Nigeria - Multiple Indicator Cluster Survey - 2007
Publication date: 2007
ii NIGERIA Multiple Indicator Cluster Survey 2007 NBS National Bureau of Statistics UNICEF United Nations Children’s Fund September 2007 iii Contributors to the report include Ahmed El-Bashir Ibrahim, Chief, Planning & Comunication Programme; Johnson O. Awotunde, M & E Officer, UNICEF-Nigeria; the M & E Officers in the Zonal Offices in Enugu, Lagos, Kaduna and Bauchi respectively, namely: Ms. Maureen Zubie- Okolo, Godwin Nwabunka, Raymond Akor and Danjuma Almustafa including M & E Officer- Emergency, Victor Okwunwa. The Nigeria Multiple Indicator Cluster Survey (MICS) was conducted by the National Bureau of Statistics. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF) and the Government of Nigeria (through the National Bureau of Statistics). The survey has been conducted as part of the third round of MICS surveys (MICS3), carried out around the world in more than 50 countries, in 2005-2006, following the first two rounds of MICS surveys that were conducted in 1995 and the year 2000. Survey tools are based on the models and standards developed by the global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: National Bureau of Statistics (NBS) 2007, Nigeria Multiple Indicator Cluster Survey 2007 Final Report. ABUJA NIGERIA: iv Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Nigeria, 2007 Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1 13 Under-five mortality rate 138 per thousand 2 14 Infant mortality rate 86 per thousand NUTRITION Nutritional status 6 4 Underweight prevalence 25.3 percent 7 Stunting prevalence 34.3 percent 8 Wasting prevalence 10.8 percent Breastfeeding 45 Timely initiation of breastfeeding 29.9 percent 15 Exclusive breastfeeding rate 11.7 percent 16 Continued breastfeeding rate at 12-15 months at 20-23 months 77.8 30.5 percent percent 17 Timely complementary feeding rate 40.9 percent 18 Frequency of complementary feeding 26.6 percent 19 Adequately fed infants 19.1 percent Salt iodization 41 Iodized salt consumption 74.9 percent Vitamin A 42 Vitamin A supplementation (under-fives) 36.6 percent 43 Vitamin A supplementation (post-partum mothers) 33.1 percent Low birth weight 9 Low birth weight infants 13.7 percent 10 Infants weighed at birth 24.1 percent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 50.5 percent 26 Polio immunization coverage 28.1 percent 27 DPT immunization coverage 27.5 percent 28 15 Measles immunization coverage 38.3 percent 31 Fully immunized children 10.9 percent 29 Hepatitis B immunization coverage 22.0 percent 30 Yellow fever immunization coverage 30.4 percent Tetanus toxoid 32 Neonatal tetanus protection 50.8 percent Care of illness 33 Use of oral rehydration therapy (ORT) 30.2 percent 34 Home management of diarrhoea 7.7 percent 35 Received ORT or increased fluids, and continued feeding 17.3 percent 23 Care seeking for suspected pneumonia 41.0 percent 22 Antibiotic treatment of suspected pneumonia 46.4 percent Solid fuel use 24 29 Solid fuels 75.0 percent Malaria 36 Household availability of insecticide-treated nets (ITNs) 4.0 percent 37 22 Under-fives sleeping under insecticide-treated nets 3.5 percent 38 Under-fives sleeping under mosquito nets 4.1 percent 39 22 Antimalarial treatment (under-fives) 35.9 percent 40 Intermittent preventive malaria treatment (pregnant women) 2.9 percent v Topic MICS Indicator Number MDG Indicator Number Indicator Value Source of supplies 96 Source of supplies (from public sources) Antimalarials 32 percent Antibiotics 27.9 percent Oral rehydration salts 32.9 percent ENVIRONMENT Water and Sanitation 11 30 Use of improved drinking water sources 49.1 percent 13 Water treatment 7.8 percent 12 31 Use of improved sanitation facilities 42.9 percent 14 Disposal of child's faeces 59.6 percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 14.7 percent 98 Unmet need for family planning 19.7 percent 99 Demand satisfied for family planning 42.7 percent Maternal and newborn health 20 Antenatal care 61.4 percent 44 Content of antenatal care Blood sample taken 57.9 percent Blood pressure measured 48.3 percent Urine specimen taken 59.0 percent Weight measured 48.3 percent 4 17 Skilled attendant at delivery 44.3 percent 5 Institutional deliveries 40.5 percent CHILD DEVELOPMENT Child development 46 Support for learning 64.5 percent 47 Father's support for learning 34.6 percent 48 Support for learning: children’s books 14.2 percent 49 Support for learning: non-children’s books 35.4 percent 50 Support for learning: materials for play 11.2 percent 51 Non-adult care 37.6 Percent vi Topic MICS Indicator Number MDG Indicator Number Indicator Value DUCATION Education 52 Pre-school attendance 32.1 percent 53 School readiness 82.9 percent 54 Net intake rate in primary education 44.4 percent 55 6 Net primary school attendance rate 64.4 percent 56 Net secondary school attendance rate 50.7 percent 57 7 Children reaching grade five 95.7 percent 58 Transition rate to secondary school 92.8 percent 59 7b Primary completion rate 36.0 percent 61 9 Gender parity index primary school secondary school 0.94 0.98 ratio ratio Literacy 60 8 Youth literacy rate 56.3 percent CHILD PROTECTION Birth registration 62 Birth registration 23.3 percent Child labour 71 Child labour 28.9 percent 72 Labourer students 63 percent 73 Student labourers 30 percent Early marriage 67 Marriage before age 15 Marriage before age 18 15.3 39.5 percent percent 68 Young women aged 15-19 currently married/in union 24.5 percent 69 Spousal age difference Women aged 15-19 Women aged 20-24 44.6 15.3 percent percent Female genital mutilation/ cutting 66 Approval for FGM/C 19.3 percent 63 Prevalence of female genital mutilation/cutting (FGM/C) 26.0 percent 64 Prevalence of extreme form of FGM/C 9.8 percent 65 FGM/C prevalence among daughters 13.3 percent vii Topic MICS Indicator Number MDG Indicator Number Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS knowledge and attitudes 82 19b Comprehensive knowledge about HIV prevention among young people 19.4 percent 89 Knowledge of mother- to-child transmission of HIV 48.1 percent 86 Attitude towards people with HIV/AIDS 14.1 percent 87 Women who know where to be tested for HIV 38.3 percent 88 Women who have been tested for HIV 12.6 percent 90 Counselling coverage for the prevention of mother-to-child transmission of HIV 36.9 percent 91 Testing coverage for the prevention of mother-to-child transmission of HIV 16.5 percent Sexual behaviour 84 Age at first sex among young people 12.9 percent 92 Age-mixing among sexual partners 33.3 percent 83 19a Condom use with non-regular partners 39.2 percent 85 Higher risk sex in the last year 39.4 percent Support to orphaned and vulnerable children 75 Prevalence of orphans 6.3 percent 78 Children’s living arrangements 7.4 percent 76 Prevalence of vulnerable children 5.2 percent 77 20 School attendance of orphans versus non- orphans 0.93 ratio 79 Malnutrition among children orphaned and made vulnerable by HIV/AIDS Underweight Stunting Wasting 1.00 1.05 0.98 ratio 80 Early sex among children orphaned and made vulnerable by HIV/AIDS 1.07 ratio viii Table of Contents Summary Table of Findings . v Table of Contents . ix List of Tables . xi List of Figures . xiii List of Abbreviations . xiv Acknowledgements . xv Executive Summary . xvi I. Introduction . 1 Background . 1 Survey Objectives . 2 II. Sample and Survey Methodology . 3 Sample Design . 3 Questionnaires . 3 Training and Fieldwork . 4 Data Processing . 5 III. Sample Coverage and the Characteristics of Households and Respondents . 6 Sample Coverage . 6 Characteristics of Households . 6 Characteristics of Respondents . 8 IV. Child Mortality . 10 V.Nutrition.………………………………………………………………………………………….12 Nutritional Status . 12 Breastfeeding . 15 Salt Iodization . 18 Vitamin A Supplements . 19 Low Birth Weight . 20 VI. Child Health . 22 Immunization . 22 Tetanus Toxoid . 24 Oral Rehydration Treatment . 25 Care Seeking and Antibiotic Treatment of Pneumonia . 27 Solid Fuel Use . 28 Malaria . 29 Sources of Supplies . 31 VII. Environment . 32 Water and Sanitation . 32 VIII. Reproductive Health . 35 Contraception . 35 Unmet Need . 35 Antenatal Care . 36 Assistance at Delivery . 37 Maternal Mortality . 38 IX. Child Development . 39 ix X. Education . 41 Pre-School Attendance and School Readiness . 41 Primary and Secondary School Participation . 41 Adult Literacy . 44 XI. Child Protection . 45 Birth Registration . 45 Child Labour . 45 Early Marriage and Polygyny . 46 Female Genital Mutilation/Cutting . 48 XII. HIV/AIDS, Sexual Behaviour, and Orphaned and Vulnerable Children . 50 Knowledge of HIV Transmission and Condom Use . 50 Sexual Behaviour Related to HIV Transmission . 52 Orphans and Vulnerable Children . 54 List of References . 56 Appendix A. Sample Design . 60 Appendix B. List of Personnel Involved in the Survey . 62 Appendix C. Estimates of Sampling Errors . 84 Appendix D. Data Quality Tables . 102 Appendix E Tabulations . 114 Appendix F. MICS Indicators: Numerators and Denominators . .210 Appendix G. Questionnaires . 214 x List of Tables Table HH.1: Results of household and individual interviews . 127 Table HH.2: Household age distribution by sex . 128 Table HH.3: Household composition . 129 Table HH.4: Women's background characteristics . 130 Table HH.5: Children's background characteristics . 131 Table CM.1: Child mortality . 132 Table NU.1: Child malnourishment . 133 Table NU.2: Initial breastfeeding . 134 Table NU.3: Breastfeeding . 135 Table NU.3w Infant feeding patterns by age . 136 Table NU.4: Adequately fed infants . 137 Table NU.5: Iodized salt consumption . 139 Table NU.6: Children's vitamin A supplementation . 140 Table NU.7: Post-partum mothers' vitamin A supplementation . 141 Table NU.8: Low birth weight infants . 142 Table CH.1: Vaccinations in first year of life . 143 Table CH.2: Vaccinations by background characteristics . 144 Table CH.2c: Vaccinations by background characteristics (continued) . 145 Table CH.3: Neonatal tetanus protection . 147 Table CH.4: Oral rehydration treatment . 148 Table CH.5: Home management of diarrhoea . 149 Table CH.6: Care seeking for suspected pneumonia . 150 Table CH.7: Antibiotic treatment of pneumonia . 151 Table CH.7A: Knowledge of the two danger signs of pneumonia . 152 Table CH.8: Solid fuel use . 154 Table CH.9: Solid fuel use by type of stove or fire . 156 Table CH.10: Availability of insecticide treated nets . 157 Table CH.11: Children sleeping under bednets . 159 Table CH.12: Treatment of children with anti-malarial drugs . 161 Table CH.13: Intermittent preventive treatment for malaria . 163 Table CH.15: Source and cost of supplies for antimalarials . 164 Table CH.16: Source and cost of supplies for antibiotics . 165 Table CH.17: Source and cost of supplies for oral rehydration salts . 165 Table EN.1: Use of improved water sources . 166 Table EN.2: Household water treatment . 168 Table EN.3: Time to source of water . 170 Table EN.4: Person collecting water . 171 Table EN.5: Use of sanitary means of excreta disposal . 173 Table EN.6: Disposal of child's faeces . 175 Table EN.7: Use of improved water sources and improved sanitation . 176 Table RH.1: Use of contraception . 178 Table RH.2: Unmet need for contraception . 180 Table RH.3: Antenatal care provider . 181 Table RH.4: Antenatal care . 182 Table RH.5: Assistance during delivery . 183 Table CD.1: Family support for learning . 184 Table CD.2: Learning materials . 185 Table CD.3: Children left alone or with other children . 186 Table ED.1: Early childhood education . 187 Table ED.2: Primary school entry . 188 Table ED.3: Primary school net attendance ratio . 189 Table ED.4: Secondary school net attendance ratio . 190 Table ED 4W Secondary school age children attending primary school . 191 xi Table ED.5: Children reaching grade 6 . 192 Table ED.5a: Children reaching grade 5 . 193 Table ED 6: Primary school completion and transition to secondary education . 194 Table ED.7: Education gender parity . 195 Table ED.8: Adult literacy . 196 Table CP.1: Birth registration . 197 Table CP.2: Child labour (5-14 years) . 199 Table CP.2A Child labour (5-17 years) . ……………………………………………200 Table CP.3: Labourer students and student labourers (5-14) . 201 Table CP.3A: Labourer Students and students labourers (5-17) . 202 Table CP.5: Early marriage . 203 Table CP.6: Spousal age difference . 204 Table CP.7: Female genital mutilation/cutting (FGM/C) . 206 Table CP.8: Female genital mutilation/cutting (FGM/C) among daughters . 208 Table HA.1: Knowledge of preventing HIV transmission . 206 Table HA.2: Identifying misconceptions about HIV/AIDS . 207 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission . 208 Table HA.4: Knowledge of mother-to-child HIV transmission . 209 Table HA.5: Attitudes toward people living with HIV/AIDS . 210 Table HA.6: Knowledge of a facility for HIV testing . 211 Table HA.7: HIV testing and counselling coverage during antenatal care . 212 Table HA.8: Sexual behaviour that increases risk of HIV infection . 213 Table HA.9: Condom use at last high-risk sex . 214 Table HA.10: Children's living arrangements and orphanhood . 216 Table HA.11: Prevalence of orphanhood and vulnerability among children . 218 Table HA.12: School attendance of orphaned and vulnerable children . 219 Table HA.14: Malnutrition among orphans and vulnerable children . 223 Table HA.15: Sexual behaviour among young women by orphanhood and vulnerability status due to AIDS . 222 Appendix Tables Table DQ.1: Age distribution of household population . 101 Table DQ.2: Age distribution of eligible and interviewed women . 102 Table DQ.3: Age distribution of eligible and interviewed under-5s . 102 Table DQ.4: Age distribution of under-5 children . 103 Table DQ.5: Heaping on ages and periods . 104 Table DQ.6: Percentage of observations missing information . 105 Table DQ.7: Presence of mother in the household and the person interviewed. 106 Table DQ.8: School attendance by single ge . 107 Table DQ.9: Sex ratio at birth among children ever born and living . 108 Table DQ.10: Distribution of women by time since last birth . 109 xii List of Figures Figure HH.1: Age and sex distribution of household population . 7 Figure CM.1: Under-five mortality rates by background characteristics . 10 Figure CM.2: Child motality rates in Nigeria, 1990 – 2007 . 11 Figure NU.1: Percent of children under five who are undernourished . 13 Figure NU 1a: Percent of children under five who are undernourished, 1999-2007 . 14 Figure NU.2: Percent of mothers who started breastfeeding within one hour and within one day of birth . 16 Figure NU.3: Infant feeding patterns by age: Percent distribution of children under 3 years by feeding pattern by age group . 17 Figure NU.4: Percent of households consuming adequately iodized salt . 19 Figure NU.5: Percent of infants weighing less than 2500 grams at birth . 21 Figure CH.1: Percent of children aged 12-23 months who received the recommended vaccination by 12 months . 23 Figure CH.2: Percent of women with a live birth in the last 24 months who are protected against neonatal tetanus . 24 Figure CH.3: Percent of children aged 0-59 months with diarrhoea who received oral rehydration treatment . 26 Figure CH.4: Percent of children aged 0-59 months with diarrhoea who received ORT or increased fluids, and continued feeding . 27 Figure HA.1: Percent of women 15-49 who have comprehensive knowledge of HIV/AIDS transmission . 51 Figure HA.2: Percent of women aged 15-19 who had sex before age 15 . 53 Appendix Figures Figure DQ 1: Age Distribution of Males and Females . 110 Figure DQ.2: Percentage Distribution by Age of Child (0-8 years) by Sex . 111 Figure DQ.3: Relative Percentage Distribution by Age (0-60) and Sex . 112 Figure DQ.4: Women Response Rates . 112 Figure DQ.5: Distribution of Male: Female Ratio by Age . 113 Figure DQ.6: Gender Parity in Children . 114 Figure DQ.7: Percentage of Observations missing by Items . 114 Figure DQ.8a: Infant Mortality Rates: Recent National Surveys Nigeria . 115 Figure DQ.8b: Under five Mortality rates: Recent National Surveys Nigeria . 116 Figure DQ .9a: Heaping in Weight Measurement . 116 Figure DQ .9b: Heaping in Height Measurement . 117 xiii List of Abbreviations AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) CSPro Census and Survey Processing System CWIQ Core Welfare Indicator Questionnaires DHS Demographic and Health Survey DPT Diphteria Pertussis Tetanus EPI Expanded Programme on Immunization FGM/C Female genital mutilation/cutting GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders ITN Insecticide Treated Net IUD Intrauterine Device LAM Lactational Amenorrhea Method LSS Living Standard Survey NLSS Nigeria Living Standard Survey MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MoH Ministry of Health NAR Net Attendance Rate NBS National Bureau of Statistics, Nigeria NDHS Nigeria Demographic and Health Survey NPC National Planning Commission, Nigeria NPopC National Population Commission ORT Oral rehydration treatment ppm Parts Per Million SPSS Statistical Package for Social Sciences UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization xiv Acknowledgements The Multiple Indicator Cluster Survey (MICS) was conceptualized to monitor the progress of Child Survival, Development, Protection and Participation (CSDPP) Programme as well as to serve as means of data generating mechanism for measuring the achievement and gaps in the targets of the millennium development goals (MDGs), particularly as it may affect the children and women. At the World Summit for Social Development in 1995, the need was also stressed for better social statistics if social development had to move to centre stage for the cause of the children of the world. The first in the series of the Multiple Indicator Cluster Survey (MICS1) was conducted in 1995 by the Federal Office of Statistics (FOS), now National Bureau of Statistics (NBS), with technical and funding assistance from UNICEF. Since then, MICS has been institutionalized within the National Integrated Survey of Households (NISH) in the National Bureau of Statistics, as a process of collecting regular, reliable and timely social statistics. The second round of MICS was conducted in 1999 with a better strategy for the execution of the survey from planning to report writing. Expectedly, the current edition of the Multiple Indicator Cluster Survey (MICS3) was better planned, executed and has achieved the aim of providing reliable data for monitoring progress of the Nigerian children and women, and the Millennium Development Goals. This report would have been impossible without the commitment of UNICEF, which provided technical and financial assistance for the project. Worthy of mention also is the significant contribution of the officials from UNICEF, Nigeria, namely: the Representative Mr. Ayalew Abai, Dr. Ahmed El Bashir Ibrahim (Chief, Planning & Communication) and Mr. Johnson Awotunde, M&E Officer. The National Bureau of Statistics acknowledges the support and cooperation from all other stakeholders who took part in the project in various forms. These include the National Planning Commission, the Federal Ministries of Health, Education, Women Affairs, Information and Communication, the National Population Commission, various Non Government Oganizations. Others include UNDP, DFID, World Bank and the MDG Office. I wish to recognize the efforts by the personnel from NBS who actively participated in the planning and implementation of the project. Foremost among them are Dr. G. O. Adewoye (Director, Censuses and Surveys), Mr. F. B. Ladejobi (Head of Field Services and Methodology) and Mrs. A. N. Adewinmbi (Head of Computer Management and Information Services). Other key personnel involved in the project were Messrs. Owolabi, R. O. Salawu, R. F. Busari, Mrs. Funke Joseph and Mr. B. A. Kareem. Special thanks go to the consultant, Prof. T. A. Bamiduro who demonstrated high level of interest and commitment to the success of the survey, Mr. Isiaka Olarewaju (current head of household surveys division), and the trio of Mrs. F. B. Ajayi, Mrs. H. I. Ogunkoya and Mrs. Olabisi Adeyinka who gave the secretariat support. Finally, on behalf of the National Bureau of Statistics, I wish to acknowledge with gratitude the cooperation of all the heads and members of sample households who were respondents during the survey. Their participation was very valuable to the conduct of the survey. Dr. Vincent O. Akinyosoye Director-General xv EXECUTIVE SUMMARY 1. Preliminaries This report is based on the Nigeria Multiple Indicator Cluster Survey, conducted in 2007 by the National Bureau of Statistics (NBS), Nigeria with financial and technical support from UNICEF, Nigeria. The survey which was Nigeria copy of global MICS3 was a response to the needs to monitor progress towards goals and targets emanating from recent international agreements including the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. The Federal Government of Nigeria has in recent times launched a number of development initiatives to improve the economic and social life of its people. The National Programme for the Eradication of Poverty (NAPEP) is concerned with strategies for poverty reduction; the National Action Committee on HIV/AIDS (NACA) has the mandate for planning, implementing and monitoring programmes for control of HIV/AIDS; the National Economic Empowerment and Development Strategy (NEEDS) focuses on wealth creation, employment generation, corruption elimination and general value orientation; the state and local government extensions of NEEDS are State Economic Empowerment and Development Strategy (SEEDS) and Local Economic Empowerment and Development Strategy (LEEDS) respectively. These and other programmes are commitments towards targets as those contained in the Millennium Development Goals. The Federal Government has also expressed strong commitment to, and declared as a matter of high priority, efforts to monitor and evaluate progress towards the attainment of the benchmarks established in these national and other global goals. The National Bureau of Statistics (NBS) with financial and technical support from international development partners and donors like UNICEF has been involved in this effort through provision of relevant data to monitor, evaluate and advise necessary adjustments in development policies and programmes. The NBS, in recent times had conducted a number of national sample surveys mostly within global generic contexts. The Nigeria Living Standard Survey (NLSS), the General Household Survey (GHS), the Core Welfare Indicator Questionnaire Survey (CWIQ) and the 1999 Multiple Indicator Cluster Survey (MICS2) are examples. MICS Nigeria 2007 has been designed to measure progress towards achievements of the Millennium Development Goals (MDG) and other international targets like the Abuja Declaration on malaria which are mainstreamed into the above-stated national commitments. Nigeria’s MICS3 is, therefore, bound to improve the country’s data base and provide a valuable tool for evidence-based planning to surmount its development challenges. More specifically, MICS Nigeria 2007 should assist monitoring and evaluating UNICEF country programmes including those on immunization, vitamin A supplementation, child development, child and women rights and protection among others. The survey should also build survey capability and enhance data analysis experience at the NBS. This executive summary report presents results on principal topics covered in MICS Nigeria 2007 expressed in outcome and impact indicators1 that are important for designing, monitoring and evaluating progress of national programmes and provide a means for comparing the situation in Nigeria with that in other countries. 1 For more information on the definitions, numerators, denominators and algorithms of Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) indicators covered in the survey: see Chapter 1, Appendix 1 and Appendix 7 of the MICS Manual – Multiple Indicator Cluster Survey Manual 2005: Monitoring the Situation of Children and Women, also available at www.childinfo.org. xvi 2. Survey Objectives MICS Nigeria 2007 should provide up-to-date information on the situation of children and women in Nigeria, strengthen national statistical capacity by focusing on data gathering, quality of survey information, statistical tracking and analysis, contribute to the improvement of data and monitoring systems in Nigeria and strengthen technical expertise in the design, implementation, and analysis of such systems. The survey should also furnish data needed for monitoring progress toward the Millennium Development Goals, and targets of A World Fit for Children (WFFC) among others, measure progress towards achievements of the goals of NEEDS and its state and local government extensions, provide statistics to complement and assess the quality of data from recent national surveys like Nigeria Living Standard Survey (NLSS), Nigeria Core Welfare Indicator Questionnaires (CWIQ) and the National Demographic and Health Survey (NDHS). 3. Sample and Survey Methodology The sample for the Nigeria MICS3 was designed to provide estimates on a large number of indicators on the situation of children and women at the country level, for urban and rural areas; and for each of the 36 States of the Federation and the Federal Capital Territory of Abuja. The States were the main reporting domains. The sample design was two-stage in each state, where a systematic sample of 30 census enumeration areas (EAs) was selected with equal probability to form the first stage or primary sampling units (PSUs). The updated 1991 Population Census Enumeration Area demarcation was used because the latest demarcation was not available for use at the time MICS3 sample was designed. Also, information about the household composition of enumeration areas was not available to permit selection of EAs with probability proportional to number of households in the enumeration area. Household listing was conducted in each of the selected EAs to provide an adequate, up-to-date frame of housing units as the secondary sampling units (SSUs). A systematic sample of 25 housing units was subsequently drawn with equal probability within each of the selected EAs and all the households in each of the selected HUs were canvassed. Thus, at state level, 750 HUs were drawn from 30 EAs which meant 27,750 HUs from 1,110 EAs at the national level. The sample was stratified by states and was hardly self weighting at either state or national level. Hence, sample weights were used for reporting state or national results. All the selected enumeration areas were successfully canvassed. Table HH.1 presents a summary of results of interviews of households, individual women aged 15 – 49 years and children aged less than five years. A total of 28,603 households (20,825 rural and 7,778 in the urban sectors) were sampled. The total number of occupied sampled households was 28,431 including 20,735 rural and 7,696 urban households. The total number of interviewed households was 26,735 including 19,569 rural and 7,166 urban households. These figures translated into 94.0 percent response rates for the total, 94.4 percent for the rural and 93.1 percent for the urban. The total number of eligible women was 27,093 with 19,674 and 7,419 for rural and urban sectors, respectively. The corresponding figures of interviewed women were 24,565, 17,928, and 6,637 respectively; these figures amounted to 85.3, 86.0 and 83.3 percent effective response rates respectively for the total, rural and urban sectors. Eligible children under-five years of age were 17,093, (12,898 rural and 4,195 urban) and interviews were achieved for 16,549, 12,494 and 4,055 respectively; again the corresponding effective response rates were 91.0, 91.4 and 90.0 percent respectively. The Questionnaires Three questionnaires were used in the survey, namely a household questionnaire to collect information on general characteristics of the household including membership and the dwelling; a questionnaire for individual women and one for children under-five. The latter questionnaires were administered in each household to women aged 15-49; and to mothers or caretakers of under-five children, respectively in households where these persons were identified. The questionnaires and the constituent modules are as follows • Household Questionnaire including the following modules xvii o Household listing o Education o Water and Sanitation o Household characteristics o Insecticide Treated Nets o Children orphaned and made vulnerable by HIV/AIDS o Child Labour o Maternal Mortality o Salt Iodization • Questionnaire for Individual Women o Child Mortality o Tetanus Toxoid o Maternal and Newborn Health o Marriage/Union o Contraception and Unmet Need o Female Genital Mutilation o HIV/AIDS o Sexual Behaviour • Questionnaire for Children Under Five o Birth Registration and Early Learning o Child Development o Vitamin A o Breastfeeding o Care of Illness o Malaria for Under-5 o Immunization o Anthropometry The questionnaires, which were based on the generic MICS3 model English version. The questionnaires were adequately pre-tested during 26–30 December 2006 in four purposively selected typical states; a stakeholders’ forum and a MICS3 Central Technical Committee (CTC), reviewed the questionnaires and effected some amendments in terms of inclusion of additional or optional modules and modifying in part the wording and flow of the questionnaires. 4. Fieldwork and Processing A programme of meetings and intensive training preceded the fieldwork; it spanned a period of four months (November 2006 to March 2007) and was moved over several locations in the country to ensure familiarity with people and places. Adequate facilities were put in place to facilitate movement of field staff and materials. Fieldwork began in all the states including FCT Abuja on 14th March, 2007 and was concluded on 12th April, 2007. Collected data were entered using the CSPro software. Data entry was done simultaneously at each of the six geopolitical zones in the country, each zone handling data from the component states. In order to ensure quality control, all questionnaires were edited, double entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS3 project and adapted to the Nigeria questionnaires were used throughout. Data processing, which included further manual editing, computer data entry and validation, commenced few days after the end of data collection in April 2007 and was completed in October 2007. After due checks for data quality and compliance with global data processing guidelines by UNICEF Nigeria and UNICEF New York, output tables were generated using the Statistical Package for Social Sciences (SPSS) software programme Version 15; and the model syntax and tabulation plans developed by UNICEF for the purpose. Provision for data processing in terms of computer software and hardware, office space and personnel was adequate while processes for xviii primary and secondary data processing phases as advised in global MICS3 manual of instructions were adhered to. 5. Characteristics of Households In the 26,735 households that were successfully interviewed, 124,840 household members were listed, 62,950 males, and 61,888 females translating to sex ratio (male: female) figure of 101.7 and an average household size of 4.67 members at the national level. The male: female ratio 101.7 seems easily in accord with the figure 101 returned by the preliminary results of 2006 Nigeria Population Census; this is however against 98.6 percent from NDHS 2003. Sex ratio across age group ranges from 60 percent for the 50-54 age-groups to 180 for persons aged 70 years and above. Corresponding figures for age groups <15, 15–64 and 65+ are 101, 98, and 160 respectively; sex ratio figures that are as low as 60 or as high as 160 are most not correct; they are suspect reflecting incorrect reporting of age by respondents. The population is 67 percent rural and 33 percent urban; eighty-four percent of the households are headed by the male and 16 percent by the female. One-member households are 13 percent of the population, 26 percent have 2-3 members while 27 percent have 4-5 members; about 15 percent of the households have at least 8 members. Dependency ratio expressing total persons aged below 15 years or above 64 years as ratio of those aged 15 to 64 years is 0.95 in the urban areas, 0.88 in the rural areas and 0.91 overall. These figures indicate some greater economic burden for the economically active urban dwellers than for their rural counterparts. Nigeria’s MICS3 shows that children aged 0-14 years constitute 43 percent of both the rural and urban populations respectively and those persons aged 0 -17 years account for 49 percent of the males, 47 percent of the females and 48 percent of the combined population; this suggests that the male population is the slightly more youthful. The age distribution of population of women of reproductive age is skewed to the right; it starts with about 17 percent in each of age brackets 15-19 and 20-24 years, reaches the maximal 20 percent in ages 25-29, drops to 16 at ages 30-34 and 13 at ages 35-39 before tailing off to nine and seven percent at ages 40-44 and 45-49 years respectively. Exactly a third of the women of reproductive age report never to have given birth; 70 percent are currently married or in union and 26 percent have never married. Forty percent of the women have no education, 19 percent have primary while 40 percent have secondary or higher education and a paltry few i.e. 1.4 percent have non- formal education. Almost 24 percent are in the richest wealth index quintile; the remaining 76 percent was shared almost equally between the other four quintiles but the poorest quintile has the lowest percentage i.e. 18 percent. Nigeria’s MICS3 shows that children under five are 50.7 percent male and 49.3 percent female; the figures translate into a sex ratio of almost 103. Seventy percent of the under five children live in rural areas while 30 percent live in the urban. Forty-seven percent of children under five have mothers with no education, 23 percent have mothers with primary education while 28 percent have mothers with at least secondary education. Only two percent of the children have mothers with non-formal education. 6. Mortality Rates In Nigeria, the infant mortality rate is estimated at 86 per thousand live births, while the under-five mortality rate is 138 per thousand live births. There are visible differences in mortality in terms of sex of child, residence, educational level and wealth quintiles of the households and geopolitical zones. The Nigerian male child has greater probability of dying at infant or at under-five than his female counterpart, 92 per 1000 live births for the infant male versus 79 per 1000 live births for the female counterpart and 144 per 1000 for the male under-five versus 131 per 1000 for the female under-five. Infant mortality rate decreases from rural to urban sectors of the population (94 to 62 per 1000), from the non-educated to secondary school educated or higher (94 to 63 per 1000 live births), and from the poorest to the richest quintiles (100 to 54 per 1000 live births). There is some geopolitical zonal variation in infant mortality rates from 64 per 1000 in the South West to 101 per 1000 in the North West. Some North-South disparity is also evident. Under-five mortality rates follow the same geopolitical zonal pattern. xix 7. Nutrition In Nigeria, 25 percent of children under-five years are moderately underweight, 34 percent moderately stunted, and 11 percent moderately wasted. Severe nutrition prevalence figures include eight percent severely underweight, 19 percent severely stunted and three percent severely wasted. Children in the North are more likely to be underweight, stunted and wasted than children in the South. Children in rural areas of the country are about 150 percent more undernourished than their counterparts in urban areas. Age of child, mother’s education and wealth status are markedly associated with malnutrition in children. The age pattern shows that a higher percentage of children aged 12-23 months are the most likely to be undernourished according to all three indices. Children whose mothers have secondary or higher education are the least likely to be undernourished; those of mothers with no education are highly prone to malnutrition. Prevalence of malnourishment decreases as wealth status improves. 8. Breastfeeding Overall, 30 percent of women with live births start breastfeeding their babies within 1 hour of delivery while 71 percent start within 1 day of delivery. Early breastfeeding (within 1 hour) is more prevalent in the rural (31 percent) than in the urban (28 percent) sectors; but breastfeeding within 1 day of birth prevails at 69 in the rural against 74 percent in the urban. Age of child since last birth, mother’s education and wealth status do not seem too relevant; but the figures are slightly relatively less for mothers of children under 6 months since last birth or for mothers with no or non- formal education. Less than 12 percent of children aged 0-5 months are adequately fed i.e. exclusively breastfed. The picture is relatively worse for those whose mothers have no education (eight percent) or who have non-formal education (three percent). Infants aged 6-9 months are 31 percent adequately fed; twenty-two percent of infants aged 9-11 months receive breast milk and complementary food at least 3 times 24 hours prior to the survey. There is some northward decline in these percentages; urban-rural differential is less impressive but mother’s education and wealth status are positively related to adequate child feeding. 9. Salt Iodization Seventy-five percent of households use adequately iodized salt, 73 percent rural and 80 percent urban. There are pronounced zonal disparities; 59-76 percent of the North versus 81-86 percent in the South. Use of adequately iodised salt increases as wealth status improves. 10. Vitamin A Supplements In Nigeria, 37 percent of children aged 6-59 months received a high dose Vitamin A supplement within the six months prior to the survey. Only about 33 percent of mothers with a live birth in the two years preceding the survey received a Vitamin A supplement within eight weeks of the birth. Improvement in mother‘s education or in wealth status enhances likelihood of Vitamin A supplementation. Age of child is not really a factor. 11. Low Birth Weight Prevalence of low birth weight is 14 percent in Nigeria; it is more prevalent in the rural than in the urban sector, in the North than in the South, among the uneducated mothers than among their educated counterparts, and among the poorest quintiles than among the richest. 12. Immunization Approximately 51 percent of children aged 12-23 months received a BCG vaccination by the age of 12 months; 28 percent had DPT3 and 28 percent had Polio 3; the coverage for measles vaccine is 38 percent. The percentage of children who had all the recommended vaccinations by their first birthday is only 11 percent. In Nigeria, children aged between 12 to 23 months are supposed to receive vaccination against hepatitis B and yellow fever. About 38 percent of children in this age bracket are reported to have received first dose of HepB. Thirty percent of the children had xx vaccination against yellow fever. About 51 percent of women with a live birth in the 12 months preceding the survey had protection against neonatal tetanus. The coverage rates are lower in rural areas, in the North, among children with mothers with no education and among children in the poorest wealth quintiles. 13. Oral Rehydration Treatment Overall, about 10 percent of under-five children had diarrhoea in the two weeks preceding the survey. Prevalence rates are higher in the rural than in the urban, higher in the North than in the South and lower in the young children (0-6 months) than among the older ones. But sex of child, rural-urban and north-south differentials, and age of child are not important factors in home management of diarrhoea. However mother’s education and wealth status are relevant. Children of mothers with secondary education or higher and those in richest wealth quintile are the most likely to use ORT in home management of diarrhoea. 14. Care Seeking and Antibiotic Treatment of Pneumonia Two percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Forty-one percent of under-five children suspected to have pneumonia were taken to any appropriate health provider. Forty-six percent of under-five children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey; sex, age, geopolitical zone, residence, and socioeconomic factors do affect prevalence of use of antibiotics just as they are important in knowledge of signs of pneumonia. 15. Solid Fuels Overall, 75 percent of households in Nigeria are using solid fuels for cooking. Of the households using solid fuels, those using wood account for 70 percent. Differentials in use of solid fuels with respect to household wealth, education of the household head, rural-urban and north-south divides and geopolitical zones or states are only too obvious. Use of solid fuels is more predominant in the rural areas in the North, in households where the household heads have no education, and among households in the first three wealth quintiles. 16. Malaria Results indicate that four percent of children under the age of five slept under any mosquito net the night prior to the survey; slight gender disparities in favour of the females in ITN use. North-South disparities exist in favour of urban area. Disparities are also in favour of the South, the educated and the richer households. One in eight under-five children were ill with fever in the two weeks prior to the survey. Fever prevalence was less among the females, among the rich and in the North. Fever does not respect education. Overall, 52 percent of children who had fever were treated with an “appropriate” anti-malarial drug; the figure is higher in the rural areas than in the urban. Age of child does not seem to matter, but geopolitical zonal differences exist. 17. Water and Sanitation Overall, 49 percent of the population is using an improved source of drinking water, 43 percent live in households using improved sanitation facilities, but less than 28 percent of the household members use improved sources of drinking water and sanitary means of excreta disposal; The likelihood of the household using improved sources of water or improved sanitation facilities increases as the level of education of the household head increases or as wealth status improves. The South fares better than the North as education and wealth are positively factors. 18. Contraception Current use of contraception was reported by 15 percent of women currently married or in union, nine percent use modern methods while six percent use traditional methods. In Nigeria, the most relatively popular methods, according to table RH.1, are injectables (3.4 percent), the Pill (2.5 percent) and periodic abstinence (2.0 percent). The condom, IUD, LAM, and withdrawal are each xxi practised by about one percent of women currently married or in union. Female sterilization and other vaginal methods fail to make an impression, Age of woman, parity (number of children already had by the woman), education of the woman, place of residence (urban or rural), and wealth status have very significant effects on contraceptive use. 19. Unmet Needs Twenty percent of women currently married or in union reported unmet need for contraception, 13 percent in respect of child spacing and seven percent in respect of limiting number of children wanted. Forty-three percent said that their demand about contraception is satisfied. Area of residence, education and wealth status respectively affect perception of the woman on the extent to which her demands for contraception have been met. 20. Antenatal Care Coverage of antenatal care (by a doctor, nurse, or midwife) is relatively high in Nigeria with 68 percent of women receiving antenatal care at least once during the pregnancy. The probability that a pregnant woman would receive appropriate antenatal care increases from the North to the South, from the uneducated to the educated, from the rural woman to the urban woman, and, 86 percent of women attending antenatal care have their blood pressure taken, 71 percent have urine specimen taken, 85 percent have their weight measured while 71 percent have blood sample taken. These figures vary across areas of residence, geopolitical zones, age of and level of education of the women, but the relative trend within each background characteristic is quite similar. 21. Assistance at Delivery About 44 percent of births occurring in the year prior to the MICS survey were delivered by skilled personnel. About one in three (31 percent) were delivered with assistance by a nurse/midwife. Doctors assisted with the delivery of 12 percent of births and two percent by auxiliary midwife. Deliveries by traditional birth attendants (TBA) were 20 percent and by relatives and friends 22 percent; there were no attendants in 10 percent of the cases. Family Support for Learning For almost two-thirds (65 percent) of under-five children, an adult engaged in more than four activities that promote learning and school readiness during the 3 days preceding the survey. The average number of activities that adults engaged in is 4. Ten percent of children were living in a household without their fathers. There are no gender differentials in terms of adult activities with children; but strong disparities across age of child, sector of residence, education of mothers exist. In Nigeria, 35 percent of children are living in households where at least 3 non-children’s books are present. However, only 14 percent of children aged 0-59 months have 3 or more children’s books; 11 percent of children aged 0-59 months had 3 or more playthings to play with in their homes, while 33 percent had none of the playthings. Child age, education of the mother, wealth of the household, and sector are relevant. 22. Pre-School Attendance and School Readiness Attendance to pre-school education in an organized learning or child education program is important for the readiness of children to school. In Nigeria, about one in three (32 percent) of children aged 36-59 months are attending pre-school; also, 83 percent of children who are currently aged 6, and attending the first grade of primary school were attending pre-school the previous year. Urban-rural and North-South differentials exist; education of the mother, age of child, wealth of the household, all count as pre-school attendance and school readiness are more emphatic in the urban areas, among the educated mothers, among southerners and in the richer households. xxii 23. Primary and Secondary School Participation In Nigeria, proportion of children of primary school entry age (age 6) attending grade 1 is 44 percent Sex differentials do not exist; however, significant differentials are observed across geopolitical zones, and urban-rural and North-South dichotomies. A positive association between mother’s education and socioeconomic status is observed. In Nigeria, primary school net attendance ratio (NAR) is just over 64, (66 for the males and 62 for the females). The sex of the child is irrelevant but North-South and rural-urban trend is noticeable; there is strong association between primary school NAR and education of mother or with socio-economic status of the household. Trend of relative disparities in primary school NAR across socio-economic characteristics of the households, education of mother, rural-urban divide, and geopolitical zones/states is identical for both sexes; it is not gender-specific. The secondary school net attendance ratio is 51; sex of the child may not matter but wealth of the household, mother’s education, rural-urban divide and geopolitical divide are all critical with mother’s education, urban residence, wealth of the household leading to higher NAR figures. Trend of the disparities in secondary school NAR across socio-economic characteristics of households, education of mother, rural-urban sectors, geopolitical zones and states are not consistent over sex, it is gender-specific. Fourteen percent of the children of secondary school age are attending primary school when they should be attending secondary school while 36 percent are not attending school at all; they are children out of school. The situation is more serious in the rural areas, among children in the lower wealth index quintile, and among children of mothers with little or no education. In Nigeria, the percentage of children entering first grade who eventually reach final grades 5 or 6 is 96 percent. Male-female, rural-urban and wealth quintile differentials are insignificant; only North-South disparity is visible. The net primary school completion rate is 36 percent while the transition rate to secondary school is 93 percent. Gender parity index is usually in favour of the male. But area of residence, mother’s education and wealth quintile status of the family are significant correlates. 24. Youth Literacy In Nigeria, female youth literacy rate is 56 percent, i.e. only 11 out of every 20 women aged 15 – 24 years are literate. Again, wealth status, area of residence and geopolitical divide are significant factors with the rich, the urban resident and the southerner the more greatly favoured. 25. Birth Registration In Nigeria’s MICS3, the births of 23 percent of under-five children have been registered. The probability that the child would have the birth registered increases from rural to urban area, and as age of child increases or education of mother or wealth status of the household improves. Main reasons for non-registration of child birth included ignorance of the benefits of birth registration (23 percent), unaffordable costs of birth registration (17 percent), and ignorance of where to do the registration (nine percent). Sheer ignorance and distance to point of registration are also reasons. 26. Child Labour Of all children aged 5-14 years, 29 percent are engaged in child labour; 21 percent are working for family business and nine percent are working outside the family unpaid. Sex of child and school participation are respectively of little consequence; but rural-urban classification, geopolitical divide, age of child, education of mother and wealth status of the household, are effective sources of variation in prevalence of child labour. The incidence is higher in the rural areas (32 percent), among children of primary school age 5-11 years (34 percent), among children of mothers with primary education or less (30-33 percent), or among the poorest households (34 percent). In Nigeria, adulthood begins at age 18; hence doing 14 hours of economic work or 28 hours of xxiii domestic work per week at ages 15 to 17 years is considered as child labour. This pushes up the figures of prevalence of child labour in the country beyond the afore-stated. 27. Early Marriage In Nigeria, 15 percent of women of reproductive age (WRA) (15-49 years) married before age 15 while 40 percent of women age 20-49 years married before age 18. One out of every four women aged 15 to 19 years is married or in union. The result shows that the problem is prone to the North as there is a strong disparity between the North and the South. Education, household wealth, and area of residence have strong influence on the prevalence of early marriage. 28. Female Genital Mutilation/Cutting In Nigeria’s MICS3, 26 percent of women aged 15-49 years had any form of FGM/C; of this number, 37 percent had flesh removed, two percent were nicked, 11 percent were sewn closed while 50 percent could not determine the form of the mutilation. FGM/C is rare in the North and rarest in the North East where two percent of the women were victims; it is popular in the South particularly in the South East (53 percent) and in the South West (51 percent). It is more prevalent in the urban areas than in the rural areas (37 percent versus 21 percent). The prevalence of FGM/C is positively associated with age, education and wealth status. It is presented as a problem of the old, the educated and the rich. The declining popularity of female genital mutilation is reflected in the figure of percentage of daughters who had suffered the practice. Thirteen percent of the daughters were affected; about two out of every three of the affected were sewn closed, 1 in every 10 had flesh removed while in three percent the method was indeterminate. The practice with respect to daughters remains a problem of the South particularly the South East and South West, the rich, the educated and the old for same reasons as suggested above. Knowledge of HIV Transmission and Condom Use In Nigeria’s MICS3, 77 percent of the interviewed women have heard of AIDS. Forty percent know 2 ways to prevent HIV transmission, 30 percent correctly identify 3 misconceptions about HIV transmission while 18 percent have comprehensive knowledge (identify 2 prevention methods and 3 misconceptions). Overall, 68 percent of women know that HIV can be transmitted from mother to child. About 48 percent, 60 percent and 56 percent respectively know that mother-to-child transmission (MCT) may occur during pregnancy, at delivery and through breast milk. The percentage of women who know all three ways is 62. Eighty-six percent of the women aged 15-49 years agree with at least one of the discriminatory statements. Thirty-eight percent of women know where to be tested, while 13 percent have actually been tested; of these, a large proportion has been told the result (82 percent). Again, some rural-urban differential is obvious in Nigeria. 29. Sexual Behaviour Related to HIV Transmission Thirteen percent of women aged 15-19 had sex before age 15 while 47 percent of women aged 20-24 years had sex before age 18. One in every 3 women aged 15-24 years is in marriage/union with spouses that are at least 10 years older. Percentage of women in each category who had sex before the prescribed age decreases from the rural to the urban area, from the North to the South, from women with no education to women with at least secondary education and from the women in the poorest wealth quintile to those in the richest quintile. These strands of sexual behaviour are therefore poverty induced, culturally related, but all moderated somehow by educational attainment. About 2 in every 5 women aged 15-24 years report having sex with a non-regular partner in the 12 months prior to the survey; also 2 in 5 of those women report using a condom when they had sex with the high risk partner. Prevalence of sexual activity of women aged 15-24 increases with age of women, decreases from the rural to the urban and from the North to the South and is negatively correlated with level of education and socio-economic status of the women. High risk sexual behaviour is negatively related to age of woman but positively correlated with her level of education and wealth status. Prevalence of condom use at last sex with a non- marital, non-cohabiting partner is 39 percent; the use is more prevalent among the urban residents xxiv or among the educated or among the richer adolescent females and among the older members of the group. 30. Orphans and Vulnerable Children In Nigeria, seven percent of children aged 0-17 years live with neither parent. In 15 instances of children living with neither parent, both parents are alive in 11 cases and one of the parents is alive in more than 2 cases. Hence, fosterhood rather than orphanhood seems the main reason for children living with neither parent. The probability that a child lives with both parents depends on area of residence, wealth of the parent, and age of child. It is less in the urban areas, more in the North, and increases with age of child. Paradoxically, the likelihood also increases as wealth status of the parents improves. In Nigeria, one percent of children aged 10-14 have lost both parents. Eighty-four percent of children aged 10-14 have both parents alive and are living with at least one such parent; 66 percent of such children are attending school. These figures give double orphans to non-orphans school attendance ratio of 0.93 and suggest that double orphans are disadvantaged compared to the non-orphaned children in terms of school attendance, no gender disparity is obvious; rural-urban differential is strongly in favour of the rural areas (1.04). Proportion of children who are orphaned or vulnerable due to AIDS (OVC) is 13 percent while 78 percent of the children so affected attend school; percentage of children who are not orphans or vulnerable due to AIDS (non-OVC) is 87 percent with school attendance rate of 67 percent. Thus OVC versus non-OVC school attendance ratio is 1.16. These figures do not indicate any disadvantage against OVC. Twenty-two percent of orphaned vulnerable under-five children are underweight, 32 percent are stunted while 11 percent are wasted. Corresponding figures for the vulnerable under-five are 28 percent under-weight, 38 percent stunted and 10 percent wasted. One in four of orphaned or vulnerable under-five children in Nigeria is underweight; about 1 in 10 is wasted while 1 in 3 is stunted. The figures for the non-orphaned or non-vulnerable counterparts are the same. The ratio of prevalence of premature sexual behaviour among OVC and non-OVC women aged 15-17 years is 1.07; the difference, 0.07 percent, between OVC and non-OVC girls is minor. 1 I. INTRODUCTION Background This report is based on the Nigeria Multiple Indicator Cluster Survey, conducted in 2007 by the National Bureau of Statistics (NBS) with financial and technical support from UNICEF Nigeria. The survey provides valuable information on the situation of children and women in Nigeria, and was based, in large part, on the needs to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see box below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” On the national scene, there have been several efforts directed towards objectives and aspirations that are similar in most material respects to the global commitments expressed in the Millennium Development Goals, the World Fit for Children goals, the UNICEF Country Programme, UN Development Assistance Framework (UNDAF), the Convention on the Rights of the Child (CRC) and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), 2 Abuja Targets for Malaria, and United Nations General Assembly (UNGA), among others. The National Programme for the Eradication of Poverty (NAPEP) has been concerned with strategies for poverty reduction in the country; National Agency for the Control of HIV/AIDS (NACA) has mandate for planning, implementing and monitoring programmes for control of HIV/AIDS; National Economic Empowerment Development Strategy (NEEDS) and its state and local government extensions, SEEDS and LEEDS respectively are supposed to focus on wealth creation, employment generation, corruption elimination and general value orientation. The Federal Government of Nigeria has expressed strong commitment to, and declared as a matter of high priority, efforts to monitor and evaluate progress towards the attainment of the benchmarks established in these national and other global goals. The National Bureau of Statistics (NBS) with strong financial and technical support from international development partners and donors like UNICEF has been involved in the national efforts to achieve the goals through provision of relevant data to monitor, evaluate and advise necessary adjustments in development programmes. The NBS, in recent times had conducted a number of national sample surveys most of them within global generic context. Nigeria Living Standard Survey (NLSS), General Household Survey (GHS), Core Welfare Indicator Questionnaire (CWIQ) Survey and the Nigeria Demographic and Health Survey (NDHS) were examples. However, MICS3 Nigeria like the generic MICS3 has been designed in the main to measure progress towards achievements of Millennium Development Goals (MDGs). More specifically, MICS3 should assist evaluation and monitoring of UNICEF country programmes including those on immunization, vitamin A supplementation, child development, child and women rights and protection among others. MICS3 global would be able to collect information on at least 99 internationally agreed upon indicators covering most situations of the household, the child, the mother and their environment. This final report presents indicator estimates for the different topics and issues covered in the survey. Survey Objectives The MICS3 Nigeria has the following primary objectives: • To provide up-to-date information for assessing the situation of children and women in Nigeria; • To furnish data needed for monitoring progress towards goals established by the Millennium Development Goals, and those of A World Fit for Children (WFFC) among others; • To measure progress towards achievements of goals of NEEDS, NAPEP, NACA and their state and local government extensions, among others; • To contribute to the improvement of data and monitoring systems in Nigeria and to strengthen technical expertise in the design, implementation, and analysis of such systems; • To provide statistics to complement and assess the quality of data from recent national surveys like the NLSS, CWIQ and NDHS. 3 II. SAMPLE AND SURVEY METHODOLOGY Sample Design The sample for the Nigeria Multiple Indicator Cluster Survey (MICS3) was designed to provide estimates on a large number of indicators on the situation of children and women at the country level, for urban and rural areas; and for each of the 36 States of the Federation and the Federal Capital Territory of Abuja. The States were the main reporting domains. The sample design was two-stage in each state, where a systematic sample of 30 census enumeration areas (EAs) was selected with equal probability to form the first stage or primary sampling units (PSUs). The updated 1991 Population Census Enumeration Area demarcation was used. Household listing was conducted in each of the selected EAs to provide an up-to-date frame of housing units (HU) as the secondary sampling units (SSUs). A systematic sample of 25 housing units was subsequently drawn with equal probability within each of the selected EAs, and all the households in each of the selected HUs were canvassed. Thus, in each state, 750 HUs were drawn yielding a total of 27,750 HUs for the country. The sample was stratified by states and was hardly self weighting at either state or national level. Hence, sample weights were used for reporting state or national results. There are differences between weighted and un-weighted numbers for most categories of the different target populations because the sampling constituted 30 EAs from each state irrespective of the number of EAs in the states. The same sampling situation is true of other classifications of the target populations e.g. classifications by residence, sex, education, wealth quintiles, and geopolitical zones. All of the selected EAs were successfully canvassed. Table HH.1 presents a summary of results of interviews of households, individual women aged 15 – 49 years and children aged under-5 years. A total of 28,603 households including 20,825 in the rural and 7,778 in the urban sectors were sampled; the total number of occupied sampled households was 28,431 including 20,735 rural and 7,696 urban households. The total number of interviewed households was 26,735 including 19,569 rural and 7,166 urban households. These figures translate into 94.0 percent response rates for the total, 94.4 percent for the rural and 93.1 percent for the urban sectors. The total figure of eligible women was 27,093 including 19,674 and 7,419 for rural and urban sectors respectively while the corresponding figures of interviewed women were 24,565, 17,928, and 6,637 respectively; which translate into 85.3, 86.0 and 83.3 percent overall response rates respectively. The eligible children under-five were 17,093, 12,898 and 4,195 and interviewed were achieved for 16,549, 12,494 and 4,055 respectively; again the corresponding overall response rates were 91.0, 91.4 and 90.0 percent respectively. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three questionnaires were used in the survey, namely a household questionnaire to collect information on general characteristics of the household including membership and the dwelling; a questionnaire for individual women and one for children under-five. The latter questionnaires were administered in each household to women aged 15-49; and to mothers or caretakers of under-five children, respectively in households where these persons were identified. The questionnaires and the constituent modules are as under-listed: 4 • Household questionnaire o Household listing o Education o Water and sanitation o Household characteristics o Insecticide treated nets o Children orphaned and made vulnerable by HIV/AIDS o Child labour o Maternal mortality o Salt iodization • Questionnaire for Individual Women o Child Mortality o Tetanus Toxoid o Maternal and Newborn Health o Marriage/Union o Contraception and Unmet Need o Female Genital Mutilation o HIV/AIDS o Sexual Behaviour • Questionnaire for Children Under-five o Birth Registration and Early Learning o Child Development o Vitamin A o Breastfeeding o Care of Illness o Malaria o Immunization o Anthropometry The questionnaires which were based on the English version of the generic MICS3 model were domesticated but not translated into local Nigerian languages. Field staff were, however, competent in the local languages, familiar with cultural practices and peculiarities of the canvassed communities. The questionnaires were pre-tested in December 2006 in four purposively selected typical states: Enugu, Osun, Benue and Kano. As a result of experiences at the pre-test and contributions from review meetings of stakeholders and MICS3 central technical committee (CTC), some amendments were effected in the questionnaires. Training and Fieldwork Prior to training of field staff, rollout meetings were held in November 2006 at national and in each of the six geo-political zones of the country. The meetings sensitised stakeholders on the MICS3 Nigeria process, discussed strategies for implementation, considered the problems and lessons learnt from the previous MICS, and agreed on steps towards improving MICS3. Training for the fieldwork was conducted at national and zonal levels. The training of the trainers (TOT) took place in December 2006; while the training for the main survey was held in February/March 2007 in the six geo-political zones simultaneously. Training included lectures on interviewing techniques and the contents of the questionnaires; practice interviews took place in purposively selected EAs that were considered typical of the environment. In each of the 36 states and the Federal Capital Territory, data were collected by two teams of field staff, each comprising 4 interviewers, one editor and one supervisor. Thus, a total of 296 interviewers, 74 editors, 74 supervisors, 37 state monitors and 6 zonal co-ordinators participated in the field work. Means of transport were provided for the core field staff to facilitate movement of the fieldworkers. State and zonal coordinators were appointed to monitor the main survey activities 5 at the state and zonal levels respectively. Fieldwork began in March 2007 and was concluded in six weeks by April 2007. Data Processing A 3-day training of trainers was organised for data processing team in Abuja in April 2007; there was also a subsequent four-day training of data processing personnel in May 2007 simultaneously at each of the six zonal data processing centres. Data entry was done using the CSPro software at each of the six data processing centers, each zone handling data from the component states. In order to ensure data quality, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS3 project and adapted to the Nigeria questionnaire were used throughout. Data processing began few days after the end of data collection in April and was completed in October 2007. Due checks for data quality and compliance with global data processing guidelines by UNICEF Nigeria and UNICEF New York was ensured. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 15, and the model syntax and tabulation plans developed by UNICEF for the purpose. Provision for data processing in terms of computer software and hardware, office space and personnel was adequate while processes for primary and secondary data processing phases as advised in global MICS3 manual of instructions were adhered to. 6 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Sample Coverage Table HH.1 presents a summary of results of interviews of households; individual women aged 15 – 49 years and in respect of children aged under-five years. A total of 28,603 households including 20,825 and 7,778 in the rural and urban sectors respectively were sampled; total number of occupied sampled households was 28,431 including 20,735 rural and 7,696 urban households. Total number of interviewed households was 26,735 including 19,569 rural and 7,166 urban households. These figures translated into 94.0 percent response rates for the total, 94.4 percent for the rural and 93.1 percent for the urban. Total figure of eligible women was 27,093 including 19,674 and 7,419 for rural and urban sectors respectively while corresponding figures of interviewed women were 24,565, 17,928, and 6,637 respectively; these figures translated into 85.3, 86.0 and 83.3 effective response rates respectively. Numbers of eligible under-five children were 17,093, 12,898 and 4,195 and interview was completed for 16,549, 12,494 and 4,055 respectively; again the corresponding overall response rates were 91.0, 91.4 and 90.0 percent respectively. Urban-rural disparities in response rates were quite marginal. Households’ response rates varied from 81 percent in Osun State to 100 percent in Katsina State; but the variations have been bridged across geopolitical zonal aggregates although the northern zones show greater household response rates. This pattern of variation is true also of women and under-five children response rates respectively. No immediate explanations could be adduced for these differentials beyond the fact that the less educated North is ever more prepared to cooperate with the interviewer and that the terrain in the North is friendlier for purposes of interviewing. Characteristics of Households The age and sex distribution of survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 26,735 households that were successfully interviewed, 124,840 household members were listed. Of these, 62,950 were males, and 61,888 were females. These results translate to sex ratio (male: female) figure of 101.7 and an average household size figure 4.67 members at the national level. Table HH.2 shows the distribution of household members by sex and age group while Figure HH.1 shows the age pyramid. The male: female ratio is 101.7, a figure that seems easily in accord with the figure 101 returned by the preliminary results of 2006 Nigeria Population Census; it however contrasts with 98.6 figures from NDHS 2003. Sex ratio across age group ranges from 60 percent for the 50-54 age-groups to 180 for persons aged 70 years and above. Corresponding figures for age groups <15, 15–64 and 65+ are 101, 98, and 160 respectively. Dependency ratio expressing total persons aged below 15 years or above 64 years as ratio of those aged 15 to 64 years is 0.95 in the urban areas, 0.88 in the rural areas and 0.91 overall. These figures indicate some greater economic burden for the economically active urban dwellers than for their rural counterparts. MICS3 Nigeria shows that children (persons aged 0 – 14 years) make 43 percent of both the rural and urban populations respectively and that persons aged 0 -17 years account for 49 percent of the males, 47 percent of the females and 48 percent of the combined population; this suggests that the male population is the slightly more youthful. 7 The age pyramid shows some of the problems of the age data. There is pronounced heaping at ages just outside the borders of eligibility. There is a massive out-transfer of children from eligible ages 0-4 to ineligible ages 5-9 and of women from eligible ages 15-19 to either ineligible ages 10- 14 or otherwise eligible ages 20-24; also there is significant out-transfer of women from the eligible ages 45-49 to ineligible ages 50-54 years. Apparently also, major out-tranfer of persons from ages 65-69 to ages 70 and above must have occurred. Table HH.3 provides basic background information on the households. The table shows distribution of households by the sex of the household head, states, urban/rural status, and number of household members. These background characteristics are also used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and un-weighted numbers of households are unequal and could not have been equal in view of MICS3 Nigeria sampling scheme. There was no sufficient information as to number of housing units in each of the EAs in the population to permit selection of EAs with probability to size at the state level and, as such, the sample at each state could not have been quite self-weighting. (See Appendix A). This and other reasons that were mentioned earlier create problems of over-sampling or under-sampling in respect of some categories of the population. The table also shows the proportions of households where at least one child under 18, at least one child under 5, and at least one eligible woman age 15-49 were found. Eighty-four percent of the households are headed by male and 16 percent by the female; these figures are in complete harmony with NDHS (NPopC, 2003) and CWIQ (NBS, 2006a) results of 2003 and 2006 respectively. This indicator has come to be regarded as a poverty index; female- headed households are believed to be more poverty-prone than the male-headed counterparts. Also rural households are twice as many as the urban households, the latter accounting for 33 percent of the total households in the population. One-member households are 13 percent of the population, 26 percent have 2-3 members while 27 percent have 4-5 members; about 15 percent of the households have at least 8 members. Again, size of household is a credible measure of poverty prevalence; large house sizes breed or aggravate poverty. Seventy-three percent of the households have at least one child aged under-18, 43 percent with at least one under-5 child and 72 percent with at least one woman of reproductive age (15 – 49). Figure HH.1: Age and sex distribution of household population, Nigeria, 2007 8 Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents aged 15-49 years and of children under age 5. Both tables provide useful information on the background characteristics of women and children and are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 is on background characteristics of female respondents 15-49 years of age. The table gives information on the distribution of women by states, urban-rural areas, geopolitical zones, age-groups, marital status, motherhood status; education2 and wealth index quintiles3. The rural population has about two thirds (67 percent) of all women aged 15–49 years, the urban population accounting for the remaining 33 percent. The age distribution of population of these women of reproductive age (WRA) is skewed to the right; it starts with about 17 percent in each of age brackets 15-19 and 20-24 years, reaches the maximal 20 percent in ages 25-29, drops to 16 at ages 30-34 and 13 at ages 35-39 before tailing off to nine and seven percent at ages 40-44 and 45-49 years respectively. The State distribution of WRA is rather clumsy due to large number of states but the geopolitical trend is more definitive and tractable. The South west and North west share the highest concentration of WRA each containing 23 percent of the women; the North central and the South east have the least i.e. 13 and 10 percent respectively. Exactly a third of the WRA report never to have given birth; 70 percent are currently married or in union and 26 percent have never married. Forty percent of the women have no education, 19 percent have primary while 40 percent have secondary or higher education and a low (1.4 percent) proportion of WRA have non-formal education. Almost 24 percent are in the richest wealth index quintile; the remaining 76 percent was shared almost equally between the other four quintiles. Further analysis is required to provide an insight into the interdendence among these factors. Classification of children 0–4 years old by some background characteristics are presented in Table HH.5. These include sex, state, geopolitical zones and area of residence, age in months, mother or caretaker’s education and wealth index quintile of the family. MICS3 Nigeria shows that children under-five are 50.7 percent male and 49.3 percent female; the figures translate into a sex ratio of almost 103 percent. Seventy percent of the under-five live in rural areas while 30 percent live in the urban. State distribution of the children is not easily summarized but two zones namely the North west and South west together account for 50 percent of the children while the remaining half are distributed between the remaining 4 zones, the South east having fewer than eight percent. The age distribution of children under-five is as follows: less than six months and 6-11 months each constitutes about 10 percent; 12-23 months, 19 percent; 24-35 months, 21 percent; while 36-47 months and 48-59 months constitute 22 and 17 percent respectively. Education empowers the mother and equips her with necessary knowledge and ability to dispense adequate health care to the child, protect him or her from hazards and give him or her good start in life. Forty-seven percent of children under-five have mothers with no education, 23 percent have mothers with primary education while 28 percent have mothers with at least secondary education. 2 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 3 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The assets used in these calculations were as follows: number of persons per sleeping room, type of floor, type of roof, type of wall, type of cooking fuel, presence of household assests including electricity supply, radio, tv, mobile phone, phone, refrigerator, watch, bicycle, motorcycle, cart, car and boat, source of drinking water and type of sanitary facility). Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long‐term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. 9 Only two percent have mothers with non-formal education. The children are distributed equally over the five wealth quintile classes. A situation where 40 percent of women of reproductive age and mothers of children under-five have no education is intolerable. 10 IV. CHILD MORTALITY One of the overarching goals of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. The infant mortality rate (IMR) is the probability of dying before the first birthday. The under-five mortality rate (U5MR) is the probability of dying before the fifth birthday. In MICS3, IMR and U5MR are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). The data used in the estimation are: the mean number of children ever born, and the proportion of those children who are dead, for five year age groups of women from age 15 to 49. The technique converts these data into probabilities of dying by taking into account both the mortality risks to which children are exposed and their length of exposure to the risk of dying. Based on previous information on mortality in Nigeria, the North model life table was selected as most appropriate. Figure CM.1: Under-five mortality rates by background characteristics, Nigeria, 2007 144 131 117 131 166 142 111 106 152 96 153 134 97 165 164 149 114 81 138 0 20 40 60 80 100 120 140 160 180 Male Female SEX North central North east North west South east South south South west ZONES Rural Urban AREA None Primary Secondary+ MOTHER'S Poorest Second Middle Fourth Richest QUINTILES TOTAL Deaths per 1000 live births 11 Table CM.1 provides estimates of child mortality by various background characteristics, while Table CM.2 provides the basic data used in the calculation of the mortality rates for the nation. In Nigeria, the infant mortality rate is estimated at 86 per thousand live births, while the under-five mortality rate is around 138 per thousand live births. There are visible differences in mortality in terms of sex of child, residence, educational level and wealth status of the parents, and states or geopolitical zones. The Nigerian male child has greater probability of dying at infant or at under- five than his female counterpart, 92 per 1000 live births for the infant male versus 79 per 1000 live births for the female counterpart and 144 per 1000 for the male under-five versus 131 per 1000 for the female under-five. IMR decreases from rural to urban sectors of the population (94 to 62 per 1000 live births), from the non-educated to secondary school educated or higher (94 to 63 per 1000), and from the poorest to the richest households (100 to 54 per 1000). There is some geopolitical zonal variation in IMR from 64 per 1000 in the South west to 101 per 1000 in the North west. Some North-South disparity is also evident. U5MR follow the same geopolitical zonal pattern. See Figure CM.1. History of mortality rates in Nigeria as provided by estimates from series of national surveys that were conducted since 1990 shows some fluctuating trends (Figure CM.2). The results are based on responses of women in different age groups and referring to various points in time. Infant mortality rate has been on the rise since 1990 when it was 87 per 1000 (NDHS, 1990), rising to 105 in 1999 (MICS2 Nigeria), and 113 in 2003 (NDHS 2003). MICS Nigeria 2007 shows a decline to 86 per 1000. Under-five mortality rates show similar pattern since 1999; it was 178 in 1999 (MICS2 1999) rising to 201 in 2003 (NDHS 2003) and declining to 138 in the current MICS Nigeria 2007. In addition to the use of indirect or direct methods for calculating mortality, many other factors may contribute to the fluctuations and inconsistent trends in infant and child mortality rates in Nigeria. Further qualification of these apparent differences as well as its determinants should be taken up in a more detailed and separate analysis. Some of these differences can be attributable to sampling errors. If confidence intervals are taken into consideration then part of these differences between and among different surveys may be attributable to sampling errors. There may also be some non- sampling errors involved where various factors can play a role in the estimates of mortality - underreporting of births and deaths, age misstatement, out-transference of births. For a brief discussion on data quality, see Appendix D. Figure CM.2: Child mortality rates in Nigeria, 1990-2007 Survey and Year NDHS 1990MICS 1999NDHS 2003MICS 2007 N um be r o f d ea th s pe r 1 00 0 220 200 180 160 140 120 100 80 60 40 20 0 Under-5 Mortality Rate Infant Mortality Rate 12 V. NUTRITION Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all children deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition are only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The World Fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. The extent of under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the survey was implemented. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In MICS3 Nigeria, weights and heights of all children under-five years of age were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children in Nigeria classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population. The results shown in Table NU.1 do not include 29 percent of children who were exluded from the analysis. Exclusion is highly associated with education of the mothers, residence, wealth status, and geopolitical zones which factors can not be non-interrelated. Exclusion rate is most acute at the extreme ages, 35 percent in children aged less than 6 months and 31 percent for those aged 13 48 – 59 months; it decreased from 33 percent at the rural sector to 20 percent at the urban, from over 40 percent for children of mothers with no or non-formal education to 14 percent for children of mothers with secondary education or higher and from over 42 percent for children in the poorest wealth quintile to 17 percent among the richest quintile. Exclusion rates are high in the North East (37 percent) and in the North West (47 percent) and highly reduced in the South South (12) and in the South West (11 percent). The exclusion rate is considered high and may affect the anthropometric results. 0 5 10 15 20 25 30 35 40 45 0 6 12 18 24 30 36 42 48 54 P er ce nt Age (in Months) Figure NU.1: Percent of children under-5 who are undernourished, Nigeria, 2007 Underweight Stunted Wasted In Nigeria, one in four i.e. 25 percent of children under five are moderately or severely underweight and eight percent are classified as severely underweight (Table NU.1). More than a third (34 percent) of children are moderately or severely stunted or too short for their age and 11 percent are moderately or severely wasted or too thin for their height. Severely stunted and severely wasted children are 19 and three percent respectively. Children in the North are more likely to be underweight, stunted and wasted than children in the South. The North West has the highest rate of moderate undernourishment (41 percent underweight, 57 percent stunted and 16 percent wasted) while the South East has the lowest on all the 3 indices of moderate undernourishment (17 percent underweight, 23 percent stunted, seven percent wasted). Figures of severe undernourishment reflect same pattern of geopolitical differences. Children in rural areas of the country are about 50 percent more undernourished than their counterparts in urban areas; the urban and rural figures are 19, 26 and 10 percent moderately 14 underweight, moderately stunted and moderately wasted respectively and 5.1, 14.4 and 2.4 percent severely underweight, severely stunted and severely wasted respectively. Age of child, mother’s education and wealth status are markedly associated with malnutrition in children. Incidence of moderate underweight is five percent at age 0-5 months, peaks at 33 percent at age 12-23 months and then drops gradually to 24 percent at age 48-59 months; severe underweight is 1% at age 0-5 months, peaks at 12 percent at age 12-35 months and declines to five percent at age 48-59 months. Wasting is most prevalent at age 6-23 months (14 -15 percent moderate, 4 -5 percent severe) and stunting is at its highest occurrence at 12-23 months (42 percent moderate, 22 percent severe) but hardly abates thence forward. Hence the age pattern shows that a higher percentage of children aged 12-23 months are the most likely to be undernourished according to all three indices. (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to health hazards like contamination in water, food, and environment. Figure NU 1A: Percent of children under five who are undernourished, Nigeria, 1999 - 2007 Survey and year MICS 2007NDHS 2003MICS 1999NDHS 1999 Pe rc en ta ge 50 40 30 20 10 0 Moderate Underw eight Severe Underw eight Moderate Stunting Severe Stunting Moderate Wasting Severe Wasting Children whose mothers have secondary or higher education are the least likely to be underweight, stunted or wasted; those of mothers with no education are highly prone to malnutrition with 34, 45 and 13 percent chance of being moderately underweight, stunted or wasted respectively. Children of mothers with non-formal education may even fare worse. Prevalence of malnourishment decreases as wealth status improves with likelihood of moderate undernourishment increasing from 16 percent underweight, 22 percent stunting and 10 percent wasting at the richest quintile to 32 percent underweight, 44 percent stunting and 13 percent wasting respectively at the poorest quintile. Boys appear to be slightly more likely to be underweight, stunted, or wasted than girls. Wealth and education are positively related while education increases from North to South. Figure NU 1A shows some curious trends in children malnutrition figures in Nigeria over the years. From MICS surveys of 1999 and 2007 some decline in moderate underweight and in moderate wasting prevalence respectively between 1999 and 2007 is contrasted by corresponding increase in moderate stunting prevalence over the same period. Similar pattern is observed in respect of severe malnourishment figures. Table NU 1 also shows that severe underweight prevalence among children in Nigeria in 2007 is 8 percent and that prevalence rate depends on residence, age of the child, education of the mother, wealth status of the household and geopolitical zone; it declines from the poorest to the richest wealth index quintile of households, from the poorly educated to the highly educated and from the rural to the urban residents. The severe underweight prevalence is also observed to be higher in the northern zones than the south. 15 Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to 2 years of age and beyond. WHO/UNICEF make the following feeding recommendations: • Early initiation of breastfeeding (within one hour after birth) • Exclusive breastfeeding for first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at 6 months • Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding (< 6 months & < 4 months) • Timely complementary feeding (6-9 months) • Continued breastfeeding (12-15 & 20-23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.2 provides the proportion of women who started breastfeeding their infants within one hour of birth, and within one day of delivery (which includes those who started within one hour) respectively. Overall, 30 percent of women with live births start breastfeeding their babies within 1 hour of delivery while 71 percent start within 1 day of delivery; corresponding figures during NDHS (2003) were 32 and 63 percent respectively. Early breastfeeding (within 1 hour) start earlier in the rural than in the urban sector (31 percent for rural women versus 29 percent for the urban others); but the trend is reversed in respect of percentage of women who start breastfeeding within 1 day of birth to 69 percent for the rural against 74 percent for the urban women . Age of child since last birth, mother’s education and wealth status do not seem too relevant; but the figures are slightly relatively less for mothers of children under 6 months since last birth or for mothers with no or non-formal education. In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Approximately 14 percent of children aged less than 3 months are exclusively breastfed; this figure may be placed against 26 percent for children under-2 months and 19 percent for children between 2-3 months old at NDHS 2003; on the other hand, 12 percent of those aged 0 - 5 months are exclusively breastfed, a figure that easily compares with MICS2 (1999) figure of 12.5 percent; these levels are all considerably lower than recommended. At age 6-9 months, 41 percent of children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 78 percent of children are still being breastfed but by age 20-23 months, only 31 percent are still being breastfed. Girls were more likely to be exclusively breastfed than boys. Greater percentage of children in the urban areas is exclusively breastfed in the first three or first five months of life than children in the rural areas (18 percent versus 13 percent for under-3 months and 15 percent versus 16 11 percent for under-5 months). Education and wealth status of mothers are relevant here. Children of mothers with non-formal education are the most disadvantaged; children of mothers with secondary or higher education fare best with respect to exclusive breastfeeding in early life. Relative figures of exclusive breastfeeding of children under-3 or under-5 months of age increase as wealth status improves. Figure NU2 shows the percentage of mothers who started breastfeeding within an hour and within a day of birth. While at least six out of every ten mothers from any of part of the country commenced breastfeeding within one day of birth, the same is not true for breastfeeding within one hour of birth. Proportion of women who commenced breastfeeding within an hour varies from four out of every ten women (43.2%) in the North central to about two out of every ten women (24.8 %) in the North west. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is about 2.5 percent and only about one percent of children are receiving breast milk after 2 years. The adequacy of infant feeding in children under-12 months is provided in Table NU.4. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 months are considered adequately fed if they are receiving breastmilk and complementary food at least two times per day, while infants aged 9-11 months are also considered adequately fed when they are receiving breastmilk and eating complementary food at least three times a day. 75.1 63 65.3 72 69.3 79.1 74.4 69 70.6 43.2 26.5 24.8 33.2 34.1 26.8 28.5 30.5 29.9 0 10 20 30 40 50 60 70 80 90 North Central North East North West Soutn East South South South West Urban Rural Nigeria P er ce nt Figure NU.2 Percent of mothers who started breastfeeding within one hour and within one day of birth, Nigeria, 2007 Within one day Within one hour 17 Less than 12 percent of children aged 0-5 months are adequately fed i.e. exclusively breastfed. The figure is relatively low for those whose mothers have no education (eight percent) or who have non-formal education (three percent). The figures are also considered low for those in the rural areas (11 percent), North East (four percent), North West (seven percent), South East (seven percent), and poorest wealth quintile (nine percent). Children in the South West, children of mothers with secondary or higher education and children in the richest wealth quintile record moderate figures of 17, 18 and 18 percent respectively while the North Central has the highest figure (31 percent) among the six geopolitical zones. The percentage of infants aged 6-8 months who are adequately fed is 31 percent. There is a North-South disparity as the Southern zones show overall higher percentages (55, 47, and 35 percent for the South East, South South and South West respectively) than the Northern zones (38, 16, and 19 percent for the North Central, North East and North West respectively). Relative disparities over mother’s educational level and wealth quintiles for infants aged 6-8 months are similar to those for infants 0-5 months, but the figures are relatively higher for the former. Twenty-two percent of infants aged 9-11 months receive breastmilk and complementary food at least 3 times in the 24 hours preceeding the survey. Urban-rural variation is negligible. Zonal and sector differences remain and mother’s education still counts. Sex of child and wealth status also has some effect. The North Central, South East, South South and the fourth wealth quintile have the highest figures (34, 34, 32, and 28 percent respectively). Male children aged 9 – 11 months are slightly more likely to be adequately fed than their female counterparts (23 percent versus 21 percent). For this age group, children in the rural areas (23 percent) fare better than those in the urban (21 percent). Little zonal disparity exists but the North Central, South East and South South show relative higher percentages (32 to 34 percent) than the other zones (7 to 21 percent). Eighteen (18) percent of infants 9–11 months whose mothers have no education are adequately fed while 26 and 24 percent of those whose mothers have primary and secondary or higher education respectively are adequately fed. Effect of wealth of household is less noticeable. Twenty-eight percent of children in the fourth wealth quintile are adequately fed as against those in the remaining four quintiles for which percentages of adequately fed range between 18 and 22 percent. Figure NU.3 Infant feeding patterns by age: Percent distribution of children under 3 years by feeding pattern by age group, Nigeria, 2007 0 10 20 30 40 50 60 70 80 90 100 0- 1 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 24 -2 5 26 -2 7 28 -2 9 30 -3 1 32 -3 3 34 -3 5 Age (in Months) P er ce nt Weaned (not breastfed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed 18 As a result of these feeding patterns, only 27 percent of children aged 6-11 months are being adequately fed. The figure ranges from 23 percent for children in the poorest wealth quintile to about 29 percent for those in the fourth or fifth wealth quintiles, from 20 percent for children of mothers with no education to 30–34 percent for those of mothers with at least primary education, from 12-17 percent for children in North East and North West to 44 percent for those in South East; male-female and rural-urban disparities are marginal. Adequate feeding among all infants (aged 0- 11 months) drops to 19 percent. There is neither gender nor rural-urban disparity. Salt Iodization Iodine Deficiency Disorders (IDD) are the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In Nigeria, there has been a massive, concerted effort by the Federal Government through the National Food and Drug Administration and Control (NAFDAC) to ensure cheap availability and consumption of adequately iodised salt. In about 91 percent of surveyed households, salt used for cooking was tested for iodine content by using salt test kits for the presence of potassium iodate content. Table NU.5 shows that salt was not available for test in 4.4 percent of households as of the time of the survey. In 75 percent of the households, salt was found to be adequately iodized and contained 15 parts per million (ppm) or more of iodine; while 21 percent of households had iodized salt with less than 15 ppm of iodine. In all, about 96 percent of households in Nigeria use iodised salt. The figures for adeqauately iodised salt in rural and urban areas are 73 percent and 80 percent respectively. There are pronounced zonal disparities; in the northern zones, between 59 and 76 percent of households use adequately iodized salt against 81 and 86 percent of the households in the southern zones. State differences in the use of iodized salt are very high; it is lowest in Yobe (40 percent) and highest in Abia (90 percent), Cross-River (92 percent) and Imo and Oyo (94 percent each) and Enugu (95 percent) respectively. Eighty percent of urban households were found to be using adequately iodized salt as compared to 73 percent in rural areas. Use of adequately iodised salt increases with wealth status; it is lowest among households in the poorest wealth quintile and highest among those in the richest quintile. (Figure NU.4). 19 75.7 59.2 67.8 85.9 82.2 81.4 79.9 72.5 74.9 North Central North East North West South East South South South West Urban Rural Nigeria Figure NU.4: Percent of households consuming adequately iodized salt, Nigeria, 2007 Vitamin A Supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables. The amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted to all children between the ages of six to 59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programs, the definition of the indicator is the percent of children 6-59 months of age receiving at least one high dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Federal Ministry of Health recommends that children aged 6-11 months be given one high dose Vitamin A capsules and children aged 12-59 months be given 20 a vitamin A capsule every 6 months. The Federal Authorities subsidises purchase of Vitamin A supplement and, through NAFDAC, releases the product for free consumption by the needy. In some parts of the country, Vitamin A capsules are linked to immunization services and are given when the child has contact with these services after six months of age. It is also recommended that mothers take a Vitamin A supplement within eight weeks of giving birth due to increased Vitamin A requirements during pregnancy and lactation. Table NU.6 shows that 37 percent of children aged 6-59 months received a high dose Vitamin A supplement within the six months prior to the survey. Approximately four percent had the supplement but prior to last 6 months. About eight percent of children received a Vitamin A supplement at some time in the past but their mother/caretaker was unable to specify when. A male child is more likely to receive vitamin A supplementation than the female (38 percent versus 36 percent); the coverage is lower (32 percent) in rural than in the urban areas (46 percent). The coverage is highest in North Central and South East zones (58 and 55 percent respectively), moderate in South South and South West (47 and 51 percent respectively) and lowest in the North East and North West (17 and 18 percent respectively). Variation is very wide across States; coverage is lowest in Bauchi (six percent) and highest in Akwa-Ibom (82 percent). Improvement in mother‘s education or in wealth status enhances likelihood of Vitamin A supplementation. The percentage receiving a supplement in the last six months increases from 22 percent among children whose mothers have no education to 48 percent of those whose mothers have primary education and 52 percent among children of mothers with secondary or higher education. It also increases from 17 percent for children in the poorest wealth quintile to 35 percent of those in the middle (third) quintile to 55 percent among those in the richest quintile. Age of child is not really a factor but the coverage is greater at ages 6–23 months (39 percent) than at the other ages where the coverage figure declines to around 34 percent. Only about 33 percent of mothers with a birth in the two years preceeding the survey received a Vitamin A supplement within eight weeks of the birth (Table NU.7). The patterns of variation in vitamin A supplementation coverage for post-partum mothers across sectors, zones, levels of mother’s education and wealth quintiles respectively are generally as observed for coverage of vitamin A supplementation in children. Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams at birth) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive often have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have been found to predispose a newborn to be born with low birth weight: i) the mother's poor nutritional status before conception, ii) short stature (due mostly to poor nutrition and infections during her childhood), and iii) poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own 21 bodies have yet to finish growing run the risk of bearing underweight babies than do fully- developed individuals. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities; those who are represent only a selected sample of all births that is not representative of the overall population. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: i) the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large), and ii) the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth4. Table NU.8 shows that 14 percent of live births two years preceeding the survey weigh below 2,500 grams at birth. Wide variations exist among the zones ranging from 18 percent in the North East to 12 percent in the South South and North Central zones; the same pattern exists between sectors, and among the wealth quintiles and levels of education. Figure NU. 5 shows the percentage of underweight children; while children in the North east region had the highest (17.5%) underweight figure, children from the North east, rural, North west and South east each had underweight prevalence higher than the national average. 4 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. Figure. NU.5: Percent of infants weighing less than 2500 grams at birth, Nigeria, 2007 14.2 12.4 11.7 17.5 15.2 13.2 11.6 12.6 13.7 Rural Urban North central North east North west South east South south South west Nigeria 22 VI. CHILD HEALTH Immunization The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children who do not receive routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of oral polio vaccine (OPV), and, a measles vaccination-all by the age of 12 months. Mothers or caretakers of children were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. In Nigeria, the recommended schedule of immunization of the child is as follows: Age Vaccines At Birth BCG OPV0 HepB1 At age 6 weeks OPV1 HepB2 DPT1 At age 10 weeks OPV2, DPT2 At age 14 weeks OPV3 HepB3 DPT3 At age 9 months Measles Yellow fever Overall, 18 percent of children aged 12-23 months had health cards (Table CH.2). Male-female variation is insignificant, but the chance of the urban child having health card is twice that of the rural child (28 percent against 14 percent). There are wide North-South as well zone-zone disparities, the rates are lowest in the North (with a lowest zonal figure of less than one percent (0.5) in the North East) and highest in the South (with the highest zonal figure of 37 in the South South). Mother’s education and wealth status affect the chances of a child having health cards; less than six percent of children of mothers with no education have health cards as against 36 percent of children of mothers with secondary education or higher. The mother was asked to recall whether or not the child had received each of the vaccinations and, for DPT and Polio, how many times. The percentage of children aged 12-23 months who received each of the vaccinations is shown in Table CH.1. The denominator for the table comprises children aged 12-23 months so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the bottom panel, only those who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Fifty-one percent of children aged 12-23 months received a BCG vaccination by the age of 12 months against 52 percent of all children irrespective of age given. The first dose of DPT was given to 49 percent (46 percent by their first birthday). The percentage declines for subsequent doses of DPT to 41 percent for the second dose, and 30 percent for the third dose (39 and 28 percent respectively before their first birthday) (Figure CH.1). Similarly, 53 percent of children received Polio 1 by age 12 months and this declines to 43 percent by the second dose and 28 23 percent by the third; but the corresponding figures irrespective of age at vaccination are 56 percent Polio 1, 46 percent Polio 2 and 29 percent Polio 3. The differences between percentage of children vaccinated by age 12 months and for all ages suggest that a number of children were vaccinated out of time. The coverage for measles vaccine is 44 percent, 38 percent before their first birthday. The percentage of children who had all the recommended vaccinations by their first birthday is low at only 11 percent. Tables CH.2 and CH.2c show vaccination coverage rates among children 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ reports. There are real disparities in coverage of all type or levels of vaccination along rural-urban and North-South partitions of the country and along levels of education and wealth status respectively. The coverage is low in rural areas, in the North, among children with mothers with no education and among children in the poorest wealth quintiles; coverage figures are higher in the urban sector or in the South and highest among children of mothers with secondary education or higher or among children in the richest quintiles. Figure CH.1: Percent of children aged 12 - 23 months who received the recommended vaccinations by 12 months, Nigeria, 2007 50.5 46.4 39 28.1 37 52.5 43.4 27.5 38.3 10.9 BCG DPT 1 DPT 2 DPT 3 Polio 0 Polio 1 Polio 2 Polio 3 Measles All 24 In Nigeria, children aged between 12-23 months are supposed to receive vaccination against hepatitis B and yellow fever. About 38 percent of children in this age bracket are reported to have received first dose of HepB1; the figure declines to 32 and 24 percent respectively at the second and third doses. Thirty-six percent of the children had vaccination against yellow fever; while forty- four of children in the same age group received measles. Again, trends of coverage of BCG, Polio, and measles vaccinations along rural-urban sectors, geopolitical zones, levels of mother’s education, and wealth quintiles are repeated in the coverage of vaccination against yellow fever or hepatitis B. Tetanus Toxoid One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1000 live births in every district. A World Fit for Children goal is to eliminate maternal and neonatal tetanus by 2010. Prevention of maternal and neonatal tetanus is to enssure that all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during their current pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met: • Received at least two doses of tetanus toxoid vaccine, the last within the prior 3 years; • Received at least 3 doses, the last within the prior 5 years; • Received at least 4 doses, the last within 10 years; or • Received at least 5 doses during lifetime. Figure CH.2: Percent of women with a live birth in the last 24 months prior to the survey who are protected against neonatal tetanus, Nigeria, 2007 56.2 32 23.5 83.5 63.2 72.6 25.9 58 77.1 41.5 72.4 50.8 North central North east North west South east South south South west ZONES None Primary Secondary + EDUCATION Rural Urban SECTOR Nigeria 25 Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 24 months. Figure CH.2 shows the protection of women against neonatal tetanus by major background characteristics. Protection against tetanus toxoid was almost entirely from doses received during the last pregnancy. About 51 percent of women with a live birth in the 12 months preceding MICS3 Nigeria had protection against neonatal tetanus. Variation in protection varies from rural to urban areas, from the North to the South, from mothers with no education to mothers with secondary education or higher and from women in the poorest wealth quintile to those in the richest quintile assume similar patterns as variations in vaccination against other childhood diseases; the increase is from rural to urban, North to South, from ‘no education’ to ‘with education’ and from poorest to richest quintiles of households. Inter-state variation in probability of a woman with live birth within the 12 months to the survey having neonatal protection against tetanus is very wide; in three states of the North West zone (Kebbi, Sokoto and Zamfara), the probability is less than 12 percent while the figures for three states in the South East zone (Anambra, Imo and Abia) are over 85 percent. Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half death due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • (ORT or increased fluids) AND continued feeding In the MICS questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, about 10 percent of children under-five had diarrhoea in the two weeks preceding the survey (Table CH.4). Diarrhoea prevalence is higher in the rural than in the urban areas (11 percent against seven percent), higher in the Northern zones (10-13 percent) than in the Southern zones (5-9 percent), low in children under 6 months (six percent), rising to peak in children in the weaning period 6 to 23 months (13-14 percent), declining to seven percent in children aged 36-47 months and further declining to six percent in children aged 48-59 months. 26 Barely one in seven (14 percent) of under-five children with diarrhoea drank more than usual while 33 percent drank the same or less (Table CH.5). Forty-six percent ate somewhat less, same or more (continued feeding), but 54 percent ate much less or ate almost none. Given these figures, only 8 percent of the children who had diarrhoea were treated at home. Figure CH.3 shows percentage of mothers with a birth in the last 24 months protected against neonatal tetanus. Four out of every ten children under five years in the urban, North central and South east areas of the country who had diarrhoea received oral rehydration treatment. Sex of the child does not count. Figure CH.3: Percent of children aged 0 - 59 months with diarrhoea who received oral rehydration treatment, Nigeria, 2007 13.5 39.1 29.2 27.9 32.9 27.3 44.7 36.4 9.9 41.1 42.0 26.7 29.6 30.7 30.2 0 10 20 30 40 50 Non-Standard Secondary Primary None Mother's Education South West South South South East North West North East North Central Zones Urban Rural Sector Female Male Gender Nigeria 27 Combining the information in Table CH.5 with those in Table CH.4 on oral rehydration therapy, it is observed that 17 percent of children either received ORT or had their fluid intake increased, and at the same time, continued feeding as it is the recommendation. (Figure CH.4). Sex of child, rural-urban and north-south dichotomies, and age of child are not important factors in home management of diarrhoea. However mother’s education and wealth status are relevant. Children of mothers with secondary education or higher and those in richest wealth quintile are the most likely to use ORT in home management of diarrhoea (39 and 50 percent respectively). Care Seeking and Antibiotic Treatment of Pneumonia Globally, pneumonia is the leading cause of death in children and the use of antibiotics in under- fives with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia Figure CH.4: Percent of children aged 0 - 59 months with diarrhoea who received oral rehydration treatment or increased fluids and continued feeding, Nigeria, 2007 7.8 23.8 16.8 15.4 20.5 16.0 19.2 17.7 14.5 18.1 20.7 16.2 17.3 0 5 10 15 20 25 Non-Standard Secondary Primary None Mother's Education South West South South South East North West North East North Central Geo-political zones Urban Rural Area Nigeria Percent 28 Table CH.6 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Two percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Prevalence of suspected pneumonia is consistent irrespective of levels of background characteristics. Forty-one percent of children suspected to have pneumonia were taken to an appropriate health provider; the figure includes 23 percent to government-owned hospital, health centre or health post and 10 percent to private hospital. Only 25 percent of those in the poorest wealth quintile sought appropriate provider with disproportionate 10 and five percent respectively from private hospital and from government hospitals. Fifty-four percent of children in the richest quintile patronize appropriate provider, almost half of them (26 percent) use government hospital. Country-wide, 41 percent of the children make use of any appropriate provider. The percentage of children who made use of appropriate health provider is lowest in the poorest wealth index quintile, stable at about 42 percent at the intermediate quintiles and highest at 54 percent in the richest quintile. Sex differential is not pronounced, but effect of education of mother seems to be only in terms of whether or not the mother has or has not education. Thirty percent of children of mothers with no education use appropriate provider, while 50 percent of children of mothers with primary education use government hospital. Forty-six percent of children of mothers with secondary education or higher use appropriate provider but just a third of the number use government hospital. However, of the 50 percent of children of mothers with primary education patronizing appropriate provider just about a quarter (13 percent) use government hospitals. The under-one year old makes the most use of appropriate provider (51 percent), the 12-35 months old makes the least use (32-34 percent) while the 36-59 month old make the relatively moderate use (44-45 percent). They each make proportionate use of government-owned health establishments. Table CH.7 presents the use of antibiotics for the treatment of suspected pneumonia in under-fives by sex, age, region, residence, and socioeconomic factors. In Nigeria, 46 percent of under-five children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. The percentage was considerably higher in the urban areas than in the rural (59 percent versus 41 percent); antibiotic treatment of pneumonia was most prevalent among infants i.e. 0-11 months and 36-47 months old (56-59 percent), and least prevalent among 12-35 months old (34- 35 percent). The table also shows that antibiotic treatment of suspected pneumonia is very low among the poorest households (29 percent), and among children whose mothers/caretakers have no education (35 percent). Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7A. Obviously, mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, 24 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is ‘develop a fever’. Thirty-two percent of mothers identified fast breathing and 40 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Although wealth status, level of education, rural-urban and north-south geographical location hardly affect knowledge of danger signs of pneumonia in children, development of fever is more easily identified by the educated than by the uneducated mothers; by the rich than by the poor quintiles and by the urban mothers/caretakers than by their rural counterparts. Blood in stool and drinking poorly are identified as danger signs of pneumonia by 29 and 19 percent of mothers/caretakers respectively. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. The use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth 29 weight, cataracts, and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Solid fuels include wood, charcoal, straw/shrubs/grass, animal dung and agricultural crop residue. Tables CH.8 and CH.9 summarise use of solid fuels and other cooking materials by background characteristics. Overall, 75 percent of households in Nigeria are using solid fuels for cooking including 70 percent using wood. Differentials in use of solid fuels with respect to household wealth, education of the household head, rural-urban and north-south geopolitical zones or states are only too obvious. Use of solid fuels is predominant in the rural areas (92 percent), in the North East geopolitical zone (95 percent), in households where the household heads have no education (93 percent) and among households in the first three wealth quintiles (99, 97, 94 percent respectively); it is least among the richest quintile (22 percent) and averagely in the urban areas (41 percent) and among households headed by persons with at least secondary education (48 percent). The solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. The type of stove used with a solid fuel is depicted in Table CH.9. The findings show that overwhelming proportion (94 percent) of households using solid fuels for cooking use open stove or fire with no chimney or hood; this relative use is neither a rural-urban issue nor a matter of level of education of the household head, nor really affected moderated by wealth status although it is slightly less prevalent among the rich in the population (4th and 5th quintiles; 92 and 90 percent respectively) than the poorest and the second quintiles (about 94 percent against 95 percent). Malaria Malaria is a leading cause of death of children under age five in Nigeria. It also contributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of insecticide-treated mosquito nets (ITNs), can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti-malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. Also, children recovering from malaria should be given extra liquids and food and, for younger children, should continue breastfeeding. The questionnaire incorporates questions on the availability and use of bed nets, both at household level and among children under five years of age, as well as anti-malarial treatment, and intermittent preventive therapy for malaria. In Nigeria, the survey results indicate that four percent of households have at least one insecticide treated net (Table CH.10). Possession of mosquito nets is associated with place of residence (urban versus rural), education of household head and wealth status; it increases from rural areas (three percent) to urban areas (five percent), from households with uneducated heads (one percent) to those with at least secondary education (eight percent) and from the poorest households (one percent) to the richest households (nine percent). Geopolitical zones are hardly a factor although state differentials are strong. Figures of percentage of households with at least one mosquito net whether treated or untreated are just marginally higher than those of households with at least one ITN and the trends are similar across regimes of associated factors. Table CH.11 shows that four percent of children under the age of five slept under any mosquito net the night prior to the interview, only slight gender disparities in favour of the females in ITN use among children under five. Children in urban areas are twice likely to sleep under mosquito nets than their rural counterparts (six percent versus three percent); this chance decreases from six percent at infant to three percent at age 48-59 months and from nine percent in the richest 30 households to one percent in the poorest households. The figure is higher in the South courtesy of South East (7 percent) and South South (nine percent) than in the North (3-4 percent). Percentage of children under-five sleeping under ITNs are fractions less than percentage of those sleeping under any net at all and the relative trends are quite similar across levels of associated factors. Questions on the prevalence and treatment of fever were asked for all children under age five. One in eight (13 percent) of under-five children were ill with fever in the two weeks prior to the survey (Table CH.12). Fever prevalence declined with age and peaked at 12-23 months (15 percent). Fever is slightly less common in the urban areas (12 percent) than in the rural areas (13 percent), in the South (19-20 percent) than in the North (10-12 percent) and among female children (12 percent) than among the male (13 percent). Incidence of fever depicts an unusual relationship with mother’s education and wealth status respectively; the incidence peaking at the intermediate level. Regional differences in fever prevalence are expectedly large; prevalence is higher in the humid, wet South East and South South (19-20 percent) and lower in the arid North (10-12 percent). Mothers were asked to report all of the medicines given to a child to treat the fever, including both medicines given at home and medicines given or prescribed at a health facility. Overall, 52 percent of children with fever two weeks preceeding the survey were treated with an “appropriate” anti-malarial drug; the figure increases from 35 percent in the poorest households to 69 percent in the richest, from 46 percent of affected children of mothers with no education to 61 percent in the cases of mothers with secondary education or higher, from 48 percent of children in the rural areas to 63 percent of their peers in the urban areas and from 51 percent of the females to 53 percent of the males. Age of child does not seem to matter, but geopolitical zonal differences exist. Thirty-six percent of children with fever two weeks prior to the survey received anti-malarial drugs within 24 hours of onset of symptoms; this is a drop of some 40 percent from the 52 percent recorded of children treated with appropriate anti-malarial drug. This drop pattern is replicated in almost all classifications of the affected children population. Thus, urban children are more likely than rural children to be treated appropriately as are the children of mothers with secondary or higher education. Little difference was noted between boys and girls receiving appropriate anti-malarial drugs. “Appropriate” anti-malarial drugs include chloroquine, SP, artemisine combination drugs, etc. In Nigeria, 36 percent of children with fever were given armodiaquine, and seven percent, SP. Five percent were given quinine while only two percent received artemisine combination therapy. A large percentage of children (over 59 percent) were given other types of medicines that are not anti-malarials, including anti-pyretics such as paracetemol, aspirin, or ibuprofen; a substantial 17 percent were given other unspecified non anti-malarial drugs. Pregnant women living in places where malaria is highly prevalent are four times more likely than other adults to get malaria and twice as likely to die of the disease. Once infected, pregnant women risk anaemia, premature delivery and stillbirth. Their babies are likely to be of low birth weight, which makes them unlikely to survive their first year of life. For this reason, steps are taken to protect pregnant women by distributing ITNs and treatment during antenatal check-ups with drugs that prevent malaria infection (Intermittent preventive treatment or IPT). In Nigeria’s MICS3, women were asked of the medicines they had received in their last pregnancy during the 2 years preceding the survey. Women are considered to have received intermittent preventive therapy if they have received at least 2 doses of SP/Fansidar during the pregnancy. Intermittent preventive treatment for malaria in pregnant women who gave birth in the two years preceding the survey is presented in Table CH.13. Fifteen percent of these women took medicine to prevent malaria during pregnancy but only three percent took SP two or more times and three percent took chloroquine. There are highly visible disparities between rural and urban sectors (26 percent vs 11 percent), between levels of education and between wealth quintiles. The figures are highest at the richest quintile (35 percent), at secondary education or higher (31 percent) and in 31 the South East (37 percent). It is lowest (four percent) among women in the poorest wealth quintile, women with no education and women in the North West respectively. Sources of Supplies In MICS3 Nigeria, questions were included to collect information on the sources and costs of four types of supplies: insecticide treated nets, antimalarials, antibiotics, and oral rehydration salts. Such information is very important in the sense that it makes possible a population-based assessment of the reach of programs and the extent to which particular target groups are covered by the programs. Such information is also useful for monitoring the provision of free or subsidized supplies, and for the assessment of costs of supplies, since prices of supplies can be a barrier to use of the supplies. For programme managers who want to find out public and private shares in the provision of the supplies, and of the relative importance of each source, information on sources and costs of supplies can be crucial. The source and cost of supplies for insecticide treated nets (ITNs) was not covered in Nigeria’s MICS3. Policies and practices on ITN availability and use are just developing and information details on its sources and costs are scanty and possibly inaccurate. Identifying types of ITN was a problem. The source and cost of supplies for antimalarials in children under five years of age are presented in Table CH.15. Overall, thirty-two percent of antimalarials come from public sources, 39 percent from private and 29 percent from other sources. Only 16 percent were free, divided in the ratio 3:13 between public and private sources. The children of richest households or the most educated mothers (secondary education or higher) obtain least from public sources (both 28 percent), least from other sources (both 25 percent) and most (both 48 percent) from private sources. Urban-rural and male-female disparities in proportions of supply from public sources are relatively small but while gender differences in supplies from either private or other sources are further bridged, such disparities are widened but in opposite direction in respect of the two sources. This pattern is also true between other two levels of education. 32 VII. ENVIRONMENT Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in MICS3 Nigeria is as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child’s faeces The distribution of the population by source of drinking water is shown in Table EN.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot), public tap/standpipe, tubewell/borehole, protected well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. Overall, 49 percent of the population is using an improved source of drinking water – 76 percent in urban areas and 37 percent in rural areas. There are North-South as well as zone-zone disparities; the percentage in the Northern zones ranges between 27 and 42 percent and in the Southern zones between 54 and 73 percent. South west recorded the highest figure (73 percent) while North east recorded the least (27 percent). State figures range from 18 percent in Gombe to 80 percent in Oyo. Education of the household head and wealth status are critical factors; the likelihood of the household using improved sources of water increases as the level of education of the household head increases or as wealth status improves. Fourteen percent of households in the poorest wealth quintile use improved source of water against 81 percent of households in the richest quintile; the figure is 66 percent among households headed by persons with secondary education or higher as against 37 percent among those headed by persons with no education. The main sources of drinking water for the population are public tap/standpipe, tubewell or borehole, and protected well; but the relative importance of each of these sources varies over States and geopolitical zones but tubewell/borehole has constant dominance. Use of in-house water treatment is presented in Table EN.2. Households were asked of ways they may be treating water at home to make it safer to drink – boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment 33 methods, separately for all households, for households using improved and unimproved drinking water sources. Boiling, adding bleach or chlorine and using a water filter are practised but relative popularities of the three methods vary across states, geopolitical zones, wealth quintiles and levels of education. The table shows that for all drinking sources, only 7.8 percent of households use appropriate water treatment method. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. Note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. Table EN.3 shows that for 17 percent of households, the drinking water source is on the premises. For almost half of all households, it takes less than 30 minutes to get to the water source and bring water, while 11 percent of households spend more than 1 hour for this purpose. Excluding those households with water on the premises, the average time to the source of drinking water is, overall, 30 minutes, 33 minutes in the rural and 23 minutes in the urban areas. Households in the richest quintile of the population take 19 minutes to get to their source of drinking water and those in the poorest quintile takes twice that time. Households headed by persons with no education take as much as 32 minutes as against 26 minutes by those headed by persons with at least secondary education. The table shows that households in North east zone take the longest among zones, 42 minutes as against a lowest average 21 minutes in the North West. State figures range from 12 minutes in Lagos State to 65 minutes in Benue. Table EN.4 shows that in 81 percent of the cases, an adult collects water when the source of drinking water is not on the premises. This percentage is shared between the adult females (46.6 percent) and adult males (34.5 percent). In 18 percent of the cases, water is collected by persons below the age of 15 years, (10 percent by the female and eight percent by the male). Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoea diseases and polio. Improved sanitation facilities for excreta disposal include: flush or pour flush to a piped sewer system, septic tank, or latrine; ventilated improved pit latrine, pit latrine with slab, and composting toilet. Forty-three percent of the population of Nigeria is living in households using improved sanitation facilities (Table EN.5). This percentage is 70 in urban areas and 31 percent in rural areas. The table indicates that use of improved sanitation facilities has strong positive association with education of the household head and wealth of the household, but is profoundly different between urban and rural areas. The rural population at best use pit latrines with slabs but mostly using pit latrines without slabs (32 percent), or simply have no facilities (28 percent). In contrast, the most common facilities in urban areas are pit latrine with slab (29 percent), flush toilets with connection to a septic tank (16 percent) or a sewage system (10 percent). Only 16 percent of the poorest quintile use sanitary means of excreta disposal; 39 percent use pit latrines without slabs, 42 percent using no facilities and less than 15 percent using pit latrines with slabs; these three means remain the most popular among households except those in the richest quintile of which about 60 percent use the more sanitary means. Households whose heads have no education have excreta disposal habits as those in the rural areas; pit latrine with slabs is their most popular sanitary means (25 percent), without slabs is 35 percent most popular while as many as 31 percent has no facilities; households where the heads have at least secondary education fare just a little less than the richest quintile of the population. Safe disposal of a child’s faeces is disposing of the stool, by the child using a toilet or by rinsing the stool into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table EN.6. It is only in about 60 percent cases that child’s faeces are safely disposed off. Education does not seem important but disparities along rural-urban line, geopolitical zoning and wealth status are quite strong. About 73 percent of the North East or 75 percent of the North West practice safe disposal of child’s stools; the figure declines to 56 percent in the South West and to 29 percent in the North Central. Safe disposal of children’s faeces is practised by only 48 percent 34 of the poorest families with the figure rising to a maximum figure of 81 percent among the richest 20 percent of the population. An overview of the percentage of household members using improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. Overall, less than 28 percent of the household members use improved sources of drinking water and sanitary means of excreta disposal. Sectors, geopolitical zones, education and wealth status all respectively show strong association with these habits. A remarkably low percentage (one percent) of the poorest quintile combines the two healthy habits, about 14 percent of households headed by persons with no education and less than 16 percent of the rural households respectively do so. North-South disparity is strong and in favour of the South. 35 VIII. REPRODUCTIVE HEALTH Contraception Appropriate family planning is important to the health of women and children by: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and 3) limiting the number of children. A World Fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Current use of contraception was reported by 15 percent of women currently married or in union (Table RH.1), nine percent use modern methods while six percent use traditional methods. In Nigeria, the most relatively popular methods, if we can actually say so, are injectables (3.4 percent), the Pill (2.5 percent) while periodic abstinence and codom recorded two percent respectively; IUD, LAM, and withdrawal are each practised by about one percent of women currently married or in union. Female sterilization and other vaginal methods fail to make an impression. Contraceptive prevalence is highest in the South West at 35 percent and next highest (22 percent) in the South South geopolitical zones; contraceptive use is rarest in the North East where prevalence is two percent of married women; all these point to very strong disparities among geopolitical zones. Age of woman, parity (number of children already had by the woman), education of the woman, place of residence (urban or rural), and wealth status have very significant effects on contraceptive use. Adolescents are far less likely to use contraception than older women. Only four percent of married or in union women aged 15-19 and eight percent of those aged 20-24 years currently use a method of contraception; contraceptive prevalence is highest among women aged 35-39 where it is 20 percent but declines to 16 percent each among 40-44 and 45-49 year old women in marriage or in union. As age is usually highly associated with parity, the pattern of variation in contraceptive use across age of women is replicated across number of children per woman; the prevalence is a negligible two percent among women without any child, rising to 12 percent among those with 1 child and levels up at 18 percent among women with 3 or more children. The percentage of women using any method of contraception rises from under five percent among those with no education to 20 percent among women with primary education, and to 30 percent among women with secondary or higher education. This pattern is also reflected across wealth classes; a meagre figure of three percent prevalence among women in the poorest quintile rises to 10 percent among those in the intermediate wealth class and to 33 percent among the richest women. It appears that the relative disparity within categories of factors like education, age of women, number of children per woman, residence and wealth status is consistent across methods. Unmet Need Unmet need5 for contraception refers to fecund women who are not using any method of contraception, but who wish to postpone the next birth or who wish to stop childbearing altogether. Unmet need is identified in Nigeria’s MICS3 by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity, and fertility preferences. Women in unmet need for spacing includes women who are currently married (or in union), fecund (are currently pregnant or think that they are physically able to become pregnant), currently not 5 Unmet need measurement in MICS is somewhat different than that used in other household surveys, such as the Demographic and Health Surveys (DHS). In DHS, more detailed information is collected on additional variables, such as postpartum amenorrhoea, and sexual activity. Results from the two types of surveys are strictly not comparable. 36 using contraception, and want to space their births. Pregnant women are considered to want to space their births when they did not want the child at the time they got pregnant. Women who are not pregnant are classified in this category if they want to have a (another) child, but want to have the child at least two years later, or after marriage. Women in unmet need for limiting are those women who are currently married (or in union), fecund, currently not using contraception, and want to limit their births. The latter group includes women who are currently pregnant but had not wanted the pregnancy at all, and women who are not currently pregnant but do not want to have a (another) child. Total unmet need for contraception is simply the sum of unmet need for spacing and unmet need for limiting number of children. Using information on contraception and unmet need, the percentage of demand for contraception satisfied is also estimated from Nigeria’s MICS3 data. The percentage of demand for contraception satisfied is defined as the proportion of women currently married or in union who are currently using contraception, of the total demand for contraception. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting), plus those who are currently using contraception. Table RH.2 shows the results of the survey on contraception, unmet need, and whether the demand for contraception is satisfied. In Nigeria, 20 percent of women currently married or in union reported unmet need for contraception, 13 percent in respect of child spacing and seven percent in limiting number of children wanted. Forty-three percent said that their demand about contraception is satisfied. Area of residence, education and wealth status respectively affect perception of the woman on the extent to which her demands for contraception have been met. The urban woman is twice more satisfied than her rural counterpart ( 62 percent against 32 percent satisfied), the educated also feels a lot more satisfied, 49 and 62 percent satisfaction felt by women with primary and secondary/tertiary education respectively contrasted against 19 percent satisfaction by counterparts with no education. Satisfaction that demands for contraception increases as wealth status improves; it is lowest among women in the poorest wealth quintile and rises systematically to over 66 percent among women in the richest quintile. Age is also a factor; the younger woman feels less satisfied than the older one; level of satisfaction peaks at 51 percent at age group 35-39 years but wanes to about 43 percent among women aged 40-49 years. State or regional differentials are large; generally, the northern woman feels less satisfied than her southern counterpart; the differentials could be a matter of differences in cultural attitude, level of education and even religion. Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The prevention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women's nutritional status and prevent infections (e.g. malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. 37 WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: • Blood pressure measurement • Urine testing for bateriuria and proteinuria • Blood testing to detect syphilis and severe anaemia • Weight/height measurement (optional) Table RH.3 shows that coverage of antenatal care (by a doctor, nurse, or midwife) is relatively high in Nigeria with 61 percent of women receiving antenatal care at least once during the pregnancy. There is a strong North-South disparity; the lowest level of antenatal care is found in North West geopolitical zone (35 percent) while the highest level is in the South East (91 percent). Antenatal care coverage is some 36 percent more in urban areas (86 percent) compared to rural areas (51 percent). Probability of the women seeing skilled health personnel for antenatal care is highly associated with education, age and wealth status; it is 44 percent for teenage mothers (15-19 years), rises to peak at 67 percent for women at the intermediate age group 30-34 years and declines to 54 percent for women aged 45-49 years; the chance is under 35 percent for women with no education, 71 percent for those with primary education and over 88 percent for women with secondary education or higher; the probability is least (24 percent) for women in the poorest quintile, 59 for those in the middle wealth quintile and 93 percent for those in the richest quintile. The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding the survey is also presented in Table RH.3. In Nigeria, the chance is greater that women visit the nurse/midwife more than the doctor for antenatal care (38 percent versus 22 percent); the relative disparity in prevalence of visits to the doctor and the nurse/midwife widens at the lower levels of education and wealth status of the women and in the rural areas or geopolitical zones where the overall probability of the woman seeing skilled health personnel is relatively low. The types of services pregnant women received are shown in table RH.4. Forty-eight percent have blood sample taken, 59 percent of women attending antenatal care have their blood pressure taken, 48 percent have urine sample take while 58 percent have blood sample taken. These figures vary across areas of residence, geopolitical zones, age and level of education of the women, but the relative trend within each background characteristic is quite similar. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of an emergency. A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. MICS3 Nigeria included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. About 44 percent of births occurring in the two years prior to the survey were delivered by skilled health personnel (Table RH.5). This percentage is highest in the South East at 85 percent and South West at 80 percent, moderate in the South South (51 percent) and North Central (46 percent); the percentage is lowest at 12 percent in the North West. The more educated the woman or the richer her household, the more likely she is to have delivered with the assistance of a skilled attendant; the percentage rises from 15 percent among women with no education to 50 percent for women with primary education and to 77 percent among those with secondary education or higher and from 12 percent among the poorest quintile to 34 percent of women in the middle quintile to 85 38 percent among the richest quintile class. In the rural areas, percentage of women assisted during delivery in the period is 32 percent compared to 73 percent in the urban areas. Overall, about one in three (31 percent) of the births in the two years prior to the survey were delivered with assistance of a nurse/midwife. Doctors assisted with the delivery of 12 percent of births and two percent by auxiliary midwife. Deliveries by traditional birth attendants (TBA) were 20 percent and by relatives and friends 22 percent; there were no attendants in 10 percent of the cases. The relative disparity in the figures of percentage deliveries with assistance of doctors, nurses or midwives, and auxiliary midwives respectively remains substantially similar across background characteristics. Also disparity in overall percentages over different levels of background characteristics is sustained in relative context for each group of skilled personnel. Maternal Mortality The complications of pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. It is estimated worldwide that around 529,000 women die each year from maternal causes. And for every woman who dies, approximately 20 more suffer injuries, infection and disabilities in pregnancy or childbirth. This means that at least 10 million women a year incur this type of damage. The most common fatal complication is post-partum haemorrhage. Sepsis, complications of unsafe abortion, prolonged or obstructed labour and the hypertensive disorders of pregnancy, especially eclampsia, claim further lives. These complications, which can occur at any time during pregnancy and childbirth without forewarning, require prompt access to quality obstetric services equipped to provide lifesaving drugs, antibiotics and transfusions and to perform the caesarean sections and other surgical interventions that prevent deaths from obstructed labour, eclampsia and intractable haemorrhage. One MDG target is to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. Maternal mortality is defined as the death of a woman from pregnancy-related causes, when pregnant or within 42 days of termination of pregnancy. The maternal mortality ratio is the number of maternal deaths per 100,000 live births. In MICS, the maternal mortality ratio is estimated by using indirect sisterhood method. To collect the information needed for the use of this estimation method, adult household members are asked a small number of questions regarding the survival of their sisters and the timing of death relative to pregnancy, childbirth and the postpartum period for deceased sisters. The information collected is then converted to lifetime risks of maternal death and maternal mortality ratios6. There are serious doubts about the credibility of MICS3 Nigeria result on maternal mortality. It has poor internal or external comparability; there are also difficulties in explaining the figures in terms of health and social indicators emanating from the survey; furthermore, the authors of the sisterhood method that was recommended and used in the calculations reiterated the weakness of the method and the limited usability of the outcome; the burden on memory of the respondents has been quite tremendous and the reference point of twelve years also detracts significantly from its reliability as estimate of the true mortality rate. For these reasons and many more, the results of maternal mortality rate is not published. 6 For more information on the indirect sisterhood method, see WHO and UNICEF, 1997. 39 IX. CHILD DEVELOPMENT It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, adult activities with children, presence of books in the home for the child, and the conditions of care are important indicators of quality of home care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting, or drawing things. For almost two-thirds (65 percent) of under-five children, an adult engaged in more than four activities that promote learning and school readiness during the 3 days preceding the survey (Table CD.1). The average number of activities that adults engaged with children was 4. The table also indicates that the father’s involvement in such activities was limited (0.7 percent). Father’s involvement with one or more activities was only 35 percent. Ten percent of children were living in a household without their fathers. There are no gender differentials in terms of adult activities with children; however, a larger proportion of fathers engaged in activities with male children (36 percent) than with the female (33 percent). Slightly larger proportions of adults engaged in learning and school readiness activities with children in urban areas (70 percent) than in rural areas (62 percent). Strong differentials by geopolitical zones, states and socio-economic status are also observed. The older children in age bracket 24-59 months are more engaged (75 percent) in activities that promote learning and school readiness than their under-2 year counterparts (49 percent). Adult engagement was greater in the 3 southern zones (71-79 percent) than in the Northern zones (54-70 percent); the figure was 75 percent for children living in the richest households as opposed to those living in the poorest households (56 percent). Father’s involvement showed a similar pattern in terms of adults’ engagement in such activities. It is noteworthy that more educated mothers and fathers engaged more in learning and school readiness activities with children than those with less education on all the four indicators. State disparities in terms of adult activities with children aged 0-59 months for whom household members engaged in four or more activities that promote learning and school readiness are too wide; the range is from 21 percent in Yobe and 27 percent in Jigawa to over 80 percent in a number of states particularly Bayelsa where it is 92 percent. The results show that Borno has a higher (74 percent) than Yobe (21 percent), so also Kano (70 percent) and Jigawa (27 percent). A further analysis will be required to explain the observed differences. Exposure to books in early years not only provides the child with greater understanding of the nature of print, but may also give the child opportunities to see others reading, such as older siblings doing school work. Presence of books is important for later school performance and IQ scores. In Nigeria, 35 percent of children are living in households where at least 3 non-children’s books are present (Table CD.2). However, only 14 percent of children aged 0-59 months have children’s books. Both the median number of non-children’s books and children’s books are low, lower than 1. While virtually zero gender differentials are observed, urban children appear to have more access to both types of books than those living in rural households. Fifty-one percent of under-five children living in urban areas live in households with more than 3 non-children’s books, while the figure is 29 percent in rural households. The proportion of under-five children who have 3 or more children’s books is 26 percent in urban areas, compared to nine percent in rural areas. The presence of both non-children’s and children’s books is positively associated with the child’s age; 40 in the homes of 39 percent of children aged 24-59 months, there are 3 or more non-children’s books, while the figure is 31 percent for children aged 0-23 months. Education and wealth status of the mother also count; the figure 19 percent in respect of mothers with no education rises to 56 percent in the case of mothers with secondary education or higher; similarly the figure increases from 12 percent in the poorest households to 62 percent in the richest households. Similar differentials exist in terms of children’s books. There are no gender differentials in proportions of children who have 3 or more playthings, or who play with homemade toys or who play with toys from the store. Urban-rural and children age differentials are observed; proportions of urban children having 3 or more toys or having homemade toys respectively to play with than their rural counterparts; but the differential is reversed in favour of the rural children in respect of ‘toys from the store’. This rural-urban movement is also observed in mother’s education, social economic status and child’s age as the proportions of children having 3 or more toys and having homemade toys each increases from children whose mother’s have no education to those of mothers with education, from children of the relatively poor households to those from the relatively rich and from children aged 0-23 months to those aged 24-59 months; the reversed is repeated in respect of proportions of children playing with toys from the store. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. In Nigeria’s MICS3, two questions were asked to find out whether children aged 0-59 months were left alone during the week preceding the survey, and whether children were left in the care of other children under 10 years of age. Table CD.3 shows that during the week preceding the survey, 35 percent of children aged 0-59 months were left in the care of other children, 19 percent were left alone and on the whole 38 percent of children were left in inadequate care during the time. In all the 3 care indicators, only 1 percent separates the males from the females with the males suffering the higher level of abandonment to the care of non-parents. Greater proportion of the rural children than urban children were left to the care of other children (38 percent versus 29 percent) or left in inadequate care (40 percent versus 33 percent). Inadequate care was most prevalent among children whose mothers had primary education than among other children; but the difference is somehow bridged in respect of children left in nobody’s care. Again all the three care indicators show that children aged 24-59 months were worse off than those aged 0-23 months; the older children have 50 percent more chance to be left under any inadequate care than their younger counterparts. Wealth of the household makes some difference; the two poorest quintiles, the third and fourth quintiles, and the richest quintile respectively form distinct social echelons. Twenty-seven percent of the children in the richest echelon are left in the care of other children, 36 percent of children of the middle echelon and 39 percent of the children of the two poorest classes have similar experience. In the case of children left under inadequate care, the corresponding figures are 32, 38 and 32 percent respectively; and in respect of children left alone, the figures are 14, 19 and 22 percent respectively. 41 X. EDUCATION Pre-School Attendance and School Readiness Attendance to pre-school education in an organized learning or child education program is important for the readiness of children to school. One of the World Fit for Children goals is the promotion of early childhood education. About one in three (32 percent) of children aged 36-59 months are currently attending pre-school at the time of the survey (Table ED.1). Urban-rural and zonal differentials are significant – the figure is as high as 57 percent in urban areas, compared to 21 percent in rural areas. Among children aged 36-59 months, attendance to pre-school is more prevalent in the South where it ranged from 47 percent in the South South to 54 percent in the South East and to 74 percent in the South West; these figures are higher than those in the North where pre-school attendance ranged from four percent in the North East to 26 percent in North Central. Education of the mothers is critical as it is only 10 percent of children of mothers with no education; the figure rises to 41 percent among those whose mothers have primary education and to 64 percent of the children of mothers with at least secondary education. Gender differential is negligible, but differentials by socioeconomic status are significant. Seventy percent of children living in richest households attend pre-school, while the figure drops to five percent in poor households. Proportion of children aged 36-47 months attending pre-school is 10 percent less than for children aged 48-59 months (28 percent versus 38 percent). Table ED.1 also shows the proportion of children in the first grade of primary school who attended pre-school the previous year, an important indicator of school readiness. Overall, 83 percent of children who are currently aged 6 and attending the first grade of primary school were attending pre-school the previous year. Gender differential is not significant but rural-urban disparity is strong, a higher figure of 91 percent in the urban areas declining to 78 percent in the rural areas. Regional differentials exist; first graders in the North East geopolitical zone have 41 percent pre- school attendance rate, the corresponding figure is 57 percent for North West. This is against over 80 percent rate in each of the other zones. Socioeconomic status and mother’s education each appears to have a positive association with school readiness; the indicator is 55 percent among the poorest households, and increases to 95 percent among those children living in the richest households; and the figure 71 percent among children of mothers with no education rises to 93 percent in children of mothers with secondary education or higher. Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. The indicators for primary and secondary school attendance include: • Net intake rate in primary education • Net primary school attendance rate • Net secondary school attendance rate • Net primary school attendance rate of children of secondary school age • Female to male education ratio (or gender parity index - GPI) The indicators of school progression include the following: • Survival rate to grade five • Transition rate to secondary school 42 • Net primary completion rate In Nigeria, proportion of children of primary school entry age (age 6) attending grade 1 is generally low; it is 44 percent overall (Table ED.2). Sex differentials do not exist; however, significant differentials are observed across geopolitical zones and states and urban-rural areas. North-South disparity is very strong; the North East and North West zones have 10 and 30 percent of children of primary school entry age in grade 1 with Taraba, Yobe, Bauchi and Borno states, all in the North East, reporting 5, 7, 8 and 11 percent respectively. The southern zones recorded relatively high figures ranging between 72 and 76 percent with Abia, Akwa-Ibom, Anambra, Lagos and Enugu States having between 70 and 85 percent respectively. Children’s participation in primary school is timelier in urban areas (59 percent) than in rural areas (39 percent). A positive association between mother’s education and socioeconomic status is observed; for children aged 6 years whose mothers have at least secondary school education, 69 percent were attending the first grade; this is against 30 percent of their counterparts by mothers with no education. In richest households, the proportion is around 69 percent, while it is just 20 percent among children living in the poorest households. Primary school net attendance ratio (NAR) is the proportion of children of primary school age i.e. ages 6 to 11 years attending school whether primary or secondary. In Nigeria, just over 64 percent of children of primary school age are attending school including 66 percent of the males and 62 percent of the females (Table ED.3). A North-South and rural-urban trend is noticeable and there is a positive association between primary school NAR and education of mother and social economic status of the household. In the urban sector, 4 out of every 5 (81 percent) children of primary school age are in school as against less than 3 out of every 5 (58 percent) in the rural areas. Primary school net attendance ratio is 14 percent in the North East, 48 percent in the North West, 84 percent further South in the North Central, and over 95 percent in any of the Southern zones. Ninety-six percent of children of primary school age by mothers with at least secondary education are attending school as against 46 percent of such children whose mothers have no education and 91 percent for the same category of children having mothers with primary education. The primary school net attendance ratio for children in richest households is 92 percent; the figure declines quite systematically to 32 percent in the case of counterpart children in the poorest households. Trend of relative disparities in primary school NAR across socio-economic status of households, education of mother, rural-urban sectors, geopolitical zones and states is identical for both sexes; it is not gender-specific. The secondary school net attendance ratio as indicated in Table ED.4 is 51 percent; there is no gender differential. In the urban sector about 2 out of every 3 (67 percent) children of secondary school age are in school as against more than 2 out of every 5 (43 percent) in the rural areas. Secondary school net attendance ratio is least in the North-East (eight percent), North West (30 percent), 59 percent in the North Central, 70 percent in the South East, 72 percent in the South South and South West (78 percent). Seventy-eight percent of children of secondary school age by mothers with at least secondary education are attending school as against 34 percent of the children whose mothers have no education and 64 percent in the case of same category of children with mothers having primary education. The secondary school net attendance ratio for children in richest households is 79 percent; the figure declines quite systematically to 17 percent in the case of their counterparts in the poorest households. Trend of the disparities in secondary school NAR across socio-economic status of households, education of mother, rural-urban sectors, and geopolitical zones/states is not consistent over sex, it is gender-specific. The primary school attendance ratio of children of secondary school age is presented in Table ED.4W. Fourteen percent of the children of secondary school age are attending primary school when they should be attending secondary school. The remaining 36 percent are not attending school at all; they are children out of school since we already indicated that 50 percent of them were attending secondary school. Proportion of children of secondary school age that are attending primary school is greater in the rural than in the urban areas (15 percent versus11 43 percent), greater among children of mothers with primary education (23 percent) than among children of mothers with no education (17 percent) or with at least secondary education (13 percent). About 17 percent of children of secondary school age in households in second and middle wealth quintiles respectively are attending primary school; this is against 14 percent of children of their counterparts in poorest or fourth quintile and against eight percent of such children in the richest households. The implication of the figures in the two preceding paragraphs is as follows. Overall, 35 percent of children of secondary school age are not attending any school; the corresponding figures for different classes of children in this age group are 88, 55 and 18 percent of those in the North East, North West and North Central zones respectively, 69 and 51 percent respectively of such children in the poorest and second poorest socio-economic classes, and 49 percent of such children of mothers with no education. The figures are lowest for children in the South West (nine percent). The percentage of children entering first grade who eventually reach grades 5 and 6 respectively are presented in Tables ED.5 and ED.5a. In Nigeria, the final grade in government-owned primary school is grade 6; it is grade 5 in privately owned primary schools; but most primary schools are government-owned. Most (94 percent) of all children starting grade one will eventually reach grade six. Notice that this number includes children that repeat grades and that eventually move up to reach grade six. The figure is consistently high (above 90 percent) except in North Eastern states of Borno (66 percent), Gombe (77 percent), Taraba (88 percent) and Yobe (71); the figure is lowest in the North Central state of Plateau (63 percent). Primary school drop-out rate is lower than 10 percent in all places apart from the afore-mentioned. Male-female, rural-urban and wealth quintile differentials are insignificant; only North-South disparity is visible. The net primary school completion rate and transition rate to secondary education are presented in Table ED.6. At the time of the survey, only 36 percent of the children of primary completion age (11 years) were attending the last grade of primary education. This value should be distinguished from the gross primary completion ratio which includes children of any age attending the last grade of primary. Some gender differential exists; it is in favour of the male children (38 percent male versus 34 percent female). There is North-South movement from six percent in the North East to 41 percent in North Central, 50 percent in the South East to 62 percent in the South South geopolitical zone. Net primary school completion rate is positively correlated with education of the mother and socio-economic status of the household. It increases from 13 percent in the poorest to 64 percent in the richest households and from 23 percent of children of mothers with no education to 66 percent of those of mothers with at least secondary education. A high percentage (93 percent) of the children that successfully completed the last grade of primary school were found at the moment of the survey to be attending the first grade of secondary school; this figure includes 94 percent of the males and 91 percent of the females. The ratio of proportion of girls to proportion of boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the Gender Parity Index (GPI). Notice that the ratios included here are obtained from net attendance ratios rather than gross attendance ratios. The last ratios provide an erroneous description of the GPI mainly because in most of the cases the majority of over-aged children attending primary education tend to be boys. Gender parity index in respect of primary school net attendance ratio increases from rural areas (0.92) to urban areas (0.98), from Northern to Southern geopolitical zones, and as education of the mother or wealth status of the household increases. A GPI figure of 0.82 in the North West zone rises to 0.98 in the more southern North Central and to 0.99 in all the southern zones. Among children of mothers with no education, the index is 0.88, evidence that the girls are obviously disadvantaged; but the disadvantage almost disappears among children of mothers with primary education (0.99) and disappears among those of mothers with at least secondary education (1.01). The girls in the poorest households are the least privileged with lowest GPI figure of 0.80 that rises through the quintiles to 1.00 among children in the richest households. A striking feature of gender parity index in respect of primary school attendance ratio is that the figure is consistently less than 44 1 over the major divisions of the population of the children; the message is that the girls are on the aggregate the disadvantaged. Table ED.7 also shows that, overall gender parity figure of 0.98 for secondary school is quite close to unity; indicating that little difference exists in the probabilities of secondary school attendance by girls and boys. But rural-urban differential exists and education of the mother and socio-economic status of the household matter; disparities are pronounced between geopolitical zones and highly more pronounced between states. In the urban area, the GPI is 1.01, an indication that the girls have but a slim edge over the boys; but in the rural areas, the boys have clear advantage over the girls when the GPI reduces to 0.94. Among children of mothers with education, secondary or higher, GPI is 1.01 putting neither of the sexes at any definite advantage over the other. Interestingly, among children of mothers with no education, the GPI is 1.07, the girls having explicit relative advantage over the boys. The GPI is lowest in the North West (0.68) and highest in the South South (1.03), but some North South differential exists in favour of the South. Adult Literacy One of the World Fit for Children goals is to assure adult literacy. Adult literacy is also an MDG indicator, relating to both men and women. In MICS3 Nigeria, only a women’s questionnaire was administered and the results are based only on females age 15-24; hence data are available on female youth literacy only. Literacy was assessed on the ability of women to read a short simple statement written on a card or on school attendance (women who had attended secondary or higher were assumed to be literate). The percent literate is presented in Table ED.8. The table shows that in Nigeria, female youth literacy rate is 56 percent, i.e. only 11 out of every 20 women aged 15-24 years are literate. The rate increases from 46 percent in the rural to 78 percent in the urban areas. It also increases from the North to the South, from the lowest figure of nine percent in the North East to 56 percent in North Central and to over 81 percent in any of the southern geopolitical zones. State disparities are very wide; northern states like Bauchi, Borno, Sokoto, Taraba, Yobe and Jigawa each records less than 10 percent female youth literacy rate against southern states like Abia, Imo and Lagos each with over 90 percent rate. Female youth literacy rate is positively associated with education of head of household or social economic status of the household. But it is negatively correlated with the age of the young women. It is slightly over zero percent in household headed by persons with no education, 14 percent
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