Pakistan - Multiple Indicator Cluster Survey - 2017

Publication date: 2017

Gilgit-Baltistan Final Report Monitoring the situation of children and women Multiple Indicator Cluster Survey 2016-17 Planning & Development Department Government of Gilgit-Baltistan United Nations Children’s Fund Title page picture is taken by Muhammad Nasir (Supervisor, Gilgit team) with the permission from her mother, at Gilgit district, Gilgit-Baltistan. Gilgit-Baltistan Multiple Indicator Cluster Survey 2016-17 Final Report September, 2017 Government of Gilgit-Baltistan The Multiple Indicator Cluster Survey (MICS) Gilgit-Baltistan, [Pakistan] was carried out during 2016-17 by Planning & Development Department of Government of Gilgit-Baltistan in collaboration with United Nations Children’s Fund (UNICEF). It was conducted as part of the 5th global round of MICS. Major funding was provided by Government of the Gilgit-Baltistan through Annual Development Programme 2016-17 and the technical support was provided by the UNICEF. The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to collect internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs), Sustainable Development Goals (SDGs) and other internationally agreed upon commitments. The major objective of this report is to facilitate the data users to review the GB-MICS, 2016-17 results swiftly. The report contains detailed information on all survey findings by various demographic, social, economic and cultural characteristics. For more information please visit www.gilgitbaltistan.gov.pk or www.mics.unicef.org Suggested citation Planning & Development Department, Government of the Gilgit-Baltistan and UNICEF Pakistan. 2017. GB Multiple Indicator Cluster Survey, 2016-17, F report. Gilgit, Pakistan: P&D Department, Government of the Gilgit-Baltistan and UNICEF Pakistan. P a g e | i SUMMARY TABLE OF SURVEY IMPLEMENTATION AND THE SURVEY POPULATION, GILGIT-BALTISTAN MICS, 2016-17 SURVEY IMPLEMENTATION Sample frame used Updated 1998 census 2012 Questionnaires Household Women (age 15-49) Children under five Interviewer training September-October, 2016 Fieldwork October 2016 to February 2017 Survey sample Households Sampled Occupied Interviewed Response rate (Percent) 6,460 6,236 6,213 99.6 Children under five Eligible Mothers/caretakers interviewed Response rate (Percent) 7,005 6,637 94.7 Women Eligible for interviews Interviewed Response rate (Percent) 11,452 10,744 93.8 SURVEY POPULATION Average household size 7.7 Percentage of population living in Urban areas Rural areas Gilgit division Baltistan division Diamer division 17.5 82.5 42.1 35.0 23.0 Percentage of population under: Age 5 Age 18 15.6 48.5 Percentage of ever married women age 15-49 years with at least one live birth in the last 2 years 25.2 HOUSING CHARACTERISTICS HOUSEHOLD OR PERSONAL ASSETS Percentage of households with Electricity Finished floor1 Finished roofing2 Finished walls3 98.0 79.1 62.5 79.4 Percentage of households that own A television A refrigerator Agricultural land Farm animals/livestock 49.3 22.7 87.2 86.6 Mean number of persons per room used for sleeping 4.0 Percentage of households where at least a member has or owns a: Mobile phone Car or Van Bank account4 92.0 13.6 60.1 1 Includes: Tiles/marble, cement, carpet (including desi chatai), polished wood etc. 2 Includes: metal/T-iron (Including GI sheets), wooden beam/bricks, cement etc.) 3 Includes: cement, bricks, stone with lime/cement/sand, cement blocks etc.) 4 In addition to account in the branches of scheduled banks, also accounts in post offices, national saving centres, Village Organizations (VOs) and Women Organizations (WO) (established by AKRSP) P a g e | ii SUMMARY TABLE OF FINDINGS5 Multiple Indicator Cluster Survey (MICS) and Millennium Development Goals (MDGs)/ Sustainable Development Goals (SDGs) Indicators*, Gilgit-Baltistan MICS, 2016-17 Indicator # Indicator Description ValueA MICS MDG/SDG CHILD MORTALITY Early Childhood Mortality 1.2 4.2 / 3.2.1 Infant mortality rate Probability of dying between birth and the first birthday 73.5 1.5 4.1 / ---- Under-five mortality rate Probability of dying between birth and the fifth birthday 91.8 A Indicator values are per 1,000 live births and rates refer to January, 2015. The East Model was assumed to approximate the age pattern of mortality in Gilgit-Baltistan, Pakistan and calculations are based on the Time Since First Birth (TSFB) version of the indirect children ever born/children surviving method. Indicator # Indicator Description Value MICS MDG/SDG NUTRITION Nutritional Status 2.1a 2.1b 1.8 / ---- Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 19.4 5.6 2.2a 2.2b ---- / 2.2.1 Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 46.2 22.2 2.3a 2.3b ---- / 2.2.2 Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 3.8 1.1 2.4 ---- / 2.2.2 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 2.9 Breastfeeding and Infant Feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 97.9 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 35.0 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 63.0 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 69.1 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 80.7 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 50.8 5 See Appendix E for a detailed description of MICS indicators * This survey is a part of MICS5 program which had MDGs focus, but as it was one of the last surveys to go to field as part of 5th round and overlaped with SDGs era, therefore, SDGs indicators included in this report P a g e | iii Indicator # Indicator Description Value MICS MDG/SDG 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 21.4 months 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 66.2 2.13 Introduction of solid, semi- solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 60.0 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 60.8 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non- breastfed children) the minimum number of times or more during the previous day 69.9 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 26.7 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children age 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 21.2 17.1 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 27.5 Salt Iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodate 68.4 Low-Birth Weight 2.20 Low-birth weight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 30.5 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 22.7 Vitamin A 2.S1 Vitamin A supplementation Percentage of children age 6-59 months who received at least one high-dose vitamin A supplement in the 6 months preceding the survey 76.9 CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 73 .3 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 70.9 P a g e | iv Indicator # Indicator Description Value MICS MDG/SDG 3.3 3.5 3.6 Diphtheria, pertussis and tetanus (DPT), hepatitis B (HepB) and haemophilus influenza type B (Hib) (PENTA) immunization coverage Percentage of children age 12-23 months who received the third dose of PENTA vaccine (diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenza B) by their first birthday 56.0 3.4 4.3 / ---- Measles immunization coverage Percentage of children age 12-23 months who received measles vaccine by their first birthday 52.2 3.8 ---- / 3.b.1 Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday 38.7 Tetanus Toxoid 3.9 Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 52.2 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 22.3 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 53.6 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 8.9 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre- packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 46.3 Acute Respiratory Infection (ARI) Symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 17.1 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 64.7 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 39.7 Solid Fuel Use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 84.8 Malaria / Fever -- Children with fever6 Percentage of children under age 5 with fever in the last 2 weeks 38.6 6 Field work has been conducted from October-2016 to Feb. 2017 (in severe cold weather), therefore, it is possible to effect the fever prevalence among children P a g e | v Indicator # Indicator Description Value MICS MDG/SDG 3.20 Care-seeking for fever Percentage of children under age 5 with fever in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 64.7 3.21 Malaria diagnostics usage Percentage of children under age 5 with fever in the last 2 weeks who had a finger or heel stick for malaria testing 5.5 3.22 6.8 / ---- Anti-malarial treatment of children under age 5 Percentage of children under age 5 with fever in the last 2 weeks who received any antimalarial treatment 0.1 3.23 Treatment with Artemisinin-based Combination Therapy (ACT) among children who received anti-malarial treatment Percentage of children under age 5 with fever in the last 2 weeks who received ACT (or other first-line treatment according to national policy) (*) 3.25 Intermittent preventive treatment for malaria during pregnancy Percentage of women age 15-49 years who received three or more doses of SP/Fansidar, at least one of which was received during an ANC visit, to prevent malaria during their last pregnancy that led to a live birth in the last 2 years 0.0 *Indicator denominator based on fewer than 25 unweighted cases WATER AND SANITATION 4.1 7.8 / 6.1.1 Use of improved drinking water sources7 Percentage of household members using improved sources of drinking water 79.0 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 3.2 4.3 7.9 / 6.2.1 Use of improved sanitation8 (Not shared) Percentage of household members using improved sanitation facilities which are not shared 86.0 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 50.4 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 53.2 4.6 ---- / 6.2.1 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent available anywhere in the household 85.5 REPRODUCTIVE HEALTH Contraception and Unmet Need - Total fertility rate Total fertility rateA for women age 15-49 years 4.6 5.1 5.4 / 3.7.2 Adolescent birth rate Age-specific fertility rateA for women age 15-19 years 46.9 5.2 Early childbearing Percentage of ever married women age 20-24 years who had at least one live birth before age 18 19.3 5.3 5.3 / ---- Contraceptive prevalence rate Percentage of women age 15-49 years currently married who are using a (modern or traditional) contraceptive method 38.1 7 Improved water sources includes: piped water (in dwelling, compound, at the neighbor, public tap/standpipe or coming from river), tube well, protected well, protected spring. 8 Improved sanitation includes: flush (sewer system, septic tank, pit latrine, etc.), Ventilated Improved Pit latrine, pit latrine with slab and composting toilets P a g e | vi Indicator # Indicator Description Value MICS MDG/SDG 5.4 5.6 / 3.7.1 Unmet need Percentage of women age 15-49 years who are currently married who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 23.8 A The age-specific fertility rate is defined as the number of live births to women in a specific age group during a specified period, divided by the average number of women in that age group during the same period, expressed per 1,000 women. The age-specific fertility rate for women age 15-19 years is also termed as the adolescent birth rate. The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. The TFR denotes the average number of children to which a woman will have given birth by the end of her reproductive years (by age 50) if current fertility rates prevailed. Maternal and Newborn Health 5.5a 5.5b 5.5 / ---- Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 72.5 27.9 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 49.1 5.S1 Content of antenatal care (All four) Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured, weight measured and gave urine and blood samples during the last pregnancy that led to a live birth 32.6 5.7 5.2 / 3.1.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 62.0 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 60.3 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 7.9 Post-Natal Health Checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 25.4 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 47.5 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 44.4 5.S2 Care provided by Lady Health Worker (LHW) Number of ever married women aged 15–49 years who have given birth in the previous 2 years and were visited by a Lady Health Worker (LHW) in the last month 33.8 P a g e | vii Indicator # Indicator Description Value MICS MDG/SDG CHILD DEVELOPMENT 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 14.2 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 31.5 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 2.3 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 6.9 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 6.3 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 63.8 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 26.5 6.8 ---- / 4.2.1 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning 62.5 LITERACY AND EDUCATION 7.1 2.3 / ---- Literacy rate among young women Percentage of young women age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 66.9 7.S1 Literacy rate 10+ (Reported) Percentage of household members age 10 years or older where it is reported that they are able to both read & write with understanding in any language excluding quranic reading, if this was the only response 53.1 7.S2 Literacy rate 15+ (Reported) Percentage of household members age 15 years or older where it is reported that they are able to both read & write with understanding in any language excluding quranic reading, if this was the only response 50.4 7.S3 Literacy rate 15-24 Years (Reported) Percentage of household members age 15-24 years where it is reported that they are able to both read & write with understanding in any language excluding quranic reading, if this was the only response 74.0 7.2 School readiness Percentage of children in first grade of primary school who attended preschool during the previous school year 87.8 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 12.0 7.4 2.1 / ---- Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 49.4 P a g e | viii Indicator # Indicator Description Value MICS MDG/SDG 7.S4 Primary school gross attendance ratio (adjusted) Percentage of children of all age currently attending primary or secondary school 91.1 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 34.8 7.6 2.2 / ---- Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 93.4 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final grade of primary school) 89.3 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 87.8 7.9 3.1 / 4.5.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 0.86 7.10 3.1 / ---- Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 0.78 7.S5 Government school attendance rate (primary) Percentage of children aged 5-9 years attending Government primary schools 55.8 CHILD PROTECTION Birth Registration 8.1 ---- / 16.9.1 Birth registration Percentage of children under age 5 whose births are reported registered 18.6 Child Labour 8.2 ---- / 8.7.1 Child labour Percentage of children age 5-17 years who are involved in child labour 44.9 Child Discipline 8.3 ---- / 16.2.1 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 84.6 Early Marriage 8.4 ---- / 5.3.1 Marriage before age 15 Percentage of women age 15-49 years who were first married before age 15 13.1 8.5 ---- / 5.3.1 Marriage before age 18 Percentage of women age 20-49 years who were first married before age 18 42.6 8.6 Women age 15-19 years currently married Percentage of women age 15-19 years who are married 13.0 8.7 Polygyny Percentage of women age 15-49 years who are in a polygynous marriage9 3.8 9 Husband has more than one wife at the same time P a g e | ix Indicator # Indicator Description Value MICS MDG/SDG 8.8a 8.8b Spousal age difference Percentage of young women who are married and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years 12.3 11.8 Attitudes Towards Domestic Violence 8.12 Attitudes towards domestic violence Percentage of women age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food 78.1 Children’s Living Arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 3.4 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 4.5 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 1.1 HIV/AIDS HIV/AIDS Knowledge and Attitudes - Have heard of AIDS Percentage of women age 15-49 years who have heard of AIDS 14.3 9.1 Knowledge about HIV prevention among all women Percentage of young women age 15-49 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 1.4 9.2 Knowledge of mother-to- child transmission of HIV Percentage of women age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV 6.7 9.3 Accepting attitudes towards people living with HIV Percentage of women age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV 12.9 HIV Testing 9.4 Women who know where to be tested for HIV Percentage of women age 15-49 years who state knowledge of a place to be tested for HIV 3.7 9.5 Women who have been tested for HIV and know the results Percentage of women age 15-49 years who have been tested for HIV in the last 12 months and who know their results 0.1 9.7 HIV counselling during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 0.3 9.8 HIV testing during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 0.1 P a g e | x Indicator # Indicator Description Value MICS MDG/SDG Orphans 9.16 6.4 / ---- Ratio of school attendance of orphans to school attendance of non- orphans Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents (0.6)* *Indicator denominator based on 25-49 unweighted cases ACCESS TO MASS MEDIA Access to Mass Media 10.1 Exposure to mass media Percentage of women age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 1.5 Use of Information/Communication Technology 10.2 Use of computers Percentage of women age 15-24 years who used a computer during the last 12 months 20.9 10.3 ---- / 5.b.1 Use of internet Percentage of women age 15-24 years who used the internet during the last 12 months 9.9 SUBJECTIVE WELL-BEING 11.1 Life satisfaction Percentage of young women age 15-24 years who are very or somewhat satisfied with their life, overall 90.5 11.2 Happiness Percentage of young women age 15-24 years who are very or somewhat happy 88.1 11.3 Perception of a better life Percentage of young women age 15-24 years whose life improved during the last one year, and who expect that their life will be better after one year 63.6 TOBACCO USE 12.1 ---- / 3.a.1 Tobacco use Percentage of women age 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month 2.7 12.2 Smoking before age 15 Percentage of women age 15-49 years who smoked a whole cigarette before age 15 0.6 POVERTY 13.1 ---- /1.2.2 Mutidimensional Poverty Proportion of men, women and children of all ages living in poverty in all its dimensions, by selected measures of multidimensional poverty 0.179 P a g e | xi TABLE OF CONTENTS SUMMARY TABLE OF SURVEY IMPLEMENTATION AND THE SURVEY POPULATION, GILGIT-BALTISTAN MICS, 2016-17 . I SUMMARY TABLE OF FINDINGS . II LIST OF TABLES . XIII LIST OF FIGURES . XVI LIST OF ABBREVIATIONS . XVII FOREWORD . XIX ACKNOWLEDGEMENTS . XXI EXECUTIVE SUMMARY . XXIII MAP OF THE GILGIT-BALTISTAN . XXVII I. INTRODUCTION . 1 Background . 1 Survey Objectives . 2 II. SAMPLE AND SURVEY METHODOLOGY . 3 Sample Design . 3 Questionnaires . 3 Training and Fieldwork . 5 Data Processing . 5 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . 7 Sample Coverage . 7 Characteristics of Households . 9 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 11 Housing characteristics, asset ownership, and wealth quintiles . 15 IV. CHILD MORTALITY . 21 V. NUTRITION . 27 Low Birth Weight . 27 Nutritional Status . 29 Breastfeeding and Infant and Young Child Feeding . 34 Salt Iodization . 48 Children’s Vitamin A Supplementation. 50 VI. CHILD HEALTH . 53 Vaccinations . 53 Neonatal Tetanus Protection . 58 Care of Illness. 60 Acute Respiratory Infections . 74 Solid Fuel Use. 80 VII. WATER AND SANITATION . 91 Use of Improved Water Sources . 91 Use of Improved Sanitation . 99 Handwashing . 110 VIII. REPRODUCTIVE HEALTH . 115 Fertility . 115 Contraception . 119 P a g e | xii Unmet Need . 123 Antenatal Care . 127 Assistance at Delivery . 134 Place of Delivery . 137 Post-natal Health Checks . 140 Lady Health Worker Visits. 153 IX. EARLY CHILDHOOD DEVELOPMENT . 157 Early Childhood Care and Education . 157 Quality of Care . 158 Developmental Status of Children . 165 X. LITERACY AND EDUCATION . 167 School Readiness . 167 Preschool Attendance. 167 Primary and Secondary School Participation . 169 Public and private primary school attendance rate . 183 Literacy Rate . 185 Literacy Rate (10+ years) . 185 Literacy Rate (15+ years) . 187 Literacy Rate (15-24 years) . 188 Literacy among Young Women . 190 XI. CHILD PROTECTION . 191 Birth Registration . 191 Child Labour . 193 Child Discipline. 200 Early Marriage and Polygyny . 204 Attitudes toward Domestic Violence . 211 Children’s Living Arrangements . 213 XII. HIV/AIDS . 217 Knowledge about HIV Transmission and Misconceptions about HIV . 217 Accepting Attitudes toward People Living with HIV . 222 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . 224 HIV Indicators for Young Women . 228 Orphans . 230 XIII. ACCESS TO MASS MEDIA AND USE OF INFORMATION/COMMUNICATION TECHNOLOGY . 231 Access to Mass Media . 231 Use of Information/Communication Technology . 232 XIV. SUBJECTIVE WELL-BEING. 235 XV. TOBACCO USE . 243 Tobacco Use . 243 XVI. MULTI-DIMENSIONAL POVERTY INDEX (MPI) . 249 Dimensions, indicators, cutoffs and weights of MPI . 250 APPENDIX A: SAMPLE DESIGN . 255 APPENDIX B: LIST OF PERSONNEL INVOLVED IN THE SURVEY/SURVEY COMMITTEES . 259 APPENDIX C: ESTIMATES OF SAMPLING ERRORS . 263 APPENDIX D: DATA QUALITY TABLES . 271 APPENDIX E: GILGIT-BALTISTAN MICS, 2016-17 INDICATORS: NUMERATORS AND DENOMINATORS . 287 APPENDIX F: QUESTIONNAIRES . 299 [ P a g e | xiii LIST OF TABLES Table HH.1: Results of household, women's and children under-5 interviews . 8 Table HH.2: Household age distribution by sex . 9 Table HH.3: Household composition . 11 Table HH.4: Women's background characteristics . 12 Table HH.5: Under-5's background characteristics . 14 Table HH.6: Housing characteristics . 16 Table HH.7: Household and personal assets . 17 Table HH.8: Wealth quintiles . 18 Table HH.9: Marital status of population age 10 years or above . 19 Table CM.1: Children ever born, children surviving and proportion dead . 21 Table CM.2: Infant and under-5 mortality rates by age groups of women . 22 Table CM.3: Infant and under-5 mortality rates by background characteristics . 23 Table NU.1: Low birth weight infants . 28 Table NU.2: Nutritional status of children . 32 Table NU.3: Initial breastfeeding . 36 Table NU.4: Breastfeeding. 38 Table NU.5: Duration of breastfeeding . 41 Table NU.6: Age-appropriate breastfeeding . 42 Table NU.7: Introduction of solid, semi-solid, or soft foods . 43 Table NU.8: Infant and young child feeding (IYCF) practices . 45 Table NU.9: Bottle feeding . 47 Table NU.10: Iodized salt consumption . 49 Table NU.11: Children's vitamin A supplementation . 51 Table CH.1: Vaccinations in the first years of life. 54 Table CH.2: Vaccinations by background characteristics . 56 Table CH.3: Neonatal tetanus protection . 59 Table CH.4: Reported disease episodes . 61 Table CH.5: Care-seeking during diarrhoea . 62 Table CH.6: Feeding practices during diarrhoea . 63 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . 66 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 69 Table CH.9: Source of ORS and zinc . 72 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) . 75 Table CH.11: Knowledge of the two danger signs of pneumonia . 78 Table CH.12: Solid fuel use. 81 Table CH.13: Solid fuel use by place of cooking . 83 Table CH.14: Care-seeking during fever . 84 Table CH.15: Treatment of children with fever . 85 Table CH.16: Diagnostics and anti-malarial treatment of children . 88 Table CH.17: Intermittent preventive treatment for malaria . 90 Table WS.1: Use of improved water sources . 92 Table WS.2: Household water treatment . 95 Table WS.3: Time to source of drinking water . 97 Table WS.4: Person collecting water . 98 Table WS.5: Types of sanitation facilities . 100 Table WS.6: Use and sharing of sanitation facilities . 103 Table WS.7: Drinking water and sanitation ladders . 107 Table WS.8: Disposal of child's faeces . 109 Table WS.9: Water and soap at place for handwashing . 111 Table WS.10: Availability of soap or other cleansing agent. 113 P a g e | xiv Table RH.1: Fertility rates. 115 Table RH.2: Adolescent birth rate and total fertility rate . 117 Table RH.3: Early childbearing . 118 Table RH.4: Trends in early childbearing . 119 Table RH.5: Use of contraception . 121 Table RH.6: Unmet need for contraception . 125 Table RH.7: Antenatal care coverage . 128 Table RH.8: Number of antenatal care visits and timing of first visit . 130 Table RH.9: Content of antenatal care . 133 Table RH.10: Assistance during delivery and cesarean section . 135 Table RH.11: Place of delivery. 138 Table RH.12: Post-partum stay in health facility . 141 Table RH.13: Post-natal health checks for newborns . 143 Table RH.14: Post-natal care visits for newborns within one week of birth . 146 Table RH.15: Post-natal health checks for mothers . 148 Table RH.16: Post-natal care visits for mothers within one week of birth . 150 Table RH.17: Post-natal health checks for mothers and newborns . 152 Table RH.18: Lady Health Worker (LHW) visits . 155 Table CD.1: Early childhood education . 157 Table CD.2: Support for learning . 159 Table CD.3: Learning materials . 162 Table CD.4: Inadequate care . 164 Table CD.5: Early child development index . 166 Table ED.1: School readiness . 167 Table ED.2: Pre-school attendance . 168 Table ED.3: Primary school entry . 170 Table ED.4: Primary school net attendance and out of school children . 171 Table ED.5: Primary school gross attendance ratio of school children (5-9) years . 174 Table ED.6: Secondary school attendance and out of school children . 176 Table ED.7: Children reaching last grade of primary school . 178 Table ED.8: Primary school completion and transition to secondary school . 180 Table ED.9: Education gender parity index (GPI) . 181 Table ED.10: Out of school gender parity . 182 Table ED.11: Public and private primary school attendance rate . 184 Table ED.12: Literacy rate among population age 10 years or above . 186 Table ED.13: Literacy rate among population age 15 years or above . 187 Table ED.14: Literacy rate among population age 15-24 years . 189 Table ED.15: Literacy (young women) . 190 Table CP.1: Birth registration . 191 Table CP.2: Children's involvement in economic activities . 195 Table CP.3: Children's involvement in household chores. 197 Table CP.4: Child labour . 199 Table CP.5: Child discipline . 201 Table CP.6: Attitudes toward physical punishment . 203 Table CP.7: Early marriage and polygyny . 205 Table CP.8: Trends in early marriage . 207 Table CP.9: Spousal age difference . 209 Table CP.10: Attitudes toward domestic violence . 212 Table CP.11: Children's living arrangements and orphanhood . 214 Table CP.12: Children with parents living abroad . 216 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission . 218 P a g e | xv Table HA.2: Knowledge of mother-to-child HIV transmission . 221 Table HA.3: Accepting attitudes toward people living with HIV/AIDS . 223 Table HA.4: Knowledge of a place for HIV testing . 225 Table HA.5: HIV counselling and testing during antenatal care . 227 Table HA.6: Key HIV/AIDS indicators (young women) . 229 Table HA.7: School attendance of orphans and non-orphans . 230 Table MT.1: Exposure to mass media . 231 Table MT.2: Use of computers and internet . 233 Table SW.1: Domains of life satisfaction . 236 Table SW.2: Overall life satisfaction and happiness . 239 Table SW.3: Perception of a better life . 240 Table TA.1: Current and ever use of tobacco . 244 Table TA.2: Age at first use of cigarettes and frequency of use . 247 Table MPI.1: The Multidimensional Poverty Index (MPI) – Total Population. 252 Table MPI.2: The Multidimensional Poverty Index (MPI) – Poor Population . 254 Tables in Appendices: Table SD.1: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Strata . 257 Table SE.1: Indicators selected for sampling error calculations. 264 Table SE.2: Sampling errors: Total sample . 265 Table SE.3: Sampling errors: Urban . 266 Table SE.4: Sampling errors: Rural . 267 Table SE.5: Sampling errors: Gilgit division . 268 Table SE.6: Sampling errors: Baltistan division . 269 Table SE.7: Sampling errors: Diamer division. 270 Table DQ.1: Age distribution of household population . 271 Table DQ.2: Age distribution of eligible and interviewed women . 272 Table DQ.4: Age distribution of children in household and under-5 questionnaires . 272 Table DQ.5: Birth date reporting: Household population . 273 Table DQ.6: Birth date and age reporting: Women . 274 Table DQ.8: Birth date and age reporting: Under-5s . 274 Table DQ.9: Birth date reporting: Children, adolescents and young people . 275 Table DQ.10: Birth date reporting: First and last births . 276 Table DQ.11: Completeness of reporting . 277 Table DQ.12: Completeness of information for anthropometric indicators: Underweight . 277 Table DQ.13: Completeness of information for anthropometric indicators: Stunting . 278 Table DQ.14: Completeness of information for anthropometric indicators: Wasting . 278 Table DQ.15: Heaping in anthropometric measurements . 278 Table DQ.16: Observation of birth certificates . 279 Table DQ.17: Observation of vaccination cards . 280 Table DQ.18: Observation of women's health cards . 281 Table DQ.19: Observation of the place for handwashing . 282 Table DQ.20: Presence of mother in the household and the person interviewed for the under-5 questionnaire . 282 Table DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules . 283 Table DQ.22: School attendance by single age . 284 Table DQ.23: Sex ratio at birth among children ever born and living . 285 P a g e | xvi LIST OF FIGURES Figure HH.1: Age and sex distribution of household population. 10 Figure CM.1: Under-5 mortality rates by area and region . 24 Figure CM.2: Trend in under-5 mortality and Infant Mortality rates . 25 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe) . 31 Figure NU.2: Initiation of breastfeeding . 37 Figure NU.3: Infant feeding patterns by age . 40 Figure NU.4: Consumption of iodized salt . 50 Figure CH.1: Vaccinations by age 12 months (measles by 24 months) . 55 Figure CH.2: Children under-5 with diarrhoea who received ORS or recommended homemade liquids . 68 Figure CH.3: Children under-5 with diarrhoea receiving oral rehydration therapy (ORT) and continued feeding . 71 Figure WS.1: Percent distribution of household members by source of drinking water . 94 Figure WS.2: Percent distribution of household members by use and sharing of sanitation facilities . 102 Figure WS.3: Use of improved drinking water sources and improved sanitation facilities by household members . 106 Figure RH.1: Age-specific fertility rates by area . 116 Figure RH.2: Differentials in contraceptive use . 123 Figure RH.3: Person assisting at delivery . 137 Figure ED.1: Education indicators by sex . 183 Figure CP.1: Children under-5 whose births are registered . 193 Figure CP.2: Child disciplining methods, children age 1-14 years . 202 Figure CP.3: Early marriage among women . 206 Figure HA.1: Women and men with comprehensive knowledge of HIV transmission . 220 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS . 224 Figure TA.1: Ever and current smokers by age group . 243 Figures in Appendix: Figure DQ.1: Household population by single ages . 286 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points . 286 P a g e | xvii LIST OF ABBREVIATIONS ACT Artemisinin-based Combination therapy AKHSP Aga Khan Health Service Pakistan AKRSP Aga Khan Rural Support Program ANC Antenatal Care ARI Acute Respiratory Infection ASFR Age specific fertility rate BCG Bacillus Calmette–Guérin BHU Basic Health Unit CBR Crude birth rate CD Child Development CM Child Mortality CMW Community midwife CP Contraceptive prevalence rate CRC Convention on the Rights of the Child CSPro Census and survey programming DPT Diphtheria, Tetanus and Pertussis ECD Early Childhood Development ECDI Early Child Development Index ED Education EPI Expanded Program on Immunization GAIN Global Alliance for Improved Nutrition GAPPD Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea GB Gilgit-Baltistan GFR Gross fertility rate GMAP Global Malaria Action Plan HH Households HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome IDD Iodine Deficiency Disorders IMR Infant mortality rate IPT Intermittent Preventive Treatment IQ Intelligence quotient IUCD Intrauterine Contraceptive Device JMP Joint Monitoring Programme LHV Lady Health Visitor LHW Lady Health Worker MCV1 Measles-Containing Vaccine MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MMR Maternal mortality rate MPI Multidimensional Poverty Index NU Nutrition ODK Open Data Kit OPHI Oxford Poverty & Human Development Initiative ORS Oral Rehydration Therapy P&DD Planning and Development Department PDHS Pakistan Demographic Health Surveys PNC Post-natal care RH Reproductive Health RHC Rural Health Centre SBA Skilled birth attendant SDGs Sustainable Development Goals SO2 Sulphur Dioxide SPSS Statistical Packages for Social Sciences STIs Sexually Transmitted Infections P a g e | xviii SW Subjective wellbeing TBA Traditional Birth attendant TFR Total Fertility Rate ToT Training of Trainers UN United Nations UNDP United Nations Development Programme UNGASS UN General Assembly Special Session UNICEF United Nations International Fund for Children Education USI Universal Salt Iodization VOs Village organizations WHO World Health Organization WOs Women organizations WS Water and Sanitation P a g e | xix FOREWORD Realizing the need for reliable data in Gilgit-Baltistan (GB), the Planning and Development Department, GB, initiated the ‘Establishment of Statistical Bureau in P&DD/MICS and Collection of Available Secondary Data from Line Departments, Gilgit-Baltistan (GB)’ project in 2016-17 with the purpose of conducting the first ever MICS in GB and establishing the Bureau of Statistics, the government’s data collecting body. The Gilgit-Baltistan - Multiple Indicator Cluster Survey (GB-MICS), 2016-17 is a district-based survey covering 121 socio-economic indicators. The results of GB-MICS 2016-17 will enable the government to measure progress made on key social indicators. The overall objective of the GB-MICS was to collect high-quality data on households’ characteristics, child mortality, nutrition, child health, reproductive health, child development, education, water and sanitation and poverty status. In the absence of Bureau of Statistics in GB, conducting the MICS was seen as a huge challenge. In addition, lack of technical human resource, natural factors such as difficult climatic conditions and terrain were also key impediments to conducting the survey. Despite these challenges, the MICS was initiated in October 2016 with data collection being successfully completed in February 2017. Despite the magnitude of this undertaking, the survey has been completed within the stipulated time period, which is exemplary. The success of this endeavor is attributable, largely, to attending to the minutest details and daily monitoring through a dashboard by the Secretary P&D who would then share the updated progress, and issues, with all stakeholders through whatsup groups. Conducting the MICS has been instrumental as it facilitates the collection of statistically sound and internationally comparable data essential for developing evidence-based policies and programmes and for monitoring progress towards global, national and provincial goals. By generating data on key indicators for children and women, this survey provides benchmark for a number of indicators at district-level and created a culture for using data for planning purposes. Undoubtedly, GB faces enormous development challenges, however it has significant potential for improvements. I believe that small population of GB is its biggest strength. This against the richness of GB’s existing social capital will allow us to significantly develop the region. I firmly believe that all stakeholders will join hands in targeting the weaker indicators and helping GB excel even further. I would like to convey my deep appreciation to the entire team of the Planning & Development Department, GB, for conducting this survey and preparing the report under the supervision of Secretary P&DD, Mr. Babar Aman Babar (PAS), which I feel will provide a valuable source for planning and decision making. I also acknowledge and appreciate technical support provided by UNICEF for making this survey a success. Dr. KAZIM NIAZ Chief Secretary Government of Gilgit-Baltistan P a g e | xxi ACKNOWLEDGEMENTS GB-MICS is the first ever survey conducted in the territory of Gilgit-Baltistan, Pakistan, highlighting the state of children and women against over 120 indicators, and has thus produced credible and diverse data on a comprehensive set of socioeconomic indicators: a pre-requisite for any effective planning and governance. The Gilgit-Baltistan Multiple Indicator Cluster Survey (GB-MICS), 2016-17, from its inception to its completion, has been a collaborative and consultative effort involving a number of stakeholders. The survey was primarily funded through the GB Annual Development Programme and implemented by the Planning & Development Department (P&DD). The Pakistan Bureau of Statistics (PBS) provided the sample design, selection of sampling points; and, most importantly, they provided fresh household listings. Meanwhile, UNICEF provided technical assistance and support for the implementation of the project. The Professional Development Centre, North (PDCN) provided a very favorable environment for conducting Trainings for Trainers and main training for field staff. A Technical Advisory Committee, constituted exclusively for reviewing the GB-MICS implementation, provided support in the finalization of survey indicators and research tools. The field work and working environment were unfavourable due to harsh weather and difficult terrain. It has been successfully completed due to exemplary teamwork spirit, quick decision making and monitoring on the part of survey core team, technical monitors and quality control teams. The enthusiasm and motivation of field teams was observed throughout the field work. The teams displayed extraordinary sense of responsibility even while toiling in the most difficult and snow bound terrain. The district functionaries, administrative departments and law enforcement agencies deserve applause for their vigilance and their role in ensuring the safety and security of MICS teams. I appreciate their efforts. The role of Deputy Commissioners, especially DC Diamer, was truly exceptional. The efforts of the Chairman Steering committee/Chief Secretary, deserve appreciation as without his guidance and support this survey would not have been completed successfully. I would like to commend the pledge of incumbent Chief Minister, Hafiz Hafeez-ur-Rehman and Chief Secretary, Dr. Kazim Niaz, to realign MICS indicators with policies and strategies. We hope that with the collective support of Chief Minister and the Chief Secretary, the P&DD, will not only sensitize all stakeholders to use this data in future planning and strategy development, but will also redouble the efforts to improve results in weak performing indicators. I also extend my gratitude to the former Chief Secretary, Mr Tahir Hussain and my predecessor, Mr. Hanif Channa for providing sincere leadership, encouragement and support in the initial phases of this project. I congratulate all officials of P&DD, Mr. Muhammad Nazir Khan, Deputy Chief and his team, who in addition to their routine office work, extended full support towards this important endeavor. Finally, and most importantly, the UNICEF representative Ms. Cristian Munduate, Chief (Planning, Monitoring, Evaluation & Reporting) Ms. Janette Shaheen Hussain and focal person, Mr. Faateh, and all other concerned UNICEF staff played the most pivotal role in the successful completion of MICS within the given time frame, who always remained available to support the survey technically; and, building capacity of P&D staff in order to enable them to conduct MICS surveys in future on their own. BABAR AMAN BABAR (PAS) Secretary P&DD/Project Director-MICS Government of Gilgit-Baltistan P a g e | xxiii EXECUTIVE SUMMARY The Gilgit-Baltistan Multiple Indicator Cluster Survey (GB-MICS) 2016-17 was designed to estimate the situation of children and women against 121 key development indicators. The MICS Survey is a unique source of information which will serve as a baseline for researchers, policy makers, and individuals to use the evidence based data for decision making. The GB-MICS, conducted between October 2016 and February 2017, is one of the largest surveys conducted in Gilgit-Baltistan with a sample size of 6,460 households. The survey forms part of the fifth global round of Multiple Indicator Clusters Surveys programme. GB-MICS, 2016-17 has been implemented by the Planning and Development Department with technical support from UNICEF, while the sampling frame and fresh household listings were provided by the Pakistan Bureau of Statistics. This report contains district level disaggregated data and findings of the GB-MICS, 2016-17. The key findings of the survey are: Early Childhood Mortality The results of the GB-MICS, 2016-17 reveals somewhat discouraging data on both infant and under five mortality. The infant mortality rate (IMR) has increased slightly from 71.0 per 1000 live births (data from PDHS 2012) to 73.5 per 1000 live births in 2016-17. Under five mortality has also increased with almost three percentage points from 89 per 1000 live births (data from PDHS 2012) to 91.8 per 1000 live births; the highest rate being for the age cohort of 20-24 months. Geographic disaggregation shows that IMR and under five mortality rate are highest in Baltistan and Diamer divisions. The data also indicates that mothers with no education/pre-school education, and those in the poorest wealth quintiles have a negative effect on both IMR and under five mortality rates. Possible explanations for the data, including the slightly upward trends, are non-availability of adequate health services despite presence of health facilities, limited accessibility to health services due to harsh geographical terrain and climate, limited affordability, and poor quality of care. During data collection it was observed that the “continuum of care” towards health seeking behaviour and knowledge about danger signs in new- born care is very limited and this could contribute to growing mortality rates. Nutritional Status About two out of ten children under the age of five in GB are underweight (19.4%) while 5.6 percent are severely underweight. Almost half of children under five (46.2%) are stunted or short for their age and just over one in five (22.2%) children are severely stunted. The results also show that 3.8 percent of the children are wasted or thin for their height and only 2.9 percent of children are overweight or too heavy for their height. These indicators could be linked to the lack of knowledge amongst women on good nutritional practices for their children, compromising children’s and their own health by doing taxing domestic chores, non-availability of a balanced diet, and non-availability of essential health services. In 2016-17, the Government of Gilgit-Baltistan with the technical support of UNICEF initiated a dedicated program on nutrition called ‘scaling up nutrition (SUN)’ to address the mother and child nutritional challenges in GB. Child Health Immunization from vaccine-preventable diseases is key to reducing child deaths. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination for protection against tuberculosis; three doses of DPT containing vaccine to protect against diphtheria, pertussis, and tetanus; and three doses of polio vaccine and a first dose of measles vaccination before a child’s first birthday for P a g e | xxiv protection from polio and measles respectively. The GB-MICS, 2016-17 results reveal that about 38.7 percent of children aged 12-23 months had received all the recommended vaccinations by 12 months of age which reflects a considerable decline compared to the PDHS 2012-13 result of 47.0 percent for the same indicator. This may be attributed to shortage of vaccines and decrease in trust in vaccines due to the traditional myths and believes etc. At the same time, a slight increase has been witnessed in measles vaccine coverage (52.2%) as compared to PDHS 2012 (51.0%). It is believed that collaboration between the private sector and government is instrumental to increase the proportion of fully vaccinated children. For instance; the Aga Khan Health Service Pakistan (AKHSP) is working in primary health in district Hunza, Nagar, Ghizer and some parts of district Gilgit. The proportion of fully vaccination in AKHSP intervention area is higher than in non-AKHSP intervention areas. In addition to private sector involvement, the high vaccination rates are also linked to mothers’ education and wealth quintiles. Water and Sanitation GB-MICS 2016-17 shows that 79.0 per cent of the population has access to improved sources of drinking water and only 3.2 percent household members in households using unimproved drinking water who use an appropriate treatment method. The results also show that 86.0 per cent of surveyed household members are using improved sanitation facilities which are not shared, whereas 50.4 per cent of them safely dispose-off faeces of children aged 0-2 years. Moreover, 53.2 percent of the households had a specific place for hand washing with water and soap or other cleansing agents present. Around 63 per cent of surveyed households used piped water that was available inside their homes or courtyards. Reproductive Health The total Fertility Rate in GB is 4.6 children per women. The survey showed that 38.1 per cent of ever married women are using a contraceptive method and 32.1 percent are using a modern method. The most common contraceptive method is IUD insertion which is currently used by 9.1 percent of ever married women. The proportion of contraception usage is highest in district Ghizer (62.9%) followed by district Hunza (59.6%) while the lowest is in district Diamer (12.7%). Maternal and New-born Health The results indicate that almost 72.5 percent of women aged 15-49 years who delivered a live birth in the last 2 years during their last pregnancy received antenatal care at least once by skilled health personnel whereas 27.9 percent have received ANC at least four times by any provider. Literacy and Education About seven out of ten young women aged 15-24 are literate. School readiness data from the survey reveals that 87.8 per cent of children in first grade of primary school attended preschool during the previous school year. Meanwhile, 91.1 per cent children of primary school age are currently enrolled for primary education and 89.3 per cent of all children have completed primary education. About 86 girls are attending primary school for every 100 boys attending. However, the ratio widens at the secondary school level for which 75 girls are attending for every 100 boys. It was also observed that only just over half of the surveyed children (55.8%) are attending government schools at primary level. Child Protection In GB, only 18.1 per cent of children age under 5 are registered. About 45 percent of children aged 5- 17 years are involved in child labour. Meanwhile, 85 percent of children aged 1-14 years had P a g e | xxv experienced psychological aggression or physical punishment as a way of discipline in the past month. Further, one out of four children (24.7%) received a severe form of physical punishment. Early Marriages The survey revealed that 13 per cent of young women aged 15-19 years are currently married while the percentage of girls marrying before 15 years of age is 13.1 per cent. The data shows that 12.3 per cent of the young women of 15-19 years have an age difference of 10 years with their spouses whereas 11.8 per cent of women between 20-24 years have an age difference more than 10 years with their spouses. Access to Mass Media and ICT Only 1.5 per cent of women aged 15-49 years read a newspaper or magazine, listen to the radio, and watch television at least once a week. The most prevalent media source is television (50.6%). About 72 per cent of women between 15-49 years of age have access to any form of media in Gilgit district while the percentage is lower for other districts, for instance in Diamer only 18.4 percent women have access to any media. The level of education for women and the wealth quintile have strong correlation with access to media. P a g e | xxvii MAP OF THE GILGIT-BALTISTAN P a g e | 1 I. INTRODUCTION Background This report is based on the Gilgit-Baltistan Multiple Indicator Cluster Survey (GB-MICS), conducted in 2016-17 by the Planning and Development Department Government of Gilgit-Baltistan (P&DD, GB) with technical support from UNICEF. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration, the Millennium Development Goals (MDGs) and now SDGs. 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 of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” The GB-MICS results will be critically important for final MDG reporting in 2015, and are expected to form part of the baseline data for the post-2017 era. GB-MICS is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health. P a g e | 2 Survey Objectives The GB-MICS has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Gilgit- Baltistan, particularly at district level; • To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention; • To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action; • To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable; • To contribute to the generation of baseline data for the post-2017 agenda; • To validate data from other sources and the results of focused interventions. This final report presents the results of the indicators and topics covered in the survey. The overall GB level results presented in this report were published in July, 2017 as part of the key findings report. The discussion for each chapter in this report is based on tables within the text that contain provincial, divisional and district level results. The report is divided into 15 chapters, focusing on different aspects of the survey. The first three chapters explain about the survey objective, methodology (sample design, questionnaires, training and fieldwork) and sample coverage, characteristics of the households, asset ownership, and wealth quintiles. The remaining 12 chapters discuss the findings on child mortality, nutrition, child health, water and sanitation, reproductive health, early child development, literacy and education, child protection, HIV/AIDS knowledge, Hepatitis B and C, access to mass media, use of information/communication technology and tobacco use. P a g e | 3 II. SAMPLE AND SURVEY METHODOLOGY Sample Design The sample for the Gilgit-Baltistan Multiple Indicator Cluster Survey was designed to provide estimates for a large number of indicators on the situation of children and women at provincial level, for urban and rural areas, for the three divisions namely Gilgit, Baltistan and Diamer and the 10 districts of GB. The districts within each region are as follows: Gilgit Division: District Gilgit, Ghizer, Hunza and Nagar Diamer Division: District Diamer and Astore Baltistan Division: District Skardu, Ghanche, Kharmang and Shigar The urban and rural areas within each district were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas was selected systematically with probability proportional to size for a total sample of 323 enumeration areas (called clusters). After a household listing was carried out within the selected enumeration areas, a systematic sample of 20 households was selected in each EA, resulting in a total sample of 6,460 households for the whole of Gilgit-Baltistan. Seventeen of the selected enumeration areas were not visited for different reasons such as due to inaccessible, falling in cantonment and resistance from the communities during the fieldwork and all these seventeen clusters were replaced by the Pakistan Bureau of Statistics and Planning and Development Department Gilgit-Baltistan. The sample was stratified by district, urban and rural areas, and is not self-weighting. For reporting provincial, divisional and district level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A, Sample Design. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; 3) an under-5 questionnaire, administered to mothers (or caretakers) for all children under 5 living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: 1. List of Household Members 2. Education 3. Child Labour 4. Child Discipline 5. Household Characteristics 6. Water and Sanitation 7. Handwashing 8. Salt Iodization The Questionnaire for Individual Women was administered to all women age 15-49 years living in the households, and included the following modules: P a g e | 4 1. Woman’s Background 2. Access to Mass Media and Use of Information/Communication Technology 3. Marriage 4. Fertility 5. Desire for Last Birth 6. Maternal and New Born Health 7. Post-natal Health Checks 8. Illness Symptoms 9. Visit from Lady Health Worker10 10. Contraception 11. Unmet Need 12. Attitudes Toward Domestic Violence 13. HIV/AIDS 14. Subjective wellbeing 15. Tobacco Use The Questionnaire for children under-five was administered to mothers (or caretakers) of children under 5 years of age11 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: 1. Age 2. Birth Registration 3. Early Childhood Development 4. Breastfeeding and Dietary Intake 5. Immunization 6. Care of Illness 7. Anthropometry The questionnaires are based on the MICS5 model questionnaire12. From the MICS5 model English version, the questionnaires were customised and translated into Urdu and were pilot-tested during ToT in district Gilgit and district Nagar in June, 2016 and pre-test was conducted in September during main training and those clusters were not selected for the survey during the main survey. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for hand washing and measured the weights and heights of children age under 5 years. Details and findings of these observations and measurements are provided in the respective sections of the report. 10 Visit from Lady Health Worker module is a survey specific module that includes questions on services provided by lady health workers. 11 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report. 12 The model MICS5 questionnaires can be found at http://mics.unicef.org/tools P a g e | 5 Training and Fieldwork After completion of the series of consultative meeting, the P&DD recruited master trainers and organized 15 days ToT (Training for trainers) in July 2016. The main purpose of the ToT was reviewing and finalization of the customized questionnaires and pilot testing it into the field. The P&DD dedicated its 5 young and energetic officers for MICS survey to cater for the absence of statistical cell at P&DD and also develop in-house human resources for future similar assignments. During the ToT, all the three questionnaires were critically reviewed through a local context lens. Additional topics such as effective communication skills, contextual field experience and challenges and selection of sampled households were very briefly inculcated to the participants. Lectures delivered from experts such as Nutrition, Antenatal Care (ANC), Post Natal Care (PNC), Growth Monitoring and Child Health to give background concepts to the trainees. During September, 2016, the main training was organized in Gilgit and more than 100 trainees were trained. These interviewers were selected after a hiring competitive process. Out of these 100 candidates 70 were selected for the main field work and the remaining 30 were kept as a backup in case of dropouts. The training contents comprised of; Introduction of MICS, a detailed description of the questionnaires; interviewing techniques; selection of households and maintaining cluster control sheets. The methodology of the training consisted of classroom lectures, quizes and tests, mock interviews and two field visits. Finally, the team supervisors and field editors trained on management of field activities, editing of completed questionnaires, maintaining cluster and interviewer control sheets. For the field survey 10 teams (1 team for each district) was formed. One team comprised of 7 members including 1 supervisor, 1 male interviewer, 3 female interviewers, 1 measurer and 1 field editor. In addition to this, four technical monitors (the P&DD officers) and six quality controllers (two teams) were deployed into the field who visited each district teams on rotation basis. The field work began in October, 2016. During the data collection, close communication and coordination maintained all the times between the MICS secretariat and field team during field work. At the field level, the field supervisor including field editors were the first monitoring layer with each team who are responsible to ensure data quality, efficient team building, revisits to households and spot checks. The next layer was the Technical Monitors and Quality Controllers. The Technical Monitors & Quality Controllers made spot checks, held debriefing sessions and support the field team. Similarly, all the field activities were monitored by MICS secretariat and progress report submitted to Secretary Planning and Chief Secretary on daily basis through online monitoring system (a dashboard on field work especially designed for this purpose). After every week, field check tables were produced and the debriefing sessions were held with the Core Team, Technical Monitors and Quality Controllers. Data Processing Data were entered using the CSPro software, Version 5.0. The data were entered on 6 desktop computers and carried out by 6 data entry operators and 1 questionnaire administratorand 4 secondary editors. For quality assurance purposes, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS programme and adapted to the GB-MICS questionnaire were used throughout. Data P a g e | 6 processing began simultaneously with data collection in October, 2016 and was completed in March 2017. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, Version 22. Model syntax and tabulation plans developed for MICS5 were customized and used for this purpose. P a g e | 7 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Sample Coverage Of the 6,460 households selected for the sample, 6,236 were found to be occupied. Of these, 6,213 were successfully interviewed for a household response rate of 99.6 percent. Despite issues of harsh weather, blockage of roads and walking by feet in the snow covered hilly areas for hours the field team worked with full devotion and dedication, which led the high response rate. In the interviewed households, 11,452 women (age 15-49 years) were identified. Of these, 10,744 were successfully interviewed, yielding a response rate of 93.8 percent within the interviewed households. There were 7,005 children under age five listed in the household questionnaires. Questionnaires were completed for 6,637 of these children, which corresponds to a response rate of 94.7 percent within interviewed households. Overall response rates of 93.5 percent and 94.4 percent are calculated for the individual interviews of women and under-5s, respectively (Table HH.1). Response rates were higher in rural than urban areas. Across divisions, response rates were lowest in Diamer division. However, for the women and children under 5 the response rate is lowest in district Gilgit having the highest urban enumeration areas in MICS GB. The reasons for low response rate were due to illiteracy and less exposure to survey interviews. The latter meant that a higher proportion of households were reluctant to providing responses as compared to other districts. In the case of district Gilgit, some women and children were not at home during the time of data collection despite several follow ups. It is significant to note that for district Diamir the response rate is higher than anticipated during the start of the survey, but good planning and dedicated efforts at all tiers, with continuous monitoring and support, led to achieve a very good response rate. P a g e | 8 Table HH.1: Results of household, women's and under-5 interviews Number of households, women and children under 5 by results of the household, women's and under-5's interviews, and household and women's and under-5's response rates, Gilgit-Baltistan, 2016-17 Total Area of residence Division Districts Urban Rural G il g it B a lt is ta n D ia m e r A s to re D ia m e r G h a n c h e G h iz e r G il g it H u n z a K h a rm a n g N a g a r S h ig a r S k a rd u Households Sampled 6,460 880 5,580 2,520 2,700 1,240 620 620 720 600 640 640 660 640 660 660 Occupied 6,236 866 5,370 2,424 2,616 1,196 609 587 711 594 615 594 603 621 656 646 Interviewed 6,213 861 5,352 2,416 2,607 1,190 605 585 708 591 611 594 601 620 652 646 Household response rate 99.6 99.4 99.7 99.7 99.7 99.5 99.3 99.7 99.6 99.5 99.3 100.0 99.7 99.8 99.4 100.0 Women Eligible 11,452 1,693 9,759 4,449 4,815 2,188 1,079 1,109 1,260 1,165 1,130 873 1,020 1,281 1,263 1,272 Interviewed 10,744 1,574 9,170 4,124 4,550 2,070 1,027 1,043 1,223 1,093 1,003 812 964 1,216 1,181 1,182 Women's response rate 93.8 93.0 94.0 92.7 94.5 94.6 95.2 94.0 97.1 93.8 88.8 93.0 94.5 94.9 93.5 92.9 Women's overall response rate 93.5 92.4 93.6 92.4 94.2 94.1 94.6 93.7 96.7 93.3 88.2 93.0 94.2 94.8 92.9 92.9 Children under 5 Eligible 7,005 941 6,064 2,109 3,081 1,815 739 1,076 758 541 666 285 621 617 933 769 Mothers/caretakers interviewed 6,637 884 5,753 1,969 2,924 1,744 725 1,019 740 505 603 265 592 596 882 710 Under-5's response rate 94.7 93.9 94.9 93.4 94.9 96.1 98.1 94.7 97.6 93.3 90.5 93.0 95.3 96.6 94.5 92.3 Under-5's overall response rate 94.4 93.4 94.6 93.1 94.6 95.6 97.5 94.4 97.2 92.9 90.0 93.0 95.0 96.4 94.0 92.3 P a g e | 9 Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 6,213 households successfully interviewed in the survey, 47,983 household members were listed. Of these, 23,098 were males, and 24,886 were females. Table HH.2: Household age distribution by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Gilgit-Baltistan, 2016-17 Total Males Females Number Percent Number Percent Number Percent Total 47,983 100.0 23,098 100.0 24,886 100.0 Age 0-4 7,467 15.6 3,902 16.9 3,565 14.3 5-9 7,156 14.9 3,645 15.8 3,511 14.1 10-14 6,292 13.1 3,098 13.4 3,194 12.8 15-19 5,396 11.2 2,431 10.5 2,964 11.9 20-24 3,743 7.8 1,538 6.7 2,205 8.9 25-29 3,387 7.1 1,426 6.2 1,962 7.9 30-34 2,650 5.5 1,182 5.1 1,468 5.9 35-39 2,230 4.6 1,031 4.5 1,199 4.8 40-44 1,875 3.9 858 3.7 1,017 4.1 45-49 1,669 3.5 796 3.4 873 3.5 50-54 1,409 2.9 718 3.1 691 2.8 55-59 1,293 2.7 592 2.6 701 2.8 60-64 1,196 2.5 631 2.7 565 2.3 65-69 819 1.7 469 2.0 350 1.4 70-74 581 1.2 317 1.4 264 1.1 75-79 331 0.7 174 0.8 158 0.6 80-84 267 0.6 171 0.7 96 0.4 85+ 222 0.5 118 0.5 104 0.4 Missing/DK 1 0.0 1 0.0 - - Dependency age groups 0-14 20,915 43.6 10,645 46.1 10,270 41.3 15-64 24,847 51.8 11,203 48.5 13,643 54.8 65+ 2,221 4.6 1,248 5.4 973 3.9 Missing/DK 1 0.0 1 0.0 - - Child and adult populations Children age 0-17 years 24,299 50.6 12,221 52.9 12,078 48.5 Adults age 18+ years 23,683 49.4 10,875 47.1 12,808 51.5 Missing/DK 1 0.0 1 0.0 - - Table HH.2 shows that 43.6 percent of the population is under 15 years and 4.6 percent is age 65 or over, showing a high dependent population. Children age less than 18 constitute 50.6 percent of the population and 49.4 percent of the population is 18 years or older. P a g e | 10 F i gure HH.1: Age and sex dist r ibut ion of household popul ation, G i l g i t -B al t is tan MIC S, 2016-17 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49 years and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provides background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers. 13 Table HH.3 provides basic background information on the households, including area, sex of the household head, number of household members, education of household head, division and district. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted total number of households is equal, since sample weights were normalized. The table also shows the weighted mean household size estimated by the survey. The data shows that 13.2 percent of the households are headed by females in GB. A majority of the households (82.5%) are in rural areas compared with 17.5 percent in urban areas. Most households (42%) are found in Gilgit division, followed by Baltistan division (35%) and Diamer division (23%). Regarding household size, 57.9 percent of the households in GB have more than 6 members and 24.4 percent of the households have 10 members or more. The average household size is 7.7 members. Forty seven percent of the household heads have only pre-school or no education. 13 See Appendix A: Sample Design, for more details on sample weights. 10 8 6 4 2 0 2 4 6 8 10 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Percent Age Males Females P a g e | 11 Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Gilgit-Baltistan, 2016-17 Weighted percent Number of households Weighted Unweighted Total 100.0 6,213 6,213 Area of residence Urban 17.5 1,090 861 Rural 82.5 5,123 5,352 Sex of household head Male 86.8 5,395 5,301 Female 13.2 818 912 Number of household members 1 0.6 36 47 2 2.8 173 203 3 4.1 257 314 4 8.9 552 582 5 11.9 742 798 6 13.8 857 883 7 12.5 777 800 8 12.0 747 696 9 9.0 558 524 10+ 24.4 1,513 1,366 Education of household head None/pre-school 46.5 2,890 3,013 Primary 17.2 1,067 1,035 Middle 10.4 645 635 Secondary 10.2 632 621 Higher 15.6 969 900 Missing/DK 0.2 10 9 At least one child age < 5 years 64.5 6,213 6,213 At least one child age 0-17 years 92.9 6,213 6,213 At least one woman age 15-49 years 96.4 6,213 6,213 Mean household size 7.7 6,213 6,213 Division Gilgit 42.1 2,614 2,416 Baltistan 35.0 2,172 2,607 Diamer 23.0 1,428 1,190 District Astore 6.9 428 605 Diamer 16.1 999 585 Ghanche 10.3 638 708 Ghizer 12.8 794 591 Gilgit 19.0 1,179 611 Hunza 4.5 279 594 Kharmang 3.9 243 601 Nagar 5.8 361 620 Shigar 4.5 281 652 Skardu 16.3 1,010 646 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. P a g e | 12 Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Gilgit-Baltistan, 2016-17 Weighted percent Number of women Weighted Unweighted Total 100.0 10,744 10,744 Area of residence Urban 18.3 1,969 1,574 Rural 81.7 8,775 9,170 Age 15-19 25.7 2,765 2,695 20-24 18.3 1,964 1,955 25-29 16.3 1,754 1,823 30-34 12.6 1,357 1,361 35-39 10.6 1,143 1,132 40-44 8.9 955 971 45-49 7.5 805 807 Marital status Currently married 63.1 6,783 6,750 Widowed 1.6 171 176 Divorced 0.8 85 84 Separated 0.2 20 18 Never married 34.3 3,684 3,716 Motherhood and recent births Never gave birth 40.7 4,373 4,361 Ever gave birth 59.3 6,371 6,383 Gave birth in last two years 25.2 2,705 2,601 No birth in last two years 34.1 3,666 3,782 Women's Education None/pre-school 46.8 5,027 4,877 Primary 11.2 1,200 1,234 Middle 10.7 1,153 1,214 Secondary 15.2 1,635 1,681 Higher 16.1 1,725 1,735 Missing/DK 0.0 4 3 Wealth index quintile Poorest 18.2 1,952 2,131 Second 19.2 2,059 2,244 Middle 20.9 2,242 2,316 Fourth 21.1 2,269 2,251 Richest 20.7 2,222 1,802 Usual language spoken in the household Sheena 46.9 5,044 3,895 Balti 30.2 3,241 4,120 Brushaski 12.9 1,390 1,834 Other languages 10.0 1,069 895 Division Gilgit 42.0 4,512 4,124 Baltistan 34.9 3,747 4,550 Diamer 23.1 2,485 2,070 District Astore 6.6 706 1,027 Diamer 16.6 1,779 1,043 Ghanche 9.6 1,036 1,223 Ghizer 13.5 1,456 1,093 Gilgit 18.3 1,968 1,003 Hunza 3.6 389 812 Kharmang 3.5 377 964 Nagar 6.5 699 1,216 Shigar 4.7 502 1,181 Skardu 17.0 1,832 1,182 Table HH.4 provides background characteristics of female respondents, age 15-49 years. The table includes information on the distribution of women according to, area, age, marital status, motherhood P a g e | 13 status, women’s education14, wealth index quintile15,16, usual language spoken in the households, division and districts. The results show that 18.3 percent of women respondents live in urban areas whereas, 81.7 percent women lives in rural areas. At division level, the distribution of women by division shows that a high proportion of women live in Gilgit (42%) followed by Baltistan (35%) and Diamer (23%). Reflecting the young population, the age distribution shows that 25.7 percent of the women are in the 15-19 age group compared to 7.5 percent in the 45-49 age group. The data further show that 63.1 percent of women are currently married while 34.3 percent have never been married. Forty seven percent of the women have only pre-school or no education, while 16 percent have higher than secondary education. Eighteen percent of women live in households in the poorest wealth quintile and 21.1 percent in the fourth quintile. In addition, 59.3 percent of the women have ever given birth and 25.2 percent of the women gave birth in the two years preceding the survey. Similarly, background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several characteristics such as: sex, division and area, age in months, respondent type, mothers (or caretaker’s) education and wealth. 14 Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondent when it is used as a background variable. 15 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). 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. 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 Filmer, D. and Pritchett, L., 2001. “Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India”. Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro and Rutstein, S.O., 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. Calverton, Maryland: Macro International Inc. 16 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest household population”, which is used interchangeably with “women in the wealthiest survey population” and similar P a g e | 14 Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Gilgit-Baltistan, 2016-17 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 6,637 6,637 Area of residence Urban 16.5 1,097 884 Rural 83.5 5,540 5,753 Sex Male 52.3 3,472 3,447 Female 47.7 3,165 3,190 Age 0-5 months 9.3 617 599 6-11 months 10.5 697 685 12-23 months 19.6 1,299 1,323 24-35 months 19.9 1,322 1,317 36-47 months 20.1 1,333 1,303 48-59 months 20.6 1,368 1,410 Respondent to the under-5 questionnaire Mother 98.6 6,543 6,543 Other primary caretaker 1.4 94 94 Mother’s education a None/pre-school 60.5 4,015 3,879 Primary 9.7 646 685 Middle 7.6 507 533 Secondary 10.6 702 716 Higher 11.5 764 822 Missing/ DK 0.0 3 2 Wealth index quintile Poorest 22.4 1,489 1,644 Second 21.4 1,419 1,499 Middle 20.5 1,363 1,370 Fourth 18.1 1,204 1,180 Richest 17.5 1,161 944 Usual language spoken in the household Sheena 54.6 3,490 2,703 Balti 31.1 1,988 2,681 Brushaski 8.5 546 736 Other languages 5.7 367 302 Division Gilgit 34.3 2,278 1,969 Baltistan 33.7 2,239 2,924 Diamer 31.9 2,120 1,744 District Astore 7.0 465 725 Diamer 24.9 1,655 1,019 Ghanche 9.1 605 740 Ghizer 9.6 634 505 Gilgit 17.8 1,184 603 Hunza 1.9 127 265 Kharmang 3.3 221 592 Nagar 5.0 334 596 Shigar 5.4 357 882 Skardu 15.9 1,055 710 a In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. Table HH.5 shows that 83.5 percent of the children under 5 are living in rural areas while 16.5 percent live in urban areas. Similarly, 52.3 percent of children under 5 are male and 47.7 percent are female. The child’s natural mother was interviewed in almost all cases (98.6%). Sixty one percent of the interviewed mothers for children under five have either no education at all or pre-school education. P a g e | 15 Twenty two percent of children live in households in the poorest wealth quintile and this proportion falls to one in six (17.5%) in the richest quintile. Fifty five percent of the under five children belongs to households where Sheena is being spoken following by Balti (31.1%) and Brushaski (8.5%). Thirty four percent of child under five belongs from Gilgit division whereas the district wise status shows that the highest proportion (24.9%) of children under five are from district Diamer, Gilgit (17.8%), Skardu (15.9 %) and the least is in district Hunza (1.9%). Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. Table HH.6 presents characteristics of housing, disaggregated by area and division, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. The majority of households in Gilgit-Baltistan (98.0%) have access to electricity. The proportion is higher in urban areas (99.9%) than rural areas (97.6%). Nearly all households (99.6%) in Gilgit division have electricity. Whereas the lowest percentage of households having electricity is in Diamer division (94.3%). Information collected on flooring for households shows that 79.1 percent of households have a finished floor. There is wide variation by division; the highest proportion of households having finished floor is in Gilgit division (94.9%) as compared to lowest in Diamer division (65.1%). In Diamer division 34.7 percent households have natural floor followed by 30.6 percent in Baltistan division and 4.5 percent in Gilgit division. There is a large variation among divisions having rudimentary roofing and finished roofing. The prevalence of rudimentary roofing is highest in Baltistan division (73.0%) and lowest in Gilgit division (14.6%) . Most households also have finished roofing and exterior walls. Overall, 29.7 percent of the households in GB use one room for sleeping and a further 39.5 percent use two rooms for sleeping. On average, there are 4.0 persons sleeping in a room at provincial level. The division wise status shows that 5.1 persons sleep in one room in Diamer division followed by 3.8 persons in Gilgit division and 3.7 percent in Baltistan division. In rural households, 4.2 persons are sleeping in one room as compared to 3.4 persons in urban areas. P a g e | 16 Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Gilgit-Baltistan, 2016-17 Total Area Division Urban Rural Gilgit Baltistan Diamer Electricity Yes 98.0 99.9 97.6 99.6 98.3 94.3 No 2.0 0.1 2.4 0.4 1.7 5.7 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 Flooring Natural floor 20.6 14.6 21.9 4.5 30.6 34.7 Finished floor 79.1 85.0 77.8 94.9 69.2 65.1 Other 0.3 0.4 0.3 0.5 0.1 0.3 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 Roof Natural roofing 0.1 0.0 0.1 0.0 0.0 0.2 Rudimentary roofing 35.6 28.0 37.2 14.6 73.0 16.9 Finished roofing 62.5 70.2 60.9 85.2 21.9 82.7 Other 1.9 1.8 1.9 0.1 5.1 0.1 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.1 Exterior walls Natural walls 0.9 0.5 1.0 0.7 0.8 1.4 Rudimentary walls 17.8 3.3 20.9 14.7 13.2 30.4 Finished walls 79.4 96.1 75.8 84.1 83.5 64.5 Other 1.9 0.1 2.2 0.5 2.4 3.6 Missing/DK 0.1 0.0 0.1 0.1 0.0 0.1 Rooms used for sleeping 1 29.7 16.0 32.7 29.2 25.6 37.0 2 39.5 37.9 39.9 38.7 40.0 40.3 3 or more 30.7 46.2 27.4 32.0 34.4 22.6 Missing/DK 0.1 0.0 0.1 0.1 0.0 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 6,213 1,090 5,123 2,614 2,172 1,428 Mean number of persons per room used for sleeping 4.0 3.4 4.2 3.8 3.7 5.1 In Table HH.7, households are distributed according to ownership of assets by households and by individual household members. This also includes ownership of dwelling. Fourteen percent of households own radio while 49.3 percent own a television. Most households also own a washing machine (30.6%), refrigerator (22.7%) and a computer (20.9%). Ownership of these assets is consiuderably high in urban areas compared to the rural areas. For example 68.8 percent household owns televisions in urban areas versus 45.1 percent in rural areas; 55.7 percent own refrigerator in urban areas compared to 15.7 percent in rural areas; 39.8 percent owns computer in urban areas compared to 16.9 percent in rural areas. Similarly, 60.4 percent owns washing machine/dryer in urban areas compared to 24.3 percent in rural areas. The region wise data depicts that 60.3 percent of the households owns television in Gilgit division, 58.5 percent in Baltistan and 14.9 percent own television in Diamer division. Agricultural land ownership of households is higher in Gilgit-Baltistan compared to the national level estimates in Pakistan. Eighty seven percent households own agricultural land and 86.6 percent of the households own a farm animal or livestock. This is higher than national level results from Pakistan DHS 2012-13 showing that 30.8 percent of households own agricultural land and 46.1 percent of households own a farm animal or livestock. The prevalence of ownership of farm animals/livestock’s varies significantly among urban (64.1%) and rural (91.4%) areas. P a g e | 17 Information collected on ownership of assets by household members shows that 92.0 percent of households have at least one household member who owns a mobile phone; 56.3 percent own a watch. Twenty five percent of households in GB have a motorcycle or scooter owned by at least one member of the households. Similarly, 13.6 percent of the household owns a car or van. The division level data shows that possessing a car or van is highest in Diamer division (16.7%), 15.3 percent in Gilgit division and the least (9.5%) is in Baltistan division. Sixty percent of the households in GB have at least one household member who has a bank account. The proportion is higher in urban areas (79.0%) than rural areas (56.1%). Table HH.7 shows that, 88.7 percent are owned by a household member and 11.3 percent of dwellings are not owned and 6.0 percent living in rented houses. Ownership of dwelling is more common in rural (92.7%) than urban areas (69.9%). While renting is more common in urban areas than the rural areas (21.7% and 2.6% respectively). Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and regions, Gilgit-Baltistan, 2016-17 Total Area Division Urban Rural Gilgit Baltistan Diamer Percentage of households that own a Radio 13.8 14.5 13.6 13.7 12.1 16.5 Television 49.3 68.8 45.1 60.3 58.5 14.9 Non-mobile telephone 7.6 10.8 7.0 7.3 8.0 7.6 Refrigerator 22.7 55.7 15.7 30.7 14.5 20.8 Computer 20.9 39.8 16.9 30.9 18.3 6.7 Washing machine/ Dryer 30.6 60.4 24.3 47.8 15.6 21.9 Air conditioner 0.8 2.7 0.4 1.0 0.2 1.4 Percentage of households that own Agricultural land 87.2 71.7 90.5 83.2 92.8 86.0 Farm animals/Livestock 86.6 64.1 91.4 80.6 90.1 92.3 Percentage of households where at least one member owns or has a Watch 56.3 64.0 54.7 56.2 43.1 76.8 Mobile telephone 92.0 98.4 90.6 95.9 87.9 91.0 Bicycle 5.6 12.6 4.1 6.2 7.7 1.3 Motorcycle or scooter 24.6 39.8 21.4 28.2 22.7 21.1 Animal-drawn cart 1.4 0.1 1.7 1.3 1.3 1.8 Bus or truck 0.2 0.6 0.1 0.1 0.2 0.5 Boat with a motor 0.0 0.1 0.0 0.0 0.1 0.0 Car / van 13.6 26.6 10.8 15.3 9.5 16.7 Bank account 60.1 79.0 56.1 68.6 54.0 53.8 Ownership of dwelling Owned by a household member 88.7 69.9 92.7 86.8 90.5 89.2 Not owned 11.3 30.1 7.3 13.2 9.5 10.8 Rented 6.0 21.7 2.6 8.6 5.1 2.5 Other 5.4 8.5 4.7 4.6 4.5 8.3 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 6,213 1,090 5,123 2,614 2,172 1,428 P a g e | 18 Table HH.8 shows how the household populations in areas, divisions and districts are distributed according to household wealth quintiles. The data show that 60.5 percent of the urban population is in the richest quintile compared with 11.1 percent in rural areas. Whereas, 23.9 percent of the rural population falls in the poorest quintile compared with only 2.2 percent in urban areas. In Gilgit division, 35.2 percent households fall in the richest quintile against 3.1 percent households living in poorest quintile. Amongst the districts, the highest households of Gilgit district are living in the richest quintile (53.5%) followed by 30.2 percent in Hunza district as compared to least in Ghanche (1.1%). Similarly, district Shigar, Ghanche, Diamer and Kharmang have highest proportion of population living in households in the poorest quintiles (44.7%, 36.4%, 36.3% and 32.0% respectively). Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintiles, according to area of residence and regions, Gilgit- Baltistan, 2016-17 Wealth index quintiles Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 47,983 Area Urban 2.2 5.2 12.1 20.0 60.5 100.0 8,632 Rural 23.9 23.2 21.7 20.0 11.1 100.0 39,351 Division Gilgit 3.1 10.1 20.4 31.2 35.2 100.0 18,895 Baltistan 30.4 28.4 20.6 12.6 8.0 100.0 16,457 Diamer 31.8 23.8 18.6 13.0 12.8 100.0 12,632 District Astore 18.5 27.7 27.2 19.1 7.4 100.0 3,193 Diamer 36.3 22.5 15.6 10.9 14.7 100.0 9,438 Ghanche 36.4 41.7 15.6 5.2 1.1 100.0 4,435 Ghizer 5.5 15.9 25.6 34.0 19.0 100.0 5,750 Gilgit 1.1 6.0 13.2 26.2 53.5 100.0 8,845 Hunza 0.1 4.8 18.0 46.9 30.2 100.0 1,487 Kharmang 32.0 23.0 25.0 15.8 4.1 100.0 1,611 Nagar 5.8 14.1 33.8 32.6 13.6 100.0 2,813 Shigar 44.7 32.4 17.1 4.6 1.3 100.0 2,381 Skardu 22.5 21.0 23.5 18.4 14.6 100.0 8,029 In table HH9 households are distributed to area, education of household head, wealth index, usual spoken language, division and district to marital status of population age 10 years or above. More than half of the women above 10 years of age are married and a slightly less than half are unmarried (51.2% and 43.8% respectively). There is less variation in marital status between urban and rural inhabitants. However, the data further shows that there is inverse proportion between currently married and never married in rural and urban areas. P a g e | 19 Table HH.9: Marital status of population age 10 years or above Percentage of households members age 10 years or above by Marital status, Gilgit-Baltistan, 2016-17 Marital Status Total number of household members aged 10 years and above Currently married Widowed Divorced Separated Never married Missing Total 51.2 4.3 0.5 0.0 43.8 0.2 33,360 Area of residence Urban 48.8 3.9 0.5 0.0 46.7 0.1 6,246 Rural 51.8 4.3 0.5 0.0 43.2 0.2 27,115 Education of household head None/pre-school 51.3 4.7 0.6 0.1 43.0 0.2 16,131 Primary 51.0 3.3 0.5 0.0 45.2 0.0 5,751 Middle 51.2 4.2 0.2 0.0 44.1 0.3 3,289 Secondary 52.6 4.1 0.3 0.0 43.0 0.0 3,325 Higher 50.1 4.1 0.3 0.0 45.4 0.1 4,810 Missing/DK (60.3) (2.7) (0.0) (0.0) (36.9) (0.0) 54 Wealth index quintile Poorest 52.8 5.3 0.7 0.1 40.9 0.2 6,257 Second 51.8 3.8 0.5 0.1 43.5 0.3 6,420 Middle 50.5 3.8 0.5 0.0 45.1 0.1 6,684 Fourth 50.2 4.5 0.5 0.0 44.7 0.1 6,923 Richest 51.0 3.9 0.2 0.0 44.7 0.1 7,077 Usual language spoken in the household Sheena 50.7 3.7 0.4 0.0 44.9 0.2 15,984 Balti 53.1 4.8 0.7 0.1 41.3 0.1 9,919 Brushaski 47.5 5.2 0.3 0.0 46.7 0.1 4,044 Other languages 56.0 3.1 0.1 0.1 40.5 0.2 1,473 Division Gilgit 49.4 4.5 0.3 0.0 45.5 0.2 13,856 Baltistan 52.4 4.7 0.7 0.1 42.1 0.1 11,468 Diamer 52.8 3.1 0.5 0.0 43.4 0.2 8,037 District Astore 46.9 3.9 0.2 0.0 49.0 0.0 2,149 Diamer 55.0 2.8 0.7 0.0 41.3 0.2 5,888 Ghanche 54.1 5.8 1.2 0.1 38.6 0.2 3,071 Ghizer 50.8 4.2 0.3 0.0 44.4 0.2 4,323 Gilgit 49.6 4.0 0.3 0.1 45.7 0.4 6,248 Hunza 51.0 6.8 0.6 0.1 41.5 0.0 1,186 Kharmang 56.7 5.6 0.5 0.1 37.0 0.1 1,122 Nagar 44.7 5.6 0.2 0.0 49.5 0.0 2,099 Shigar 54.0 5.5 0.7 0.3 39.4 0.0 1,585 Skardu 50.1 3.7 0.4 0.0 45.8 0.0 5,690 ( ) Figures that are based on 25-49 unweighted cases P a g e | 21 IV. CHILD MORTALITY One of the overarching goals of the Millennium Development Goals (MDGs) is the reduction of 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. The infant mortality rate is the probability of dying before the first birthday, while the under-five mortality rate is the probability of dying before the fifth birthday. In GB-MICS, an indirect method, known as the Brass method17, was used. Robust estimates of the aforementioned indicators are produced by this indirect method, and are comparable with those obtained by applying direct methods. The data used by the indirect methods are: the mean number of children ever born for five-year time- since-first-birth groups of women age 15 to 49 years, and the proportion of these children who are dead, also for five-year time-since-first-birth groups of women (Table CM.1). The technique converts the proportions dead among children of women in each time-since-first-birth group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Pakistan, the East model life table was selected as most appropriate. Table CM.1: Children ever born, children surviving and proportion dead Mean and total numbers of children ever born, children surviving and proportion dead by age of women, Gilgit-Baltistan, 2016-17 Children ever born Children surviving Proportion dead Number of women age 15-49 years Mean Total Mean Total Total 4.2 24,040 3.8 21,601 0.1 5,728 Time since first birth 0-4 1.6 2,298 1.5 2,133 0.1 1,423 5-9 3.3 4,250 3.0 3,906 0.1 1,296 10-14 4.7 5,229 4.3 4,738 0.1 1,106 15-19 6.1 6,688 5.5 5,999 0.1 1,099 20-24 6.9 5,575 6.0 4,825 0.1 804 Table CM.2 provides estimates of infant and under-five mortality rates derived from proportion dead among children of women in various time-since-first-birth groups from 0-4 to 20-24 months. This table provides estimates of infant and under-5 mortality rates for various points in time prior to the survey. These estimates are later used in Figure CM.2 to compare the trend indicated by these rates with those from other data sources. 17 United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division. United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN. International Union for the Scientific Study of Population, 2013. Tools for Demographic Estimation. Paris, UNFPA. P a g e | 22 Table CM.2: Infant and under-5 mortality rates by age groups of women Indirect estimates of infant and under-5 mortality rates by age of women, and reference dates for estimates, East model, Gilgit-Baltistan, 2016-17 Reference date Infant mortality rate Under-5 mortality rate Time since first birth 0-4 2015.0 73.5 91.8 5-9 2012.6 71.0 88.4 10-14 2010.0 76.0 95.3 15-19 2007.2 79.2 99.9 20-24 2003.9 94.3 121.6 To obtain the most recent single estimates of the two indicators by background characteristics, estimates from time since first birth groups 0-4 and 5-9 are averaged and presented in Table CM.3. The infant mortality rate in GB is estimated at 73.5 deaths per thousand live births, while the probability of dying under age 5 (U5MR) is around 91.8 per thousand live births. Probability of dying among males is higher than females. The infant mortality rate for males is 90.3 deaths per thousand live births compared with 57.1 deaths per thousand for females. The infant and under five mortality rates are prominent in urban and rural areas being the mortality rates for both infant and under-five are double in rural than the urban area of GB. Infant mortality rate in rural areas is 79.7 deaths per thousand live births compared with 40.3 deaths per thousand live births in urban areas whereas the under-five mortality rate in rural areas is 100.7 and 40 in urban areas. There are also differences in infant and under-5 mortality in terms of mother's educational levels and wealth quintiles. Under-5 mortality for children whose mothers have primary education is high (109.1 deaths per thousand live births), 99.3 deaths per thousand live births having pre-school or no education of mothers and the rates is less for children whose mothers have higher than primary education. More than half of the infant and under-five mortality rates are children having mother with no education, pre and primary education. Both the infant and under-five mortality rates have prominent relationship with the wealth quintiles. The data shows that as the wealth quintiles increases, both the infant and under-five mortality rate decreases. The infant mortality rate is highest amongst the poorest (116.4 deaths per 1000 live births) and declines from second wealth quintiles (96.5 deaths per 1000 live births) to the richest (37.9 deaths per 1000 live births). Information on usual language spoken in households shows that infant (91.8 deaths per 1000 live births) and under-five (118.1deaths per 1000 live births) mortality is highest in households speak other languages and the least is with Brushaski language for both infant (45.5 deaths per 1000 live births) and under-five mortality rates (53.7 deaths per 1000 live births). At division level, both infant and under-five mortality rates are less than half of the infant and under- five mortalities in Diamer and Baltistan division as compared to Gilgit division. The data shows that the infant mortality rates are lowest in Gilgit division at 40.5 deaths per thousand live births and highest in Diamer division at 95.1 per thousand live births. The under-five mortality rate is also highest in Diamer division (122.9 deaths per 1000 live births), 118.1 in Baltistan division and lowest in 47.3 in Gilgit division. At the district level, the infant mortality rate is highest in district Kharmang (132 deaths per 1000 live births), Diamer (103 deaths per 1000 live births) and Shigar (102 deaths per 1000 live births) as compared to the lowest infant mortality rates are in district Gilgit (45.9 deaths per 1000 live births), Hunza (44 deaths per 1000 live births) and Ghizer (10 deaths per 1000 live births). Similar trend of under-five mortalities are for the same districts. P a g e | 23 Table CM.3: Infant and under-5 mortality rates by background characteristics Indirect estimates of infant and under-five mortality rates by selected background characteristics, Time Since First Birth (TSFB) version, (by using East Model), Gilgit-Baltistan, 2016-17 Infant mortality rate1 Under-five mortality rate2 Total 73.5 91.8 Area of residence Urban 40.3 47.0 Rural 79.7 100.7 Sex Male 90.3 112.4 Female 57.1 70.3 Mother's education None/pre-school 99.3 128.9 Primary 109.1 143.0 Middle 39.2 45.6 Secondary 37.1 43.0 Higher 40.9 47.7 Wealth index quintile Poorest 116.4 153.4 Second 96.5 124.8 Middle 63.3 77.7 Fourth 54.1 65.2 Richest 35.9 41.5 Usual language spoken in the household Sheena 65.4 80.6 Balti 91.0 117.0 Brushaski 45.5 53.7 Other languages 91.8 118.1 Division Gilgit 40.5 47.3 Baltistan 91.8 118.1 Diamer 95.1 122.9 District Astore 70.3 87.3 Diamer 103.1 134.4 Ghanche 72.8 90.9 Ghizer 10.9 12.2 Gilgit 45.9 54.2 Hunza 44.0 51.7 Kharmang 132.2 176.0 Nagar 67.2 83.1 Shigar 102.0 132.8 Skardu 91.0 116.9 1 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 2 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate Rates refer to January, 2015. The East Model was assumed to approximate the age pattern of mortality in Gilgit-Baltistan, Pakistan and calculations are based on the Time Since First Birth (TSFB) version of the indirect children ever born/children surviving method. P a g e | 24 Fi gure C M.1: Unde r-5 mo rtal i ty rates b y area an d d iv is io n, G i lg i t -Bal t is tan MIC S, 2016-17 Figure CM.2 shows under-5 mortality rates from GB-MICS are obtained from Table CM.2. The MICS estimates indicate a decline in mortality during 2004-2016. The U5MR estimate (104 per thousand live births) from MICS, which is the most recent, is about 12 percent higher than the estimate from PDHS conducted about 4-years before MICS (2012-13). It should be noted that the PDHS uses a direct method of mortality estimation. However, MICS results are considerably higher than those indicated by PDHS 2012-13. 42 65 78 125 153 48 43 46 143 129 47 101 87 134 91 12 54 52 176 83 133 117 92 0 50 100 150 200 Wealth index quintile Richest Fourth Middle Second Poorest Mother's education Higher Secondary Middle Primary None/pre-school Area Urban Rural District Astore Diamer Ghanche Ghizer Gilgit Hunza Kharmang Nagar Shigar Skardu Gilgit-Baltistan Under-5 Mortality Rates per 1,000 Births P a g e | 25 Fi gure CM.2: Trend in unde r-5 m ortal i ty rate , 2004-2016, Gi l g i t -B al t i s tan MIC S, 2016-17 9288 95 100 122 0 40 80 120 160 2002 2004 2006 2008 2010 2012 2014 2016 Per 1,000 live births GB-MICS 2016-17 P a g e | 27 V. NUTRITION Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also for the new-born’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight shoots primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during pregnancy, Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In developing countries like Pakistan, teenagers who give birth when their own bodies have yet to finish growing, run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the countries like Pakistan (developing countries) are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.18 18 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Source of Data on Birth Weight in Developing Countries in “Bulletin of the World Health Organization”, P a g e | 28 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Gilgit-Baltistan, 2016-17 Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live- born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Total 16.1 19.0 50.3 13.7 1.0 100.0 30.5 22.7 2,705 Area of residence Urban 11.5 21.5 50.0 15.9 1.2 100.0 27.9 31.0 462 Rural 17.1 18.5 50.3 13.2 0.9 100.0 31.0 21.0 2,244 Mother’s age at birth Less than 20 years 19.9 19.2 47.0 12.7 1.3 100.0 33.8 19.2 246 20-34 years 16.0 18.6 50.2 14.1 1.0 100.0 30.2 24.1 2,004 35-49 ywears 14.6 20.4 52.3 12.4 0.4 100.0 30.1 18.5 455 Birth order 1 19.6 19.6 48.0 11.0 1.8 100.0 33.9 34.3 511 2-3 15.3 19.8 50.9 13.1 0.7 100.0 30.3 27.4 925 4-5 15.5 16.7 50.6 16.7 0.4 100.0 28.5 17.2 608 6+ 15.2 19.3 50.8 13.6 1.1 100.0 29.9 12.3 662 Mother’s educationa None/pre-school 16.4 20.8 49.0 12.9 0.9 100.0 31.9 10.1 1,526 Primary 17.7 15.6 53.5 13.0 0.2 100.0 29.7 20.7 298 Middle 17.9 18.2 42.0 19.9 2.0 100.0 31.0 29.3 216 Secondary 16.2 18.7 51.7 12.6 0.8 100.0 30.4 35.6 303 Higher 12.7 14.6 56.7 14.6 1.4 100.0 24.9 63.0 361 Wealth index quintile Poorest 22.9 17.8 49.7 9.0 0.6 100.0 35.8 4.4 566 Second 21.0 17.0 50.3 10.7 1.1 100.0 33.5 11.3 589 Middle 14.1 20.5 50.8 13.7 1.0 100.0 29.8 23.6 565 Fourth 14.2 21.5 47.3 16.1 0.9 100.0 30.1 35.1 493 Richest 6.9 18.5 53.3 20.0 1.2 100.0 22.0 44.2 492 Usual language spoken in the household Sheena 8.8 20.9 52.5 17.3 0.5 100.0 25.3 20.8 1,439 Balti 33.0 13.1 44.7 8.0 1.2 100.0 41.5 8.1 796 Brushaski 11.0 19.4 54.7 12.0 3.0 100.0 26.7 63.3 232 Other languages 8.7 26.6 51.3 12.1 1.3 100.0 28.9 43.5 239 Division Gilgit 10.9 23.3 45.4 19.1 1.3 100.0 28.4 49.7 966 Baltistan 33.5 12.7 45.5 7.7 0.7 100.0 41.6 7.9 873 Diamer 4.6 20.5 60.6 13.6 0.8 100.0 21.6 7.7 866 District Astore 12.4 24.6 50.0 12.9 0.0 100.0 30.8 10.5 189 Diamer 2.4 19.3 63.5 13.8 1.0 100.0 19.1 6.9 677 Ghanche 26.6 8.3 59.3 3.9 1.9 100.0 33.7 9.1 240 Ghizer 12.2 23.6 47.9 12.0 4.4 100.0 30.2 73.2 260 Gilgit 9.9 24.0 42.0 24.1 0.0 100.0 27.7 34.4 516 Hunza 5.9 17.7 63.8 11.7 1.0 100.0 21.1 92.9 49 Kharmang 22.8 41.5 28.1 6.8 0.8 100.0 50.1 7.5 96 Nagar 13.5 22.6 46.5 16.8 0.6 100.0 30.4 46.7 140 Shigar 45.8 9.5 34.3 9.7 0.7 100.0 49.7 3.9 143 Skardu 35.8 9.4 45.3 9.5 0.0 100.0 41.3 8.7 394 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth (*) Figures that are based on fewer than 25 unweighted cases a Total includes 1 unweighted case of mother's education missing In Gilgit-Baltistan, about 23 percent of births were weighed at birth with big prevalence differences across districts; only 4 percent births were weighed in Shigar district compared to 93 percent in Hunza district. Approximately 31 percent of infants are estimated to weigh less than 2,500 grams at birth (Table NU.1). Among divisions, Diamer had the lowest proportion of low birth weight babies (22%) P a g e | 29 and the highest proportion was in Baltistan division (42%). The prevalence of low birth weight does not vary considerably by area of residence but mothers having higher education levels had lowest proportion of birth weight babies (25%). 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. Under nutrition is associated with more than half of all child 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 children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The MDG target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards19. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height – can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median weight 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 height 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. Weight-for-height can be used to assess wasting and overweight status. Children whose weight-for- height is more than two standard deviations below the median weight of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS5, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended20 by UNICEF. Findings in this section are based on the 19 http://www.who.int/childgrowth/standards/technical_report 20 MICS Supply Procurement Instructions: http://mics.unicef.org/tools#survey-design P a g e | 30 results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories and mean z-scores for all three anthropometric indicators. Children whose full birth date (month and year) were not obtained, and children whose measurements were outside a plausible range are excluded from Table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.12, DQ.13, and DQ.14 in Appendix – D. These tables show that due to incomplete dates of birth, implausible measurements, and/or missing weight and/or height, 1.7 percent of children have been excluded from calculations of the weight-for-age, 3.0 percent from the height-for- age, and 2.5 percent for the weight-for-height. Percentage of interviews completed for eligible children is shown in Table DQ.3. The completeness of reporting of both year and month is 99 percent for interviews conducted for children under 5 (Table DQ.5). There was no heaping in the weight measurements, however, a slight heaping was observed in the height measurements where interviewers preferred the digits two (DQ.15). In Gilgit-Baltistan, almost one in five children under the age of five are moderately or severely underweight (19%) and 6 percent are classified as severely underweight (Table NU.2). Overall, 46 percent of children are moderately or severely stunted or too short for their age and 4 percent of children are moderately or severely wasted or too thin for their height, whereas less than 3 percent are overweight or too heavy for their height. Boys have a slightly higher rate of underweight, stunting, and wasting than girls. Children in rural areas have higher rate of underweight and stunting compared to in urban areas. Among divisions, Diamer has the highest rates of underweight and stunting. It also has the highest rates of moderate and sevre wasting which is more than four times the rate of Gilgit and Baltistan division. All three anthropometric indicators are found to be better in Gilgit division. Underweight, stunting and wasting indicators are inversely correlated with mother’s education and wealth. Among women with higher education, 25 percent of children are stunted, 8 percent are underweight and 1 percent are wasted compared to more than 54 percent for stunting and 25 percent underweight among children whose mother have pre-school or no education. More than half of the children living in the poorest households are stunted (62%) whereas proportion of underweight children living in the poorest households also witnessed higher prevalence (31%) compared to 26 percent and 7 percent of children living in the richest households that are stunted and underweight. The age pattern shows that a higher percentage of children age 18-59 months are undernourished as prevalence of underweight and stunting is higher in this age cohort in comparison to children who are younger (Figure NU.1). P a g e | 31 F i gure N U.1 : Underwei ght , s tunted , wasted and ove rwe ight ch i ldren under age 5 (m ode rate and se vere ) , G i l g i t -B al t is tan M IC S, 2016-17 Underweight Stunted Wasted Overweight 0 10 20 30 40 50 60 0 12 24 36 48 60 P e r c e n t Age in months P a g e | 32 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Gilgit-Baltistan, 2016-17 Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Total 19.4 5.6 -1.1 6,521 46.2 22.2 -1.9 6,441 3.8 1.1 2.9 0.0 6,470 Area of residence Urban 12.0 2.8 -0.8 1,082 37.6 14.6 -1.6 1,074 2.1 0.5 3.9 0.2 1,076 Rural 20.9 6.1 -1.1 5,439 48.0 23.7 -1.9 5,367 4.2 1.2 2.7 0.0 5,394 Sex Male 20.4 6.4 -1.1 3,408 47.6 22.9 -1.9 3,359 4.6 1.3 3.1 0.0 3,370 Female 18.3 4.6 -1.0 3,113 44.8 21.3 -1.8 3,082 3.0 0.8 2.8 0.1 3,100 Age 0-5 months 11.2 2.6 -0.5 610 13.8 6.1 -0.5 610 7.6 2.3 5.5 -0.2 603 6-11 months 18.4 6.3 -0.9 691 22.9 8.7 -1.1 682 9.8 2.6 3.3 -0.2 684 12-17 months 16.9 4.5 -0.9 636 38.4 16.5 -1.6 629 7.8 2.2 2.0 -0.2 631 18-23 months 21.2 7.6 -1.1 654 52.3 24.5 -2.1 643 4.9 1.1 3.2 -0.1 647 24-35 months 20.1 5.9 -1.1 1,299 55.3 27.3 -2.2 1,284 1.8 0.9 2.6 0.1 1,292 36-47 months 21.3 5.6 -1.2 1,299 56.3 28.4 -2.2 1,281 1.1 0.1 2.3 0.2 1,294 48-59 months 21.4 5.8 -1.3 1,333 55.5 27.1 -2.2 1,312 1.3 0.4 2.8 0.2 1,320 Mother’s education None/pre-school 25.1 8.0 -1.3 3,930 54.3 28.4 -2.1 3,865 4.9 1.5 2.6 0.0 3,892 Primary 16.9 2.8 -0.9 642 46.8 20.1 -1.8 639 3.1 1.0 2.9 0.1 641 Middle 10.5 2.1 -0.8 500 37.1 12.2 -1.5 498 1.9 0.4 2.4 0.2 498 Secondary 8.0 1.4 -0.6 690 30.4 10.8 -1.4 687 2.8 0.1 3.6 0.2 688 Higher 8.2 1.5 -0.5 757 25.1 8.7 -1.2 749 1.1 0.4 4.7 0.2 748 Wealth index quintile Poorest 31.1 11.4 -1.5 1,458 62.2 36.7 -2.4 1,432 6.2 2.0 2.2 -0.1 1,439 Second 23.4 6.9 -1.2 1,395 52.8 26.6 -2.0 1,367 4.5 1.9 3.1 0.0 1,382 Middle 17.5 3.3 -1.0 1,335 45.9 20.6 -1.8 1,325 3.6 0.7 3.1 0.0 1,334 Fourth 14.2 2.8 -0.9 1,186 38.8 15.2 -1.7 1,178 2.3 0.3 2.2 0.1 1,175 Richest 7.3 2.0 -0.5 1,147 26.3 7.6 -1.2 1,139 2.0 0.2 4.3 0.2 1,140 Usual language spoken in the household Sheena 20.3 6.5 -1.1 3,425 44.6 21.9 -1.8 3,372 5.1 1.7 2.5 -0.1 3,394 Balti 18.5 4.1 -1.1 1,957 53.3 26.4 -2.1 1,940 1.9 0.3 3.8 0.2 1,946 Brushaski 10.1 2.2 -0.7 543 33.2 10.6 -1.5 535 1.7 0.2 3.2 0.2 542 Other languages 25.4 8.2 -1.2 597 44.3 20.1 -1.9 594 4.9 1.1 2.4 -0.2 588 P a g e | 33 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Gilgit-Baltistan, 2016-17 Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Total 19.4 5.6 -1.1 6,521 46.2 22.2 -1.9 6,441 3.8 1.1 2.9 0.0 6,470 Division Gilgit 11.8 2.7 -0.7 2,246 34.5 12.7 -1.5 2,226 1.7 0.2 2.8 0.2 2,233 Baltistan 19.0 4.1 -1.1 2,202 53.6 27.6 -2.1 2,181 1.6 0.3 3.4 0.2 2,188 Diamer 28.1 10.3 -1.4 2,073 51.2 26.7 -2.0 2,033 8.5 2.8 2.5 -0.3 2,048 District Astore 13.6 3.1 -0.8 452 33.8 11.5 -1.3 449 4.3 0.9 1.7 -0.1 449 Diamer 32.1 12.3 -1.5 1,622 56.1 31.0 -2.1 1,584 9.7 3.4 2.8 -0.3 1,599 Ghanche 13.6 3.0 -0.9 598 52.3 24.3 -2.0 590 0.9 0.4 4.4 0.4 594 Ghizer 15.9 3.3 -0.9 630 43.9 15.9 -1.8 622 1.5 0.6 3.2 0.1 620 Gilgit 10.7 2.6 -0.7 1,160 29.9 11.9 -1.4 1,150 2.0 0.1 2.7 0.1 1,156 Hunza 5.2 0.4 -0.5 125 19.0 5.1 -1.1 124 0.3 0.0 2.6 0.1 124 Kharmang 27.8 6.7 -1.5 213 65.5 32.6 -2.5 207 1.9 0.6 2.8 0.0 209 Nagar 10.2 2.3 -0.7 332 38.4 12.2 -1.6 331 1.7 0.1 2.8 0.3 333 Shigar 19.9 3.9 -1.2 353 61.3 32.8 -2.4 351 0.8 0.0 3.3 0.3 353 Skardu 19.9 4.4 -1.1 1,038 49.4 26.8 -2.0 1,033 2.3 0.3 3.0 0.1 1,033 1 MICS indicator 2.1a and MDG indicator 1.8 - Underweight prevalence (moderate and severe) 2 MICS indicator 2.1b - Underweight prevalence (severe) 3 MICS indicator 2.2a - Stunting prevalence (moderate and severe) 4 MICS indicator 2.2b - Stunting prevalence (severe) 5 MICS indicator 2.3a - Wasting prevalence (moderate and severe) 6 MICS indicator 2.3b - Wasting prevalence (severe) 7 MICS indicator 2.4 - Overweight prevalence P a g e | 34 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival. It can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water, are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.21 UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond.22 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.23 A summary of key guiding principles24, 25 for feeding 6-23 month olds is provided in the table on next page along with proximate measures for these guidelines. The guiding principles for which proximate measures and indicators exist, are: continued breastfeeding; appropriate frequency of meals (but not energy density); and appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Dietary diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For dietary diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).26 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: the appropriate number of meals/snacks/milk feeds; food items from at least 4 food groups; and breastmilk or at least 2 milk feeds (for non-breastfed children). 21 Bhuta Z. et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 22 WHO (2003). Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February 2003. 23 WHO (2003). Global Strategy for Infant and Young Child Feeding. 24 PAHO (2003). Guiding principles for complementary feeding of the breastfed child. 25 WHO (2005). Guiding principles for feeding non-breastfed children 6-24 months of age 26 WHO (2008). Indicators for assessing infant and young child feeding practices. Part 1: Definitions. P a g e | 35 Table Guiding Principle (age 6-23 months) Proximate measures NU.4 Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.6 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups27 eaten in the last 24 hours na Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists NU.9 Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple na Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists Table NU.3 is based on mothers’ report of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.28 Although a very important step is management of lactation and establishment of a physical and emotional relationship between the baby and the mother, In Gilgit-Baltistan, only 35 percent of babies are breastfed for the first time within one hour of birth, while 90 percent of newborns start breastfeeding within one day of birth. By district, 95 percent of babies in Shigar district were breastfed within one day of birth compared to 82 percent of babies in Kharmang. The data also show that 28 percent of newborns receive prelacteal feed. The findings are presented in Figure NU.2 by district and area of residence. 27 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. 28 Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). P a g e | 36 Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Gilgit-Baltistan, 2016-17 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live- born children in the last two years Within one hour of birth2 Within one day of birth Total 97.9 35.0 89.5 28.0 2,705 Area of residence Urban 97.3 29.4 89.5 39.1 462 Rural 98.0 36.2 89.4 25.7 2,244 Months since last birth 0-11 months 98.3 36.2 89.1 29.8 1,390 12-23 months 97.4 33.8 89.8 26.1 1,315 Assistance at delivery Skilled attendant 98.4 31.3 88.0 31.4 1,678 Traditional birth attendant 97.5 34.3 95.2 22.2 133 Relative/Friend 98.4 43.9 92.8 23.3 857 Other/Missing (61.8) (3.1) (60.2) (6.3) 38 Place of delivery Home 98.4 41.2 92.9 22.7 1,041 Health facility 98.4 31.6 88.2 31.6 1,630 Public 98.2 27.1 86.3 36.1 1,272 Private 99.1 47.3 94.9 15.7 359 Other/DK/Missing (56.6) (13.6) (45.1) (15.9) 34 Mother’s educationa None/pre-school 97.8 40.2 91.6 26.3 1,526 Primary 97.1 28.3 85.3 28.6 298 Middle 98.9 30.2 90.6 30.1 216 Secondary 97.8 24.1 88.0 28.7 303 Higher 98.2 31.2 84.2 32.6 361 Wealth index quintile Poorest 98.0 38.7 92.6 21.5 566 Second 96.8 34.3 87.9 21.0 589 Middle 98.9 30.9 88.8 27.1 565 Fourth 96.8 38.2 88.3 30.7 493 Richest 98.9 33.3 89.7 42.2 492 Usual language spoken in the household Sheena 98.0 42.3 90.8 35.5 1,439 Balti 98.3 15.5 89.4 15.0 796 Brushaski 96.9 36.8 83.9 28.1 232 Other languages 96.3 54.8 86.9 26.4 239 Division Gilgit 97.9 44.1 89.1 32.3 966 Baltistan 98.2 15.2 89.7 13.9 873 Diamer 97.5 45.0 89.6 37.4 866 District Astore 98.4 23.0 82.7 32.7 189 Diamer 97.2 51.1 91.5 38.7 677 Ghanche 97.8 13.3 89.5 15.2 240 Ghizer 95.2 63.3 88.7 7.8 260 Gilgit 99.0 36.2 90.0 45.0 516 Hunza 97.4 70.3 90.3 33.8 49 Kharmang 95.9 6.3 81.8 19.5 96 Nagar 99.2 28.0 86.0 30.7 140 Shigar 98.5 21.0 94.9 20.7 143 Skardu 98.8 16.4 89.9 9.4 394 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases a Total includes 1 unweighted case of mother's education missing P a g e | 37 F i gure NU.2 : In i t i at i on of bre astfee ding, Gi lg i t -B al t i s tan MICS, 2016-17 The set of Infant and Young Child Feeding indicators reported in Tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to the interview. Data are subject to a number of limitations, some related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed; referring to infant’s age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. In Gilgit-Baltistan, approximately 63 percent of children age less than six months are exclusively breastfed. With 69 percent predominantly breastfed, it is evident that water-based liquids are replacing feeding of breastmilk to the greatest degree. By age 12-15 months, 81 percent of children are breastfed, and by age 20-23 months, 51 percent continue to be breastfed. Exclusive breastfeeding for children age less than six months is slightly higher in urban areas than rural areas. In Baltistan division, fewer children (56%) are exclusively breastfed compared to children in the other divisions. Predominant breastfeeding ranges from 62 percent in Baltistan division to 78 percent in Diamer division. 83 92 90 89 90 90 82 86 95 90 90 89 89 23 51 13 63 36 70 6 28 21 16 29 36 35 0 20 40 60 80 100 120 P e r c e n t Within one day Within one hour P a g e | 38 Table NU.4: Breast feeding Percentage of living children according to breastfeeding status at selected age groups, Gilgit-Baltistan, 2016-17 Children age 0-3 months Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent ever breastfed Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent ever breastfed Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Total 99.7 71.4 76.0 389 99.8 63.0 69.1 617 80.7 412 50.8 449 Area of residence Urban 100.0 75.8 77.6 61 100.0 69.3 72.6 90 76.5 80 52.4 75 Rural 99.7 70.6 75.7 328 99.8 62.0 68.6 527 81.8 332 50.5 374 Sex Male 99.4 73.0 76.9 191 99.6 60.0 67.5 304 84.0 220 50.9 245 Female 100.0 69.9 75.2 198 100.0 66.0 70.8 312 77.0 192 50.7 204 Mother’s educationa None/pre-school 100.0 76.7 83.3 220 100.0 70.4 77.9 334 81.6 242 50.8 277 Primary (100.0) (70.0) (72.8) 46 100.0 66.2 67.9 71 (72.4) 33 (20.6) 36 Middle (100.0) (75.7) (78.0) 30 100.0 61.4 64.3 45 (71.7) 40 (63.0) 36 Secondary (100.0) (52.9) (54.3) 53 100.0 44.8 50.8 84 92.2 48 (49.0) 35 Higher (97.3) (65.2) (66.9) 40 98.7 49.9 55.9 82 80.0 48 61.6 66 Wealth index quintile Poorest 100.0 78.7 84.7 81 100.0 70.7 78.3 126 83.3 80 55.6 102 Second 98.7 75.0 84.1 85 99.2 70.3 78.1 131 73.9 90 43.3 88 Middle 100.0 63.0 65.1 97 100.0 58.1 60.1 137 80.6 87 49.9 108 Fourth 100.0 69.2 74.1 67 100.0 62.3 71.1 105 85.7 83 47.6 69 Richest (100.0) (72.7) (72.7) 60 100.0 53.2 58.3 117 80.9 72 56.8 83 Usual language spoken in the household Sheena 100.0 76.6 81.5 233 100.0 66.3 73.6 354 80.3 234 49.1 267 Balti 99.0 61.4 66.1 113 99.4 55.3 60.7 179 78.8 119 51.9 109 Brushaski (100.0) (65.1) (65.1) 24 100.0 61.3 62.8 50 91.4 34 51.9 39 Other languages (*) (*) (*) 14 (100.0) (82.5) (88.2) 24 (*) 7 (48.6) 21 Division Gilgit 100.0 74.4 74.4 125 100.0 63.7 68.2 220 82.7 142 57.3 159 Baltistan 99.1 59.7 67.6 127 99.5 55.5 61.6 203 78.2 128 51.9 129 Diamer 100.0 79.6 85.3 137 100.0 70.3 78.1 193 81.0 143 43.5 161 District Astore 100.0 65.8 81.9 32 100.0 51.8 71.7 49 (84.8) 28 (55.8) 26 Diamer 100.0 83.8 86.4 104 100.0 76.6 80.4 144 80.1 115 41.1 135 Ghanche (100.0) (77.7) (80.2) 30 100.0 74.3 77.7 44 (77.1) 39 (61.2) 34 Ghizer (100.0) (84.9) (84.9) 30 (100.0) (82.0) (83.2) 46 (90.6) 33 (77.8) 47 Gilgit (100.0) (74.9) (74.9) 73 100.0 59.3 65.8 133 (76.0) 83 (46.5) 80 Hunza (*) (*) (*) 6 (*) (*) (*) 11 (*) 8 (*) 8 Kharmang (100.0) (63.8) (69.2) 13 100.0 57.8 65.1 20 (90.1) 19 (58.2) 12 Nagar (100.0) (53.2) (53.2) 16 100.0 53.9 55.4 30 (95.7) 18 (53.6) 25 Shigar (100.0) (75.4) (77.6) 18 100.0 61.9 66.5 28 85.2 22 47.2 29 P a g e | 39 Table NU.4: Breast feeding Percentage of living children according to breastfeeding status at selected age groups, Gilgit-Baltistan, 2016-17 Children age 0-3 months Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent ever breastfed Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent ever breastfed Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Total 99.7 71.4 76.0 389 99.8 63.0 69.1 617 80.7 412 50.8 449 Skardu (98.3) (46.2) (58.7) 66 99.0 45.9 53.3 111 (71.4) 48 (47.2) 54 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.8 - Predominant breastfeeding under 6 months 3 MICS indicator 2.9 - Continued breastfeeding at 1 year 4 MICS indicator 2.10 - Continued breastfeeding at 2 years ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases a Total includes 1 unweighted case of mother's education missing P a g e | 40 Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. At the earliest ages, the majority of children are exclusively breastfed anyhow considerable proportion of babies also received other milk formula with breastfed even at the early age of 0-1 months. About 52 percent of children are receiving breastmilk at age 2 years. F i gure NU.3: Infant feedin g p atte rns b y age , Gi lg i t -B al t i s tan MIC S, 2016-17 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 21.4 months for any breastfeeding, 4.1 months for exclusive breastfeeding, and 4.9 months for predominant breastfeeding. There is no difference in median duration for any breastfeeding while slight differentials are observed for exclusive and predominant breastfeeding. Exclusively breastfed Breastfed and complimentary foods Weaned (not breastfed) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age in months Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk / formula Breastfed and complimentary foods Weaned (not breastfed) P a g e | 41 Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Gilgit-Baltistan, 2016-17 Median duration (in months) of: Number of children age 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Median (Total) 21.4 4.1 4.9 3,936 Area of residence Urban 21.5 4.2 4.4 648 Rural 21.4 4.0 5.0 3,288 Sex Male 21.7 3.5 4.4 2,042 Female 21.0 4.9 5.3 1,894 Mother’s education None/pre-school 21.5 4.8 5.5 2,285 Primary 18.7 3.9 4.3 386 Middle 22.3 3.9 5.1 322 Secondary 21.4 0.6 1.6 447 Higher 22.6 2.5 3.3 495 Wealth index quintile Poorest 21.5 4.6 5.2 839 Second 21.2 4.7 5.6 840 Middle 21.7 3.9 4.5 837 Fourth 21.1 4.1 5.2 727 Richest 21.6 2.9 3.4 693 Usual language spoken in the household Sheena 21.2 4.3 5.1 2,103 Balti 21.4 3.5 4.7 1,147 Brushaski 21.2 3.7 3.9 326 Other languages 21.9 4.1 4.3 360 Division Gilgit 22.3 4.0 4.6 1,377 Baltistan 21.4 3.5 4.7 1,278 Diamer 20.6 4.5 5.2 1,281 District Astore 21.2 2.7 4.6 280 Diamer 20.5 4.9 5.2 1,000 Ghanche 21.9 4.3 4.9 348 Ghizer 23.3 4.6 5.0 372 Gilgit 20.6 3.7 4.7 745 Hunza 22.4 4.3 4.6 71 Kharmang 21.5 3.6 4.8 136 Nagar 21.2 3.0 3.2 189 Shigar 20.5 3.3 3.9 206 Skardu 21.3 0.5 2.8 589 Mean 20.4 4.0 5.0 3,936 1 MICS indicator 2.11 - Duration of breastfeeding The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children age 6-23 months are considered to be appropriately fed if they are receiving breastmilk and solid, semi-solid or soft food. As a result of feeding patterns, only 67 percent of children of age 6-23 months are being appropriately breastfed and age-appropriate breastfeeding among all children age 0-23 months, drops to 66 percent. At divisional level, age-appropriate breastfeeding among all children age 0-23 months ranges from 62 percent in Baltistan to 69 percent in Gilgit. A slight variation across districts is also observed. P a g e | 42 Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Gilgit-Baltistan, 2016-17 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi-solid or soft foods Number of children Percent appropriately breastfed2 Number of children Total 63.0 617 67.2 1,997 66.2 2,613 Area of residence Urban 69.3 90 69.8 357 69.7 446 Rural 62.0 527 66.7 1,640 65.5 2,167 Sex Male 60.0 304 68.9 1,067 66.9 1,372 Female 66.0 312 65.3 929 65.5 1,242 Mother’s educationa None/pre-school 70.4 334 65.5 1,155 66.6 1,490 Primary 66.2 71 56.1 194 58.8 265 Middle 61.4 45 68.7 177 67.2 221 Secondary 44.8 84 81.5 211 71.1 295 Higher 49.9 82 70.8 259 65.8 341 Wealth index quintile Poorest 70.7 126 64.5 421 65.9 547 Second 70.3 131 63.1 418 64.8 548 Middle 58.1 137 68.7 425 66.1 562 Fourth 62.3 105 69.9 371 68.2 476 Richest 53.2 117 70.7 362 66.4 479 Usual language spoken in the household Sheena 66.3 354 69.8 1,061 68.9 1,415 Balti 55.3 179 63.5 572 61.6 751 Brushaski 61.3 50 63.2 180 62.8 229 Other languages 82.5 24 60.2 102 64.4 126 Division Gilgit 63.7 220 70.5 708 68.9 928 Baltistan 55.5 203 64.1 620 61.9 824 Diamer 70.3 193 66.7 669 67.5 862 District Astore 51.8 49 59.0 130 57.0 179 Diamer 76.6 144 68.5 539 70.2 683 Ghanche 74.3 44 67.0 185 68.4 229 Ghizer 82.0 46 77.9 197 78.7 243 Gilgit 59.3 133 68.5 367 66.1 501 Hunza 67.8 11 69.5 37 69.1 48 Kharmang 57.8 20 66.5 68 64.5 88 Nagar 53.9 30 64.0 106 61.8 136 Shigar 61.9 28 63.3 104 63.0 133 Skardu 45.9 111 61.7 263 57.0 374 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding a Total includes 1 unweighted case of mother's education missing In Gilgit-Baltistan, 60 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day (Table NU.7). The proportion is higher (69%) in urban areas compared to 58 percent in rural areas. Similarly, mother living in household with higher wealth are more like give their children solid, semi-solid or soft food. P a g e | 43 Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Gilgit-Baltistan, 2016-17 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods1 Number of children age 6-8 months Total 60.1 332 (*) 20 60.0 352 Area of residence Urban 69.4 63 (*) 4 71.1 66 Rural 57.9 269 (*) 17 57.4 285 Sex Male 62.2 193 (*) 12 61.0 204 Female 57.2 139 (*) 8 58.7 147 Mother’s education None/pre-school 53.6 192 (*) 11 54.0 203 Primary (58.7) 36 (*) 6 (54.5) 42 Middle (56.9) 30 (*) 1 (58.1) 31 Secondary (84.0) 36 (*) 0 (84.2) 37 Higher (74.5) 37 (*) 2 (75.7) 39 Wealth index quintile Poorest 52.8 77 (*) 6 50.8 83 Second 54.9 66 (*) 5 56.4 71 Middle 65.0 62 (*) 2 66.2 64 Fourth 54.5 62 (*) 1 55.0 63 Richest 74.7 65 (*) 6 73.3 71 Usual language spoken in the household Sheena 65.2 166 (*) 8 65.1 174 Balti 51.6 91 (*) 6 53.7 98 Brushaski (61.6) 30 (*) 2 (63.6) 32 Other languages (51.0) 28 (*) 4 (43.9) 32 Division Gilgit 66.6 116 (*) 10 65.8 126 Baltistan 52.3 93 (*) 5 53.6 97 Diamer 59.9 122 (*) 6 59.2 128 District Astore (48.9) 28 (*) 1 (48.0) 28 Diamer 63.1 95 (*) 5 62.3 100 Ghanche (55.1) 28 (*) 2 (54.3) 29 Ghizer (64.3) 44 (*) 2 (61.9) 46 Gilgit (*) 48 (*) 7 (70.1) 56 Hunza (*) 5 (*) 0 (*) 5 Kharmang (41.2) 11 (*) 0 (41.2) 11 Nagar (57.5) 19 (*) 0 (58.5) 19 Shigar (57.9) 19 (*) 0 (58.9) 19 Skardu (50.6) 35 (*) 2 (53.9) 38 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Overall, 70 percent of the children age 6-23 months are receiving solid, semi-solid and soft foods the minimum number of times (Table NU.8). A slightly higher proportion of children in urban areas (79%) were achieving the minimum meal frequency compared to children in rural areas (68%). The proportion of children (27%), receiving the minimum dietary diversity or foods from at least 4 food groups, was much lower than that for minimum meal frequency indicating the need to focus on improving diet quality and nutrients intake among this vulnerable group. A higher proportion of older (18-23 month) children (43%) were achieving the minimum dietary diversity compared to younger (6-8 month old) children (4%). The overall assessment using the indicator of minimum acceptable diet revealed that only 20 percent of children are benefitting from a diet sufficient in both diversity and P a g e | 44 frequency. The proportion is slightly higher in urban areas (29%) compared to rural areas (18%). Children living in the richest households, those whose mothers have higher education and from Gilgit division are most likely to receive as recommended the minimum meal frequency, minimum dietary diversity, and minimum acceptable diet. P a g e | 45 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Gilgit- Baltistan, 2016-17 Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Total 22.5 65.6 21.2 1,547 41.1 84.7 17.1 60.8 449 26.7 69.9 20.3 1,997 Area of residence Urban 31.3 76.5 30.8 270 51.1 87.6 25.5 65.2 86 36.1 79.2 29.5 357 Rural 20.7 63.3 19.2 1,277 38.7 84.0 15.1 59.7 363 24.7 67.9 18.3 1,640 Sex Male 21.7 64.2 20.6 847 46.8 87.1 19.4 63.9 221 26.9 69.0 20.3 1,067 Female 23.5 67.3 22.0 701 35.6 82.3 14.9 57.7 229 26.5 71.0 20.2 929 Age 6-8 months 3.7 51.7 3.7 332 (*) (*) (*) (*) 20 3.9 52.4 3.5 352 9-11 months 11.9 51.9 10.9 320 (11.1) (85.7) (0.0) (85.9) 25 11.8 54.3 10.1 345 12-17 months 29.5 72.2 28.5 517 37.0 86.3 14.4 65.1 123 31.0 74.9 25.8 640 18-23 months 38.4 80.4 35.4 379 48.0 85.3 21.0 56.4 280 42.5 82.5 29.3 659 Mother’s educationd None/pre-school 16.8 59.1 15.8 903 33.8 78.3 7.1 50.0 252 20.5 63.3 13.9 1,155 Primary 19.2 66.4 19.2 129 32.4 89.3 13.4 63.1 64 23.6 74.0 17.3 194 Middle 18.5 73.3 15.5 137 (55.1) (93.0) (21.4) (82.9) 39 26.6 77.7 16.8 177 Secondary 31.5 75.6 30.3 181 (46.6) (100.0) (30.6) (67.6) 30 33.6 79.1 30.4 211 Higher 45.5 80.5 42.9 197 66.9 92.9 50.9 84.0 62 50.7 83.5 44.8 259 Wealth index quintile Poorest 8.3 49.4 7.4 331 25.5 73.3 7.8 53.4 90 12.0 54.5 7.5 421 Second 14.4 59.3 13.0 313 30.2 83.5 8.9 49.5 104 18.3 65.3 12.0 418 Middle 24.1 70.6 22.3 327 37.3 81.6 7.1 54.5 97 27.2 73.1 18.8 425 Fourth 30.6 70.9 29.0 301 55.2 94.8 25.7 77.6 70 35.3 75.4 28.3 371 Richest 38.2 80.5 37.4 274 62.8 93.0 40.5 75.3 88 44.1 83.5 38.2 362 Usual language spoken in the household Sheena 26.9 67.3 24.7 816 44.0 79.8 17.7 55.4 245 30.9 70.2 23.1 1,061 Balti 10.6 57.9 10.6 448 24.8 89.4 5.2 65.0 123 13.6 64.7 9.4 572 Brushaski 31.9 73.1 30.5 132 59.6 97.0 31.0 71.1 47 39.2 79.4 30.7 180 Other languages 18.1 63.7 18.1 81 (*) (*) (*) (*) 21 21.2 66.5 18.7 102 Division Gilgit 36.1 79.4 35.1 549 56.8 93.6 32.6 71.3 158 40.8 82.6 34.6 708 Baltistan 12.2 60.2 12.2 483 25.5 89.9 6.5 64.6 137 15.2 66.8 11.0 620 Diamir 17.6 56.0 14.8 515 38.7 70.9 10.6 46.5 154 22.5 59.4 13.8 669 P a g e | 46 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Gilgit- Baltistan, 2016-17 Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Total 22.5 65.6 21.2 1,547 41.1 84.7 17.1 60.8 449 26.7 69.9 20.3 1,997 District Astore 21.0 48.3 20.2 102 (37.0) (71.8) (11.7) (47.2) 28 24.5 53.3 18.4 130 Diamer 16.8 57.9 13.5 413 39.1 70.7 10.3 46.3 126 22.0 60.8 12.7 539 Ghanche 8.3 55.5 8.3 144 (18.2) (86.9) (5.4) (63.0) 41 10.5 62.4 7.7 185 Ghizer 28.6 77.9 26.6 172 (*) (*) (*) (*) 25 31.0 79.3 27.9 197 Gilgit 42.1 82.0 41.7 268 (55.4) (92.5) (31.2) (68.5) 99 45.7 84.8 38.9 367 Hunza 57.2 82.2 54.2 28 (*) (*) (*) (*) 9 65.4 86.6 54.8 37 Kharmang 3.3 39.3 3.3 58 (*) (*) (*) (*) 10 5.3 45.6 3.3 68 Nagar 24.7 73.0 24.7 80 (59.2) (100.0) (24.9) (62.4) 25 33.0 79.5 24.8 106 Shigar 5.4 55.5 5.4 79 24.4 88.0 6.4 46.4 25 10.0 63.4 5.6 104 Skardu 20.4 71.4 20.4 202 (32.2) (93.8) (7.9) (74.3) 61 23.1 76.6 17.5 263 1 MICS indicator 2.17a - Minimum acceptable diet (breastfed) 2 MICS indicator 2.17b - Minimum acceptable diet (non-breastfed) 3 MICS indicator 2.14 - Milk feeding frequency for non-breastfed children 4 MICS indicator 2.16 - Minimum dietary diversity 5 MICS indicator 2.15 - Minimum meal frequency a Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. b Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times. c The minimum acceptable diet for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while it for non-breastfed children further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds. ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases d Total includes 1 unweighted case of mother's education missing P a g e | 47 The continued practice of bottle-feeding is a matter of concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.9 shows that 28 percent of children under 2 years in Gilgit-Baltistan are fed using a bottle with a nipple. More than one-third (36%) of the children under 2 years are bottle fed in Baltistan division compared to 19 percent in Diamer division. The practice of bottle feeding ranges 13 percent in Ghizer district to 41 percent in Skardu district. Urabn areas have a higher rate of bootle feeding compared to rural areas (35% and 26% respectively). Bottle feeding has a positive relation with education of the mother and household wealth. Evidently, bottle feeding is 21 percent for children whose mother have pre-school or no education compared to 39 percent of children whose mothers have higher education. The data further show that 25 percent of children age less than six months are fed using a bottle with a nipple even though the children are expected to be exclusively breastfed at that age. Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Gilgit-Baltistan, 2016-17 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months Total 27.5 2,613 Area of residence Urban 34.8 446 Rural 26.0 2,167 Sex Male 28.5 1,372 Female 26.4 1,242 Age 0-5 months 25.1 617 6-11 months 29.4 697 12-23 months 27.6 1,299 Mother’s educationa None/pre-school 21.0 1,490 Primary 31.5 265 Middle 36.8 221 Secondary 35.5 295 Higher 39.4 341 Wealth index quintile Poorest 19.9 547 Second 23.4 548 Middle 29.6 562 Fourth 30.4 476 Richest 35.5 479 Usual language spoken in the household Sheena 23.4 1,415 Balti 36.1 751 Brushaski 27.8 229 Other languages 27.3 126 Division Gilgit 28.6 928 Baltistan 35.6 824 Diamer 18.6 862 District Astore 20.6 179 Diamer 18.1 683 Ghanche 33.0 229 Ghizer 12.6 243 Gilgit 35.8 501 Hunza 37.8 48 Kharmang 25.4 88 Nagar 27.3 136 Shigar 31.0 133 Skardu 41.2 374 1 MICS indicator 2.18 - Bottle feeding a Total includes 1 unweighted case of mother's education missing P a g e | 48 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. The 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 indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In Pakistan iodine deficiency disorders have been recognized as a public health problem for nearly 50 years. Various surveys have reflected that Pakistan is a country with more than half of the population estimated to be at risk for IDD (Iodine Deficiency Disorders). The situation is worse especially in the northern districts of Pakistan which is considered to be one of the most severely endemic areas in the world for IDD. A National IDD Control Program was initiated in 1989 with a focus on elimination of IDD through Universal Salt Iodization (USI). The Program has been implemented by Government of Pakistan with the support for national USI partners including UNICEF, the Micronutrient Initiative and GAIN (Global Alliance for Improved Nutrition). The Program is being implemented in all provinces with the objective to improve the availability and accessibility of adequately iodized salt to the entire population including the most vulnerable. P a g e | 49 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Gilgit-Baltistan, 2016-17 Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM1 Total 99.4 6,213 0.3 20.4 10.9 68.4 100.0 6,197 Area of residence Urban 99.6 1,090 0.3 11.9 10.4 77.5 100.0 1,088 Rural 99.4 5,123 0.3 22.2 11.0 66.5 100.0 5,108 Education of household head None/pre-school 99.3 2,890 0.4 27.6 11.6 60.4 100.0 2,882 Primary 99.5 1,067 0.2 17.4 12.1 70.2 100.0 1,063 Middle 99.2 645 0.1 15.0 11.7 73.1 100.0 641 Secondary 99.6 632 0.4 14.0 10.8 74.8 100.0 632 Higher 99.7 969 0.3 9.8 7.0 82.9 100.0 969 Wealth index quintile Poorest 98.8 1,254 0.8 42.2 13.5 43.5 100.0 1,248 Second 99.7 1,235 0.1 27.0 14.3 58.6 100.0 1,233 Middle 99.2 1,223 0.3 15.5 9.9 74.2 100.0 1,218 Fourth 99.5 1,283 0.2 9.9 8.7 81.2 100.0 1,279 Richest 99.8 1,218 0.2 7.2 8.0 84.5 100.0 1,218 Usual language spoken in the household Sheena 99.7 2,925 0.1 17.2 9.4 73.3 100.0 2,919 Balti 99.3 1,897 0.5 28.8 14.7 56.0 100.0 1,892 Brushaski 99.2 755 0.7 13.3 8.2 77.8 100.0 755 Other languages 98.8 636 0.3 18.3 9.8 71.7 100.0 630 Division Gilgit 99.2 2,614 0.4 10.4 8.0 81.2 100.0 2,602 Baltistan 99.3 2,172 0.4 28.0 15.0 56.6 100.0 2,167 Diamer 100.0 1,428 0.0 27.0 9.9 63.0 100.0 1,428 District Astore 99.9 428 0.1 25.3 7.2 67.3 100.0 428 Diamer 100.0 999 0.0 27.7 11.1 61.2 100.0 999 Ghanche 99.4 638 0.4 54.1 11.6 33.9 100.0 636 Ghizer 99.1 794 0.2 7.2 4.8 87.8 100.0 789 Gilgit 99.2 1,179 0.3 9.8 10.2 79.8 100.0 1,173 Hunza 99.0 279 1.0 4.4 5.4 89.3 100.0 279 Kharmang 99.9 243 0.0 33.5 23.5 43.0 100.0 243 Nagar 99.2 361 0.7 24.4 10.1 64.8 100.0 361 Shigar 98.4 281 0.5 18.2 21.8 59.5 100.0 278 Skardu 99.4 1,010 0.6 12.9 13.2 73.4 100.0 1,010 1 MICS indicator 2.19 - Iodized salt consumption (*) Figures that are based on fewer than 25 unweighted cases a Total includes 9 unweighted cases of household head’s education missing In 99 percent of households, salt used for cooking was tested for iodine content by using salt test kits to test the presence of potassium iodate content in the salt. Table NU.10 shows that there are almost no household without salt. These households are, however, included in the denominator of the indicator. In 68 percent of households, salt is found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt was lowest in Baltistan division (57%) and highest in Gilgit division (81%). More urban households (78%) were found to be using adequately iodized salt compared to 67 percent in rural areas. Similarly, 85 percent of richest households are using adequately iodized salt compared to 44 percent of poorest households. The consumption of adequately iodized salt is graphically presented in Figure NU.4. P a g e | 50 Fi gure NU.4: Consump tion of iod ized sal t , Gi lg i t -B al t i s tan MIC S, 2016-17 Children’s Vitamin A Supplementation Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for 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 developing world and particularly in countries with 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 in child health and immune function 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 where vitamin A deficiency is common, current international recommendations call for high-dose supplementation every 4–6 months for all children aged 6–59 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 helps protect their children during the first months of life and helps to replenish the mother's own stores of vitamin A which are depleted during pregnancy and lactation. Under Pakistan's National Health Policy 2001, vitamin A supplements are to be provided annually to all children aged 6-59 months on National 75 72 46 93 90 95 67 75 81 87 88 77 57 73 84 90 93 79 67 61 34 88 80 89 43 65 60 73 77 66 44 59 74 81 85 68 0 20 40 60 80 100 P e r c e n t Any iodine 15+ PPM of iodine P a g e | 51 Immunisation Days through the Expanded Programme on Immunization (EPI) network. This survey uses as an indicator the percentage of children 6–35 months of age who receive at least one high- dose of vitamin A supplement in the preceding 6 months. GB-MICS, 2016-17 finds that about 77 percent of children aged 6–59 months in Gilgit-Baltistan received at least one dose of vitamin A supplement during the 6 months period prior to the interview (Table NU.11). Children age 6–11 months have least coverage (70%) compared to older children age 24-35 months who have highest coverage (79%). Among divisions, nine in ten children (89%) in Baltistan division received Vitamin A dose during the last 6 months compared to only six in ten children in Diamer division (64%). The results also varies across districts ranges from 59 percent in Diamer district to 96 percent equally in Kharmang and Shigar district. Table NU.11: Children's vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Gilgit-Baltistan, 2016-17 Percentage of children who received Vitamin A during the last 6 months1 Number of children age 6-59 months Total 76.9 5,876 Area of residence Urban 85.0 988 Rural 75.2 4,888 Sex Male 76.0 3,075 Female 77.8 2,801 Age 6-11 months 70.0 697 12-23 months 77.1 1,299 24-35 months 79.1 1,322 36-47 months 77.4 1,333 48-59 months 77.5 1,224 Mother’s education None/pre-school 73.3 3,573 Primary 78.4 562 Middle 83.9 458 Secondary 85.0 611 Higher 82.3 670 Wealth index quintile Poorest 66.1 1,327 Second 76.4 1,244 Middle 79.1 1,203 Fourth 82.2 1,072 Richest 83.1 1,029 Usual language spoken in the household Sheena 72.0 3,070 Balti 90.0 1,756 Brushaski 81.1 489 Other languages 60.2 328 Division Gilgit 76.8 2,023 Baltistan 88.8 1,978 Diamer 64.4 1,875 District Astore 83.6 409 Diamer 59.0 1,466 Ghanche 86.9 540 Ghizer 63.9 579 Gilgit 79.4 1,034 Hunza 91.2 113 Kharmang 96.1 199 Nagar 87.0 298 Shigar 96.1 318 Skardu 85.9 920 1 MICS indicator 2.S1 - Vitamin A supplementation a Total includes 2 unweighted cases of mother's education missing P a g e | 53 VI. CHILD HEALTH Vaccinations The Millennium Development Goal (MDG) 4 was to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still millions of children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT containing vaccine to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and a first dose of measles vaccination before a child’s first birthday (N.B., due to the epidemiology of disease in a country, the first dose of measles vaccine may be recommended at 12 months or later). The vaccination schedule followed by the Pakistan Expanded Program on Immunization (EPI) provides all the above mentioned vaccinations. This includes polio at birth, three doses of pentavalent vaccine comprising of antigens against diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenza type b (Hib), three doses of pneumococcal conjugate vaccine and one does of measles during the first year of life followed by second dose of measles at the age of 12-15 months. Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the GB-MICS are based on children age 12-23 months. Information on vaccination coverage was collected for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied vaccination information from the cards onto the MICS questionnaire. If no vaccination card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations, and for Polio, Penta and pneumococcal, how many doses were received. Information was also obtained from vaccination records at health facilities for all children through a separate questionnaire. The final vaccination coverage estimates are based on information obtained from the vaccination records at health facility, vaccination card or mother’s report of vaccinations received by the child. P a g e | 54 Table CH.1: Vaccinations in the first years of life Percentage of children age 12-23 months and 24-35 months vaccinated against vaccine preventable childhood diseases at any time before the survey and by their first birthday, Gilgit-Baltistan, 2016-17 Children age 12-23 months: Children age 24-35 months: Vaccinated at any time before the survey according to: Vaccinated by 12 months of agea Vaccinated at any time before the survey according to: Vaccinated by 12 months of age Vaccination card Mother's report Either Vaccination card Mother's report Either Antigen BCG1 39.3 34.2 73.5 73.3 22.2 54.0 76.2 75.3 Polio At birth 37.3 29.1 66.5 66.2 21.5 42.3 63.8 63.0 1 38.4 52.0 90.4 89.9 21.2 69.1 90.3 88.7 2 36.8 47.1 83.9 81.8 20.9 68.4 89.3 87.4 32 34.4 38.7 73.1 70.9 19.9 63.6 83.5 80.6 DPT / PENTA 1 38.7 27.9 66.6 66.3 21.7 46.9 68.6 67.4 2 37.2 25.5 62.7 61.1 21.4 44.4 65.8 64.4 33,4,5 34.8 22.9 57.8 56.0 20.3 38.8 59.1 56.7 Measles 16 32.0 24.8 56.8 52.2 18.7 45.6 64.3 55.8 2 16.5 1.6 18.0 0.0 15.4 2.7 18.1 17.5 Fully vaccinated7, b 31.7 12.8 44.6 38.7 19.7 25.0 44.7 37.1 No vaccinations 0.0 8.2 8.2 8.2 0.0 9.2 9.2 9.6 Number of children 1,299 1,299 1,299 1,299 1,322 1,322 1,322 1,322 1 MICS indicator 3.1 - Tuberculosis immunization coverage 2 MICS indicator 3.2 - Polio immunization coverage 3 MICS indicator 3.3 - Diphtheria, pertussis and tetanus (DPT) immunization coverage 4 MICS indicator 3.5 - Hepatitis B immunization coverage 5 MICS indicator 3.6 - Haemophilus influenzae type B (Hib) immunization coverage 6 MICS indicator 3.4; MDG indicator 4.3 - Measles immunization coverage 7 MICS indicator 3.8 - Full immunization coverage a All MICS indicators refer to results in this column b Includes: BCG, Polio3, PENTA3, and Measles-1 (MCV1) as per the vaccination schedule in Gilgit-Baltistan The percentage of children age 12-23 months and 24-35 months who have received each of the specific vaccinations by source of information (vaccination records at health facilities or vaccination card and mother’s recall) is shown in Table CH.1 and Figure CH.1. The denominators for the table are comprised of children age 12-23 months and 24-35 months so that only children who are old enough to be fully vaccinated are counted. In the first three columns in each panel of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the vaccination records at health facilities or the mother’s report. In the last column in each panel, only those children who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards or records, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards or records. P a g e | 55 Fi gure C H.1 : Vacci nat ions b y age 12 months , Gi lg i t -Bal t i s tan MIC S, 2016-17 The results show that 73.3 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT/pentavalent vaccine was given to 66.3 percent. The percentage declines to 61.1 percent for the second dose of pentavalent vaccine, and 56.0 percent for the third dose. Similarly, 89.9 percent of children received Polio 1 by age 12 months and this declines to 70.9 percent by the third dose. The coverage for the first dose of measles vaccine by 12 months is lower than most of the other vaccines at 52.2 percent. As a result, the percentage of children who had all the recommended vaccinations by their first birthday is low at only 38.7 percent. 73 66 90 82 71 66 61 56 52 0 39 8 BCG Polio at birth Polio1 Polio2 Polio3 PENTA-1 PENTA-2 PENTA-3 Measles-I Measles-II Fully vaccinated No vaccinations Percent Children Age 12-23 months 75 63 89 87 81 67 64 57 56 17 37 10 BCG Polio at birth Polio1 Polio2 Polio3 PENTA-1 PENTA-2 PENTA-3 Measles-I Measles-II Fully vaccinated No vaccinations Children Age 24-35 months P a g e | 56 Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against vaccine preventable childhood diseases, Gilgit-Baltistan, 2016-17 Percentage of children age 12-23 months who received: Percentage with vaccination card seen Number of children age 12-23 months Percentage of children age 24-35 months who received: Percent age with vaccina tion card seen Number of children age 24-35 months BCG Polio PENTA Measles- 1 (MCV1) Fulla None Measles 2 Full[a] Non e At birth 1 2 3 1 2 3 Total 73.5 66.5 90.4 83.9 73.1 66.6 62.7 57.8 56.8 44.6 8.2 39.9 1,299 18.1 44.7 9.2 22.2 1,322 Area of residence Urban 76.5 74.8 95.0 90.0 81.9 70.6 65.3 61.8 59.0 49.5 4.4 43.2 234 19.7 52.1 6.5 23.5 201 Rural 72.9 64.6 89.4 82.6 71.2 65.7 62.1 56.9 56.3 43.5 9.1 39.2 1,065 17.8 43.3 9.6 21.9 1,121 Sex Male 75.9 67.5 91.3 84.8 72.6 68.3 64.7 59.1 57.1 43.4 7.8 40.9 694 17.4 45.7 9.2 21.7 671 Female 70.8 65.3 89.3 82.9 73.7 64.5 60.4 56.2 56.3 45.9 8.7 38.8 606 18.8 43.6 9.1 22.6 652 Mother’s educationb None/pre-school 63.0 54.8 88.0 78.2 63.7 52.9 48.5 43.1 43.7 31.7 10.9 32.0 759 10.3 30.0 13.1 14.0 795 Primary 81.1 66.6 92.0 89.4 86.1 76.4 69.9 66.4 64.7 46.3 3.6 40.8 118 26.9 60.8 4.7 29.5 121 Middle 80.4 80.9 92.4 87.5 78.4 81.7 76.9 71.3 67.2 55.0 7.6 46.1 113 26.1 57.7 3.3 30.2 100 Secondary 92.5 87.7 93.7 91.8 86.0 90.5 89.2 82.5 77.5 67.3 5.3 53.5 133 31.0 72.6 0.0 37.6 151 Higher 94.9 91.5 95.8 96.6 92.7 91.0 89.9 87.7 84.8 75.6 2.5 59.5 176 33.5 71.5 5.1 37.8 154 Wealth index quintile Poorest 60.0 48.2 83.7 69.5 53.9 49.0 44.8 36.3 38.3 22.5 14.8 26.2 269 7.1 24.8 13.2 10.2 292 Second 68.9 59.9 87.1 83.3 70.2 61.7 58.5 53.1 50.1 39.2 10.4 33.8 276 13.4 38.8 10.4 19.9 291 Middle 74.2 67.2 92.3 85.0 75.8 68.4 62.7 58.9 58.8 46.0 6.8 42.9 282 22.6 50.4 8.3 26.2 275 Fourth 80.2 75.6 91.6 87.5 79.1 72.9 68.8 65.2 63.5 53.1 7.0 42.3 239 23.6 59.1 7.0 27.2 250 Richest 86.8 85.1 98.3 96.2 89.2 83.5 81.5 78.5 76.0 65.8 1.1 56.8 234 27.2 55.2 5.6 30.6 214 Usual language spoken in the household Sheena 58.9 54.5 86.3 76.7 64.1 47.7 43.4 40.8 38.9 31.1 12.5 29.1 699 11.9 28.6 13.9 15.2 688 Balti 93.8 78.9 96.6 94.5 85.2 92.0 87.4 76.0 78.1 58.1 1.6 48.4 374 16.9 61.9 4.2 19.4 396 Brushaski 95.7 93.0 93.5 93.3 85.6 92.3 91.9 91.6 85.4 74.7 3.9 68.3 118 50.7 78.3 0.8 60.5 97 Other languages 73.5 71.6 91.9 83.5 75.7 72.3 69.7 66.8 65.1 52.3 8.1 49.1 109 29.1 51.6 5.4 37.4 142 Division Gilgit 84.6 86.6 90.0 87.7 82.4 82.8 78.9 77.5 73.9 65.7 8.8 57.0 462 33.1 62.4 9.2 39.3 449 Baltistan 93.1 79.6 96.6 94.0 85.5 92.1 86.7 75.4 76.9 57.9 2.0 49.9 422 15.2 58.5 4.5 17.8 455 Diamer 41.3 30.8 84.5 69.5 50.4 22.0 19.6 17.2 15.4 7.6 14.0 10.8 416 5.1 10.3 14.1 8.5 419 District Astore 62.7 60.2 83.9 80.5 74.3 52.0 46.7 40.6 40.4 22.4 13.1 35.9 77 10.4 28.7 16.9 17.4 101 Diamer 36.5 24.1 84.6 66.9 44.9 14.9 13.2 11.6 9.2 4.2 14.2 5.1 339 3.4 4.4 13.3 5.7 318 Ghanche 93.6 76.4 98.4 98.4 89.3 92.9 88.7 77.7 76.4 55.2 1.1 42.1 129 11.9 50.7 3.6 13.9 118 Ghizer 97.4 96.7 96.3 97.4 89.0 96.3 97.4 95.8 93.5 84.8 2.6 81.2 121 50.2 76.1 0.6 60.1 129 P a g e | 57 Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against vaccine preventable childhood diseases, Gilgit-Baltistan, 2016-17 Percentage of children age 12-23 months who received: Percentage with vaccination card seen Number of children age 12-23 months Percentage of children age 24-35 months who received: Percent age with vaccina tion card seen Number of children age 24-35 months BCG Polio PENTA Measles- 1 (MCV1) Fulla None Measles 2 Full[a] Non e At birth 1 2 3 1 2 3 Total 73.5 66.5 90.4 83.9 73.1 66.6 62.7 57.8 56.8 44.6 8.2 39.9 1,299 18.1 44.7 9.2 22.2 1,322 Gilgit 73.3 79.6 85.0 80.4 78.3 71.1 64.4 63.3 59.2 52.6 14.1 42.3 243 18.3 50.5 16.3 21.9 244 Hunza 100.0 98.4 100.0 100.0 97.4 100.0 97.1 97.1 98.8 94.2 0.0 86.8 30 59.8 77.2 0.0 63.6 23 Kharmang 100.0 91.0 100.0 97.9 96.4 100.0 100.0 91.6 93.8 78.5 0.0 54.9 45 26.9 77.5 0.0 29.4 48 Nagar 94.7 88.4 91.9 91.2 78.4 92.7 90.0 86.9 80.4 65.5 4.6 53.2 67 48.0 77.4 1.5 58.2 53 Shigar 95.5 79.1 95.8 94.2 90.2 93.7 90.2 81.8 80.5 62.4 3.1 45.8 69 13.9 60.8 5.5 19.1 73 Skardu 90.0 79.2 94.8 89.8 78.1 88.9 80.5 67.3 71.4 52.8 2.7 55.7 178 14.8 57.6 5.6 16.9 215 a Includes: BCG, Polio3, PENTA3 and Measles-1 (MCV1) as per the vaccination schedule in Gilgit-Baltistan b Total includes 1 unweighted case of mother's education missing P a g e | 58 Table CH.2 shows that 44.6 percent of children age 12-23 months received all the recommended vaccines according to the vaccination schedule in GB. At district level the percentage of fully recommended vaccines availed by 24-35 age groups starts form 4.4 percent in Diamer to 77.5 percent in district Kharmang. None of the children of Hunza district between 12-23 months of age group remained out of BCG vaccines, polio and Penta 1 at birth. There is ignorable gender differentials in terms of full vaccination coverage. The wealth quintiles is positively associated with the BCG, polio and pentavalent vaccines. Also, there are slightly differences between urban and rural areas. Neonatal Tetanus Protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. Following on the 42nd and 44th World Health Assembly calls for elimination of neonatal tetanus, the global community continues to work to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1,000 live births in every district by 2015. The strategy for preventing maternal and neonatal tetanus is to ensure that all pregnant women receive at least two doses of tetanus toxoid vaccine. If a woman has not received at least two doses of tetanus toxoid during a particular pregnancy, she (and her newborn) are also considered to be protected against tetanus if the woman: Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years; Received at least 3 doses, the last within the previous 5 years; Received at least 4 doses, the last within the previous 10 years; Received 5 or more doses anytime during her life.29 To assess the status of tetanus vaccination coverage, women who had a live birth during the two years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth, and if so, how many. Women who did not receive two or more tetanus toxoid vaccinations during this recent pregnancy were then asked about tetanus toxoid vaccinations they may have previously received. Interviewers also asked women to present their vaccination card on which dates of tetanus toxoid are recorded and referred to information from the cards when available. Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 2 years. More than half of women (52.2%) in GB who had a live birth in the two years before the survey are protected against tetanus. Furthermore, 41.7 percent of women received at least two doses of tetanus toxoid during the last pregnancy. Protection against tetanus is notably higher among women in Baltistan division (72.1%) than the rest of the divisions. Educational attainment and household wealth are strongly associated with protection against tetanus. For example, only 37.8 percent of women in the poorest wealth quintile are protected against tetanus compared with 63.3 percent of women in the richest wealth quintile. Similarly, protection against tetanus is higher among women with higher education (75.9%) than those with only pre-school or no education (39.9%). Women in urban areas (56.7%) are also more likely to be protected against tetanus than their rural counterparts (51.2%). 29 Deming, M.S. et al. 2002. Tetanus toxoid coverage as an indicator of serological protection against neonatal tetanus. Bulletin of the World Health Organization 80(9):696-703 P a g e | 59 Table CH.3: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Gilgit-Baltistan, 2016-17 Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus1 Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Total 41.7 6.8 1.6 1.3 0.8 52.2 2,705 Area of residence Urban 47.1 6.6 1.4 1.1 0.5 56.7 462 Rural 40.6 6.8 1.6 1.4 0.9 51.2 2,244 Mother’s educationa None/pre-school 31.6 6.4 1.2 0.5 0.2 39.9 1,526 Primary 49.7 7.4 1.4 0.4 1.4 60.3 298 Middle 47.3 6.2 2.2 1.8 0.0 57.5 216 Secondary 59.7 7.2 1.5 3.7 2.0 74.1 303 Higher 59.4 8.0 3.0 3.3 2.3 75.9 361 Wealth index quintile Poorest 31.9 5.4 0.2 0.3 0.0 37.8 566 Second 40.6 5.5 1.7 0.5 0.1 48.4 589 Middle 45.8 8.4 1.1 1.2 0.2 56.7 565 Fourth 43.3 7.1 2.3 3.0 1.1 56.8 493 Richest 47.9 7.6 2.9 2.0 3.0 63.3 492 Usual language spoken in the household Sheena 29.2 5.3 1.6 1.6 1.0 38.8 1,439 Balti 62.8 8.8 1.0 0.4 0.4 73.4 796 Brushaski 45.7 11.0 4.2 2.8 1.8 65.4 232 Other languages 42.3 4.6 1.2 1.3 0.0 49.3 239 Division Gilgit 43.3 7.4 3.0 2.8 2.1 58.7 966 Baltistan 62.7 8.4 0.6 0.4 0.1 72.1 873 Diamer 18.7 4.4 1.0 0.6 0.0 24.7 866 District Astore 31.1 7.0 2.1 2.9 0.0 43.2 189 Diamer 15.2 3.6 0.7 0.0 0.0 19.6 677 Ghanche 57.6 7.5 0.2 1.0 0.3 66.5 240 Ghizer 42.6 7.7 2.1 4.8 0.8 58.0 260 Gilgit 40.5 6.1 3.4 1.5 3.2 54.8 516 Hunza 52.5 13.0 9.3 10.2 2.5 87.5 49 Kharmang 80.5 4.6 0.5 0.0 0.0 85.6 96 Nagar 51.7 10.0 0.8 1.1 0.5 64.2 140 Shigar 59.4 6.6 0.6 0.6 0.3 67.5 143 Skardu 62.6 10.5 0.9 0.0 0.0 74.0 394 1 MICS indicator 3.9 - Neonatal tetanus protection a Total includes 1 unweighted case of mother's education missing P a g e | 60 Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading killers of children under 5. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable pneumonia and diarrhoea death by reducing mortality from pneumonia to 3 deaths per 1000 live births and mortality from diarrhoea to 1 death per 1000 live births by 2025. Malaria is also a major killer of children under 5, killing about 1200 children every day. The Global Malaria Action Plan (GMAP) aims to reduce malaria deaths to near zero by 2015 Table CH.4 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the two weeks preceding the survey. These results are not measures of true prevalence, and should not be used as such, but rather the period-prevalence of those illnesses over a two-week time window. The definition of a case of diarrhoea or fever, in this survey, was the mother’s or caretaker’s report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS survey, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. The timing of the survey and the location of the teams might thus considerably affect the results, which must consequently be interpreted with caution. For these reasons, although the period-prevalence over a two-week time window is reported, these data should not be used to assess the epidemiological characteristics of these diseases but rather to obtain denominators for the indicators related to use of health services and treatment. Overall, 22.3 percent of under five children were reported to have had diarrhoea in the two weeks preceding the survey, 17.1 percent symptoms of ARI, and 38.6 percent had an episode of fever (Table CH.4). There is no clear variation in sex and area of the under five children. Diarrhoea is negatively associated with age of children under five. At divisional level, the fever is reported highest in Gilgit region (44.3%) compared and least in Diamer division (31.7%). The wealth quintiles appears no relationship with diarrhoea, ARI and fever. P a g e | 61 Table CH.4: Reported disease episodes Percentage of children age 0-59 months for whom the mother/caretaker reported an episode of diarrhoea, symptoms of acute respiratory infection (ARI), and/or fever in the last two weeks, Gilgit-Baltistan, 2016-17 Percentage of children who in the last two weeks had: Number of children age 0-59 months An episode of diarrhea Symptoms of ARI An episode of fever Total 22.3 17.1 38.6 6,637 Area of residence Urban 18.4 12.7 38.9 1,097 Rural 23.1 18.0 38.5 5,540 Sex Male 23.1 17.6 39.2 3,472 Female 21.5 16.6 37.9 3,165 Age 0-11 months 25.0 17.8 42.2 1,314 12-23 months 29.2 16.4 41.8 1,299 24-35 months 24.4 17.2 40.0 1,322 36-47 months 17.6 18.3 36.3 1,333 48-59 months 15.8 15.9 32.8 1,368 Mother’s educationa None/pre-school 24.1 17.8 35.8 4,015 Primary 26.2 19.2 45.6 646 Middle 17.7 18.7 48.1 507 Secondary 19.1 15.3 40.7 702 Higher 15.8 12.5 39.0 764 Wealth index quintile Poorest 27.5 18.8 37.7 1,489 Second 26.1 19.0 35.7 1,419 Middle 19.7 17.9 39.9 1,363 Fourth 19.4 16.5 40.7 1,204 Richest 17.0 12.4 39.5 1,161 Usual language spoken in the household Sheena 22.6 13.9 37.2 3,490 Balti 23.4 25.9 41.1 1,988 Brushaski 22.9 17.1 44.3 546 Other languages 16.7 6.9 33.2 612 Division Gilgit 19.7 16.4 44.3 2,278 Baltistan 22.7 24.5 39.3 2,239 Diamer 24.6 10.1 31.7 2,120 District Astore 21.7 22.1 50.5 465 Diamer 25.5 6.7 26.4 1,655 Ghanche 18.9 20.2 35.8 605 Ghizer 9.3 8.1 30.8 634 Gilgit 23.3 19.1 49.7 1,184 Hunza 13.3 18.3 37.7 127 Kharmang 11.8 9.8 22.0 221 Nagar 29.2 21.8 53.5 334 Shigar 21.0 34.9 47.7 357 Skardu 27.8 26.6 42.0 1,055 a Total includes 2 unweighted cases of mother's education missing P a g e | 62 Table CH.5: Care-seeking during diarrhea Percentage of children age 0-59 months with diarrhoea in the last two weeks for whom advice or treatment was sought, by source of advice or treatment, Gilgit-Baltistan, 2016-17 An episode of diarrhoea Number of children age 0-59 months Percentage of children with diarrhoea for whom: Number of children age 0-59 months with diarrhoea in the last two weeks Advice or treatment was sought from: No advice or treatment sought Health facilities or providers Other source A health facility or provider1, b Public Private Community health providera Total 22.3 6,637 36.6 19.7 1.0 7.4 53.6 39.0 1,481 Area of residence Urban 18.4 1,097 30.3 34.8 0.3 4.1 59.1 36.2 202 Rural 23.1 5,540 37.5 17.3 1.1 8.0 52.8 39.4 1,279 Sex Male 23.1 3,472 39.4 19.5 1.0 6.2 56.3 37.5 801 Female 21.5 3,165 33.2 20.0 1.0 8.9 50.4 40.8 680 Age 0-11 months 25.0 1,314 36.0 21.8 0.4 6.4 55.3 39.9 328 12-23 months 29.2 1,299 33.5 23.2 0.8 6.9 53.4 38.0 380 24-35 months 24.4 1,322 36.2 15.8 0.8 9.2 50.0 41.8 322 36-47 months 17.6 1,333 36.9 19.6 2.3 5.4 55.2 38.9 234 48-59 months 15.8 1,368 42.8 16.4 1.0 9.5 55.2 35.2 216 Mother’s educationc None/pre-school 24.1 4,015 39.4 16.1 1.1 8.2 52.4 39.0 966 Primary 26.2 646 34.4 21.7 0.5 7.0 53.7 39.4 169 Middle 17.7 507 36.5 23.1 0.0 7.4 57.5 38.2 90 Secondary 19.1 702 25.6 31.8 1.1 4.4 56.7 40.2 134 Higher 15.8 764 28.9 29.9 1.0 5.3 56.7 37.7 121 Wealth index quintile Poorest 27.5 1,489 39.3 12.1 2.0 9.9 49.5 40.6 410 Second 26.1 1,419 39.7 17.4 1.3 10.4 54.8 34.3 370 Middle 19.7 1,363 42.3 21.5 0.3 5.9 60.4 34.1 269 Fourth 19.4 1,204 28.7 22.2 0.4 4.5 47.8 48.6 234 Richest 17.0 1,161 26.3 34.6 0.1 2.4 57.5 39.8 198 Usual language spoken in the household Sheena 22.6 3,490 32.3 19.9 0.4 9.1 49.8 40.5 789 Balti 23.4 1,988 42.5 17.6 1.2 4.5 57.6 38.9 465 Brushaski 22.9 546 46.8 27.0 3.2 6.0 68.3 28.3 125 Other languages 16.7 612 30.3 18.5 1.6 10.2 47.0 41.0 102 Division Gilgit 19.7 2,278 30.4 33.5 0.9 3.8 60.6 36.4 449 Baltistan 22.7 2,239 40.2 17.0 1.2 5.8 54.7 40.3 509 Diamer 24.6 2,120 38.3 10.6 0.9 12.2 46.6 39.9 522 District Astore 21.7 465 36.7 14.5 0.6 3.2 48.5 48.1 101 Diamer 25.5 1,655 38.6 9.6 0.9 14.3 46.1 38.0 422 Ghanche 18.9 605 59.0 18.2 4.3 7.1 72.1 24.4 114 Ghizer 9.3 634 35.5 45.3 0.0 4.8 74.0 21.0 59 Gilgit 23.3 1,184 24.0 34.8 0.0 3.0 56.0 41.0 276 Hunza 13.3 127 (16.5) (52.8) (1.5) (4.5) (69.3) (27.7) 17 Kharmang 11.8 221 47.1 10.2 2.6 12.8 57.3 29.9 26 Nagar 29.2 334 47.9 19.0 3.8 5.5 64.0 34.4 97 Shigar 21.0 357 57.6 14.6 0.5 3.2 70.1 27.8 75 Skardu 27.8 1,055 27.8 17.7 0.0 5.4 43.7 50.7 293 1 MICS indicator 3.10 - Care-seeking for diarrhoea a Community health providers includes both public (Community health worker and Mobile/Outreach clinic) and private (Mobile clinic) health facilities b Includes all public and private health facilities and providers, but excludes private pharmacy ( ) Figures that are based on 25-49 unweighted cases c Total includes 2 unweighted cases of mother's education missing P a g e | 63 Table CH.6: Feeding practices during diarrhea Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Gilgit-Baltistan, 2016-17 Had diarrhoea in last two weeks Number of children age 0-59 months Drinking practices during diarrhoea Eating practices during diarrhoea Number of children aged 0-59 months with diarrhoea Child was given to drink: Total Child was given to eat: Total Much less Somewhat less About the same More Nothing Missing / DK Much less Somewhat less About the same More Nothing Missing/ DK Total 22.3 6,637 8.3 29.8 52.1 7.6 2.1 0.0 100.0 11.1 30.6 47.2 2.9 8.2 0.0 100.0 1,481 Area of residence Urban 18.4 1,097 2.6 30.2 58.2 6.8 2.3 0.0 100.0 6.4 33.0 53.9 2.9 3.7 0.0 100.0 202 Rural 23.1 5,540 9.3 29.8 51.2 7.7 2.1 0.0 100.0 11.8 30.2 46.1 2.9 8.9 0.0 100.0 1,279 Sex Male 23.1 3,472 9.3 30.7 50.9 7.4 1.6 0.0 100.0 10.9 31.7 46.6 2.1 8.6 0.0 100.0 801 Female 21.5 3,165 7.2 28.7 53.6 7.8 2.7 0.0 100.0 11.3 29.2 47.8 3.9 7.8 0.0 100.0 680 Age 0-11 months 25.0 1,314 5.5 25.0 60.0 4.3 5.1 0.0 100.0 8.2 20.3 38.9 0.2 32.5 0.0 100.0 328 12-23 months 29.2 1,299 9.0 27.8 51.9 9.6 1.7 0.0 100.0 12.8 31.1 49.3 4.3 2.5 0.0 100.0 380 24-35 months 24.4 1,322 8.5 33.3 47.8 9.0 1.3 0.1 100.0 11.0 35.0 49.5 3.3 1.0 0.1 100.0 322 36-47 months 17.6 1,333 8.2 31.7 53.4 5.9 0.8 0.0 100.0 11.1 31.1 55.0 2.1 0.7 0.0 100.0 234 48-59 months 15.8 1,368 11.5 33.4 45.7 8.7 0.8 0.0 100.0 12.8 38.1 43.8 4.9 0.4 0.0 100.0 216 Mother’s educationa None/pre-school 24.1 4,015 8.7 29.8 53.5 5.5 2.4 0.0 100.0 10.6 30.4 49.3 2.5 7.1 0.0 100.0 966 Primary 26.2 646 9.0 31.7 51.0 7.9 0.5 0.0 100.0 11.0 35.3 37.8 2.4 13.5 0.0 100.0 169 Middle 17.7 507 10.3 20.6 56.1 9.4 3.6 0.0 100.0 11.0 24.0 50.9 4.6 9.5 0.0 100.0 90 Secondary 19.1 702 5.6 37.2 47.1 7.8 2.1 0.2 100.0 14.3 36.9 43.6 1.4 3.6 0.2 100.0 134 Higher 15.8 764 5.9 26.2 45.3 21.8 0.8 0.0 100.0 11.7 23.1 44.3 7.1 13.8 0.0 100.0 121 Wealth index quintile Poorest 27.5 1,489 10.1 28.5 51.8 5.7 3.9 0.1 100.0 13.7 28.6 49.9 3.0 4.6 0.1 100.0 410 Second 26.1 1,419 13.1 28.7 49.2 7.6 1.4 0.0 100.0 13.3 30.0 45.7 3.3 7.8 0.0 100.0 370 Middle 19.7 1,363 7.4 30.0 52.2 8.8 1.6 0.0 100.0 12.4 32.8 43.4 2.2 9.2 0.0 100.0 269 Fourth 19.4 1,204 3.5 36.1 52.3 6.8 1.3 0.0 100.0 5.5 33.8 45.0 2.7 13.0 0.0 100.0 234 Richest 17.0 1,161 2.9 26.9 58.1 10.8 1.3 0.0 100.0 6.4 29.2 51.8 3.1 9.5 0.0 100.0 198 Usual language spoken in the household Sheena 22.6 3,490 3.3 29.9 60.5 4.9 1.4 0.0 100.0 5.2 30.3 55.7 2.7 6.1 0.0 100.0 789 Balti 23.4 1,988 17.9 28.0 42.5 8.0 3.5 0.1 100.0 19.9 30.8 36.5 2.5 10.2 0.1 100.0 465 Brushaski 22.9 546 7.0 32.5 32.8 25.5 2.2 0.0 100.0 16.7 29.7 31.3 7.3 15.0 0.0 100.0 125 Other languages 16.7 612 5.2 34.1 55.0 4.6 1.1 0.0 100.0 9.5 33.2 48.9 0.9 7.5 0.0 100.0 102 P a g e | 64 Table CH.6: Feeding practices during diarrhea Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Gilgit-Baltistan, 2016-17 Had diarrhoea in last two weeks Number of children age 0-59 months Drinking practices during diarrhoea Eating practices during diarrhoea Number of children aged 0-59 months with diarrhoea Child was given to drink: Total Child was given to eat: Total Much less Somewhat less About the same More Nothing Missing / DK Much less Somewhat less About the same More Nothing Missing/ DK Total 22.3 6,637 8.3 29.8 52.1 7.6 2.1 0.0 100.0 11.1 30.6 47.2 2.9 8.2 0.0 100.0 1,481 Division Gilgit 19.7 2,278 5.9 33.8 48.4 10.6 1.4 0.0 100.0 9.6 32.0 42.5 4.0 11.9 0.0 100.0 449 Baltistan 22.7 2,239 16.5 29.8 42.3 7.5 3.8 0.1 100.0 18.0 32.2 36.4 2.9 10.5 0.1 100.0 509 Diamer 24.6 2,120 2.5 26.4 65.0 5.1 1.1 0.0 100.0 5.7 27.8 61.7 1.9 2.9 0.0 100.0 522 District Astore 21.7 465 0.4 49.6 32.2 15.4 2.4 0.0 100.0 4.4 55.9 24.0 2.8 12.9 0.0 100.0 101 Diamer 25.5 1,655 3.0 20.8 72.8 2.6 0.8 0.0 100.0 6.0 21.1 70.7 1.7 0.5 0.0 100.0 422 Ghanche 18.9 605 58.7 23.5 15.8 0.7 1.4 0.0 100.0 53.4 30.4 14.7 0.0 1.5 0.0 100.0 114 Ghizer 9.3 634 13.8 21.9 49.4 10.5 4.3 0.0 100.0 13.0 22.4 48.6 4.7 11.2 0.0 100.0 59 Gilgit 23.3 1,184 3.0 35.8 55.4 5.0 0.9 0.0 100.0 4.7 33.8 47.5 2.8 11.1 0.0 100.0 276 Hunza 13.3 127 (10.7) (26.8) (43.2) (19.3) (0.0) (0.0) 100.0 (18.8) (29.2) (41.5) (0.0) (10.5) (0.0) 100.0 17 Kharmang 11.8 221 13.1 40.7 25.4 11.6 8.0 1.3 100.0 26.8 34.6 28.6 0.0 8.7 1.3 100.0 26 Nagar 29.2 334 8.4 36.7 28.8 24.8 1.2 0.0 100.0 19.8 33.2 24.6 7.7 14.7 0.0 100.0 97 Shigar 21.0 357 14.6 45.9 23.0 8.0 8.5 0.0 100.0 17.6 48.5 25.4 0.6 7.9 0.0 100.0 75 Skardu 27.8 1,055 0.8 27.2 59.2 9.7 3.1 0.0 100.0 3.5 28.5 48.3 4.9 14.8 0.0 100.0 293 ( ) Figures that are based on 25-49 unweighted cases a Total includes 2 unweighted cases of mother's education missing P a g e | 65 Table CH.6 provides statistics on drinking and feeding practices during diarrhoea. For 7.6 percent of under-five children with diarrhoea, they were given more than usual to drink while 52.1 percent were given the same or less to drink. About 29.8 percent were given somewhat less, same or more (continued feeding) to eat, but 8.3 percent were given much less or almost nothing to eat. Eating and drinking patterns during diarrhoea varied by education of the mother. Children born to mothers with higher education are four times more lik

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