7 52.7 596 Kebbi 62.9 66.6 55.8 70.5 48.9 11.6 551 Sokoto 75.9 68.4 78.2 77.5 63.0 58.5 424 Zamfara 74.8 49.3 60.0 60.5 30.8 9.1 479 South East Abia 90.3 84.6 81.9 94.0 69.4 59.8 229 Anambra 59.3 72.8 57.6 85.9 33.4 26.5 446 Ebonyi 69.9 72.4 74.5 86.0 44.3 40.9 368 Enugu 85.1 70.5 68.4 85.3 49.5 46.9 320 Imo 73.9 57.6 55.1 88.9 31.0 20.6 323 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 231 Table 13.3.2—Continued Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about AIDS2 Number of men Background characteristic A healthy-looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS South South Akwa Ibom 81.7 54.2 49.2 76.3 32.9 31.2 451 Bayelsa 95.8 85.5 66.7 80.3 61.6 58.6 187 Cross River 86.9 54.6 56.9 76.5 37.9 33.9 310 Delta 87.0 85.7 73.9 89.0 60.1 53.3 473 Edo 78.2 69.3 69.8 88.5 48.1 41.6 365 Rivers 85.2 65.0 64.8 61.2 47.7 44.4 658 South West Ekiti 92.0 75.0 84.4 92.4 63.7 25.5 148 Lagos 86.6 69.0 76.8 80.4 54.3 47.6 948 Ogun 50.3 63.1 71.3 73.8 31.4 26.6 358 Ondo 68.0 53.2 64.2 67.5 34.8 16.4 404 Osun 92.8 41.5 87.0 88.7 35.5 32.5 356 Oyo 62.1 41.3 70.5 64.5 28.1 25.5 629 Education No education 62.9 58.5 59.1 65.2 39.8 28.4 3,685 Primary 72.2 57.0 60.7 70.5 36.9 31.0 2,907 Secondary 77.6 66.3 67.2 81.4 44.4 37.0 8,281 More than secondary 89.4 86.4 81.1 92.7 67.6 59.1 2,486 Wealth quintile Lowest 65.2 54.1 60.1 63.0 38.3 26.9 2,862 Second 71.0 61.5 63.3 73.4 42.4 32.3 2,992 Middle 74.4 63.5 62.6 76.6 41.2 34.9 3,338 Fourth 79.5 67.2 68.9 82.2 46.8 40.4 3,835 Highest 81.7 77.8 73.3 87.4 54.5 47.0 4,332 Total 75.3 66.0 66.4 77.7 45.5 37.4 17,359 1 Two most common local misconceptions: the AIDS virus can be transmitted by mosquito bites and the AIDS virus can be transmitted by supernatural means. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the 2 most common local misconceptions about AIDS transmission or prevention. Despite the government’s efforts to increase awareness of HIV prevention and treatment, overall awareness among women and men has not increased substantially since 2008. The proportion of women and men age 15-49 with comprehensive knowledge increased only 3 percentage points and 1 percentage point, respectively. 13.2 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing knowledge about prevention of mother-to-child transmission (PMTCT) of HIV and use of antiretroviral medication prior to delivery are critical in reducing mother-to-child transmission. The PMTCT programme in Nigeria was established in 2001 (FMoH, 2011d). To obtain information on knowledge of PMTCT, respondents were asked whether 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 65 percent of women and 62 percent of men know that HIV can be transmitted through breastfeeding. In addition, 52 percent of women and 53 percent of men know that the risk of mother-to-child transmission can be reduced if the mother takes special drugs during pregnancy. These figures are an improvement from the 2008 NDHS (28 percent of women and 39 percent of men). Overall, 49 percent of women and 45 percent of men know that HIV can be transmitted by breastfeeding and that the risk of mother-to-child transmission can be reduced by taking special drugs. Knowledge regarding PMTCT is higher in urban than in rural areas and increases with increasing education and wealth. More than half of women in the South East (54 percent), South South (52 percent), and North Central (51 percent) zones are knowledgeable about PMTCT. Men in the South West (29 percent) are least likely to have knowledge regarding PMTCT. 232 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Nigeria 2013 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 59.9 47.5 44.6 14,576 56.8 45.8 39.5 6,511 15-19 54.5 41.6 38.8 7,820 53.1 39.8 34.7 3,619 20-24 66.2 54.4 51.3 6,757 61.6 53.3 45.5 2,892 25-29 67.7 55.4 52.2 7,145 64.5 57.3 49.4 2,757 30-39 70.3 57.6 54.6 10,185 64.0 58.0 49.0 4,589 40-49 65.3 50.5 48.0 7,042 65.9 55.4 47.7 3,501 Marital status Never married 65.8 50.8 47.3 9,326 60.1 49.9 42.9 8,378 Ever had sex 75.6 59.2 55.4 3,732 69.7 57.0 48.9 3,461 Never had sex 59.2 45.2 42.0 5,593 53.3 44.9 38.7 4,918 Married/living together 64.3 52.3 49.6 27,830 63.3 55.6 47.5 8,723 Divorced/separated/ widowed 71.9 56.6 53.1 1,793 63.8 52.9 45.2 258 Currently pregnant Pregnant 64.8 54.0 51.3 4,710 na na na na Not pregnant or not sure 65.1 51.9 48.9 34,238 na na na na Residence Urban 76.1 61.8 58.4 16,414 64.4 56.1 46.2 7,611 Rural 56.9 45.1 42.5 22,534 59.7 50.2 44.5 9,748 Zone North Central 63.6 54.9 50.8 5,572 58.5 50.7 43.6 2,685 North East 57.1 49.9 46.4 5,766 58.2 54.8 50.2 2,515 North West 56.3 49.1 47.0 11,877 58.5 58.8 50.1 5,185 South East 81.5 57.2 54.3 4,476 75.1 48.8 42.8 1,686 South South 72.9 54.8 52.1 4,942 76.5 56.2 51.8 2,445 South West 72.1 51.8 48.7 6,314 53.3 41.4 29.3 2,843 State North Central FCT-Abuja 62.1 55.3 49.7 315 55.4 48.8 45.6 175 Benue 89.3 73.4 72.4 1,240 86.5 62.9 59.0 616 Kogi 75.7 54.8 52.4 704 24.0 41.3 16.1 333 Kwara 53.3 44.6 31.8 596 64.8 48.3 44.7 274 Nasarawa 64.7 60.0 57.4 594 75.0 64.4 60.2 282 Niger 45.7 48.0 43.4 1,462 37.9 42.8 35.8 701 Plateau 51.5 39.7 37.2 662 68.0 44.8 42.5 302 North East Adamawa 59.3 73.7 56.7 828 56.5 56.0 52.0 358 Bauchi 46.1 28.8 27.9 1,161 74.5 70.8 64.7 512 Borno 58.6 50.1 48.8 1,412 46.6 45.4 39.4 676 Gombe 52.0 44.1 41.6 550 74.1 73.0 67.6 255 Taraba 74.0 61.4 61.3 844 86.6 70.0 68.9 325 Yobe 54.1 47.6 45.9 971 24.2 24.5 21.4 390 North West Jigawa 51.2 40.6 38.9 1,353 64.3 45.6 39.1 510 Kaduna 65.5 59.9 58.6 2,136 63.4 77.5 56.7 1,033 Kano 54.8 53.0 48.9 3,189 77.3 75.2 72.0 1,592 Katsina 66.1 60.8 57.9 1,525 49.4 55.2 44.2 596 Kebbi 47.3 30.0 28.2 1,244 23.8 18.5 17.4 551 Sokoto 55.5 52.1 51.3 1,098 45.9 50.3 38.6 424 Zamfara 48.0 33.6 33.3 1,332 42.4 36.3 30.1 479 South East Abia 85.5 51.2 49.3 518 79.5 66.9 59.2 229 Anambra 73.4 51.4 50.8 1,052 63.5 37.1 33.1 446 Ebonyi 78.2 45.7 42.2 1,122 81.3 46.1 39.3 368 Enugu 86.2 74.2 70.3 951 77.3 55.2 48.8 320 Imo 88.3 64.5 59.8 833 78.6 48.9 42.7 323 South South Akwa Ibom 66.6 53.1 48.5 864 78.5 67.7 62.8 451 Bayelsa 78.5 47.4 41.9 364 85.5 54.3 52.2 187 Cross River 81.1 66.6 64.2 703 91.0 78.4 76.0 310 Delta 73.4 59.9 58.7 993 76.8 61.8 57.7 473 Edo 65.1 45.0 42.8 742 79.3 57.3 51.2 365 Rivers 75.3 53.0 51.0 1,276 63.9 33.9 28.9 658 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 233 Table 13.4—Continued 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 South West Ekiti 55.6 50.5 42.9 326 67.6 41.5 36.1 148 Lagos 81.4 67.4 63.6 1,964 55.6 50.6 32.4 948 Ogun 58.8 40.0 38.5 883 37.5 32.1 27.6 358 Ondo 62.5 33.9 30.1 808 55.4 34.4 28.3 404 Osun 97.6 69.2 69.1 765 56.5 44.4 34.3 356 Oyo 64.1 39.9 36.8 1,568 52.6 35.5 21.8 629 Education No education 48.2 39.0 36.9 14,729 45.9 39.8 35.7 3,685 Primary 69.0 51.9 49.0 6,734 63.9 49.8 43.7 2,907 Secondary 75.4 59.0 55.6 13,927 64.6 52.9 45.1 8,281 More than secondary 87.0 79.8 75.3 3,558 73.3 75.0 61.7 2,486 Wealth quintile Lowest 42.8 32.9 31.3 7,132 45.1 38.3 33.9 2,862 Second 56.5 44.8 42.6 7,428 60.4 50.1 44.6 2,992 Middle 66.6 52.3 49.2 7,486 65.6 55.6 49.1 3,338 Fourth 74.0 58.1 54.6 7,992 66.3 54.5 46.2 3,835 Highest 80.6 68.1 64.3 8,910 66.7 60.5 49.4 4,332 Total 65.0 52.1 49.2 38,948 61.8 52.8 45.2 17,359 na = Not applicable 13.3 ACCEPTING ATTITUDES TOWARD THOSE LIVING WITH HIV AND AIDS The HIV/AIDS epidemic has generated fear, anxiety, and prejudice against people living with HIV and AIDS, and people who are HIV positive face widespread stigma and discrimination. These societal attitudes can adversely affect both people’s willingness to be tested for HIV and their adherence to antiretroviral therapy. Reducing stigma and discrimination is therefore an important factor in the prevention, management, and control of the HIV epidemic. In the 2013 NDHS, women and men who had heard of AIDS were asked a series of questions to assess the level of stigma associated with HIV and AIDS. These questions referred to attitudes regarding four situations: whether they would care for a family member with HIV in their own home, whether they would buy fresh vegetables from a shopkeeper with HIV, whether they would allow an HIV-positive teacher to continue teaching, and whether they would not want to keep secret the HIV-positive status of a family member. Tables 13.5.1 and 13.5.2 present results for women and men age 15-49, respectively. Seven in 10 women and men (69 percent and 68 percent, respectively) reported that they would be willing to take care of a family member with HIV at home. Men were slightly more likely than women to say that they would buy fresh vegetables from a shopkeeper who has HIV (54 percent versus 49 percent). More than half of women and men believed that a female teacher with HIV should be allowed to continue teaching (58 percent and 55 percent, respectively). Thirty-six percent of women and 47 percent of men reported that they would not want to keep secret the fact that a family member was infected with HIV. Accepting attitudes were more common among respondents in urban areas, those with more than a secondary education, and those in the highest wealth quintile. The proportion of women expressing accepting attitudes regarding all four situations was highest in the North East (18 percent); the proportion for men was highest in the South South (22 percent). Less than 1 percent of men in Kano and Kebbi expressed accepting attitudes regarding all four situations. Overall, 12 percent of women and 13 percent of men expressed accepting attitudes regarding all four situations. These figures were lower than those recorded in the 2008 NDHS (13 percent and 22 percent, respectively). 234 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Nigeria 2013 Percentage of respondents who: Percentage expressing acceptance attitudes on all four indicators Number of respondents who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 68.5 47.1 57.6 34.5 10.7 13,319 15-19 65.5 44.0 56.1 34.9 10.0 7,001 20-24 71.8 50.5 59.3 34.1 11.6 6,318 25-29 71.3 51.1 60.4 35.1 11.7 6,615 30-39 70.4 50.4 59.7 36.6 12.4 9,595 40-49 67.9 47.0 55.4 38.8 11.5 6,534 Marital status Never married 71.1 52.0 63.2 36.2 12.0 8,793 Ever had sex 76.9 56.3 66.7 34.7 12.6 3,650 Never had sex 67.0 49.0 60.7 37.3 11.6 5,143 Married/living together 68.6 47.3 56.4 35.6 11.2 25,559 Divorced/separated/ widowed 72.5 52.0 60.9 39.9 13.9 1,712 Residence Urban 71.6 55.2 63.6 37.0 13.2 15,971 Rural 67.6 43.5 54.0 35.1 10.2 20,093 Zone North Central 84.2 55.1 69.3 36.8 15.8 4,651 North East 72.9 53.2 66.0 48.2 17.9 5,078 North West 68.7 50.9 55.9 25.9 11.4 11,331 South East 81.0 44.6 54.6 37.9 8.8 4,432 South South 69.3 47.8 63.1 35.0 9.9 4,660 South West 47.4 39.3 46.5 43.4 6.2 5,911 State North Central FCT-Abuja 87.8 68.5 73.2 19.9 9.2 285 Benue 89.5 42.6 66.0 33.7 11.8 1,237 Kogi 86.3 52.7 66.0 39.3 20.5 619 Kwara 69.8 55.1 64.0 13.6 4.9 552 Nasarawa 83.2 62.7 88.4 63.5 34.5 490 Niger 85.0 58.0 64.8 33.7 11.3 935 Plateau 82.0 67.5 74.9 54.8 25.5 533 North East Adamawa 69.8 56.7 75.1 29.9 9.7 743 Bauchi 79.8 37.8 54.5 54.6 16.5 1,013 Borno 85.5 67.8 85.6 45.8 27.7 1,136 Gombe 81.8 74.1 76.1 48.0 26.4 437 Taraba 69.8 48.4 74.9 36.4 12.8 807 Yobe 51.0 43.8 35.4 68.8 14.4 943 North West Jigawa 52.6 32.5 46.0 21.4 2.8 1,265 Kaduna 85.8 65.9 71.7 12.4 8.7 2,046 Kano 60.1 55.7 51.8 25.6 15.4 3,179 Katsina 88.5 41.7 68.9 29.8 16.8 1,520 Kebbi 70.5 55.7 55.7 27.4 4.4 944 Sokoto 72.2 57.4 60.4 18.9 12.6 1,088 Zamfara 50.8 34.9 31.2 52.8 11.6 1,291 South East Abia 81.5 53.5 68.0 21.0 5.9 511 Anambra 78.2 46.0 40.9 30.6 5.7 1,047 Ebonyi 74.9 37.2 51.2 67.5 15.1 1,103 Enugu 92.4 52.2 68.6 34.3 10.7 946 Imo 79.3 38.8 52.0 22.0 3.9 824 South South Akwa Ibom 64.0 45.8 56.2 38.4 7.9 829 Bayelsa 68.1 38.2 50.5 66.6 21.7 328 Cross River 91.8 57.1 82.0 17.4 4.8 678 Delta 65.8 39.0 72.7 38.2 16.2 918 Edo 59.8 40.7 55.0 26.0 2.2 713 Rivers 68.9 57.5 58.0 36.7 10.5 1,194 South West Ekiti 62.0 48.9 62.4 38.7 11.2 325 Lagos 70.1 51.6 59.8 26.2 8.6 1,928 Ogun 18.1 23.4 26.9 58.5 1.6 858 Ondo 40.9 35.7 41.8 34.5 5.4 712 Osun 24.4 28.8 37.4 83.4 9.2 763 Oyo 46.6 37.5 43.6 41.6 3.1 1,327 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 235 Table 13.5.1—Continued Percentage of respondents who: Percentage expressing acceptance attitudes on all four indicators Number of respondents who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Education No education 66.2 42.2 50.5 34.6 10.9 12,629 Primary 67.0 41.9 54.2 39.5 9.7 6,266 Secondary 70.4 51.4 62.0 36.2 11.5 13,622 More than secondary 81.0 73.0 78.5 33.6 16.7 3,546 Wealth quintile Lowest 60.5 36.4 43.7 37.8 9.6 6,080 Second 69.3 42.2 53.6 34.8 10.6 6,632 Middle 72.4 49.3 61.3 38.4 12.6 6,860 Fourth 68.7 51.5 60.5 36.9 11.7 7,692 Highest 73.8 59.1 67.5 32.9 12.5 8,800 Total 69.4 48.7 58.3 36.0 11.5 36,064 Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Nigeria 2013 Percentage of respondents who: Percentage expressing acceptance attitudes on all four indicators Number of respondents who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 65.7 49.4 51.5 41.8 10.0 5,996 15-19 62.0 44.1 47.1 40.3 7.5 3,233 20-24 70.1 55.6 56.5 43.6 13.0 2,762 25-29 69.8 56.4 55.8 47.0 13.5 2,683 30-39 69.5 56.6 57.1 49.5 15.4 4,475 40-49 69.9 56.9 57.3 50.8 15.9 3,421 Marital status Never married 67.7 53.7 55.2 43.6 12.2 7,850 Ever had sex 73.4 56.3 61.9 47.6 17.1 3,408 Never had sex 63.4 51.8 50.0 40.5 8.5 4,442 Married/living together 69.0 54.5 54.8 49.1 14.2 8,468 Divorced/separated/ widowed 61.7 48.8 51.1 53.8 16.4 257 Residence Urban 66.7 60.9 60.2 46.9 14.8 7,479 Rural 69.5 48.4 50.5 46.3 12.0 9,096 Zone North Central 75.3 46.5 54.6 49.6 15.6 2,517 North East 78.4 58.2 60.3 36.3 11.9 2,367 North West 60.9 62.1 49.6 43.9 7.4 4,939 South East 83.0 41.6 47.1 58.0 17.7 1,665 South South 76.3 56.3 70.2 53.7 22.3 2,383 South West 50.2 48.4 51.5 44.5 12.4 2,704 State North Central FCT-Abuja 89.4 63.2 72.9 14.6 8.8 165 Benue 73.6 48.4 55.8 48.0 14.7 616 Kogi 87.4 38.9 49.8 48.9 10.2 320 Kwara 48.5 39.9 55.2 36.3 4.6 272 Nasarawa 83.5 66.2 66.3 70.9 30.9 245 Niger 77.2 34.7 40.2 54.2 17.6 631 Plateau 71.8 57.4 69.1 58.6 21.1 268 North East Adamawa 77.9 52.9 66.4 50.7 19.3 350 Bauchi 73.3 50.0 56.0 39.8 11.0 486 Borno 77.9 75.9 59.0 23.2 10.8 645 Gombe 84.3 60.4 74.0 53.9 24.2 240 Taraba 85.0 52.7 58.7 46.3 8.8 303 Yobe 76.8 45.0 54.3 20.2 2.0 345 Continued… 236 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.5.2—Continued Percentage of respondents who: Percentage expressing acceptance attitudes on all four indicators Number of respondents who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus North West Jigawa 64.3 45.0 43.6 31.6 6.0 496 Kaduna 50.7 66.8 44.6 57.7 6.8 1,008 Kano 47.1 86.5 48.6 45.8 0.1 1,529 Katsina 81.2 39.3 44.1 12.9 2.4 593 Kebbi 53.4 51.9 67.1 32.3 0.2 442 Sokoto 90.9 72.7 74.2 68.9 55.0 404 Zamfara 79.8 19.4 38.7 49.3 6.0 467 South East Abia 87.7 42.1 54.3 68.9 22.5 227 Anambra 69.3 36.3 39.5 55.2 17.2 442 Ebonyi 86.6 45.0 50.3 54.0 18.2 363 Enugu 96.0 51.0 63.8 52.5 19.5 316 Imo 81.7 35.3 32.3 63.9 12.5 317 South South Akwa Ibom 84.0 61.6 72.0 61.9 33.6 440 Bayelsa 79.5 52.2 79.0 38.9 16.3 187 Cross River 90.9 60.4 79.2 35.8 11.6 303 Delta 77.2 46.9 71.3 76.9 33.6 470 Edo 78.6 41.7 66.2 49.3 17.9 364 Rivers 60.9 67.4 63.3 46.0 15.3 618 South West Ekiti 79.2 66.8 69.1 73.8 40.6 148 Lagos 63.3 54.5 56.7 42.5 15.0 931 Ogun 25.8 29.8 27.6 50.7 10.5 325 Ondo 50.2 41.4 43.7 40.6 5.3 356 Osun 43.2 65.4 58.8 18.3 4.0 355 Oyo 39.9 38.5 52.2 55.3 11.6 589 Education No education 66.1 46.3 42.7 41.5 7.8 3,265 Primary 66.8 44.0 45.5 50.3 10.8 2,758 Secondary 66.8 53.1 55.7 47.0 12.8 8,077 More than secondary 77.5 78.4 78.9 47.7 24.9 2,474 Wealth quintile Lowest 67.5 42.5 43.9 39.9 7.1 2,536 Second 69.4 51.3 48.3 44.1 9.0 2,786 Middle 69.0 50.2 50.5 48.5 12.5 3,217 Fourth 67.4 55.9 57.3 50.0 15.2 3,751 Highest 68.3 63.9 66.9 47.7 18.6 4,284 Total 68.3 54.0 54.9 46.6 13.3 16,575 13.4 ATTITUDES TOWARDS NEGOTIATING SAFER SEX 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 68 percent of women and 74 percent of men in Nigeria believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with other women. Urban women (69 percent) are more likely than rural women (66 percent) to express this sentiment. However, men show the opposite pattern; rural men are slightly more likely than urban men to believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows he has sex with other women (75 percent and 72 percent, respectively). Seventy-five percent of women and 88 percent of men believe that it would be justified for women to ask their husband or partner to use a condom if they know that he has an STI. Women age 30-39 and men age 40-49, never-married men and women who have ever had sex, urban respondents, those with more than a secondary education, and those in the highest wealth quintile are more likely to agree that a woman is justified in asking her husband or partner to use a condom if she knows that he has an STI. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 237 Women and men in the South West are most likely to say that a woman is justified in asking her husband or partner to use a condom if she knows that he has an STI (84 percent and 92 percent, respectively). Among both women and men, this proportion decreases with increasing education and wealth. However, there is no clear pattern by education or wealth in the proportion of respondents agreeing that a woman is justified in refusing to have sex with her husband if she knows that he has sex with other women. The proportion of women who believe that a woman is justified in asking her husband to use a condom if she knows that he has an STI is slightly higher than the figure reported in the 2008 NDHS (75 percent and 70 percent, respectively). Table 13.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with other women, and percentage who believe that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI), by background characteristics, Nigeria 2013 Women Men Background characteristic Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of women Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of men Age 15-24 65.7 71.0 14,576 71.4 83.2 6,511 15-19 62.8 66.0 7,820 70.0 78.8 3,619 20-24 69.2 76.8 6,757 73.1 88.6 2,892 25-29 68.1 77.3 7,145 75.9 89.7 2,757 30-39 69.3 79.6 10,185 73.7 90.1 4,589 40-49 68.1 75.1 7,042 75.5 91.2 3,501 Marital status Never married 62.7 73.1 9,326 71.1 85.4 8,378 Ever had sex 66.5 85.9 3,732 66.3 92.9 3,461 Never had sex 60.2 64.5 5,593 74.4 80.2 4,918 Married/living together 69.1 75.5 27,830 76.1 89.8 8,723 Divorced/separated/ widowed 68.6 79.9 1,793 68.1 88.7 258 Residence Urban 69.1 82.3 16,414 71.8 92.4 7,611 Rural 66.4 69.9 22,534 74.9 83.9 9,748 Zone North Central 48.3 62.7 5,572 66.7 85.2 2,685 North East 68.9 61.1 5,766 87.1 85.8 2,515 North West 83.6 81.1 11,877 86.3 85.9 5,185 South East 59.5 69.8 4,476 61.9 89.2 1,686 South South 58.6 83.0 4,942 62.5 89.5 2,445 South West 65.6 85.4 6,314 61.1 92.2 2,843 State North Central FCT-Abuja 43.6 73.7 315 42.4 62.7 175 Benue 57.0 64.3 1,240 75.9 89.0 616 Kogi 49.6 59.1 704 62.9 97.5 333 Kwara 50.1 85.7 596 51.3 98.4 274 Nasarawa 57.9 66.5 594 73.4 88.1 282 Niger 39.4 50.2 1,462 70.1 79.7 701 Plateau 42.8 61.4 662 66.2 75.2 302 North East Adamawa 62.7 63.6 828 88.0 89.7 358 Bauchi 74.1 63.1 1,161 95.7 91.9 512 Borno 75.2 58.9 1,412 81.8 85.5 676 Gombe 54.6 62.9 550 93.7 88.6 255 Taraba 75.2 85.1 844 87.8 97.1 325 Yobe 61.1 37.6 971 79.4 63.8 390 North West Jigawa 73.4 71.6 1,353 82.3 76.5 510 Kaduna 83.5 79.5 2,136 86.3 91.6 1,033 Kano 89.9 91.0 3,189 96.4 94.4 1,592 Katsina 89.0 92.2 1,525 89.2 91.3 596 Kebbi 86.3 82.9 1,244 58.8 50.7 551 Sokoto 87.1 88.9 1,098 80.6 94.2 424 Zamfara 67.5 49.3 1,332 90.3 81.8 479 Continued… 238 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.6—Continued Women Men Background characteristic Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of women Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of men South East Abia 43.9 56.9 518 49.3 92.4 229 Anambra 70.7 75.2 1,052 59.1 90.1 446 Ebonyi 60.7 53.6 1,122 72.2 91.4 368 Enugu 53.6 80.1 951 69.2 87.3 320 Imo 60.0 81.1 833 55.6 85.1 323 South South Akwa Ibom 41.1 65.8 864 58.7 75.5 451 Bayelsa 46.4 93.7 364 38.3 97.8 187 Cross River 73.3 89.1 703 68.2 86.0 310 Delta 59.9 80.7 993 64.2 96.9 473 Edo 59.5 84.0 742 69.6 94.6 365 Rivers 64.5 89.6 1,276 64.1 90.2 658 South West Ekiti 64.2 78.9 326 46.5 98.1 148 Lagos 73.2 92.0 1,964 53.1 91.7 948 Ogun 69.4 87.1 883 72.2 88.9 358 Ondo 43.6 78.7 808 59.9 82.8 404 Osun 65.9 94.5 765 40.5 98.4 356 Oyo 65.6 76.7 1,568 82.6 96.0 629 Education No education 70.2 66.1 14,729 79.1 77.7 3,685 Primary 63.9 75.6 6,734 74.0 87.2 2,907 Secondary 66.3 80.8 13,927 70.8 89.9 8,281 More than secondary 68.5 89.6 3,558 74.0 95.5 2,486 Wealth quintile Lowest 70.1 62.9 7,132 80.0 76.6 2,862 Second 69.1 68.5 7,428 80.0 84.0 2,992 Middle 64.1 73.1 7,486 74.6 89.6 3,338 Fourth 65.8 81.1 7,992 69.7 90.9 3,835 Highest 68.5 86.9 8,910 67.4 93.1 4,332 Total 67.5 75.2 38,948 73.5 87.6 17,359 13.5 ATTITUDES TOWARD CONDOM EDUCATION FOR YOUTH Condom use is one of the most effective strategies for combating the spread of HIV. However, educating youths about condoms is sometimes controversial, with some people believing that it promotes early sexual initiation. To gauge attitudes toward condom education for youth, the 2013 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 data focus on adult opinions, results are tabulated for respondents age 18-49. Table 13.7 shows that 35 percent of women and 44 percent of men support teaching young people age 12-14 about condoms for HIV prevention. Support of condom education for youth is highest among women and men who have never been married (50 percent each) and lowest among women and men who are married or living together (32 percent and 41 percent, respectively). Support for educating youth on the use of condoms for HIV prevention is higher in urban than in rural areas. Among women, support of condom education for youth is highest in the South East (49 percent); among men, it is highest in the South South (59 percent). In contrast, support is lowest among women in Bauchi (15 percent) and men in Oyo (13 percent). The proportion of men and women who support condom education for youth increases with increasing education and wealth. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 239 Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 should be taught about using a condom to avoid AIDS, by background characteristics, Nigeria 2013 Women Men Background characteristic Percentage who agree Number Percentage who agree Number Age 18-24 37.6 9,709 46.1 4,227 18-19 37.6 2,952 44.8 1,335 20-24 37.7 6,757 46.7 2,892 25-29 37.0 7,145 47.0 2,757 30-39 35.0 10,185 43.5 4,589 40-49 30.7 7,042 41.1 3,501 Marital status Never married 50.3 5,497 49.5 6,098 Married or living together 31.8 26,815 40.7 8,719 Divorced/separated/ widowed 41.3 1,769 44.0 258 Residence Urban 39.1 14,345 46.5 6,612 Rural 32.6 19,736 42.6 8,463 Zone North Central 37.6 4,866 46.9 2,394 North East 25.3 5,036 33.1 2,209 North West 30.3 10,358 42.0 4,412 South East 48.8 3,937 54.1 1,417 South South 48.0 4,293 58.9 2,142 South West 32.2 5,591 37.8 2,502 State North Central FCT-Abuja 33.7 286 23.2 163 Benue 56.4 1,078 58.7 537 Kogi 38.5 583 43.3 297 Kwara 20.0 504 50.9 239 Nasarawa 54.9 541 54.4 248 Niger 24.6 1,283 38.8 629 Plateau 31.9 590 49.9 281 North East Adamawa 34.9 725 54.5 306 Bauchi 15.3 1,024 27.7 450 Borno 19.9 1,230 22.0 614 Gombe 24.2 486 44.3 217 Taraba 45.7 738 40.6 283 Yobe 19.5 833 27.6 339 North West Jigawa 39.6 1,210 27.7 437 Kaduna 46.8 1,857 56.4 907 Kano 23.6 2,710 46.5 1,332 Katsina 36.7 1,359 33.4 514 Kebbi 18.4 1,111 47.2 475 Sokoto 25.2 953 25.7 345 Zamfara 18.2 1,156 28.6 402 South East Abia 52.9 475 67.0 200 Anambra 44.1 927 36.2 391 Ebonyi 53.2 960 57.0 297 Enugu 52.8 845 69.5 251 Imo 41.8 731 53.0 277 South South Akwa Ibom 41.7 740 62.1 402 Bayelsa 63.1 296 75.7 155 Cross River 65.0 649 71.0 266 Delta 54.9 839 45.6 416 Edo 29.1 619 55.0 300 Rivers 43.7 1,149 58.1 603 South West Ekiti 43.0 275 54.9 123 Lagos 35.4 1,770 49.7 857 Ogun 50.5 800 36.0 333 Ondo 29.2 704 42.9 352 Osun 24.0 659 36.4 306 Oyo 20.9 1,383 13.3 532 Continued… 240 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.7—Continued Women Men Background characteristic Percentage who agree Number Percentage who agree Number Education No education 23.8 13,430 29.3 3,283 Primary 36.1 6,123 39.9 2,556 Secondary 43.4 10,996 49.5 6,758 More than secondary 52.2 3,531 54.6 2,477 Wealth quintile Lowest 22.9 6,275 30.0 2,415 Second 31.1 6,477 40.8 2,578 Middle 37.9 6,480 47.0 2,857 Fourth 37.7 6,954 48.3 3,363 Highest 44.4 7,895 50.1 3,862 Total 35.3 34,081 44.3 15,075 13.6 HIGHER-RISK SEX Information on multiple sexual partners and the practice of protected sex is vital in preventing sexually transmitted infections, including HIV, and monitoring intervention programmes to control the spread of the epidemic. The 2013 NDHS included questions on respondents’ sexual partners in the past 12 months and during their lifetime. Respondents were asked detailed questions about their sexual behaviour, including the number of partners they had in the 12 months preceding the survey. Women and men who had multiple sexual partners were asked about condom use during the last time they had sexual intercourse and the total number of lifetime sexual partners they had. The results are shown in Tables 13.8.1 and 13.8.2 for women and men age 15-49, respectively. 13.6.1 Multiple Sexual Partners A much larger proportion of men than women reported having two or more sexual partners in the 12 months preceding the survey (13 percent versus 1 percent). Two percent each of never-married women and women who were divorced, separated, or widowed reported having two or more sexual partners, as compared with 1 percent of married women. Women who had two or more partners in the 12 months preceding the survey were more likely than men to report using a condom during their last sexual intercourse (29 percent and 20 percent, respectively). Never-married women and men were most likely to report condom use during their last sexual intercourse (64 percent and 58 percent, respectively). Men have a mean of 4.1 lifetime sexual partners, as compared with 1.5 partners among women. The mean number of lifetime sexual partners for women and men is highest in the South South (2.0 and 6.9, respectively). Mean number of lifetime sexual partners increases with increasing education and wealth. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 241 Table 13.8.1 Multiple sexual partners: Women Among all women age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for women who ever had sexual intercourse, by background characteristics, Nigeria 2013 All women Among women who had 2+ partners in the past 12 months: Among women who ever had sexual intercourse1: Background characteristic Percentage who had 2+ partners in the past 12 months Number of women Percentage who reported using a condom during last sexual intercourse Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 1.1 14,576 40.6 158 1.4 9,266 15-19 0.7 7,820 38.1 53 1.2 3,403 20-24 1.6 6,757 41.9 105 1.4 5,863 25-29 1.2 7,145 36.1 87 1.6 6,902 30-39 1.0 10,185 22.8 106 1.7 10,042 40-49 1.1 7,042 7.1 76 1.6 6,981 Marital status Never married 1.9 9,326 63.5 174 1.9 3,719 Married or living together 0.8 27,830 3.6 223 1.5 27,696 Divorced/separated/ widowed 1.6 1,793 (21.8) 29 2.0 1,776 Residence Urban 1.3 16,414 43.7 210 1.7 13,122 Rural 1.0 22,534 15.3 217 1.4 20,069 Zone North Central 1.9 5,572 17.2 105 1.5 4,550 North East 0.7 5,766 (26.9) 40 1.4 5,076 North West 1.0 11,877 27.8 113 1.3 10,597 South East 1.0 4,476 (45.5) 45 1.7 3,527 South South 1.3 4,942 38.7 66 2.0 4,153 South West 0.9 6,314 32.5 58 1.8 5,288 State North Central FCT-Abuja 3.6 315 * 11 1.9 257 Benue 5.6 1,240 (10.9) 70 2.2 1,041 Kogi 0.0 704 * 0 1.1 535 Kwara 0.1 596 * 1 1.5 460 Nasarawa 0.9 594 * 5 1.4 508 Niger 0.6 1,462 * 8 1.1 1,223 Plateau 1.5 662 * 10 1.5 526 North East Adamawa 0.2 828 * 1 1.4 689 Bauchi 1.5 1,161 * 18 1.4 1,074 Borno 0.9 1,412 * 13 1.1 1,206 Gombe 0.5 550 * 3 1.2 493 Taraba 0.5 844 * 5 2.0 760 Yobe 0.0 971 * 0 1.1 853 North West Jigawa 1.5 1,353 * 20 1.3 1,294 Kaduna 2.1 2,136 * 44 1.6 1,895 Kano 1.3 3,189 (0.0) 42 1.1 2,632 Katsina 0.2 1,525 * 3 1.2 1,433 Kebbi 0.1 1,244 * 1 1.1 1,112 Sokoto 0.1 1,098 * 1 1.2 982 Zamfara 0.3 1,332 * 3 1.2 1,250 South East Abia 1.4 518 * 7 1.6 428 Anambra 0.9 1,052 * 9 1.8 829 Ebonyi 0.2 1,122 * 3 1.7 899 Enugu 0.7 951 * 7 1.5 704 Imo 2.2 833 * 18 2.1 667 South South Akwa Ibom 0.8 864 * 7 2.1 734 Bayelsa 3.2 364 (37.9) 12 2.5 306 Cross River 0.2 703 * 1 1.7 625 Delta 1.2 993 * 12 2.0 817 Edo 0.6 742 * 4 1.7 575 Rivers 2.3 1,276 * 30 2.3 1,096 South West Ekiti 2.0 326 * 6 2.1 270 Lagos 1.3 1,964 * 26 2.1 1,645 Ogun 0.8 883 * 7 1.7 771 Ondo 1.1 808 * 9 1.7 693 Osun 0.5 765 * 4 1.7 586 Oyo 0.3 1,568 * 5 1.5 1,322 Continued… 242 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.8.1—Continued All women Among women who had 2+ partners in the past 12 months: Among women who ever had sexual intercourse1: Background characteristic Percentage who had 2+ partners in the past 12 months Number of women Percentage who reported using a condom during last sexual intercourse Number of women Mean number of sexual partners in lifetime Number of women Education No education 0.7 14,729 8.6 101 1.3 14,045 Primary 1.2 6,734 9.0 80 1.6 6,150 Secondary 1.3 13,927 37.8 182 1.8 9,896 More than secondary 1.8 3,558 63.7 63 2.0 3,100 Wealth quintile Lowest 0.6 7,132 (8.0) 46 1.2 6,635 Second 1.0 7,428 7.0 78 1.4 6,668 Middle 1.0 7,486 17.1 76 1.5 6,237 Fourth 1.2 7,992 34.6 93 1.7 6,501 Highest 1.5 8,910 52.6 135 1.9 7,150 Total 1.1 38,948 29.3 427 1.5 33,191 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 Means are calculated excluding respondents who gave non-numeric responses. Table 13.8.2 Multiple sexual partners: Men Among all men age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for men who ever had sexual intercourse, by background characteristics, Nigeria 2013 All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Background characteristic Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 3.9 6,511 50.5 257 3.2 2,185 15-19 1.1 3,619 (46.1) 40 2.3 558 20-24 7.5 2,892 51.3 217 3.6 1,627 25-29 13.0 2,757 38.9 359 4.0 2,281 30-39 17.3 4,589 17.1 792 4.3 4,299 40-49 23.2 3,501 4.4 811 4.6 3,389 Marital status Never married 6.7 8,378 57.6 559 4.5 3,391 Married or living together 18.7 8,723 6.4 1,633 4.0 8,519 Divorced/separated/ widowed 10.2 258 (53.4) 26 4.8 244 Type of union In polygynous union 80.8 1,469 1.5 1,186 3.8 1,457 In non-polygynous union 6.2 7,254 19.1 447 4.0 7,062 Not currently in union 6.8 8,636 57.4 586 4.5 3,635 Residence Urban 10.8 7,611 35.6 825 4.7 5,087 Rural 14.3 9,748 10.5 1,393 3.7 7,067 Zone North Central 10.3 2,685 24.6 275 4.2 2,083 North East 13.3 2,515 9.6 334 2.5 1,715 North West 13.5 5,185 3.2 698 2.0 3,080 South East 5.4 1,686 46.1 92 5.2 1,190 South South 14.6 2,445 29.7 356 6.9 1,957 South West 16.3 2,843 36.7 463 5.2 2,129 State North Central FCT-Abuja 13.8 175 55.5 24 2.9 128 Benue 11.2 616 (18.2) 69 7.1 496 Kogi 6.5 333 * 22 2.8 239 Kwara 14.2 274 32.8 39 3.5 211 Nasarawa 8.9 282 (29.7) 25 5.0 224 Niger 8.5 701 (15.9) 60 2.5 560 Plateau 12.1 302 (21.4) 36 4.6 225 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 243 Table 13.8.2—Continued All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Background characteristic Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men North East Adamawa 5.2 358 * 19 2.7 251 Bauchi 19.6 512 2.3 100 1.9 347 Borno 12.8 676 22.7 86 2.5 461 Gombe 14.2 255 9.3 36 2.3 164 Taraba 14.6 325 6.2 47 4.4 256 Yobe 11.5 390 (0.0) 45 1.3 236 North West Jigawa 15.7 510 0.0 80 1.8 349 Kaduna 8.4 1,033 8.7 87 2.4 713 Kano 10.8 1,592 0.0 172 1.4 698 Katsina 23.2 596 8.8 138 2.1 421 Kebbi 12.9 551 1.9 71 3.6 331 Sokoto 8.9 424 (0.0) 38 1.5 249 Zamfara 23.5 479 1.0 113 1.7 320 South East Abia 11.1 229 (38.1) 25 5.1 171 Anambra 2.1 446 * 10 5.3 297 Ebonyi 6.6 368 * 24 4.2 269 Enugu 4.0 320 * 13 4.5 203 Imo 6.2 323 * 20 6.8 250 South South Akwa Ibom 9.9 451 54.7 45 4.4 369 Bayelsa 18.4 187 31.4 35 10.4 152 Cross River 9.6 310 (31.8) 30 6.3 225 Delta 29.4 473 15.2 139 8.9 382 Edo 13.5 365 56.4 49 6.9 276 Rivers 9.0 658 (20.8) 59 6.6 552 South West Ekiti 13.5 148 54.6 20 5.3 112 Lagos 14.4 948 43.1 136 5.1 734 Ogun 16.3 358 (34.9) 58 6.3 281 Ondo 17.9 404 26.8 72 5.8 266 Osun 15.5 356 52.5 55 5.1 262 Oyo 19.3 629 26.0 121 4.4 475 Education No education 17.7 3,685 2.4 654 2.1 2,741 Primary 15.2 2,907 8.6 441 4.2 2,247 Secondary 9.7 8,281 30.1 804 4.8 5,087 More than secondary 12.9 2,486 45.2 320 5.2 2,079 Wealth quintile Lowest 16.5 2,862 1.2 471 2.1 1,942 Second 13.9 2,992 4.8 417 3.0 2,096 Middle 11.0 3,338 14.0 367 4.2 2,271 Fourth 11.9 3,835 30.8 457 5.1 2,673 Highest 11.7 4,332 44.0 506 5.3 3,173 Total 12.8 17,359 19.8 2,219 4.1 12,154 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 Means are calculated excluding respondents who gave non-numeric responses. 13.6.2 Point Prevalence and Cumulative Prevalence of Concurrent Sexual Partners The point prevalence and cumulative prevalence of concurrent sexual partners are new concepts incorporated for the first time in the 2013 NDHS. The point prevalence of concurrent sexual partners is defined as the percentage of respondents who had two (or more) sexual partners concurrently at the point in time six months before the survey. The cumulative prevalence of concurrent sexual partners is the percentage of respondents who had two (or more) sexual partners concurrently at any time during the 12 months preceding the survey. Table 13.9 shows the point prevalence and cumulative prevalence of concurrent sexual partners among all respondents during the 12 months before the survey. It also shows the percentage of respondents who had concurrent sexual partners among those who had multiple sexual partners during the 12 months before the survey. 244 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Both the point prevalence and the cumulative prevalence are less than 1 percent among women. Among men, the point prevalence is 7 percent and the cumulative prevalence is 9 percent. The point prevalence and cumulative prevalence for women are similar in urban and rural areas. For men, however, they are higher in rural than in urban areas. Not surprisingly, men in a polygynous union have the highest point and cumulative prevalence (49 percent and 57 percent), while men who are not currently in a union have the lowest cumulative prevalence (5 percent). Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners Percentage of all women and men age 15-49 who had concurrent sexual partners six months before the survey (point prevalence1), percentage of all women and all men age 15-49 who had any concurrent sexual partners during the 12 months before the survey (cumulative prevalence2), and among women and men age 15-49 who had multiple sexual partners during the 12 months before the survey, percentage who had concurrent sexual partners, by background characteristics, Nigeria 2013 Among all respondents: Among all respondents who had multiple partners during the 12 months before the survey: Background characteristic Point prevalence of concurrent sexual partners1 Cumulative prevalence of concurrent sexual partners2 Number of respondents Percentage who had concurrent sexual partners2 Number of respondents WOMEN Age 15-24 0.4 0.7 14,576 68.6 158 15-19 0.2 0.5 7,820 77.2 53 20-24 0.6 1.0 6,757 64.4 105 25-29 0.5 0.9 7,145 75.1 87 30-39 0.3 0.8 10,185 72.7 106 40-49 0.4 0.8 7,042 76.5 76 Marital status Never married 0.7 1.4 9,326 74.7 174 Married or living together 0.3 0.6 27,830 72.1 223 Divorced/separated/ widowed 0.2 1.0 1,793 (60.9) 29 Residence Urban 0.4 0.9 16,414 69.8 210 Rural 0.4 0.7 22,534 74.9 217 Total 15-49 0.4 0.8 38,948 72.4 427 MEN Age 15-24 1.3 2.6 6,511 65.1 257 15-19 0.2 0.6 3,619 (59.0) 40 20-24 2.8 5.0 2,892 66.2 217 25-29 5.3 9.2 2,757 70.9 359 30-39 9.3 12.5 4,589 72.3 792 40-49 14.6 17.3 3,501 74.8 811 Marital status Never married 2.5 4.4 8,378 66.5 559 Married or living together 11.0 14.0 8,723 74.5 1,633 Divorced/separated/ widowed 2.3 4.7 258 (46.3) 26 Type of union In polygynous union 49.4 57.3 1,469 70.9 1,186 In non-polygynous union 3.2 5.2 7,254 84.0 447 Not currently in union 2.5 4.5 8,636 65.6 586 Residence Urban 5.7 8.1 7,611 74.6 825 Rural 7.6 10.1 9,748 70.7 1,393 Total 15-49 6.8 9.2 17,359 72.2 2,219 Note: Two sexual partners are considered to be concurrent if the date of the most recent sexual intercourse with the earlier partner is after the date of the first sexual intercourse with the later partner. Figures in parentheses are based on 25-49 unweighted cases. 1 The percentage of respondents who had 2 (or more) sexual partners that were concurrent at the point in time 6 months before the survey 2 The percentage of respondents who had 2 (or more) sexual partners that were concurrent any time during the 12 months preceding the survey HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 245 Seven in 10 respondents who had multiple partners in the 12 months preceding the survey had concurrent sexual partners. Among respondents who have never been married, the proportion who had concurrent sexual partners was higher among women (75 percent) than among men (67 percent); however, among married respondents, the proportion was higher among men (75 percent) than women (72 percent). The proportion of women who had multiple partners during the 12 months preceding the survey and had concurrent partners is higher in rural areas than in urban areas (75 percent and 70 percent, respectively). The opposite is true for men (75 percent in urban areas and 71 percent in rural areas). 13.7 TRANSACTIONAL SEX Transactional sex involves the exchange of money, favours, or gifts for sexual intercourse. This type of sexual intercourse is associated with a 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. In the 2013 NDHS, men who had sexual intercourse in the 12 months preceding the survey were asked if they had paid anyone for sexual intercourse during that time. Those who had engaged in paid sexual intercourse in the past 12 months were asked if they used a condom the last time they paid for sexual intercourse. Table 13.10 shows that 5 percent of men reported ever paying for sexual intercourse and 2 percent reported having paid sex in the 12 months preceding the survey. The practice of paid sex in the 12 months preceding the survey was most common among men who were divorced, widowed, or separated (5 percent) and men in the South South (3 percent). Two in three men who reported engaging in paid sex used a condom the last time they paid for sex. Condom use by men who paid for sexual intercourse is highest among those age 20-24 (77 percent), those who have never been married (70 percent), and those living in urban areas (75 percent). The proportion of men reporting that they used a condom the last time they paid for sex increases with increasing wealth. Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse Percentage of men age 15-49 who ever paid for sexual intercourse and percentage reporting payment for sexual intercourse in the past 12 months, and among them, the percentage reporting that a condom was used the last time they paid for sexual intercourse, by background characteristics, Nigeria 2013 Among all men: Among men who paid for sex in the past 12 months: Background characteristic Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Percentage reporting condom use at last paid sexual intercourse Number of men Age 15-24 2.4 1.4 6,511 72.4 88 15-19 0.9 0.6 3,619 * 21 20-24 4.2 2.3 2,892 77.2 67 25-29 5.7 2.7 2,757 63.3 75 30-39 6.8 2.1 4,589 68.3 95 40-49 5.3 1.1 3,501 (51.5) 40 Marital status Never married 4.4 2.3 8,378 70.2 191 Married or living together 4.7 1.1 8,723 56.8 95 Divorced/separated/ widowed 10.8 4.8 258 * 12 Residence Urban 6.2 1.9 7,611 75.1 147 Rural 3.5 1.5 9,748 57.1 151 Zone North Central 3.8 1.3 2,685 (75.9) 34 North East 3.3 1.7 2,515 (44.7) 44 North West 1.4 0.9 5,185 (46.6) 46 South East 4.2 2.4 1,686 (64.4) 40 South South 10.0 3.4 2,445 78.8 82 South West 8.3 1.8 2,843 (75.5) 52 Continued… 246 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.10—Continued Among all men: Among men who paid for sex in the past 12 months: Background characteristic Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Percentage reporting condom use at last paid sexual intercourse Number of men State North Central FCT-Abuja 1.3 1.0 175 * 2 Benue 8.6 1.8 616 * 11 Kogi 3.8 0.6 333 * 2 Kwara 0.5 0.5 274 * 1 Nasarawa 3.2 2.5 282 * 7 Niger 3.2 1.4 701 * 10 Plateau 0.8 0.4 302 * 1 North East Adamawa 1.6 0.7 358 * 2 Bauchi 2.0 1.0 512 * 5 Borno 4.3 3.2 676 * 21 Gombe 3.5 2.4 255 * 6 Taraba 8.7 2.3 325 * 7 Yobe 0.3 0.3 390 * 1 North West Jigawa 1.1 1.0 510 * 5 Kaduna 2.7 1.4 1,033 * 14 Kano 0.3 0.0 1,592 na 0 Katsina 4.1 3.1 596 * 19 Kebbi 1.3 1.3 551 * 7 Sokoto 0.2 0.1 424 na 0 Zamfara 0.2 0.2 479 * 1 South East Abia 9.7 4.0 229 * 9 Anambra 3.2 3.2 446 * 14 Ebonyi 2.2 0.9 368 * 3 Enugu 3.6 0.4 320 * 1 Imo 4.5 3.6 323 * 12 South South Akwa Ibom 6.2 4.7 451 * 21 Bayelsa 4.7 3.7 187 * 7 Cross River 6.0 5.2 310 * 16 Delta 15.2 3.1 473 * 15 Edo 10.3 3.1 365 * 11 Rivers 11.9 1.8 658 * 12 South West Ekiti 2.5 0.5 148 * 1 Lagos 17.5 2.8 948 * 27 Ogun 6.0 2.3 358 * 8 Ondo 7.1 2.6 404 * 10 Osun 2.8 1.0 356 * 3 Oyo 0.8 0.4 629 * 2 Education No education 1.6 1.0 3,685 (43.4) 37 Primary 5.0 2.0 2,907 63.8 59 Secondary 5.4 2.1 8,281 68.4 172 More than secondary 6.4 1.2 2,486 (85.1) 29 Wealth quintile Lowest 1.2 0.5 2,862 * 13 Second 2.5 1.3 2,992 (48.6) 38 Middle 4.1 2.1 3,338 65.2 69 Fourth 5.3 2.2 3,835 66.0 83 Highest 8.2 2.2 4,332 78.4 94 Total 4.7 1.7 17,359 66.0 298 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. 13.8 TESTING FOR HIV 13.8.1 General HIV Testing Knowledge of HIV status is important for helping individuals make specific decisions about adopting safer sex practices to reduce their 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. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 247 To assess awareness 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. Respondents who reported that they had been tested for HIV were asked whether they received the results of their last test. The findings for women and men age 15-49 are presented in Tables 13.11.1 and 13.11.2, respectively. Overall, 60 percent of women and 71 percent of men know a place where they can get an HIV test, an improvement since the 2008 NDHS (when the figures were 49 percent and 65 percent, respectively). Knowledge of a place for HIV testing is highest among sexually active women and men who have never been married (83 percent and 86 percent, respectively) and among urban women and men (77 percent and 81 percent, respectively). Knowledge of where to get HIV testing increases with increasing education and wealth. Across age groups, the youngest female and male respondents (age 15-19) are least likely to know a place where they can go to be tested for HIV (51 percent and 56 percent, respectively). By marital status, never-married women and men who have not yet initiated sexual activity are least likely to know a place to obtain an HIV test (57 percent each). Among the zones, women’s and men’s knowledge of a place to get tested for HIV is lowest in the North West (39 percent and 55 percent, respectively). Tables 13.11.1 and 13.11.2 also show respondents’ experience with prior HIV testing and whether they received their results. Overall, one in four women have been tested for HIV and received the result of the last test. Among men, the corresponding proportion is 20 percent. Seven in 10 women and 78 percent of men have never been tested for HIV. Among women and men tested for HIV in the past 12 months, only 10 percent each received their test results. However, this is an improvement of 3 percentage points from the figure recorded in the 2008 NDHS (7 percent each). Urban women are more likely than rural women to have been tested for HIV in the past 12 months and to have received the test results (14 percent and 7 percent, respectively). The proportion of women and men who had been tested in the past 12 months and had received the results of their last test was lowest in the North West and highest in the South South. Coverage ranged from 4 percent in the North West to 17 percent in the South South among women and from 2 percent in the North West to 17 percent in the South South among men. Among the states, the percentage of women who had been tested for HIV in the past 12 months and received the results of their last test was highest in Cross River (33 percent) and lowest in Kebbi (1 percent). Among men, the corresponding proportions were 30 percent in Cross River and 1 percent in Kebbi and Zamfara. It is noteworthy that the prevalence of HIV testing is very low in Kano, especially among men. Less than 1 percent of men know their status, and none of them reported having been tested in the past 12 months and receiving the results of their last test. 248 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.11.1 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 were tested in the past 12 months and received the results of the last test, according to background characteristics, Nigeria 2013 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 56.2 15.8 3.3 80.8 100.0 19.2 7.9 14,576 15-19 50.5 7.6 1.6 90.8 100.0 9.2 4.2 7,820 20-24 62.8 25.3 5.4 69.3 100.0 30.7 12.3 6,757 25-29 64.4 33.9 6.1 60.1 100.0 39.9 15.3 7,145 30-39 65.1 34.6 6.2 59.1 100.0 40.9 12.3 10,185 40-49 57.6 22.8 3.9 73.3 100.0 26.7 6.3 7,042 Marital status Never married 67.4 18.8 3.2 78.0 100.0 22.0 9.5 9,326 Ever had sex 82.8 35.2 5.9 58.9 100.0 41.1 18.0 3,732 Never had sex 57.1 7.9 1.4 90.7 100.0 9.3 3.8 5,593 Married/living together 57.3 27.0 5.2 67.9 100.0 32.1 10.3 27,830 Divorced/separated/ widowed 69.6 33.6 5.0 61.4 100.0 38.6 10.5 1,793 Residence Urban 77.4 37.5 7.1 55.4 100.0 44.6 14.3 16,414 Rural 47.9 16.4 3.0 80.6 100.0 19.4 7.1 22,534 Zone North Central 63.1 27.7 4.7 67.5 100.0 32.5 13.0 5,572 North East 52.2 18.0 2.9 79.1 100.0 20.9 8.1 5,766 North West 38.7 12.9 1.9 85.2 100.0 14.8 3.9 11,877 South East 82.1 41.0 6.5 52.5 100.0 47.5 15.4 4,476 South South 73.2 35.5 5.7 58.8 100.0 41.2 17.0 4,942 South West 80.4 34.2 9.3 56.5 100.0 43.5 12.1 6,314 State North Central FCT-Abuja 81.3 53.6 3.9 42.4 100.0 57.6 23.8 315 Benue 89.3 35.4 7.4 57.2 100.0 42.8 19.5 1,240 Kogi 62.1 37.0 2.4 60.6 100.0 39.4 14.3 704 Kwara 64.0 14.7 17.8 67.6 100.0 32.4 5.9 596 Nasarawa 61.8 31.3 1.8 66.9 100.0 33.1 14.5 594 Niger 39.3 11.4 0.8 87.8 100.0 12.2 6.5 1,462 Plateau 58.9 35.8 2.3 61.9 100.0 38.1 13.4 662 North East Adamawa 67.0 35.4 1.4 63.2 100.0 36.8 14.3 828 Bauchi 33.8 10.4 1.5 88.0 100.0 12.0 4.2 1,161 Borno 45.3 7.2 2.8 90.0 100.0 10.0 3.7 1,412 Gombe 47.9 27.9 4.5 67.6 100.0 32.4 12.9 550 Taraba 70.9 33.0 5.1 61.9 100.0 38.1 16.6 844 Yobe 57.5 9.5 2.9 87.6 100.0 12.4 3.6 971 North West Jigawa 25.8 5.5 3.5 91.1 100.0 8.9 2.5 1,353 Kaduna 82.3 34.3 3.6 62.1 100.0 37.9 9.2 2,136 Kano 41.2 17.4 1.8 80.8 100.0 19.2 5.3 3,189 Katsina 32.8 3.5 0.4 96.2 100.0 3.8 1.2 1,525 Kebbi 6.2 2.2 0.8 96.9 100.0 3.1 0.9 1,244 Sokoto 10.9 3.7 0.3 96.0 100.0 4.0 1.1 1,098 Zamfara 36.0 3.2 2.3 94.4 100.0 5.6 1.1 1,332 South East Abia 80.5 38.3 1.9 59.7 100.0 40.3 18.8 518 Anambra 81.5 37.6 15.9 46.5 100.0 53.5 6.7 1,052 Ebonyi 75.2 33.2 4.6 62.2 100.0 37.8 15.4 1,122 Enugu 85.1 44.3 1.6 54.1 100.0 45.9 17.4 951 Imo 89.8 53.5 5.7 40.8 100.0 59.2 22.1 833 South South Akwa Ibom 77.6 30.5 8.2 61.3 100.0 38.7 17.2 864 Bayelsa 82.0 26.3 3.3 70.4 100.0 29.6 6.9 364 Cross River 85.5 51.2 6.3 42.4 100.0 57.6 32.6 703 Delta 66.4 24.7 8.5 66.9 100.0 33.1 10.8 993 Edo 65.3 28.8 4.3 66.9 100.0 33.1 11.5 742 Rivers 70.8 45.1 3.1 51.8 100.0 48.2 19.0 1,276 South West Ekiti 65.5 18.9 16.6 64.5 100.0 35.5 7.6 326 Lagos 89.5 43.5 11.7 44.7 100.0 55.3 16.9 1,964 Ogun 81.7 30.2 1.6 68.1 100.0 31.9 8.0 883 Ondo 70.4 35.0 6.5 58.5 100.0 41.5 14.9 808 Osun 88.4 26.7 15.3 58.1 100.0 41.9 8.2 765 Oyo 72.5 31.3 7.6 61.0 100.0 39.0 9.9 1,568 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 249 Table 13.11.1—Continued Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Ever tested and received results Ever tested, did not receive results Never tested1 Education No education 33.7 7.5 1.8 90.8 100.0 9.2 2.6 14,729 Primary 63.6 25.2 5.2 69.6 100.0 30.4 9.0 6,734 Secondary 77.8 34.4 6.0 59.6 100.0 40.4 13.7 13,927 More than secondary 95.5 64.0 10.4 25.6 100.0 74.4 29.3 3,558 Wealth quintile Lowest 26.7 3.9 1.1 94.9 100.0 5.1 1.8 7,132 Second 43.5 12.1 2.4 85.6 100.0 14.4 5.2 7,428 Middle 61.9 23.2 4.0 72.8 100.0 27.2 9.2 7,486 Fourth 74.2 33.1 6.4 60.6 100.0 39.4 13.0 7,992 Highest 87.4 48.3 8.5 43.1 100.0 56.9 19.0 8,910 Total 60.3 25.3 4.7 70.0 100.0 30.0 10.1 38,948 1 Includes “don’t know/missing” Table 13.11.2 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 were tested in the past 12 months and received the results of the last test, according to background characteristics, Nigeria 2013 Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Background characteristic Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 62.9 9.1 0.8 90.1 100.0 9.9 5.4 6,511 15-19 56.1 4.1 0.5 95.4 100.0 4.6 2.3 3,619 20-24 71.5 15.4 1.3 83.4 100.0 16.6 9.4 2,892 25-29 77.1 23.5 2.0 74.5 100.0 25.5 13.0 2,757 30-39 77.3 29.1 1.9 69.0 100.0 31.0 13.5 4,589 40-49 74.2 27.9 1.7 70.4 100.0 29.6 10.9 3,501 Marital status Never married 69.1 15.4 1.0 83.5 100.0 16.5 8.8 8,378 Ever had sex 85.9 30.2 1.7 68.1 100.0 31.9 17.5 3,461 Never had sex 57.4 5.0 0.6 94.4 100.0 5.6 2.7 4,918 Married/living together 73.1 25.0 1.9 73.1 100.0 26.9 10.8 8,723 Divorced/separated/ widowed 79.1 27.7 2.8 69.5 100.0 30.5 11.5 258 Residence Urban 81.0 27.1 1.7 71.2 100.0 28.8 11.9 7,611 Rural 63.7 15.3 1.3 83.4 100.0 16.6 8.3 9,748 Zone North Central 76.0 28.2 1.8 70.0 100.0 30.0 16.3 2,685 North East 71.3 15.6 0.9 83.5 100.0 16.5 9.6 2,515 North West 55.1 5.7 1.2 93.1 100.0 6.9 1.7 5,185 South East 83.5 36.0 2.5 61.5 100.0 38.5 14.0 1,686 South South 85.1 31.8 1.3 66.9 100.0 33.1 17.3 2,445 South West 77.0 25.4 1.7 72.9 100.0 27.1 10.1 2,843 State North Central FCT-Abuja 83.8 40.1 2.6 57.3 100.0 42.7 24.5 175 Benue 81.3 34.9 1.8 63.3 100.0 36.7 23.7 616 Kogi 88.4 26.7 1.8 71.5 100.0 28.5 11.2 333 Kwara 80.4 26.1 4.6 69.4 100.0 30.6 11.8 274 Nasarawa 69.7 27.8 0.7 71.5 100.0 28.5 14.8 282 Niger 68.2 15.5 1.1 83.4 100.0 16.6 8.9 701 Plateau 66.9 40.7 1.7 57.6 100.0 42.4 25.0 302 North East Adamawa 79.4 29.2 0.6 70.2 100.0 29.8 15.2 358 Bauchi 59.3 10.2 0.4 89.4 100.0 10.6 6.1 512 Borno 74.9 8.1 0.7 91.2 100.0 8.8 6.9 676 Gombe 71.4 25.1 3.0 71.9 100.0 28.1 11.4 255 Taraba 75.8 33.2 2.1 64.7 100.0 35.3 22.6 325 Yobe 69.6 2.2 0.1 97.7 100.0 2.3 2.0 390 Continued… 250 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.11.2—Continued Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Background characteristic Ever tested and received results Ever tested, did not receive results Never tested1 North West Jigawa 67.0 4.7 1.4 93.9 100.0 6.1 3.6 510 Kaduna 81.3 15.4 1.2 83.5 100.0 16.5 2.4 1,033 Kano 55.3 0.5 0.0 99.5 100.0 0.5 0.0 1,592 Katsina 58.5 9.2 0.2 90.7 100.0 9.3 4.8 596 Kebbi 12.7 3.1 0.0 96.9 100.0 3.1 1.5 551 Sokoto 36.5 2.1 0.1 97.8 100.0 2.2 1.1 424 Zamfara 46.7 4.6 8.8 86.6 100.0 13.4 0.9 479 South East Abia 83.7 30.4 0.7 69.0 100.0 31.0 14.2 229 Anambra 85.4 26.7 5.8 67.5 100.0 32.5 8.6 446 Ebonyi 82.5 37.6 0.4 62.1 100.0 37.9 18.1 368 Enugu 80.9 42.1 1.7 56.3 100.0 43.7 12.9 320 Imo 84.4 45.2 2.5 52.2 100.0 47.8 17.7 323 South South Akwa Ibom 86.4 33.5 1.3 65.2 100.0 34.8 21.6 451 Bayelsa 80.4 16.5 1.7 81.8 100.0 18.2 7.9 187 Cross River 86.5 37.9 4.1 58.0 100.0 42.0 29.7 310 Delta 85.1 16.7 0.2 83.1 100.0 16.9 6.0 473 Edo 90.3 27.2 2.1 70.7 100.0 29.3 14.0 365 Rivers 82.1 45.4 0.4 54.2 100.0 45.8 21.1 658 South West Ekiti 86.2 24.6 2.6 72.8 100.0 27.2 8.5 148 Lagos 87.3 36.7 1.6 61.7 100.0 38.3 13.4 948 Ogun 51.8 13.8 2.6 83.6 100.0 16.4 4.6 358 Ondo 68.5 25.0 2.2 72.7 100.0 27.3 11.6 404 Osun 83.8 20.1 0.3 79.5 100.0 20.5 9.8 356 Oyo 75.3 18.5 1.4 80.1 100.0 19.9 7.7 629 Education No education 46.4 2.5 1.0 96.6 100.0 3.4 1.0 3,685 Primary 66.1 14.1 1.2 84.7 100.0 15.3 6.3 2,907 Secondary 77.3 20.9 1.5 77.6 100.0 22.4 10.0 8,281 More than secondary 93.9 53.0 2.5 44.5 100.0 55.5 26.9 2,486 Wealth quintile Lowest 44.3 3.2 1.3 95.5 100.0 4.5 1.7 2,862 Second 61.6 10.2 1.0 88.8 100.0 11.2 5.5 2,992 Middle 72.8 18.2 1.2 80.6 100.0 19.4 9.2 3,338 Fourth 78.4 23.6 1.5 74.9 100.0 25.1 11.5 3,835 Highest 88.3 37.9 2.1 60.0 100.0 40.0 17.4 4,332 Total 71.3 20.4 1.5 78.1 100.0 21.9 9.9 17,359 1 Includes “don’t know/missing” 13.8.2 HIV Counselling and Testing during Pregnancy HIV screening is a key tool in the prevention of HIV transmission from mother to child. Table 13.12 shows that 36 percent of women who gave birth during the two years prior to the survey received HIV counselling during antenatal care (ANC). The proportion of women who received counselling varies across area of residence, education, and wealth status; as expected, it is higher in urban than in rural areas and increases with increasing education and wealth. Overall, 20 percent of women were offered and accepted an HIV test during antenatal care and received the test results and post-test counselling, 8 percent were tested and received the results but did not receive post-test counselling, and 5 percent did not receive the results. Twenty-three percent of women received counselling on HIV and HIV test results during ANC were received by. Close to 3 in 10 women (28 percent) who had an HIV test during ANC or labour received their results. Five percent did not receive their results. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 251 Table 13.12 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 pretest counselling, the percentage who received an HIV test during antenatal care for their most recent birth by whether they received their results and post-test counselling, and percentage who received an HIV test at the time of ANC or labour for their most recent birth by whether they received their test results, according to background characteristics, Nigeria 2013 Percentage who received counselling on HIV during antenatal care1 Percentage who were tested for HIV during antenatal care and who: Percentage who received counselling on HIV and an HIV test during ANC, and the results Percentage who had an HIV test during ANC or labour and who:2 Number of women who gave birth in the past two years3 Background characteristic Received results and received post-test counselling Received results and did not receive post-test counselling Did not receive results Received results Did not receive results Age 15-24 28.9 16.0 5.3 4.0 17.4 21.8 4.2 3,900 15-19 19.1 9.9 4.0 2.3 10.7 14.4 2.6 1,064 20-24 32.5 18.2 5.8 4.6 19.9 24.6 4.8 2,836 25-29 39.3 22.2 9.1 5.7 25.9 32.0 5.9 3,490 30-39 40.5 22.9 9.2 5.5 27.5 32.3 5.8 4,171 40-49 30.7 15.2 5.2 5.2 17.6 20.5 5.8 911 Marital status Never married 47.0 26.6 9.2 6.9 30.7 37.1 8.5 288 Married or living together 35.3 19.7 7.6 5.0 22.8 27.6 5.3 11,924 Divorced/separated/ widowed 45.4 26.2 10.8 3.7 31.0 37.5 4.5 261 Residence Urban 60.2 36.0 13.4 8.7 42.5 49.9 9.2 4,404 Rural 22.5 11.2 4.5 3.0 12.7 16.1 3.2 8,069 Zone North Central 37.5 19.6 8.8 4.9 23.4 29.5 5.2 1,692 North East 26.3 17.5 3.9 2.7 16.9 21.8 2.8 2,152 North West 18.6 9.9 4.0 2.3 11.4 13.9 2.3 4,554 South East 58.7 45.9 11.2 5.6 45.7 58.1 6.8 1,150 South South 49.0 23.6 17.5 7.9 34.8 41.7 8.7 1,191 South West 66.9 30.0 11.9 12.9 39.0 42.3 13.2 1,733 State North Central FCT-Abuja 56.7 32.0 29.1 3.8 47.7 61.4 3.8 75 Benue 36.1 19.7 10.8 5.9 24.5 34.5 6.8 374 Kogi 56.1 31.8 19.2 3.7 44.2 51.1 3.7 168 Kwara 56.9 13.8 9.2 26.2 19.2 23.1 26.4 161 Nasarawa 42.4 28.6 5.8 1.5 29.7 34.6 1.5 197 Niger 25.2 8.9 3.0 0.6 9.9 12.4 0.6 514 Plateau 28.7 28.0 6.0 2.0 26.1 34.1 2.0 204 North East Adamawa 55.6 36.7 4.2 0.8 38.8 41.7 1.0 289 Bauchi 16.2 11.3 0.6 1.5 9.7 11.8 1.5 573 Borno 11.6 9.5 1.0 1.9 6.6 10.5 2.2 408 Gombe 47.2 30.6 8.4 4.6 31.2 39.0 4.8 231 Taraba 25.3 18.1 13.4 3.4 18.4 32.3 3.5 300 Yobe 22.9 12.3 1.4 5.2 11.6 14.2 5.2 350 North West Jigawa 17.2 6.7 1.5 3.5 5.2 8.6 3.6 608 Kaduna 31.5 32.0 2.0 4.7 27.6 34.1 4.7 496 Kano 30.0 14.3 11.7 3.0 22.8 26.0 3.0 1,188 Katsina 15.2 4.7 0.0 0.4 3.0 4.7 0.4 688 Kebbi 9.8 2.8 0.8 1.4 2.6 3.6 1.4 479 Sokoto 6.6 4.1 0.9 0.2 4.6 5.0 0.2 444 Zamfara 7.5 2.6 2.5 2.0 3.8 5.2 2.0 652 South East Abia 74.1 51.3 1.0 1.5 50.3 52.6 1.5 135 Anambra 62.7 55.2 4.2 9.4 47.9 61.8 13.3 245 Ebonyi 46.7 36.7 6.5 5.7 34.5 43.5 6.2 313 Enugu 55.6 44.8 17.7 3.8 45.9 63.6 4.0 230 Imo 64.9 46.2 24.4 5.6 55.7 72.1 6.7 228 South South Akwa Ibom 51.0 24.9 10.3 13.2 30.0 36.0 15.8 202 Bayelsa 35.2 20.5 7.8 6.1 24.5 28.3 7.2 95 Cross River 58.6 44.4 5.5 6.0 44.3 49.9 6.0 221 Delta 43.0 17.8 11.7 12.8 22.9 29.8 13.9 220 Edo 50.3 11.9 32.7 10.2 38.5 46.0 10.8 168 Rivers 48.6 19.1 30.6 1.2 41.3 50.4 1.2 285 South West Ekiti 66.9 21.0 7.7 25.2 26.4 29.4 26.3 78 Lagos 79.5 35.6 21.2 16.3 55.5 56.8 16.7 519 Ogun 59.4 20.1 11.1 0.5 25.7 31.2 0.5 294 Ondo 40.0 29.5 9.0 6.9 32.9 38.8 6.9 225 Osun 92.7 40.4 0.2 27.4 40.4 42.0 28.0 189 Oyo 59.5 27.3 8.6 11.9 33.1 36.5 11.9 428 Continued… 252 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.12—Continued Percentage who received counselling on HIV during antenatal care1 Percentage who were tested for HIV during antenatal care and who: Percentage who received counselling on HIV and an HIV test during ANC, and the results Percentage who had an HIV test during ANC or labour and who:2 Number of women who gave birth in the past two years3 Background characteristic Received results and received post-test counselling Received results and did not receive post-test counselling Did not receive results Received results Did not receive results Education No education 14.1 5.7 2.9 1.8 6.8 8.7 1.9 5,940 Primary 37.3 19.6 6.5 5.2 21.2 26.5 5.6 2,253 Secondary 60.6 37.0 13.0 8.7 42.1 51.0 9.1 3,466 More than secondary 84.3 52.5 23.0 12.1 67.6 76.1 13.2 815 Wealth quintile Lowest 7.3 2.8 1.8 0.9 3.3 4.8 1.0 2,888 Second 18.5 8.5 3.2 2.6 8.6 12.1 2.7 2,842 Middle 35.7 19.7 6.8 4.8 21.7 26.9 5.2 2,360 Fourth 56.3 32.8 10.9 8.3 36.5 44.1 8.6 2,247 Highest 76.0 45.2 19.2 10.7 57.2 65.2 11.4 2,135 Total 15-49 35.8 20.0 7.7 5.0 23.2 28.1 5.3 12,473 1 In this context, “pretest counselling” means that someone talked with the respondent about all 3 of the following topics: (1) babies getting the AIDS virus from their mother, (2) preventing the virus, and (3) getting tested for the virus. 2 Women were asked whether they received an HIV test during labour only if they were not tested for HIV during ANC. 3 The denominator for percentages includes women who did not receive antenatal care for their last birth in the past 2 years. 13.9 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 rates of STI transmission, including transmission of HIV (WHO and UNAIDS, 2007). To examine this practice, men interviewed in the 2013 NDHS were asked whether they were circumcised. The results are presented in Table 13.13. Table 13.13 Male circumcision Percentage of men age 15-49 who report having been circumcised, by background characteristics, Nigeria 2013 Percentage circumcised Number of men Among circumcised men: age at circumcision Number of men circumcised Background characteristic During infancy/ before 5 years 5-13 years 14-19 years 20 or more years Don’t know/ missing Total Age 15-24 98.6 6,511 62.6 31.0 0.1 0.0 6.3 100.0 6,419 15-19 98.5 3,619 62.1 31.1 0.0 0.0 6.8 100.0 3,563 20-24 98.7 2,892 63.3 30.9 0.2 0.0 5.7 100.0 2,855 25-29 99.3 2,757 64.4 30.2 0.4 0.0 5.0 100.0 2,737 30-39 99.3 4,589 62.2 31.7 0.5 0.1 5.4 100.0 4,558 40-49 98.6 3,501 59.2 34.6 0.5 0.2 5.4 100.0 3,450 Residence Urban 99.0 7,611 69.6 23.5 0.2 0.0 6.7 100.0 7,533 Rural 98.8 9,748 56.3 38.3 0.5 0.1 4.9 100.0 9,630 Zone North Central 99.4 2,685 84.1 8.9 0.6 0.0 6.4 100.0 2,669 North East 99.6 2,515 44.7 49.3 1.0 0.2 4.7 100.0 2,505 North West 99.1 5,185 22.8 75.8 0.0 0.0 1.3 100.0 5,138 South East 98.7 1,686 96.9 0.4 0.1 0.2 2.4 100.0 1,664 South South 97.6 2,445 85.1 0.6 0.1 0.0 14.2 100.0 2,386 South West 98.6 2,843 88.4 2.5 0.4 0.0 8.7 100.0 2,802 State North Central FCT-Abuja 97.8 175 79.7 12.6 0.6 0.2 6.9 100.0 171 Benue 99.1 616 91.1 7.3 1.0 0.0 0.6 100.0 611 Kogi 99.7 333 95.7 3.6 0.1 0.0 0.6 100.0 332 Kwara 99.5 274 91.7 4.9 0.2 0.0 3.2 100.0 273 Nasarawa 99.3 282 73.3 20.9 0.3 0.0 5.5 100.0 280 Niger 99.9 701 86.2 6.7 0.4 0.0 6.7 100.0 701 Plateau 99.6 302 58.1 13.0 1.8 0.0 27.1 100.0 301 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 253 Table 13.13—Continued Percentage circumcised Number of men Among circumcised men: age at circumcision Number of men circumcised Background characteristic During infancy/ before 5 years 5-13 years 14-19 years 20 or more years Don’t know/ missing Total North East Adamawa 98.1 358 37.1 55.7 5.2 1.8 0.3 100.0 351 Bauchi 99.8 512 8.2 84.9 0.6 0.0 6.2 100.0 511 Borno 100.0 676 68.2 30.7 0.0 0.0 1.2 100.0 676 Gombe 99.2 255 24.2 72.2 0.9 0.0 2.7 100.0 253 Taraba 100.0 325 89.9 8.3 0.5 0.0 1.2 100.0 325 Yobe 99.8 390 34.7 48.5 0.0 0.0 16.9 100.0 390 North West Jigawa 100.0 510 2.8 96.0 0.0 0.0 1.2 100.0 510 Kaduna 99.8 1,033 57.3 41.2 0.0 0.0 1.4 100.0 1,031 Kano 99.9 1,592 3.1 96.9 0.0 0.0 0.0 100.0 1,590 Katsina 100.0 596 58.1 41.1 0.0 0.2 0.6 100.0 596 Kebbi 93.0 551 19.2 79.8 0.4 0.0 0.5 100.0 512 Sokoto 100.0 424 4.0 95.2 0.0 0.0 0.9 100.0 424 Zamfara 99.3 479 11.9 80.5 0.0 0.2 7.4 100.0 475 South East Abia 98.1 229 99.4 0.0 0.0 0.0 0.6 100.0 224 Anambra 98.5 446 97.0 0.5 0.0 0.0 2.5 100.0 439 Ebonyi 99.4 368 95.7 1.3 0.2 0.8 1.9 100.0 366 Enugu 98.7 320 99.9 0.1 0.0 0.0 0.0 100.0 316 Imo 98.5 323 93.4 0.0 0.0 0.0 6.6 100.0 318 South South Akwa Ibom 98.4 451 92.9 0.0 0.0 0.0 7.1 100.0 444 Bayelsa 99.6 187 97.6 1.8 0.3 0.0 0.2 100.0 187 Cross River 89.4 310 97.4 0.0 0.0 0.0 2.6 100.0 278 Delta 99.6 473 94.8 1.4 0.3 0.0 3.5 100.0 471 Edo 97.5 365 82.8 0.9 0.2 0.0 16.1 100.0 356 Rivers 98.9 658 65.4 0.0 0.0 0.0 34.6 100.0 651 South West Ekiti 99.6 148 96.7 0.2 0.2 0.0 2.9 100.0 147 Lagos 98.6 948 91.5 2.9 0.3 0.0 5.4 100.0 935 Ogun 99.8 358 92.5 4.5 1.1 0.0 1.8 100.0 357 Ondo 96.7 404 66.2 3.5 0.9 0.0 29.4 100.0 391 Osun 97.1 356 86.1 0.6 0.0 0.3 13.0 100.0 346 Oyo 99.5 629 94.7 1.8 0.0 0.0 3.5 100.0 626 Religion Catholic 98.7 2,014 91.9 2.5 0.2 0.1 5.3 100.0 1,988 Other Christian 98.4 6,181 87.0 3.2 0.6 0.1 9.2 100.0 6,081 Islam 99.3 8,907 38.1 58.3 0.2 0.0 3.4 100.0 8,842 Traditionalist 97.1 161 72.5 18.7 2.5 0.8 5.4 100.0 157 Missing 100.0 79 64.5 32.8 0.0 0.0 2.8 100.0 79 Ethnic group Ekoi (97.7) 20 100.0 0.0 0.0 0.0 0.0 100.0 20 Fulani 98.9 953 31.9 63.0 0.3 0.0 4.8 100.0 943 Hausa 99.3 4,719 17.2 80.5 0.1 0.0 2.2 100.0 4,685 Ibibio 97.6 419 88.7 0.9 0.0 0.0 10.3 100.0 409 Igala 99.8 196 93.6 4.1 0.0 0.0 2.4 100.0 195 Igbo 99.0 2,330 93.9 0.7 0.2 0.1 5.1 100.0 2,308 Ijaw/Izon 99.1 346 88.6 2.6 0.1 0.0 8.8 100.0 343 Kanuri/Beriberi 100.0 292 55.8 39.3 0.1 0.0 4.8 100.0 292 Tiv 98.6 448 94.3 4.2 0.5 0.0 1.0 100.0 442 Yoruba 98.9 2,341 89.4 2.4 0.1 0.0 8.1 100.0 2,316 Other 98.4 5,247 74.2 16.7 0.8 0.1 8.2 100.0 5,164 Education No education 98.5 3,685 33.4 62.1 0.3 0.2 4.0 100.0 3,631 Primary 99.2 2,907 59.0 34.4 0.7 0.1 5.8 100.0 2,883 Secondary 98.9 8,281 72.3 21.1 0.3 0.0 6.3 100.0 8,186 More than secondary 99.1 2,486 74.0 19.7 0.3 0.0 5.9 100.0 2,463 Wealth quintile Lowest 99.1 2,862 31.8 63.2 0.4 0.2 4.4 100.0 2,836 Second 98.9 2,992 47.2 47.9 0.6 0.2 4.1 100.0 2,961 Middle 99.0 3,338 65.4 28.7 0.6 0.1 5.3 100.0 3,303 Fourth 98.8 3,835 71.2 22.6 0.2 0.0 5.9 100.0 3,788 Highest 98.7 4,332 81.9 10.3 0.1 0.0 7.7 100.0 4,276 Total 98.9 17,359 62.1 31.8 0.3 0.1 5.7 100.0 17,164 Note: Total includes 48 cases with missing information on ethnicity. Figures in parentheses are based on 25-49 unweighted cases. 254 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Overall, 99 percent of male respondents reported that they were circumcised. The practice is almost universal and shows little variation across age groups, urban-rural residence, zones, states, religion, or ethnicity. Among men who are circumcised, urban men are more likely than rural men to be circumcised during infancy or before age 5 (70 percent and 56 percent, respectively). The practice of circumcision before age 5 is less prevalent in the North West and North East zones (23 percent and 45 percent, respectively), while in the South East zone 97 percent of circumcisions occur during infancy or before age 5. The practice of circumcising men during infancy or before age 5 is not common in Jigawa and Kano (3 percent each). Among the religious groups, Islam has the lowest percentage of men circumcised during infancy or before age 5 (38 percent). Almost 6 in 10 (58 percent) Muslim men were circumcised between age 5 and age 13. Table 13.14 shows that one in five men were circumcised at a health facility, 55 percent were circumcised at home, and 7 percent were circumcised at the home of a health worker or health professional. Thirteen percent of men did not know the place where they were circumcised. The practice of circumcision at ritual sites is uncommon (1 percent). Sixty-one percent of circumcisions were performed by a traditional practitioner, family member, or friend. Only 24 percent of men were circumcised by a health worker or professional. Fourteen percent of men did not know who performed the circumcision. Urban men were almost twice as likely as rural men to be circumcised at a health facility (27 percent and 15 percent, respectively) and by a health worker or professional (33 percent and 17 percent, respectively). Table 13.14 Place and provider for male circumcision Percent distribution of circumcised men by place and provider of circumcision, according to background characteristics, Nigeria 2013 Place where circumcised Provider of circumcision Number of men circum- cised Background characteristic Health facility Home of a health worker/ profes- sional Circum- cision done at home Ritual site Other home/ place Don’t know/ missing Total Traditional practi- tioner/ family/ friend Health worker/ profes- sional Other Don’t know/ missing Total Age 15-24 24.2 8.1 51.2 0.4 2.9 13.2 100.0 56.2 28.9 0.9 14.0 100.0 6,419 15-19 24.2 8.3 50.7 0.4 2.2 14.1 100.0 54.9 29.4 1.0 14.7 100.0 3,563 20-24 24.1 7.8 51.8 0.4 3.7 12.1 100.0 57.7 28.4 0.8 13.1 100.0 2,855 25-29 23.4 7.4 53.6 0.5 4.0 11.1 100.0 60.2 26.6 0.8 12.4 100.0 2,737 30-39 18.3 7.1 54.7 0.5 5.0 14.3 100.0 62.2 21.3 1.0 15.4 100.0 4,558 40-49 13.9 6.1 63.5 1.0 4.7 10.9 100.0 70.8 16.1 1.0 12.1 100.0 3,450 Residence Urban 27.1 8.1 42.9 0.5 3.0 18.5 100.0 47.3 32.6 0.9 19.2 100.0 7,533 Rural 15.2 6.7 64.5 0.6 4.8 8.2 100.0 72.3 17.3 0.9 9.5 100.0 9,630 Zone North Central 22.3 4.2 60.3 1.3 3.5 8.5 100.0 63.0 24.7 0.5 11.9 100.0 2,669 North East 10.4 3.4 67.4 0.8 16.7 1.4 100.0 79.9 14.8 3.6 1.7 100.0 2,505 North West 10.3 10.8 77.4 0.1 0.5 0.9 100.0 88.4 10.9 0.2 0.6 100.0 5,138 South East 38.6 16.6 22.7 0.4 2.2 19.4 100.0 23.9 53.8 2.0 20.3 100.0 1,664 South South 28.7 3.0 35.2 0.9 1.7 30.5 100.0 35.3 31.5 0.2 33.0 100.0 2,386 South West 28.4 5.6 33.9 0.3 2.6 29.2 100.0 38.1 31.3 0.4 30.2 100.0 2,802 State North Central FCT-Abuja 36.0 30.4 4.1 0.0 21.0 8.5 100.0 26.5 63.0 0.0 10.6 100.0 171 Benue 43.2 2.1 38.9 2.4 7.4 6.0 100.0 41.9 38.9 1.6 17.6 100.0 611 Kogi 28.5 2.5 64.9 0.0 0.7 3.4 100.0 66.8 30.0 0.5 2.7 100.0 332 Kwara 15.0 3.8 60.9 7.4 0.5 12.3 100.0 72.2 20.1 0.0 7.7 100.0 273 Nasarawa 10.7 3.0 80.5 0.0 1.3 4.6 100.0 80.4 13.3 0.2 6.1 100.0 280 Niger 10.6 2.4 85.5 0.0 0.4 1.2 100.0 84.6 13.9 0.0 1.5 100.0 701 Plateau 10.0 0.7 52.4 0.0 0.6 36.4 100.0 47.1 8.5 0.0 44.4 100.0 301 North East Adamawa 37.1 0.9 56.9 4.9 0.2 0.0 100.0 53.3 46.7 0.0 0.0 100.0 351 Bauchi 4.6 0.5 94.1 0.3 0.2 0.4 100.0 94.4 4.5 0.7 0.4 100.0 511 Borno 6.2 8.2 40.1 0.0 41.1 4.4 100.0 67.6 15.2 12.3 4.8 100.0 676 Gombe 8.7 1.9 84.9 0.2 3.9 0.4 100.0 88.7 9.4 0.9 1.1 100.0 253 Taraba 5.0 5.3 49.6 0.0 39.5 0.6 100.0 89.6 9.1 0.3 1.0 100.0 325 Yobe 6.6 0.4 92.7 0.0 0.0 0.2 100.0 92.3 7.4 0.1 0.2 100.0 390 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 255 Table 13.14—Continued Place where circumcised Provider of circumcision Number of men circum- cised Background characteristic Health facility Home of a health worker/ profes- sional Circum- cision done at home Ritual site Other home/ place Don’t know/ missing Total Traditional practi- tioner/ family/ friend Health worker/ profes- sional Other Don’t know/ missing Total North West Jigawa 1.4 9.5 84.3 0.0 4.6 0.2 100.0 97.3 2.4 0.0 0.4 100.0 510 Kaduna 41.8 0.7 53.9 0.2 0.2 3.3 100.0 55.3 42.8 0.3 1.6 100.0 1,031 Kano 0.1 0.6 99.3 0.0 0.0 0.0 100.0 99.7 0.1 0.1 0.1 100.0 1,590 Katsina 11.0 3.1 85.3 0.0 0.2 0.3 100.0 86.2 13.6 0.0 0.2 100.0 596 Kebbi 3.3 92.4 2.9 0.2 0.0 1.3 100.0 95.1 3.6 0.0 1.3 100.0 512 Sokoto 0.6 0.0 99.3 0.0 0.1 0.0 100.0 98.6 0.6 0.8 0.0 100.0 424 Zamfara 0.8 0.0 98.2 0.3 0.0 0.7 100.0 99.1 0.3 0.0 0.5 100.0 475 South East Abia 58.3 8.8 14.4 0.0 11.8 6.6 100.0 13.6 68.8 11.0 6.6 100.0 224 Anambra 10.6 25.9 9.1 0.6 0.4 53.5 100.0 9.4 36.4 0.3 53.8 100.0 439 Ebonyi 27.9 28.3 41.7 0.4 0.2 1.7 100.0 44.8 52.9 0.5 1.8 100.0 366 Enugu 59.1 8.1 30.2 0.6 0.6 1.4 100.0 32.6 66.0 0.0 1.4 100.0 316 Imo 55.4 4.4 18.1 0.3 2.0 19.8 100.0 18.3 56.1 1.8 23.7 100.0 318 South South Akwa Ibom 50.9 2.0 30.5 0.0 1.4 15.2 100.0 30.6 52.3 0.0 17.1 100.0 444 Bayelsa 22.2 1.8 57.9 11.1 0.1 6.8 100.0 67.3 25.6 0.3 6.8 100.0 187 Cross River 21.6 3.3 58.2 0.0 0.9 16.0 100.0 53.4 27.0 0.0 19.7 100.0 278 Delta 36.4 8.9 46.8 0.0 3.5 4.5 100.0 51.5 43.3 0.3 4.9 100.0 471 Edo 35.4 0.7 39.0 0.2 1.3 23.4 100.0 34.8 34.8 0.1 30.3 100.0 356 Rivers 9.2 1.0 11.6 0.0 1.7 76.5 100.0 10.2 10.7 0.4 78.8 100.0 651 South West Ekiti 45.3 1.9 25.3 0.0 0.7 26.9 100.0 25.5 45.9 0.0 28.6 100.0 147 Lagos 35.4 5.4 36.3 0.0 3.2 19.7 100.0 42.3 36.0 0.8 20.9 100.0 935 Ogun 33.2 3.4 53.8 0.4 4.4 4.8 100.0 59.2 36.1 0.2 4.5 100.0 357 Ondo 26.4 3.5 34.9 2.1 1.0 32.0 100.0 38.7 25.7 0.5 35.1 100.0 391 Osun 47.7 2.7 28.5 0.0 5.0 16.1 100.0 34.8 48.5 0.0 16.7 100.0 346 Oyo 1.9 10.7 23.1 0.0 0.7 63.6 100.0 24.4 12.2 0.0 63.4 100.0 626 Religion Catholic 41.2 9.5 32.1 0.6 1.7 14.9 100.0 32.8 47.7 1.0 18.6 100.0 1,988 Other Christian 34.0 5.6 33.7 1.0 3.8 21.9 100.0 36.8 38.8 0.7 23.7 100.0 6,081 Islam 6.7 7.9 74.7 0.3 4.6 5.7 100.0 84.5 8.7 1.1 5.6 100.0 8,842 Traditionalist 9.2 12.0 58.1 2.1 4.6 14.0 100.0 74.7 10.5 0.3 14.5 100.0 157 Missing 11.9 7.6 59.8 0.0 1.1 19.6 100.0 60.9 19.5 0.0 19.6 100.0 79 Ethnic group Ekoi 15.2 0.0 62.1 0.0 0.0 22.8 100.0 55.3 22.0 0.0 22.8 100.0 20 Fulani 3.6 3.5 83.3 0.2 4.7 4.6 100.0 89.4 5.0 0.9 4.7 100.0 943 Hausa 3.3 11.0 83.0 0.1 1.4 1.2 100.0 94.1 4.6 0.3 1.0 100.0 4,685 Ibibio 42.3 2.7 33.7 0.0 1.6 19.8 100.0 32.4 44.8 0.3 22.5 100.0 409 Igala 32.0 2.9 57.7 0.0 2.3 5.0 100.0 63.0 31.8 1.1 4.1 100.0 195 Igbo 40.8 13.7 23.4 0.2 2.4 19.6 100.0 24.8 52.8 1.5 20.9 100.0 2,308 Ijaw/Izon 20.5 3.6 52.2 5.0 1.8 17.0 100.0 57.0 25.0 0.1 17.9 100.0 343 Kanuri/Beriberi 7.3 2.9 53.7 0.2 30.5 5.4 100.0 77.0 9.9 8.9 4.2 100.0 292 Tiv 39.3 3.2 34.6 1.8 12.5 8.7 100.0 46.5 35.4 0.8 17.2 100.0 442 Yoruba 28.7 5.6 33.3 1.0 2.2 29.2 100.0 37.8 32.2 0.4 29.6 100.0 2,316 Other 23.2 4.1 51.8 0.7 6.0 14.3 100.0 56.4 26.3 1.1 16.2 100.0 5,164 Education No education 1.6 8.9 79.4 0.4 6.7 3.1 100.0 93.0 2.4 1.5 3.1 100.0 3,631 Primary 12.2 5.5 66.1 0.9 4.6 10.6 100.0 72.2 14.8 0.8 12.1 100.0 2,883 Secondary 27.5 7.0 45.4 0.5 2.9 16.7 100.0 49.1 32.1 0.8 18.0 100.0 8,186 More than secondary 34.4 8.2 37.8 0.5 3.2 15.9 100.0 42.7 39.4 0.6 17.3 100.0 2,463 Wealth quintile Lowest 2.5 8.3 80.2 0.3 5.7 2.9 100.0 91.6 3.5 1.2 3.7 100.0 2,836 Second 10.0 7.6 69.4 1.0 5.7 6.4 100.0 79.4 11.8 1.2 7.6 100.0 2,961 Middle 18.5 5.8 61.5 0.6 3.8 9.9 100.0 66.5 21.2 1.0 11.2 100.0 3,303 Fourth 27.1 7.1 47.5 0.6 3.4 14.3 100.0 52.4 31.8 0.6 15.2 100.0 3,788 Highest 35.2 7.8 29.9 0.4 2.4 24.3 100.0 32.8 41.2 0.7 25.3 100.0 4,276 Total 20.4 7.3 55.0 0.6 4.0 12.7 100.0 61.4 24.0 0.9 13.7 100.0 17,164 Note: Total includes 48 cases with missing information on ethnicity. 256 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour 13.10 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS In the 2013 NDHS, respondents who had ever had sexual intercourse were asked if in the past 12 months they experienced a disease acquired through sexual contact or if they 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 13.15 shows the self-reported prevalence of STIs and STI symptoms among women and men. Overall, 8 percent of women and 4 percent of men reported having had an STI or experiencing STI symptoms during the 12 months preceding the survey. Four percent of women reported having an STI; 6 percent had a bad-smelling, abnormal discharge, and 3 percent had a genital sore or ulcer. The prevalence of STIs and STI symptoms is highest among never-married women (15 percent). Women in urban areas are slightly more likely than women in rural areas to have had an STI or STI symptoms. The prevalence of STIs or STI symptoms among women is higher in the South East (15 percent) than in other zones. It is of interest that one in three women (32 percent) in Kaduna reported having an STI or STI symptoms. Women who have attended school are more than twice as likely to report STIs or STI symptoms as women with no education. Among men, 2 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. The highest prevalence of self- reported STIs or STI symptoms among men (14 percent) was recorded in Zamfara and Imo. Table 13.15 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Nigeria 2013 Percentage of women who reported having in the past 12 months: Percentage of men who reported having in the past 12 months: Background characteristic STI Bad- smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer Number of women who ever had sexual intercourse STI Bad- smelling/ abnormal discharge from penis Genital sore/ulcer STI/ abnormal discharge from penis/ sore or ulcer Number of men who ever had sexual intercourse Age 15-24 3.2 6.1 3.7 8.0 9,268 1.8 2.8 1.5 4.2 2,201 15-19 2.2 6.0 3.5 7.3 3,404 0.9 3.3 1.3 4.4 559 20-24 3.8 6.1 3.9 8.4 5,864 2.0 2.7 1.6 4.1 1,642 25-29 4.2 7.1 3.6 9.0 6,913 2.3 3.1 1.9 4.6 2,318 30-39 4.5 6.5 3.2 8.6 10,071 1.5 2.0 1.2 3.0 4,415 40-49 3.6 4.9 2.7 6.7 7,015 1.3 2.3 0.7 3.0 3,475 Marital status Never married 6.4 11.1 6.2 14.7 3,732 2.5 3.1 1.7 4.8 3,461 Married/living together 3.5 5.5 2.9 7.2 27,749 1.2 2.1 1.0 3.0 8,693 Divorced/separated/ widowed 4.0 6.3 3.9 8.3 1,786 3.3 3.0 2.6 5.1 256 Male circumcision1 Circumcised na na na na na 1.6 2.4 1.3 3.5 12,296 Not circumcised na na na na na 4.0 3.6 0.0 5.1 93 Residence Urban 5.6 7.1 3.4 9.8 13,175 1.9 1.9 1.0 3.0 5,252 Rural 2.7 5.5 3.3 7.0 20,092 1.5 2.8 1.4 3.9 7,157 Zone North Central 3.4 7.0 3.9 8.9 4,576 2.1 3.6 1.9 4.6 2,099 North East 2.2 6.3 4.2 7.6 5,072 1.6 3.3 2.1 4.2 1,728 North West 5.0 5.6 2.8 7.4 10,615 0.6 2.4 0.7 2.7 3,101 South East 8.2 9.8 5.0 14.5 3,537 4.6 2.3 1.6 6.2 1,264 South South 2.0 5.9 3.3 7.6 4,175 1.3 1.3 1.1 2.5 2,001 South West 2.2 4.3 1.9 5.3 5,293 1.4 1.7 0.7 2.4 2,216 State North Central FCT-Abuja 2.8 5.3 0.9 6.8 257 1.1 0.9 0.2 1.1 131 Benue 6.4 19.2 9.2 23.5 1,043 1.9 4.4 4.5 6.6 500 Kogi 1.9 2.1 0.6 2.5 536 3.7 3.9 0.4 3.9 240 Kwara 0.2 0.5 0.0 0.7 461 0.6 0.6 0.3 0.9 211 Nasarawa 6.8 8.9 7.2 12.8 510 1.9 3.6 1.6 5.2 224 Niger 0.9 1.2 0.9 1.7 1,232 1.2 2.6 0.5 2.9 562 Plateau 4.7 6.5 5.1 7.7 537 5.3 8.4 4.2 10.2 230 Continued… HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 257 Table 13.15—Continued Percentage of women who reported having in the past 12 months: Percentage of men who reported having in the past 12 months: Background characteristic STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer Number of women who ever had sexual intercourse STI Bad smelling/ abnormal discharge from penis Genital sore/ulcer STI/ abnormal discharge from penis/ sore or ulcer Number of men who ever had sexual intercourse North East Adamawa 1.5 15.6 13.8 18.6 691 1.5 5.3 0.9 6.3 251 Bauchi 0.6 0.9 1.3 2.2 1,068 0.3 0.5 0.5 1.0 354 Borno 1.0 0.9 0.9 1.3 1,203 3.7 3.9 4.2 4.8 464 Gombe 1.0 2.7 2.2 4.3 494 1.0 5.7 3.0 7.7 167 Taraba 7.0 14.0 5.8 16.0 760 0.6 2.6 1.2 3.2 257 Yobe 3.0 8.1 4.7 9.1 856 0.7 2.9 1.9 4.4 236 North West Jigawa 0.9 2.4 1.5 3.4 1,297 0.6 2.7 1.3 3.3 352 Kaduna 23.2 24.9 12.3 32.1 1,900 1.4 1.6 0.7 2.2 738 Kano 1.8 1.2 0.6 2.1 2,633 0.1 0.1 0.0 0.1 696 Katsina 0.6 0.4 0.6 1.0 1,441 0.6 0.6 0.6 0.6 419 Kebbi 0.4 2.9 0.9 3.0 1,113 0.3 0.5 0.0 0.5 334 Sokoto 0.5 0.7 0.2 1.0 983 0.4 2.4 0.4 2.4 245 Zamfara 0.9 1.0 0.8 1.4 1,248 0.0 13.6 2.3 14.2 316 South East Abia 2.3 2.0 0.7 3.3 427 2.1 0.5 0.0 2.1 171 Anambra 9.4 6.6 8.3 11.9 837 3.7 2.9 1.9 5.3 358 Ebonyi 7.7 17.0 5.4 23.9 900 1.3 0.7 0.6 2.3 269 Enugu 14.5 12.0 3.4 18.5 705 3.0 4.7 4.8 6.5 208 Imo 4.5 6.7 4.9 8.2 668 12.2 2.5 0.6 13.9 259 South South Akwa Ibom 2.6 8.9 8.4 10.3 738 2.0 2.8 1.8 4.1 379 Bayelsa 0.7 5.0 7.7 9.5 305 3.2 3.1 1.6 4.2 154 Cross River 1.6 4.4 3.3 6.8 625 3.3 3.2 1.0 4.4 248 Delta 1.1 0.6 0.6 2.0 819 0.3 0.3 1.9 2.2 387 Edo 3.2 7.8 1.9 9.3 576 1.1 0.6 1.3 2.8 280 Rivers 2.1 7.7 1.6 9.2 1,112 0.1 0.1 0.0 0.1 554 South West Ekiti 1.8 10.8 4.9 12.0 270 0.3 0.0 0.4 0.7 113 Lagos 3.6 4.0 2.6 6.3 1,648 1.4 1.4 0.7 2.1 753 Ogun 3.4 3.5 1.0 3.6 771 1.4 1.9 0.6 2.5 285 Ondo 1.0 0.9 1.2 1.7 694 3.9 2.8 2.2 4.5 318 Osun 0.0 2.7 0.5 2.7 586 1.5 4.4 0.3 5.7 262 Oyo 1.3 6.2 1.9 6.8 1,323 0.0 0.0 0.0 0.0 485 Education No education 2.2 3.8 2.3 4.9 14,072 0.7 2.5 1.4 3.0 2,747 Primary 4.0 7.6 4.2 9.6 6,151 1.9 2.8 0.9 3.7 2,294 Secondary 5.6 8.2 4.1 10.9 9,926 2.2 2.6 1.5 4.1 5,220 More than secondary 5.4 7.7 3.7 10.3 3,119 1.3 1.5 0.7 2.5 2,149 Wealth quintile Lowest 1.6 3.1 1.8 4.3 6,652 1.0 3.2 1.2 3.9 1,944 Second 3.5 6.9 3.6 8.5 6,665 1.0 3.2 1.5 3.7 2,112 Middle 4.0 7.3 4.6 9.6 6,240 1.9 3.3 2.2 4.6 2,317 Fourth 5.1 6.6 3.2 8.7 6,526 1.9 1.6 0.7 2.9 2,735 Highest 5.0 6.9 3.5 9.4 7,185 2.0 1.6 0.8 2.9 3,302 Total 3.9 6.2 3.3 8.1 33,267 1.6 2.4 1.2 3.5 12,410 na = Not applicable 1 Excludes 20 cases with missing information on status of male circumcision. Women and men who reported having an STI and/or STI symptoms in the past 12 months were asked whether they sought any advice or treatment. Figure 13.1 shows that 40 percent of women sought advice or treatment from a clinic, hospital, private doctor, or other health professional; 22 percent sought advice or medicine from a shop or pharmacy; and 27 percent sought no advice or treatment. Men were more likely than women to seek advice or treatment for STIs or STI symptoms, with 45 percent seeking advice or treatment from a health facility or health professional and 27 percent from a shop or pharmacy. Twenty percent of men did not seek advice or treatment. 258 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Figure 13.1 Women and men seeking treatment for STIs 40 22 11 27 45 27 11 20 Clinic/hospital/private doctor/other health professional Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment Percentage Women Men NDHS 2013 13.11 PREVALENCE OF MEDICAL INJECTIONS Use of non-sterile injections in a health care setting can contribute to the transmission of blood- borne pathogens because it amplifies the effects 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. To obtain information for this indicator, respondents in the 2013 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 while medical injections can also be self-administered (e.g., insulin for diabetes), these injections are not included in the calculation. Table 13.16 shows the reported prevalence of injections and safe injection practices. Twenty-six percent of women and 23 percent of men reported receiving an injection from a health worker during the 12 months preceding the survey. The average number of medical injections received over the 12-month period was one per person for both women and men. The prevalence of safe medical injection practices is universal among women and men (97 percent and 98 percent, respectively). Looking at differentials across subgroups of women, the prevalence of medical injections is highest among women age 25-29 (31 percent), those living in urban areas (30 percent) and the South East (36 percent), those with more than a secondary education (38 percent), and those in the highest wealth quintile (34 percent). Among men, the prevalence is highest among those age 25-29 and age 30-39 (25 percent each), those in the North Central zone (28 percent), and those with more than a secondary education (27 percent). HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 259 Table 13.16 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the last 12 months, the average number of medical injections per person in the last 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 2013 Women Men Background characteristic Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respondents For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respondents For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months Age 15-24 23.1 0.9 14,576 96.3 3,363 19.7 0.8 6,511 97.9 1,282 15-19 17.9 0.7 7,820 96.0 1,399 19.4 0.7 3,619 97.6 702 20-24 29.1 1.2 6,757 96.5 1,963 20.1 0.9 2,892 98.2 580 25-29 30.9 1.3 7,145 97.1 2,206 25.2 1.1 2,757 97.3 695 30-39 29.2 1.3 10,185 97.2 2,979 24.5 1.3 4,589 98.0 1,124 40-49 22.8 1.1 7,042 96.7 1,603 24.2 1.4 3,501 97.6 847 Marital status Never married 21.5 1.0 9,326 96.2 2,002 20.9 0.9 8,378 98.0 1,747 Ever had sex 28.7 1.4 3,732 95.3 1,071 25.3 1.2 3,461 98.3 877 Never had sex 16.6 0.7 5,593 97.3 931 17.7 0.7 4,918 97.8 871 Married/living together 27.6 1.2 27,830 96.9 7,692 24.5 1.3 8,723 97.5 2,133 Divorced/separated/ widowed 25.5 1.2 1,793 96.9 457 25.9 1.6 258 96.8 67 Residence Urban 29.9 1.3 16,414 97.4 4,904 22.2 1.1 7,611 97.5 1,692 Rural 23.3 1.0 22,534 96.2 5,246 23.1 1.1 9,748 97.9 2,255 Zone North Central 26.7 1.4 5,572 96.6 1,488 27.7 1.4 2,685 97.4 743 North East 22.0 0.7 5,766 97.0 1,271 24.6 1.0 2,515 96.7 618 North West 20.1 0.8 11,877 97.5 2,390 16.1 0.6 5,185 98.8 836 South East 35.6 1.7 4,476 95.8 1,596 27.3 1.4 1,686 98.6 460 South South 28.4 1.2 4,942 95.1 1,405 25.0 1.2 2,445 97.0 611 South West 31.7 1.4 6,314 97.9 2,000 23.9 1.4 2,843 97.8 679 State North Central FCT-Abuja 32.1 1.6 315 96.1 101 9.5 0.4 175 (96.9) 17 Benue 25.1 1.4 1,240 96.7 311 28.1 1.6 616 98.7 173 Kogi 30.9 2.0 704 98.5 218 35.6 1.5 333 97.9 119 Kwara 28.7 1.1 596 99.9 171 29.3 1.5 274 96.8 80 Nasarawa 27.6 1.1 594 96.9 164 28.8 1.9 282 100.0 81 Niger 26.4 1.5 1,462 94.4 386 29.5 1.4 701 94.9 207 Plateau 20.7 0.9 662 95.7 137 21.9 1.2 302 99.1 66 North East Adamawa 29.6 1.0 828 97.7 245 38.8 1.4 358 99.2 139 Bauchi 25.3 0.9 1,161 98.0 293 43.3 2.3 512 95.2 221 Borno 11.3 0.3 1,412 100.0 160 9.6 0.3 676 (92.6) 65 Gombe 27.2 0.7 550 98.3 149 29.4 1.3 255 97.8 75 Taraba 26.3 1.1 844 93.8 222 16.3 0.7 325 95.6 53 Yobe 20.7 0.5 971 94.7 201 16.5 0.6 390 100.0 64 North West Jigawa 20.2 0.6 1,353 96.0 274 26.0 0.8 510 98.4 133 Kaduna 23.9 0.7 2,136 98.5 510 4.5 0.1 1,033 (92.7) 47 Kano 12.4 0.4 3,189 99.6 396 3.1 0.1 1,592 (98.2) 49 Katsina 20.4 0.6 1,525 97.4 312 13.4 0.4 596 100.0 80 Kebbi 36.6 2.5 1,244 95.4 455 36.6 1.2 551 99.6 202 Sokoto 8.8 0.3 1,098 92.1 97 26.3 1.0 424 98.7 112 Zamfara 26.0 0.9 1,332 99.3 347 44.8 2.4 479 99.2 215 South East Abia 32.0 1.4 518 99.2 165 34.3 1.6 229 99.4 78 Anambra 40.0 2.2 1,052 90.7 420 15.0 1.0 446 100.0 67 Ebonyi 30.3 1.5 1,122 96.4 340 27.1 1.2 368 98.2 100 Enugu 32.5 1.6 951 97.7 309 31.5 1.4 320 95.8 101 Imo 43.3 1.9 833 97.9 361 35.3 1.9 323 100.0 114 South South Akwa Ibom 32.7 1.5 864 88.4 283 31.7 1.9 451 97.6 143 Bayelsa 23.3 1.3 364 97.5 85 24.0 1.4 187 97.4 45 Cross River 36.7 2.0 703 96.6 258 27.8 1.2 310 99.1 86 Delta 10.7 0.4 993 97.4 107 28.1 1.3 473 97.7 133 Edo 36.7 1.6 742 96.2 272 23.8 1.1 365 93.7 87 Rivers 31.4 1.1 1,276 96.9 400 17.9 0.7 658 96.4 118 Continued… 260 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.16—Continued Women Men Background characteristic Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respondents For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respondents For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months South West Ekiti 30.5 1.4 326 98.5 100 22.2 1.2 148 91.9 33 Lagos 37.7 1.9 1,964 97.5 739 24.5 1.2 948 97.2 233 Ogun 25.5 1.3 883 97.1 226 13.6 2.2 358 (97.9) 49 Ondo 28.8 1.3 808 97.6 233 25.2 1.1 404 98.3 102 Osun 31.3 1.1 765 100.0 240 18.9 0.8 356 98.9 67 Oyo 29.5 1.3 1,568 98.0 463 31.1 1.5 629 98.8 196 Education No education 18.3 0.7 14,729 96.0 2,696 18.0 0.8 3,685 96.5 664 Primary 28.0 1.3 6,734 96.2 1,883 22.9 1.3 2,907 97.2 665 Secondary 30.4 1.3 13,927 97.3 4,232 23.7 1.1 8,281 98.0 1,959 More than secondary 37.6 1.7 3,558 97.4 1,339 26.5 1.2 2,486 98.6 659 Wealth quintile Lowest 16.3 0.6 7,132 96.6 1,164 19.3 0.9 2,862 96.1 552 Second 21.2 0.9 7,428 96.2 1,574 21.2 0.9 2,992 97.8 634 Middle 26.6 1.2 7,486 96.3 1,994 25.4 1.3 3,338 98.8 847 Fourth 30.2 1.3 7,992 96.7 2,416 23.5 1.2 3,835 97.0 901 Highest 33.7 1.5 8,910 97.5 3,003 23.4 1.1 4,332 98.3 1,013 Total 26.1 1.1 38,948 96.8 10,150 22.7 1.1 17,359 97.7 3,947 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. Figures in parentheses are based on 25-49 unweighted cases. 13.12 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. The period between the initiation of sexual activity and marriage is often a time of sexual experimentation and may involve risky behaviours. This section examines comprehensive knowledge among youth of HIV/AIDS transmission and prevention as well as knowledge of where to obtain condoms. Issues such as age at first sex, age difference between partners, sex related to alcohol use, and voluntary counselling and testing for HIV also are covered. 13.12.1 Knowledge about HIV and AIDS and of Sources for Condoms Knowledge of how HIV is transmitted is crucial to enable 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 13.17 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. Twenty-four percent of young women age 15-24 and 34 percent of young men have comprehensive knowledge about HIV. Comprehensive knowledge is higher among youth in urban areas than those in rural areas. Among young women, the level of comprehensive knowledge about HIV is highest in the South West (28 percent) and lowest in the South East (12 percent). Among young men, the level of knowledge is highest in the North West (45 percent) and lowest in the North Central zone (17 percent). The proportion of both young women and young men with comprehensive knowledge increases with increasing education and wealth. Less than half (46 percent) of young women and two in three young men (68 percent) know where to obtain a condom. Knowledge of a source for condoms is higher in urban areas than rural areas among both young women (61 percent and 34 percent, respectively) and young men (77 percent and 60 percent, HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 261 respectively). At the zonal level, young women in the South South (73 percent) are most likely and those in the North West (20 percent) least likely to know a condom source. Young men show the same pattern; knowledge is highest in the South South (88 percent) and lowest in the North West (47 percent). Knowledge of where to obtain a condom increases with increasing education and wealth. Table 13.17 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Nigeria 2013 Women Men Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents Age 15-19 22.4 39.3 7,820 29.3 59.5 3,619 15-17 20.6 34.5 4,867 26.4 53.8 2,284 18-19 25.3 47.1 2,952 34.4 69.2 1,335 20-24 26.4 52.6 6,757 38.6 78.1 2,892 20-22 25.9 49.3 4,677 37.3 74.6 1,997 23-24 27.6 60.1 2,080 41.6 86.1 895 Marital status Never married 25.5 56.9 7,744 34.2 68.1 6,027 Ever had sex 27.6 83.3 2,466 35.9 95.0 1,719 Never had sex 24.5 44.6 5,277 33.5 57.4 4,308 Ever married 22.8 32.5 6,833 24.7 63.5 485 Residence Urban 29.5 61.3 6,098 41.1 77.3 2,899 Rural 20.4 34.1 8,478 27.4 60.2 3,612 Zone North Central 24.8 51.4 2,197 16.6 75.7 997 North East 26.8 28.3 2,258 27.3 58.3 941 North West 24.9 19.8 4,470 45.2 46.5 1,971 South East 11.8 65.7 1,695 30.1 80.1 700 South South 25.6 72.6 1,901 38.2 88.2 896 South West 28.4 72.0 2,056 31.2 83.8 1,005 State North Central FCT-Abuja 38.8 62.0 106 18.9 80.7 40 Benue 24.4 70.0 523 16.1 88.2 291 Kogi 36.5 55.4 303 21.1 83.6 137 Kwara 43.7 51.0 236 12.5 78.4 101 Nasarawa 10.5 52.4 226 18.2 76.2 114 Niger 18.7 34.6 576 14.6 57.6 226 Plateau 13.8 40.2 227 18.0 62.0 88 North East Adamawa 26.7 31.8 335 30.8 82.5 138 Bauchi 12.2 12.4 446 29.6 31.6 176 Borno 34.2 28.5 601 22.7 68.7 245 Gombe 24.4 22.4 210 18.7 47.7 110 Taraba 46.7 50.7 305 46.2 72.9 120 Yobe 17.3 29.0 362 20.0 46.8 152 North West Jigawa 18.5 7.9 471 23.9 43.4 182 Kaduna 19.5 65.8 870 28.8 57.0 350 Kano 27.8 12.9 1,229 75.6 49.6 723 Katsina 27.6 14.5 548 51.0 57.6 194 Kebbi 9.2 1.3 454 4.5 38.6 199 Sokoto 49.1 2.9 413 49.0 37.6 166 Zamfara 24.2 3.8 485 6.5 17.9 158 South East Abia 1.1 61.2 155 48.9 83.9 84 Anambra 9.8 69.1 390 15.1 85.8 161 Ebonyi 13.3 60.7 455 28.9 70.3 179 Enugu 12.1 64.6 394 48.4 87.9 157 Imo 17.4 72.5 301 14.6 74.2 119 South South Akwa Ibom 20.4 69.1 365 27.3 83.6 175 Bayelsa 18.0 92.1 157 52.9 99.7 73 Cross River 23.6 83.3 229 37.5 82.4 121 Delta 32.5 79.2 426 51.0 92.7 184 Edo 31.4 63.6 313 35.0 96.9 158 Rivers 22.6 62.4 411 33.1 79.9 185 Continued… 262 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.17—Continued Women Men Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents South West Ekiti 25.7 59.0 120 25.4 94.9 56 Lagos 31.6 81.7 581 48.5 90.9 306 Ogun 42.7 86.8 238 23.7 65.7 107 Ondo 8.7 51.5 294 19.0 70.4 161 Osun 47.1 70.9 276 30.2 97.8 136 Oyo 20.5 69.6 547 22.4 81.3 238 Education No education 17.5 11.9 4,448 20.6 30.2 1,082 Primary 19.3 39.2 1,805 26.1 54.8 765 Secondary 27.3 62.3 7,529 35.5 77.0 4,200 More than secondary 44.2 87.8 794 56.9 93.1 464 Wealth quintile Lowest 14.6 8.8 2,413 22.5 35.0 1,103 Second 19.0 27.1 2,916 28.3 57.4 1,103 Middle 23.8 48.1 3,048 32.9 74.2 1,393 Fourth 28.6 61.3 3,135 36.8 78.7 1,495 Highest 32.8 73.0 3,064 43.1 83.6 1,416 Total 24.2 45.5 14,576 33.5 67.8 6,511 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the 2 most common local misconceptions about AIDS transmission or prevention of the AIDS virus. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 2 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 13.12.2 Age at First Sexual Intercourse among Youth 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 13.18 shows that 17 percent of young women and 3 percent of young men age 15-24 initiated sexual activity before age 15, and 52 percent of young women and 19 percent of young men age 18-24 had their first sexual intercourse before age 18. As expected, the proportion of youth who initiated 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 education. Young women in rural areas are more likely than their urban counterparts to have initiated sex before age 15 (24 percent versus 7 percent) and before age 18 (64 percent versus 34 percent). Analysis by zone shows that the proportion of young women who had their first sexual intercourse before age 15 is highest in the North West (29 percent) and lowest in the South East and South West (7 percent each). There is no difference in initiation of sex among young men before age 15 by urban-rural residence. However, rural young men are slightly more likely than urban young men to have initiated sex before age 18 (21 percent and 18 percent, respectively). The proportion of young men initiating sexual intercourse by age 18 is highest in the South South (33 percent). The North West has the lowest proportion of young men who initiated sex by age 15 and age 18. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 263 Table 13.18 Age at first sexual intercourse among young people Percentage of young women and young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Nigeria 2013 Women Men Background characteristic Percentage who had sexual intercourse before age 15 Number of respondents (15-24) Percentage who had sexual intercourse before age 18 Number of respondents (18-24) Percentage who had sexual intercourse before age 15 Number of respondents (15-24) Percentage who had sexual intercourse before age 18 Number of respondents (18-24) Age 15-19 15.6 7,820 na na 2.9 3,619 na na 15-17 15.3 4,867 na na 2.6 2,284 na na 18-19 16.2 2,952 53.4 2,952 3.4 1,335 21.2 1,335 20-24 18.7 6,757 51.1 6,757 4.0 2,892 18.6 2,892 20-22 19.7 4,677 53.9 4,677 4.4 1,997 19.3 1,997 23-24 16.4 2,080 44.8 2,080 3.0 895 16.9 895 Marital status Never married 4.8 7,744 23.4 3,915 3.3 6,027 18.2 3,746 Ever married 30.9 6,833 71.0 5,794 4.7 485 28.7 481 Knows condom source1 Yes 10.2 6,627 41.2 4,947 4.7 4,413 23.6 3,184 No 22.8 7,950 62.8 4,762 0.6 2,098 6.6 1,043 Residence Urban 7.4 6,098 34.4 4,028 3.4 2,899 17.7 1,900 Rural 24.0 8,478 64.1 5,681 3.4 3,612 20.8 2,327 Zone North Central 9.7 2,197 41.3 1,490 5.9 997 26.4 706 North East 22.8 2,258 63.0 1,528 1.9 941 13.7 635 North West 28.9 4,470 71.6 2,952 0.2 1,971 4.5 1,199 South East 6.6 1,695 27.4 1,156 4.6 700 29.7 431 South South 10.8 1,901 45.7 1,251 5.7 896 32.7 593 South West 7.1 2,056 33.7 1,332 5.7 1,005 25.9 664 State North Central FCT-Abuja 4.8 106 28.5 77 0.9 40 10.4 28 Benue 16.2 523 53.9 361 11.8 291 37.9 211 Kogi 7.4 303 34.7 183 1.0 137 10.6 100 Kwara 2.4 236 28.2 144 4.8 101 24.0 66 Nasarawa 6.9 226 41.6 173 9.9 114 37.3 79 Niger 11.9 576 46.6 397 0.6 226 22.5 154 Plateau 5.3 227 24.2 155 6.3 88 18.7 67 North East Adamawa 11.7 335 48.5 233 7.1 138 26.7 86 Bauchi 39.9 446 79.7 308 2.7 176 13.0 114 Borno 23.0 601 53.7 418 1.1 245 13.7 183 Gombe 19.3 210 67.7 146 0.4 110 10.5 72 Taraba 14.9 305 70.5 199 0.6 120 20.9 78 Yobe 20.6 362 62.7 224 0.0 152 0.0 101 North West Jigawa 39.3 471 85.6 328 1.0 182 7.0 108 Kaduna 22.7 870 68.2 592 0.3 350 10.9 224 Kano 18.5 1,229 60.5 750 0.0 723 0.5 463 Katsina 35.2 548 78.2 383 0.0 194 6.8 113 Kebbi 28.8 454 63.3 322 0.0 199 5.8 123 Sokoto 32.9 413 80.0 268 0.4 166 3.8 86 Zamfara 45.7 485 82.8 310 0.0 158 1.3 81 South East Abia 8.3 155 26.3 112 5.9 84 32.6 56 Anambra 5.5 390 21.7 265 3.9 161 14.6 106 Ebonyi 8.7 455 36.7 292 0.0 179 35.7 108 Enugu 4.0 394 23.0 287 4.2 157 17.9 88 Imo 7.5 301 28.2 199 11.9 119 54.8 73 South South Akwa Ibom 16.0 365 53.6 241 8.7 175 35.2 127 Bayelsa 13.6 157 75.4 90 7.5 73 57.2 41 Cross River 7.8 229 47.9 176 7.0 121 30.0 76 Delta 10.4 426 46.5 272 2.2 184 32.0 127 Edo 1.8 313 26.3 190 4.5 158 26.9 92 Rivers 14.0 411 40.4 283 5.8 185 28.7 130 South West Ekiti 8.4 120 39.0 69 1.3 56 33.5 32 Lagos 4.9 581 24.2 387 6.5 306 21.7 216 Ogun 10.5 238 36.3 155 11.3 107 20.8 81 Ondo 8.7 294 41.4 190 6.6 161 28.8 108 Osun 0.9 276 24.5 170 3.2 136 21.4 86 Oyo 10.0 547 41.8 362 4.1 238 34.2 141 Continued… 264 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.18—Continued Women Men Background characteristic Percentage who had sexual intercourse before age 15 Number of respondents (15-24) Percentage who had sexual intercourse before age 18 Number of respondents (18-24) Percentage who had sexual intercourse before age 15 Number of respondents (15-24) Percentage who had sexual intercourse before age 18 Number of respondents (18-24) Education No education 35.7 4,448 79.0 3,150 0.3 1,082 10.5 680 Primary 19.6 1,805 65.0 1,194 5.0 765 23.4 415 Secondary 6.9 7,529 36.0 4,598 4.0 4,200 21.6 2,677 More than secondary 2.2 794 14.1 767 3.0 464 16.5 455 Wealth quintile Lowest 37.5 2,413 80.3 1,557 2.0 1,103 13.9 657 Second 26.0 2,916 69.2 1,965 2.2 1,103 16.1 689 Middle 13.4 3,048 50.7 2,041 3.9 1,393 22.4 912 Fourth 7.8 3,135 39.2 2,097 4.4 1,495 24.0 1,024 Highest 5.5 3,064 27.4 2,049 3.9 1,416 17.9 946 Total 17.0 14,576 51.8 9,709 3.4 6,511 19.4 4,227 na = Not available 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 13.12.3 Trends in Age at First Sexual Intercourse among Youth Figure 13.2 shows the percentage of young women and men age 15-19 who had sexual intercourse before exact age 15 and age 18 in the 2008 and 2013 NDHS surveys. Among young women, there was practically no change in the proportion who had sexual intercourse before age 15 or age 18 in the five-year period between the two surveys. Among young men age 15-19, the proportion who had their first sexual intercourse by age 15 declined from 6 percent in 2008 to 3 percent in 2013. The proportion of young men age 18-19 who had sexual intercourse before age 18 declined from 26 percent to 21 percent over the same period. Figure 13.2 Trends in age of first sexual intercourse 15 6 53 26 16 3 53 21 Percentage of women 15-19 who had sexual intercourse before exact age 15 Percentage of men 15-19 who had sexual intercourse before exact age 15 Percentage of women 18-19 who had sexual intercourse before exact age 18 Percentage of men 18-19 who had sexual intercourse before exact age 18 Percent 2008 NDHS 2013 NDHS 13.12.4 Abstinence and Premarital Sex The period between initiation of sexual intercourse and marriage is often a time of sexual experimentation. Table 13.19 presents information on premarital sexual intercourse and condom use among never-married youth age 15-24 in Nigeria. HIV- and AIDS-related Knowledge, Attitudes, and Behaviour • 265 Table 13.19 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 2013 Women Men Background characteristic Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married respondents Percentage who used a condom at last sexual intercourse Number of respondents Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married respondents Percentage who used a condom at last sexual intercourse Number of respondents Age 15-19 79.8 15.9 5,508 37.2 876 85.6 10.7 3,573 49.5 381 15-17 87.4 9.8 3,829 30.7 374 92.9 4.6 2,280 42.8 105 18-19 62.5 29.9 1,679 42.0 502 72.8 21.3 1,293 52.0 275 20-24 39.4 49.2 2,236 48.7 1,099 50.9 39.1 2,453 61.2 958 20-22 44.2 44.4 1,603 45.9 712 56.4 33.5 1,739 60.1 583 23-24 27.3 61.2 633 53.9 387 37.6 52.7 714 62.9 376 Knows condom source1 Yes 53.4 38.1 4,406 48.2 1,681 60.2 31.4 4,105 59.2 1,288 No 87.6 8.8 3,337 17.5 295 95.6 2.7 1,921 24.1 51 Residence Urban 68.4 24.6 4,361 51.3 1,074 70.3 22.6 2,837 66.0 641 Rural 67.8 26.7 3,383 34.4 902 72.6 21.9 3,190 50.4 698 Zone North Central 74.7 19.4 1,247 42.6 242 58.3 33.6 891 65.2 299 North East 84.2 12.7 754 19.9 95 81.5 12.9 825 35.9 107 North West 88.0 9.4 1,365 49.2 129 95.8 3.3 1,797 (38.3) 59 South East 61.2 28.0 1,369 53.8 383 57.0 28.0 681 61.8 191 South South 49.3 43.7 1,467 38.1 641 47.9 44.6 879 57.9 392 South West 61.5 31.5 1,542 46.5 486 61.3 30.6 954 59.6 292 State North Central FCT-Abuja 66.1 24.6 75 (49.3) 18 69.7 24.0 37 * 9 Benue 68.7 28.1 278 32.8 78 45.8 50.1 244 48.4 122 Kogi 72.4 22.8 211 62.5 48 65.6 32.5 129 74.1 42 Kwara 75.6 16.4 175 45.1 29 60.7 22.5 97 (79.8) 22 Nasarawa 62.7 23.1 126 (16.7) 29 48.1 40.0 106 69.2 42 Niger 89.7 7.4 233 * 17 65.6 22.4 193 (82.2) 43 Plateau 79.2 15.0 150 (58.3) 23 71.7 22.0 85 * 19 North East Adamawa 81.0 17.2 160 (7.3) 28 66.2 17.0 128 (42.7) 22 Bauchi 99.1 0.9 84 * 1 92.6 5.0 143 * 7 Borno 93.0 5.6 196 * 11 82.7 12.3 216 * 27 Gombe 88.6 8.0 58 * 5 84.4 7.6 96 * 7 Taraba 54.4 34.8 148 20.0 52 58.3 39.7 111 24.2 44 Yobe 100.0 0.0 108 * 0 100.0 0.0 131 * 0 North West Jigawa 100.0) (0.0) 54 * 0 96.6 2.2 147 * 3 Kaduna 58.9 32.3 387 50.7 125 84.8 13.6 305 * 42 Kano 100.0 0.0 535 * 0 100.0 0.0 696 * 0 Katsina 98.7 0.0 77 * 0 93.2 4.1 169 * 7 Kebbi 97.2 2.8 130 * 4 96.6 3.4 184 * 6 Sokoto 100.0 0.0 104 * 0 96.1 0.5 153 * 1 Zamfara 100.0 0.0 78 * 0 100.0 0.0 143 * 0 South East Abia 63.1 30.1 128 58.2 39 61.1 26.4 83 (58.0) 22 Anambra 63.3 22.2 313 51.1 69 52.4 23.7 161 (40.5) 38 Ebonyi 55.4 32.8 376 36.6 123 54.1 35.6 169 71.4 60 Enugu 66.4 26.1 316 69.0 82 68.2 19.4 155 (56.4) 30 Imo 59.7 29.5 236 66.5 70 49.3 35.7 113 (73.7) 40 South South Akwa Ibom 40.4 49.8 284 35.8 141 39.2 53.2 172 72.3 91 Bayelsa 47.9 48.6 118 33.7 57 46.7 44.3 71 43.8 31 Cross River 43.6 46.1 166 32.1 77 51.3 42.9 118 61.1 51 Delta 53.5 41.4 316 46.0 131 46.2 47.7 181 39.3 86 Edo 60.8 35.3 267 48.2 94 51.7 37.9 156 72.3 59 Rivers 46.8 44.4 315 31.3 140 52.6 40.2 181 54.2 73 South West Ekiti 55.0 38.9 98 39.4 38 60.2 33.1 54 (82.8) 18 Lagos 58.3 34.6 489 53.1 169 57.5 35.2 304 60.3 107 Ogun 67.4 26.1 147 (36.5) 38 67.7 28.1 102 * 29 Ondo 47.9 42.1 226 40.3 95 53.8 35.8 154 59.8 55 Osun 73.1 23.2 230 72.7 53 66.7 28.2 133 67.0 38 Oyo 66.4 26.0 352 (32.4) 92 66.3 22.2 206 (35.7) 46 Continued… 266 • HIV- and AIDS-related Knowledge, Attitudes, and Behaviour Table 13.19—Continued Women Men Background characteristic Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never married respondents Percentage who used a condom at last sexual intercourse Number of respondents Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never married respondents Percentage who used a condom at last sexual intercourse Number of respondents Education No education 92.4 5.6 639 (1.4) 36 94.0 4.3 846 (27.5) 37 Primary 73.4 20.0 737 23.5 148 77.5 18.1 694 37.6 125 Secondary 67.8 25.9 5,697 42.4 1,475 68.9 23.9 4,044 57.3 966 More than secondary 42.0 47.2 671 63.2 317 42.5 47.7 442 77.9 211 Wealth quintile Lowest 88.0 8.5 514 17.2 44 90.8 6.2 925 14.4 57 Second 72.4 22.0 1,002 22.9 220 78.9 16.2 957 49.7 155 Middle 67.5 25.8 1,739 37.2 448 67.7 25.8 1,319 53.1 341 Fourth 66.5 27.9 2,073 45.0 578 65.1 28.1 1,430 61.5 402 Highest 64.1 28.3 2,416 55.0 685 63.7 27.5 1,395 68.1 384 Total 68.2 25.5 7,744 43.6 1,975 71.5 22.2 6,027 57.9 1,339 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 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Sixty-eight percent of never-married young women have never had sexual intercourse, while 26 percent had sexual intercourse during the 12 months preceding the survey. Among never-married, sexually active young women, 44 percent used a condom during their last sexual intercourse. At the zonal level, condom use is highest in the South East (54 percent) and lowest in the North East (20 percent). Among never-married young men, 72 percent have never had sexual intercourse, while 22 percent had sexual intercourse during the 12 months preceding the survey. Overall, 58 percent of never-married, sexually active young men used a condom during their last sexual intercourse. Condom use is highest in the North Central zone (65 percent) and lowest in the North East (36 percent). Among both young women and young men, condom use increases with increasing education and wealth. For example, 78 percent of sexually active, never-married young men with more than a secondary education used a condom the last time they had sexual intercourse, as compared with 38 percent of young men with a primary education. 13.12.5 Multiple Partnerships among Young People Tables 13.20.1 and 13.20.2 present information on young people age 15-24 who had two or more sexual partners during the 12 months preceding the survey and condom use during the last sexual encounter among those with two or more partners. Table 13.20.1 shows that 1 percent of young women reported having sexual intercourse with more than