Sierra Leone - Demographic and Health Survey - 2009

Publication date: 2009

Sierra Leone 2008Demographic and Health Survey SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY 2008 Statistics Sierra Leone Ministry of Health and Sanitation Freetown, Sierra Leone ICF Macro Calverton, Maryland USA July 2009 World Bank This report presents the findings of the 2008 Sierra Leone Demographic and Health Survey (SLDHS) carried out by Statistics Sierra Leone (SSL) in collaboration with the Ministry of Health and Sanitation (MOHS). The Government of Sierra Leone provided financial assistance in terms of funding and in-kind contributions of government staff time, office space, and logistical support. Additional funding for the survey was provided by the U.S. Agency for International Development (USAID), the United Nations Population Fund (UNFPA), the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the Department for International Development (DFID), and The World Bank. Logistical support was also received from the United Nations High Commission for Refugees (UNHCR), the World Health Organization (WHO), and the World Food Programme (WFP). ICF Macro, an ICF International Company, provided technical assistance and medical supplies and equipment for the survey through the MEASURE DHS programme, which is funded by USAID and designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. The UNFPA Country Support Team provided backstopping support. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of the donor organizations. Additional information about the survey may be obtained from Statistics Sierra Leone, A.J. Momoh Street, Tower Hill, PMB 595, Freetown, Sierra Leone; Telephone +232-22-223287/ +232-76-609989; Fax +232-22- 223897; Email: statistics@statistics.sl / info@statistics.sl Information about the DHS programme may be obtained from MEASURE DHS, ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 1-301-572-0200; Fax: 1-301-572-0999; Email: reports@macrointernational.com; Internet: www.measuredhs.com. Suggested citation: Statistics Sierra Leone (SSL) and ICF Macro. 2009. Sierra Leone Demographic and Health Survey 2008. Calverton, Maryland, USA: Statistics Sierra Leone (SSL) and ICF Macro. Contents | iii CONTENTS TABLES AND FIGURES . ix ACKNOWLEDGEMENTS . xvii FOREWORD . xix PREFACE . xxi SUMMARY OF FINDINGS . xxiii CONTRIBUTORS TO THE SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY . xxix MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxxi MAP OF SIERRA LEONE .xxxii CHAPTER 1 INTRODUCTION 1.1 Geography . 1 1.2 History. 1 1.3 Economy . 2 1.4 Population . 3 1.5 Population and Family Planning Policies and Programmes . 3 1.6 Health Policies and Programmes . 4 1.7 Objectives and Organization of the 2008 SLDHS . 6 1.8 Sample Design . 6 1.9 Questionnaires . 7 1.10 Anaemia and HIV Testing . 8 1.10.1 Haemoglobin Testing . 8 1.10.2 HIV Testing . 8 1.11 Training of Field Staff . 9 1.12 Main Fieldwork (Data Collection) . 10 1.13 Data Processing . 10 1.14 Response Rates . 10 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Introduction . 13 2.2 Household Population by Age, Sex and Residence . 13 2.2.1 Household Composition . 14 2.2.2 Children’s Living Arrangement and Orphanhood . 15 2.3 School Attendance by Survivorship of Parents and by Orphanhood Status . 17 2.4 Education of the Household Population . 18 2.5 School Attendance Ratios . 21 2.6 Grade Repetition and Drop-out Rate . 22 2.7 Household Drinking Water . 23 2.8 Sanitation Facilities . 25 2.9 Other Household Characteristics . 26 2.10 Household Durable Goods . 28 2.11 Wealth Quintiles . 28 2.12 Birth Registration . 29 2.13 Child Labour . 29 iv | Contents CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Background Characteristics of Survey Respondents . 33 3.2 Educational Attainment . 34 3.3 Literacy. 36 3.4 Access to Mass Media . 38 3.5 Employment . 39 3.6 Occupation . 42 3.7 Earnings, Employers, and Continuity of Employment . 44 3.8 Health Insurance . 45 3.9 Knowledge and Attitudes Concerning Tuberculosis . 45 3.10 Smoking . 47 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4.1 Current Fertility . 51 4.2 Fertility Differentials . 53 4.3 Fertility Trends . 55 4.4 Children Ever Born and Children Surviving . 56 4.5 Birth Intervals . 57 4.6 Age at First Birth . 58 4.7 Adolescent Fertility and Motherhood . 59 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods . 63 5.2 Ever Use of Contraception . 65 5.3 Current Use of Contraceptive Methods . 67 5.4 Differentials in Contraceptive Use by Background Characteristics . 69 5.5 Number of Children at First Use of Contraception . 70 5.6 Knowledge of the Fertile Period . 72 5.7 Source of Contraception . 72 5.8 Informed Choice . 73 5.9 Future Use of Contraception . 74 5.10 Reasons for Not Intending to Use Contraception . 75 5.11 Preferred Method for Future Use . 76 5.12 Exposure to Family Planning Messages . 76 5.13 Contact of Non-users with Family Planning Providers . 78 5.14 Husband/Partner’s Knowledge of Women’s Contraceptive Use . 79 5.15 Men’s Attitudes Towards Contraception . 80 CHAPTER 6 PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status . 83 6.2 Polygyny . 84 6.3 Age at First Marriage . 86 6.4 Age at First Sexual Intercourse . 88 6.5 Recent Sexual Activity . 90 6.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 93 6.7 Menopause . 94 Contents | v CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 95 7.2 Desire to Limit Childbearing by Background Characteristics . 97 7.3 Need for Family Planning Services . 98 7.4 Ideal Family Size . 100 7.5 Mean Ideal Number of Children by Background Characteristics . 101 7.6 Fertility Planning Status . 102 7.7 Wanted Fertility Rates . 102 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Definition, Methodology, and Data Quality . 105 8.2 Levels and Trends . 106 8.3 Differentials in Infant and Child Mortality . 107 8.3.1 Socioeconomic Differentials in Infant and Child Mortality . 107 8.3.2 Demographic Differentials in Infant and Child Mortality . 109 8.4 Perinatal Mortality . 110 8.5 High-Risk Fertility Behaviour . 112 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care . 115 9.2 Number and Timing of Antenatal Care Visits . 117 9.3 Components of Antenatal Care . 117 9.4 Tetanus Toxoid Injections . 119 9.5 Place of Delivery . 120 9.6 Assistance during Delivery . 121 9.7 Postnatal Care . 123 9.8 Problems in Accessing Health Care . 126 CHAPTER 10 CHILD HEALTH 10.1 Child’s Size at Birth . 129 10.2 Vaccination Coverage . 130 10.3 Trends in Vaccination Coverage . 133 10.4 Acute Respiratory Infection . 134 10.5 Fever . 135 10.6 Diarrhoeal Disease . 137 10.7 Knowledge of ORS Packets . 141 10.8 Stool Disposal . 141 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 143 11.1.1 Measurement of Nutritional Status among Young Children . 143 11.1.2 Results of Data Collection . 144 11.1.3 Levels of Malnutrition . 147 11.2 Initiation of Breastfeeding . 148 11.3 Breastfeeding Status by Age . 150 11.4 Duration and Frequency of Breastfeeding . 152 vi | Contents 11.5 Types of Complementary Foods . 154 11.6 Infant and Young Child Feeding (IYCF) Practices . 156 11.7 Anaemia in Children . 158 11.8 Iodization of Household Salt . 160 11.9 Micronutrient Intake among Children . 161 11.10 Nutritional Status of Women . 164 11.11 Foods Consumed by Mothers . 165 11.12 Micronutrient Intake among Mothers . 167 11.13 Anaemia in Adults . 169 CHAPTER 12 MALARIA 12.1 Mosquito Nets . 171 12.1.1 Ownership of Mosquito Nets . 171 12.1.2 Use of Mosquito Nets by Children . 173 12.1.3 Use of Mosquito Nets by Women . 174 12.2 Intermittent Preventive Treatment of Malaria in Pregnancy . 176 12.2.1 Malaria Prophylaxis during Pregnancy . 176 12.2.2 Prevalence and Management of Childhood Malaria . 178 CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 HIV/AIDS Knowledge, Transmission, and Prevention Methods . 183 13.1.1 Awareness of HIV/AIDS . 183 13.1.2 Knowledge of HIV/AIDS Transmission and Prevention Methods . 185 13.1.3 Rejection of Misconceptions about HIV/AIDS . 187 13.2 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 189 13.3 Stigma Associated with AIDS and Attitudes Related to HIV/AIDS . 190 13.4 Attitudes towards Negotiating Safer Sex . 193 13.5 Attitudes towards Condom Education for Youth . 194 13.6 Higher-risk Sex . 196 13.6.1 Multiple Partners and Condom Use . 196 13.6.2 Transactional Sex . 200 13.7 Coverage of HIV Counselling and Testing . 200 13.7.1 HIV Testing during Antenatal Care . 203 13.8 Male Circumcision . 204 13.9 Self-reporting of Sexually Transmitted Infections . 204 13.10 Prevalence of Medical Injections . 206 13.11 HIV/AIDS-Related Knowledge and Sexual Behaviour among Youth . 208 13.11.1 HIV/AIDS-Related Knowledge among Young Adults . 208 13.11.2 Knowledge of Condom Sources among Young Adults . 209 13.11.3 Trends in Age at First Sex . 209 13.11.4 Condom Use at First Sex . 211 13.11.5 Abstinence and Premarital Sex . 212 13.11.6 Higher-risk Sex and Condom Use among Young Adults . 213 13.11.7 Cross-generational Sexual Partners . 215 13.11.8 Drunkenness during Sexual Intercourse among Young Adults . 216 13.11.9 Voluntary HIV Counselling and Testing among Young Adults . 217 Contents | vii CHAPTER 14 HIV PREVALENCE AND ASSOCIATED FACTORS 14.1 Coverage of HIV Testing . 220 14.1.1 Coverage by Sex, Residence, and Region . 220 14.1.2 Coverage by Socio-demographic Characteristics . 221 14.2 HIV Prevalence . 223 14.2.1 HIV Prevalence by Age . 223 14.2.2 HIV Prevalence by Socio-economic Characteristics . 223 14.2.3 HIV Prevalence by Demographic Characteristics . 224 14.2.4 HIV Prevalence by Sexual Behaviour Indicators . 226 14.3 HIV Prevalence by Other Characteristics Related to HIV Risk . 228 14.4 HIV Prevalence among Youth . 229 14.5 HIV Prevalence among Couples . 232 14.6 Measuring the HIV Burden in Sierra Leone . 232 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Employment and Form of Earnings. 235 15.2 Use of Earnings . 236 15.3 Woman’s Participation in Decision-making . 239 15.4 Attitudes toward Wife Beating . 243 15.5 Attitudes toward Refusing Sex with Husband . 246 15.6 Women’s Empowerment Indicators . 250 15.7 Current Use of Contraception by Women’s Status . 252 15.8 Reproductive Health Care by Women’s Status . 253 CHAPTER 16 FEMALE CIRCUMCISION 16.1 Knowledge and Prevalence of Female Circumcision. 255 16.2 Flesh Removal and Infibulation . 256 16.3 Age at Circumcision . 256 16.4 Person Performing Circumcision . 258 16.5 Circumcision of Daughters . 258 16.6 Perceived Benefits of Undergoing Female Circumcision . 261 16.7 Attitudes toward Female Circumcision . 264 CHAPTER 17 ADULT AND MATERNAL MORTALITY 17.1 Introduction . 267 17.2 Data Collection. 267 17.3 Data Quality . 268 17.4 Direct Estimates of Adult Mortality . 270 17.5 Direct Estimates of Maternal Mortality . 271 REFERENCES . 273 APPENDIX A SAMPLE DESIGN . 275 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 283 viii | Contents APPENDIX C DATA QUALITY TABLES . 293 APPENDIX D PERSONS INVOLVED IN THE 2008 SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY . 305 APPENDIX E QUESTIONNAIRES . 311 Tables and Figures | ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 10 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 13 Table 2.2 Household composition . 15 Table 2.3 Children’s living arrangements and orphanhood . 16 Table 2.4 School attendance by survivorship of parents and by orphanhood status . 17 Table 2.5.1 Educational attainment of the female household population . 19 Table 2.5.2 Educational attainment of the male household population . 20 Table 2.6 School attendance ratios . 22 Table 2.7 Grade repetition and dropout rates . 23 Table 2.8 Household drinking water . 25 Table 2.9 Household sanitation facilities . 26 Table 2.10 Household characteristics . 27 Table 2.11 Household durable goods . 28 Table 2.12 Wealth quintiles . 29 Table 2.13 Birth registration of children under age five . 29 Table 2.14 Child labour . 30 Figure 2.1 Population Pyramid . 14 Figure 2.2 Age-specific Attendance Rates for the de facto Population Age 5-24 . 21 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 34 Table 3.2.1 Educational attainment: Women . 35 Table 3.2.2 Educational attainment: Men . 36 Table 3.3.1 Literacy: Women . 37 Table 3.3.2 Literacy: Men . 37 Table 3.4.1 Exposure to mass media: Women . 38 Table 3.4.2 Exposure to mass media: Men . 39 Table 3.5.1 Employment status: Women . 40 Table 3.5.2 Employment status: Men . 42 Table 3.6.1 Occupation: Women . 43 Table 3.6.2 Occupation: Men . 44 Table 3.7 Type of employment: Women . 45 Table 3.8.1 Knowledge and attitudes concerning tuberculosis: Women . 46 Table 3.8.2 Knowledge and attitudes concerning tuberculosis: Men . 47 Table 3.9.1 Use of tobacco: Women . 48 Table 3.9.2 Use of tobacco: Men . 49 Figure 3.1 Women’s Employment Status in the Past 12 Months . 41 x | Contents CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS Table 4.1 Current fertility . 52 Table 4.2 Fertility by background characteristics . 54 Table 4.3 Trends in age-specific fertility rates . 55 Table 4.4 Children ever born and living . 56 Table 4.5 Birth intervals . 57 Table 4.6 Age at first birth . 58 Table 4.7 Median age at first birth . 59 Table 4.8 Teenage pregnancy and motherhood . 60 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence . 53 Figure 4.2 Total Fertility Rate by Background Characteristics . 54 Figure 4.3 Percentage of Adolescent Women Who Have Begun Childbearing by Background Characteristics . 60 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 64 Table 5.2 Knowledge of contraceptive methods by background characteristics . 65 Table 5.3.1 Ever use of contraception: Women . 66 Table 5.3.2 Ever use of contraception: Men . 67 Table 5.4 Current use of contraception by age . 68 Table 5.5 Current use of contraception by background characteristics . 70 Table 5.6 Number of children at first use of contraception . 71 Table 5.7 Knowledge of fertile period . 72 Table 5.8 Source of modern contraception methods . 73 Table 5.9 Informed choice . 74 Table 5.10 Future use of contraception . 75 Table 5.11 Reason for not intending to use contraception in the future . 75 Table 5.12 Preferred method of contraception for future use . 76 Table 5.13 Exposure to family planning messages . 77 Table 5.14 Contact of non-users with family planning providers . 79 Table 5.15 Husband/partner’s knowledge of women’s use of contraception . 80 Table 5.16 Male attitudes towards contraceptive use . 81 Figure 5.1 Current Use of Contraception among Currently Married Women Age 15-49 . 69 Figure 5.2 Contraceptive Use among Currently Married Women by Residence, Level of Education, and Wealth Quintile . 71 Figure 5.3 Exposure to Specific Family Planning Messages . 78 CHAPTER 6 PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 84 Table 6.2.1 Number of women’s co-wives . 85 Table 6.2.2 Number of men’s wives . 85 Table 6.3 Age at first marriage . 86 Table 6.4.1 Median age at first marriage: Women . 87 Table 6.4.2 Median age at first marriage: Men . 88 Table 6.5 Age at first sexual intercourse . 89 Table 6.6.1 Median age at first intercourse: Women . 89 Tables and Figures | xi Table 6.6.2 Median age at first intercourse: Men . 90 Table 6.7.1 Recent sexual activity: Women . 91 Table 6.7.2 Recent sexual activity: Men . 92 Table 6.8 Postpartum amenorrhoea, abstinence and insusceptibility . 93 Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility . 94 Table 6.10 Menopause . 94 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 96 Table 7.2.1 Desire to limit childbearing: Women . 97 Table 7.2.2 Desire to limit childbearing: Men . 97 Table 7.3 Unmet need and demand for family planning among currently married women . 99 Table 7.4 Ideal number of children . 100 Table 7.5 Mean ideal number of children. 101 Table 7.6 Fertility planning status . 102 Table 7.7 Wanted fertility rates . 103 Figure 7.1 Fertility Preferences among Married Women . 96 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 106 Table 8.2 Early childhood mortality rates by background characteristics . 108 Table 8.3 Early childhood mortality rates by demographic characteristics . 110 Table 8.4 Perinatal mortality . 111 Table 8.5 High-risk fertility behaviour . 113 Figure 8.1 Trends in Infant and Under-five Mortality in the 15 Years Preceding the Survey . 107 Figure 8.2 Under-five Mortality by Mother’s Background Characteristics . 109 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 116 Table 9.2 Number of antenatal care visits and timing of first visit . 117 Table 9.3 Components of antenatal care . 118 Table 9.4 Tetanus toxoid injections . 120 Table 9.5 Place of delivery . 121 Table 9.6 Assistance during delivery . 122 Table 9.7 Timing of first postnatal check-up . 124 Table 9.8 Type of provider of first postnatal check-up . 125 Table 9.9 Problems in accessing health care . 126 Figure 9.1 Assistance of Skilled Provider during Childbirth . 123 xii | Contents CHAPTER 10 CHILD HEALTH Table 10.1 Child’s weight and size at birth . 130 Table 10.2 Vaccinations by source of information . 131 Table 10.3 Vaccinations by background characteristics . 133 Table 10.4 Vaccinations in first year of life. 134 Table 10.5 Prevalence and treatment of symptoms of ARI . 135 Table 10.6 Prevalence and treatment of fever . 136 Table 10.7 Prevalence of diarrhoea . 137 Table 10.8 Diarrhoea treatment . 139 Table 10.9 Feeding practices during diarrhoea . 140 Table 10.10 Knowledge of ORS packets . 141 Table 10.11 Disposal of children’s stools . 142 Figure 10.1 Vaccination Coverage among Children Age 12-23 Months . 132 Figure 10.2 Vaccination Coverage during the First Year of Life among Children Age 12-23 Months . 132 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 145 Table 11.2 Initial breastfeeding . 149 Table 11.3 Breastfeeding status by age . 151 Table 11.4 Median duration and frequency of breastfeeding . 153 Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview . 155 Table 11.6 Infant and young child feeding (IYCF) practices . 157 Table 11.7 Prevalence of anaemia in children . 160 Table 11.8 Presence of iodized salt in household . 161 Table 11.9 Micronutrient intake among children . 163 Table 11.10 Nutritional status of women . 164 Table 11.11 Foods consumed by mothers in the day and night preceding the interview . 166 Table 11.12 Micronutrient intake among mothers . 168 Table 11.13.1 Prevalence of anaemia in women . 169 Table 11.13.2 Prevalence of anaemia in men . 170 Figure 11.1 Nutritional Status of Children by Age . 147 Figure 11.2 Types of Prelacteal Liquids Received by Last-born Children in the Five Years Preceding the Survey . 150 Figure 11.3 Infant Feeding Practices . 152 Figure 11.4 Infant and Young Child Feeding (IYCF) Practices . 158 CHAPTER 12 MALARIA Table 12.1 Ownership of mosquito nets . 172 Table 12.2 Use of mosquito nets by children . 173 Table 12.3.1 Use of mosquito nets by women . 175 Table 12.3.2 Use of mosquito nets by pregnant women . 176 Table 12.4 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy . 177 Table 12.5 Prevalence and prompt treatment of fever . 179 Table 12.6 Type and timing of anti-malarial drugs . 180 Table 12.7 Availability at home of anti-malarial drugs received by children with fever . 181 Tables and Figures | xiii CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS. 184 Table 13.2 Knowledge of HIV prevention methods . 186 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 187 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 188 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 190 Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women . 192 Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men . 193 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 194 Table 13.7 Adult support of education about condom use to prevent AIDS . 195 Table 13.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women . 197 Table 13.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men . 199 Table 13.9 Payment for sexual intercourse: Men . 200 Table 13.10.1 Coverage of prior HIV testing: Women . 201 Table 13.10.2 Coverage of prior HIV testing: Men . 202 Table 13.11 Pregnant women counselled and tested for HIV. 203 Table 13.12 Male circumcision . 204 Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STIs symptoms . 205 Table 13.14 Prevalence of medical injections . 207 Table 13.15 Comprehensive knowledge about AIDS and knowledge of a source for condoms among youth . 209 Table 13.16 Age at first sexual intercourse among youth . 210 Table 13.17 Condom use at first sexual intercourse among youth . 211 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 212 Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Women . 213 Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Men . 214 Table 13.20 Age-mixing in sexual relationships among women age 15-19 . 216 Table 13.21 Drunkenness during sexual intercourse among youth . 217 Table 13.22 Recent HIV tests among youth . 218 Figure 13.1 Women and Men Age 15-49 Who Sought Advice or Treatment for STIs . 206 Figure 13.2 Facility Where Last Medical Injection Was Received . 208 Figure 13.3 Abstinence, Being Faithful, and Condom Use (ABC) among Young Women and Men . 215 xiv | Contents CHAPTER 14 HIV PREVALENCE AND ASSOCIATED FACTORS Table 14.1 Coverage of HIV testing by residence and region . 221 Table 14.2 Coverage of HIV testing by selected background characteristics . 222 Table 14.3 HIV prevalence by age . 223 Table 14.4 HIV prevalence by socio-economic characteristics . 224 Table 14.5 HIV prevalence by demographic characteristics . 225 Table 14.6 HIV prevalence by sexual behaviour . 227 Table 14.7 HIV prevalence by selected characteristics . 228 Table 14.8 Prior HIV testing by current HIV status . 229 Table 14.9 HIV prevalence among young people by background characteristics . 230 Table 14.10 HIV prevalence among young people by sexual behaviour . 231 Table 14.11 HIV prevalence among couples . 233 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women. 236 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women . 237 Table 15.2.2 Control over men’s cash earnings . 238 Table 15.3 Women’s control over her own earnings and over those of her husband . 239 Table 15.4.1 Women’s participation in decision-making . 240 Table 15.4.2 Women’s participation in decision-making according to men . 240 Table 15.5.1 Women’s participation in decision-making . 241 Table 15.5.2 Men’s attitudes towards wives’ participation in decision-making . 243 Table 15.6.1 Attitude toward wife beating: Women . 245 Table 15.6.2 Attitude toward wife beating: Men . 246 Table 15.7.1 Attitudes towards a wife refusing to have sexual intercourse with husband: Women . 247 Table 15.7.2 Attitudes towards a wife refusing to have sexual intercourse with husband: Men . 248 Table 15.7.3 Men’s attitudes towards a husband’s rights when his wife refuses to have sexual intercourse . 250 Table 15.8 Indicators of women’s empowerment . 252 Table 15.9 Current use of contraception by women’s empowerment . 253 Table 15.10 Reproductive health care by women’s empowerment . 254 Figure 15.1 Number of Household Decisions in Which Currently Married Women Participate . 242 CHAPTER 16 FEMALE CIRCUMCISION Table 16.1 Knowledge and prevalence of female circumcision . 256 Table 16.2 Age at circumcision . 257 Table 16.3 Person performing circumcision . 258 Table 16.4 Practice of female circumcision among respondent’s daughters . 259 Table 16.5 Type of female circumcision among daughters . 260 Table 16.6 Daughter’s age at circumcision . 261 Table 16.7 Perceived benefits of undergoing female circumcision . 262 Table 16.8 Beliefs about female circumcision . 264 Table 16.9 Attitudes toward female circumcision . 265 Tables and Figures | xv CHAPTER 17 ADULT AND MATERNAL MORTALITY Table 17.1 Data on siblings . 268 Table 17.2 Indicators on data quality . 269 Table 17.3 Estimates of age-specific female and male adult mortality . 270 Table 17.4 Maternal mortality . 272 Figure 17.1 Female Mortality Rates for the Period 2001-2008 and Model Life Table Rates, by Age Group . 271 Figure 17.2 Male Mortality Rates for the Period 2001-2008 and Model Life Table Rates, by Age Group . 271 APPENDIX A SAMPLE DESIGN Table A.1 Distribution of Enumeration Areas (EAs) by domain and local council, and by urban-rural specification . 276 Table A.2 Distribution of the household population by domain and local council, and by urban-rural specification . 276 Table A.3 Distribution of households by domain and local council, and by urban-rural specification . 277 Table A.4 Sample allocation of Enumeration Areas (EAs) and households by domain and local council, and by urban-rural specification . 278 Table A.5 Expected number of completed interviews for women and men by domain and local council, and by urban-rural specification . 279 Table A.6 Sample implementation: Women . 281 Table A.7 Sample implementation: Men . 282 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Sierra Leone 2008 . 285 Table B.2 Sampling errors: Total sample, SLDHS 2008 . 286 Table B.3 Sampling errors: Urban sample, SLDHS 2008 . 287 Table B.4 Sampling errors: Rural sample, SLDHS 2008 . 288 Table B.5 Sampling errors: Eastern sample, SLDHS 2008 . 289 Table B.6 Sampling errors: Northern sample, SLDHS 2008. 290 Table B.7 Sampling errors: Southern sample, SLDHS 2008 . 291 Table B.8 Sampling errors: Western sample, SLDHS 2008 . 292 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 293 Table C.2.1 Age distribution of eligible and interviewed women . 294 Table C.2.2 Age distribution of eligible and interviewed men . 294 Table C.3 Completeness of reporting . 295 Table C.4 Births by calendar year . 296 Table C.5 Reporting of age at death in days . 296 Table C.6 Reporting of age at death in months . 297 Table C.7 Nutritional status of children by NCHS/CDC/WHO International Reference Population . 298 Table C.8 Coverage of HIV testing by social and demographic characteristics: Women . 300 Table C.9 Coverage of HIV testing by social and demographic characteristics: Men . 301 Table C.10 Coverage of HIV testing by sexual behaviour characteristics: Women . 302 Table C.11 Coverage of HIV testing by sexual behaviour characteristics: Men . 303 Acknowledgements | xvii ACKNOWLEDGEMENTS The 2008 Sierra Leone Demographic and Health Survey (SLDHS) represents the continued efforts in Sierra Leone to obtain reliable and accurate data on fertility behaviour, contraceptive practice, and other reproductive health issues. The survey results are critical and timely as additional information is provided relating to child survival and knowledge regarding HIV/AIDS. Such wealth of information will no doubt be tremendously useful in charting future directions for the population and health programmes including monitoring, evaluation, and research. The 2008 SLDHS overwhelmingly received active support from a large number of institutions and individuals who were instrumental in the implementation and its overall success. The support and active involvement of the officials of the Ministry of Health and Sanitation are greatly acknowledged. As a result of the adequate funding provided by the Sierra Leone Government, UNFPA, UNDP, DFID, UNICEF, USAID and The World Bank, logistical support by WHO, WFP, and UNHCR, and technical support by ICF Macro, a huge success was recorded and achieved. I wish to acknowledge with much gratitude the tremendous support received from the Senior Management and staff of Statistics Sierra Leone, and in particular the Demographic and Social Statistics Division, Geographic Information System Division and the Data Processing Division. The unflinching support and leadership role provided by the resident SLDHS Consultant, during the implementation period of the survey, is worth mentioning. All the field staffs who were engaged in data collection, and all the data processing staff, and coordinators, worked tirelessly and their efforts are hereby acknowledged. Sincere thanks are extended to the 2008 SLDHS Technical and Steering Committees, whose technical and policy guidance, respectively, made possible the successful implementation of the entire process. Finally, my appreciation goes to all the households, men and women who were selected and who responded very well during the survey. Without their participation and support, this project would have been a failure. Their cooperation is therefore greatly appreciated. Samura Kamara (Ph.D.) Minister of Finance and Economic Development Ministerial Building Freetown Foreword | xix FOREWORD It is generally acknowledged that meaningful development for any Nation can be achieved only when the Statistical information needed for the formulation of polices is readily available and properly documented. Statistics Sierra Leone (SSL), being the agency charged with the responsibility of demographic data collection and analysis has been relentless in the efforts to obtain reliable and up-to- date data for the country. The Demographic and Health Survey (DHS) is an internationally acknowledged survey designed to obtain information on health issues that affect the management and development of the population. Although the objectives of the 2008 Sierra Leone Demographic and Health Survey (SLDHS) focus on the specific issues and trends that are peculiar to the Sierra Leone situation, the survey was designed in conformity with international standards. The 2008 SLDHS, which is the first DHS conducted in Sierra Leone, is specifically aimed at obtaining and providing information on general fertility and fertility preferences, use and knowledge of family planning methods, maternal and childhood health, maternal and childhood mortality, breast feeding practices, nutrition, HIV/AIDS and other health issues. Although the 2008 SLDHS estimates the national total fertility rate (TFR), at 5.1 children which is still relatively high compared to the desired targets, the reported increase in the knowledge of other health issues among the population offers a ray of hope. The 2008 SLDHS was funded by the Sierra Leone government, UNFPA, UNDP, UNICEF, DFID, The World Bank, USAID, while UNHCR, WFP, and WHO provided logistical support, and ICF Macro and the UNFPA Country Support Team provided technical backstopping. The Ministry of Health and Sanitation and other stakeholders also assisted in various ways to ensure the overall success of the project. The efforts of all these organizations are deeply appreciated by the Ministry of Health and Sanitation of Sierra Leone. It is hoped that users at all levels will find the report useful. Honorable Mr. Sheiku Tejan Koroma Ministry of Health and Sanitation of Sierra Leone Freetown Preface | xxi PREFACE One of the mandates of Statistics Sierra Leone (SSL) is to collect, collate, process, analyse, publish and disseminate population census and survey data at all levels. Statistics Sierra Leone has the additional mandate of being the focal point for policy formulation and coordination of population activities in the country. By this mandate, Statistics Sierra Leone occupies the leadership position in the population sector and the major provider of information on the Sierra Leone population. The successful conduct of the 2008 Sierra Leone Demographic and Health Survey (SLDHS) and the production of this report, within a reasonably short time frame, undoubtedly underscores Statistics Sierra Leone’s leadership role. The compilation of the report has been borne out of the need to meet the yearnings of policy makers, programme implementers, and researchers, who require timely data for their day-to-day operations. The report contains detailed information on the demographic, health, and social indicators that will enable us measure progress in the Sierra Leone Society. I commend the following for funding the survey: 1. Government of Sierra Leone 2. UNFPA 3. UNDP 4. UNICEF 5. USAID 6. DFID 7. The World Bank The following provided logistical support to the survey: UNHCR,WFP, and WHO. It is my sincere hope that the end users will thoroughly acquaint themselves with this report and take advantage of the findings for their developmental aspirations. Professor Lawrence Kamara Statistician General Statistics Sierra Leone Freetown Summary of Findings | xxiii SUMMARY OF FINDINGS The 2008 Sierra Leone Demographic and Health Survey (SLDHS) is the first DHS survey to be held in Sierra Leone. Teams visited 353 sample points across Sierra Leone and collected data from a nationally representative sample of 7,374 women age 15-49 and 3,280 men age 15- 59. The primary purpose of the 2008 SLDHS is to provide policy-makers and planners with de- tailed information on fertility, family planning, childhood mortality, maternal and child health, female circumcision, maternal mortality, nutri- tion, knowledge of HIV/AIDS and other sexu- ally transmitted infections, and HIV prevalence rates. FERTILITY Survey results indicate that there has been little or no decline in the total fertility rate over the past two decades, from 5.7 children per woman in 1980-85 to 5.1 children per woman for the three years preceding the 2008 SLDHS (approximately 2004-07). Fertility is lower in urban areas than in rural areas (3.8 and 5.8 chil- dren per woman, respectively). Regional varia- tions in fertility are marked, ranging from 3.4 births per woman in the Western Region (where the capital, Freetown, is located) to almost six births per woman in the Northern and Eastern regions. Women with no education give birth to almost twice as many children as women who have been to secondary school (5.8 births, com- pared with 3.1 births). Fertility is also closely associated with household wealth, ranging from 3.2 births among women in the highest wealth quintile to 6.3 births among women in the lowest wealth quintile, a difference of more than three births. Research has demonstrated that children born too close to a previous birth are at increased risk of dying. In Sierra Leone, only 18 percent of births occur within 24 months of a previous birth. The interval between births is relatively long; the median interval is 36 months. Childbearing begins early in Sierra Leone. The median age at first birth is 19.3 years for women age 25-49. Thirty-four percent of girls age 15-19 have begun childbearing: more than one-quarter have already had a child and 6 per- cent are pregnant with their first child. Marriage and sexual behaviour patterns are important determinants of fertility levels. Almost three-fourths of women age 15-49 are currently married—65 percent are formally married and 10 percent are living together with a man. The proportion of men age 15-49 who are married (55 percent) is lower than the proportion of women who are married, probably because men tend to marry later than women. Thirty-seven percent of married women in Sierra Leone are in polygynous unions. The median age at first marriage is 17.0 years for women age 25-49, compared with 24.5 years for men the same age. Women who are currently in their early 20s have a slightly higher median age at first marriage than older women, indicating that younger women may be marrying at later ages than women did in the past. Women and men generally do not wait until marriage to initiate sexual activity. The median age at first intercourse is 16.1 years among women and 18.7 years among men age 25-49. Urban women, those living in the Western Re- gion, better educated women and those in the highest wealth quintile tend to wait longer to initiate sexual activity. Among men, the median age at first sexual intercourse is similar across all sub-groups. There is a considerable desire among Sierra Leonean women to control the number and tim- ing of their births. Thirty percent of married women do not want any more children or are sterilized, and another 25 percent would like to wait at least two years before their next child. On average, Sierra Leonean women would like to have five children (5.0); this number is slightly less than the current fertility rate of 5.1 children per woman, and one child more than the four children suggested in the National Popula- tion Policy. Sixteen percent of recent births were mistimed (wanted later) and 10 percent were not wanted at all. These results indicate that there is a need for additional family planning services, especially those concerned with spacing births. xxiv | Summary of Findings FAMILY PLANNING The vast majority of Sierra Leonean women and men know of at least one method of contra- ception. Contraceptive pills and injectables are known to about 60 percent of currently married women and 49 percent of married men. Male condoms are known to 58 percent of married women and 80 percent of men. A higher propor- tion of respondents reported knowing a modern method of family planning than a traditional method. About one in five (21 percent) currently married women has used a contraceptive method at some time—19 percent have used a modern method and 6 percent have used a traditional method. However, only about one in twelve cur- rently married women (8 percent) is currently using a contraceptive method. Modern methods account for almost all contraceptive use, with 7 percent of married women reporting use of a modern method, compared with only 1 percent using a traditional method. Injectables and the pill are the most widely used methods (3 and 2 percent of married women, respectively), fol- lowed by LAM and male condoms (less than 1 percent each). Current use of contraception is slightly high- er among all women (10 percent) than among currently married women (8 percent). This is because contraceptive use is much higher among sexually active unmarried women (34 percent), who are included in the all women category. Married women in urban areas are more likely to use contraception (16 percent) than those in rural areas (5 percent). Use increases with educational attainment, from 6 percent among married women with no education to 22 percent among those who have attended secon- dary school. Use of contraception also rises as wealth status increases, from 4 percent among married women in the lowest wealth quintile to 20 percent among those in the highest wealth quintile. Half of women using modern contraceptive methods obtain their methods from the public sector, primarily from government health centres (18 percent), government family planning clinics (15 percent), and government hospitals (14 per- cent). More than one-third (39 percent) of women use the private medical sector to obtain their contraceptive methods; 26 percent of users get their methods from pharmacies. Eight per- cent of women using a modern method obtain their method from a private hospital or clinic, and 6 percent get their method from other sources, mostly from friends or relatives. Twenty-eight percent of currently married women who are not using contraception say they intend to use family planning in the future, 48 percent do not intend to use a family planning method, and 23 percent are unsure. The most common reasons for not intending to use a con- traceptive method are opposition to the use of family planning by respondents or their hus- band/partner (each mentioned by 14 percent), desire for more children, lack of knowledge of methods, and fear of side effects (11 percent each). There continues to be considerable scope for increased use of family planning in Sierra Leone. Overall, 36 percent of married women in Sierra Leone have an unmet need for family planning, most of which is due to a desire for spacing births (21 percent) rather than a need for limiting births (15 percent). CHILD HEALTH Examination of levels of infant and child mortality is essential for assessing population and health policies and programmes. Infant and child mortality rates are also used as indices re- flecting levels of poverty and deprivation in a population. The 2008 survey data show that over the past 15 years, infant and under-five mortality have decreased by 26 percent. Still, one in seven Sierra Leonean children dies before reaching age five. For the most recent five-year period before the survey (approximately calendar years 2003 to 2008), the infant mortality rate was 89 deaths per 1,000 live births and the under-five mortality rate was 140 deaths per 1,000 live births. The neonatal mortality rate was 36 deaths per 1,000 live births and the post-neonatal mortality rate was 53 deaths per 1,000 live births. The child mortality rate was 56 deaths per 1,000 children surviving to age one year. Mortality rates at all ages of childhood show a strong relationship with the length of the pre- ceding birth interval. Under-five mortality is three times higher among children born less than two years after a preceding sibling (252 deaths Summary of Findings | xxv per 1,000 births) than among children born four or more years after a previous child (deaths 81 per 1,000 births). Only 40 percent of Sierra Leonean children age 12-23 months are fully immunized, i.e., re- ceived BCG and measles vaccinations, and three doses each of DPT and polio vaccines. Looking at coverage for specific vaccines, 82 percent of children received the BCG vaccination, 77 per- cent received the first dose of DPT vaccine, and 76 percent received the first dose of polio vac- cine (Polio 1). Coverage declines for subsequent vaccinations, with only 60 percent of children receiving the recommended three doses of DPT vaccine, and 50 percent receiving all three doses of polio vaccine. Only 60 percent of children received the measles vaccination. Sixteen per- cent of children have received no vaccinations at all. Seven percent of children under five years were reported to have had a cough with short, rapid breathing—not just a blocked or runny nose—in the two weeks preceding the survey. Almost five in ten children (46 percent) with these symptoms were taken to a health facility or provider for treatment. Children who were less likely to be taken for treatment were those age 24-35 months, children living in the Eastern Re- gion, children whose mothers have little or no education, and children in the poorest house- holds (lowest wealth quintile). Fever is a symptom of malaria and other acute infections in children. Twenty-five percent of children under age five were reported to have had a fever in the two weeks before the survey. About four in ten children with fever were taken to a health facility or provider for treatment, and three in ten children with fever were given anti- malarial drugs. Almost half of children who were ill with diarrhoea in the two weeks preceding the survey were taken to a health facility or provider (47 percent). Mothers reported that almost nine in ten (86 percent) children with diarrhoea were treated with some form of oral rehydration ther- apy (ORT) or increased fluids, and over two- thirds were given a solution prepared from a packet of oral rehydration salts (68 percent). MATERNAL HEALTH Almost nine in ten mothers (87 percent) in Sierra Leone receive antenatal care from a health professional (doctor, nurse, midwife, or MCH aid). Only 5 percent of mothers receive antenatal care from a traditional midwife or a community health worker; 7 percent of mothers do not re- ceive any antenatal care. In Sierra Leone, over half of mothers have four or more antenatal care (ANC) visits, about 20 percent have one to three ANC visits, and only 7 percent have no antenatal care at all. The survey shows that not all women in Sierra Leone receive antenatal care services early in preg- nancy. Only 30 percent of mothers obtain ante- natal care in the first three months of pregnancy, 41 percent make their first visit in the fourth or fifth month, and 17 percent in have their first visit in the sixth or seventh month. Only 1 per- cent of women have their first ANC visit in their eighth month of pregnancy or later. Neonatal tetanus is a leading cause of neona- tal death in developing countries where a high proportion of deliveries occur at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) vaccinations are given to pregnant women to prevent neonatal tetanus. The survey results show that, for the most recent live birth in the five years preceding the survey, most women (75 percent) in Sierra Leone re- ceived two or more tetanus injections during pregnancy and 79 percent of births are protected against neonatal tetanus. One-third (34 percent) of women age 15-49 with a live birth in the two years preceding the survey received some type of anti-malarial medicine during their last pregnancy. However, in the vast majority of cases, the practice was not in accordance with national policy, i.e., only 20 percent of women reported taking SP/Fansidar— the recommended drug for intermittent preven- tive treatment of malaria during pregnancy in Sierra Leone—at least once during their preg- nancy. Increasing the proportion of babies delivered in health facilities is an important factor in re- ducing health risks to both mother and child. SLDHS data show that the majority of births in Sierra Leone (72 percent) are delivered at home; only 25 percent are delivered in health facilities, mostly public sector facilities. Less than half (42 xxvi | Summary of Findings percent) of births in Sierra Leone are delivered with the help of a health professional (i.e., doc- tor, nurse/midwife, or MCH aid), while 45 per- cent are delivered by a traditional birth atten- dant. About one in eleven births are attended by relatives (9 percent) and 1 percent of all births occur without any type of assistance. Postnatal care coverage is low in Sierra Leone: only 38 percent of mothers receive post- natal care within 4 hours of delivery, 20 percent receive care within two days after delivery, and 5 percent receive care 3-41 days after delivery. About one-third of mothers (33 percent) do not get any postnatal care. The maternal mortality ratio estimated from SLDHS data for the seven-year period preceding the survey is 857 maternal deaths per 100,000 births. BREASTFEEDING AND NUTRITION Poor nutritional status is one of the most im- portant health and welfare problems facing Si- erra Leone today and particularly afflicts women and children. The data show that 36 percent of children under five are stunted (too short for their age) and 10 percent of children under five are wasted (too thin for their height). Overall, 21 percent of children are underweight, which may reflect stunting, wasting, or both. For women, at the national level 11 percent of women are con- sidered to be thin (body mass index <18.5); however, only 4 percent of women are consid- ered severely thin. At the other end of a spec- trum, 20 percent of women age 15-49 are con- sidered to be overweight (body mass index 25.0- 25.9) and 9 percent are considered obese (body mass index ≥30.0). Poor breastfeeding and infant feeding prac- tices can have adverse consequences for the health and nutritional status of children. Fortu- nately, breastfeeding in Sierra Leone is almost universal and generally of fairly long duration; 86 percent of newborns are breastfed within the first day after delivery. However, only 11 per- cent of infants under six months of age are ex- clusively breastfed, which is the recommended practice for children under six months. The me- dian duration of any breastfeeding is 19.7 months in Sierra Leone, although the median duration of exclusive breastfeeding is extremely short—less than one month. Infant and young child feeding (IYCF) prac- tices include timely introduction of solid and semi-solid foods beginning at age six months, and thereafter increasing the amount and variety of foods and the frequency of feeding as the child gets older, while still maintaining frequent breastfeeding. Guidelines have been established with respect to IYCF practices for children age 6-23 months. Overall, only 23 percent of chil- dren are fed in accordance with IYCF practices. Ensuring that children age 6-59 months re- ceive enough vitamin A may be the single most effective child survival intervention. The survey results show that 26 percent of children age 6-59 months received a vitamin A supplement in the six months preceding the survey. Moreover, 75 percent of children age 6-35 months living with their mother consumed foods rich in vitamin A in the 24 hours preceding the survey, and 59 percent consumed foods rich in iron. With re- gard to iron supplements, only 20 percent of children age 6-59 months received an iron sup- plement in the seven days preceding the survey. Determining anaemia levels among women and their children under five was one component of the SLDHS. As a result of the testing carried out during the survey it was found that 76 per- cent of children age 6-59 months have anaemia; 28 percent have mild anaemia, 44 percent have moderate anaemia, and about 4 percent have se- vere anaemia. Prevalence of anaemia in children decreases with increasing level of the mother’s education and increasing household wealth status (wealth index). Urban children are some- what less likely to be anaemic than rural chil- dren. Children in the Northern Region (79 per- cent) were the most likely to be anaemic. Forty-five percent of women in Sierra Leone have some level of anaemia; the majority are mildly anaemic (34 percent), 11 percent are moderately anaemic, and about 1 percent were found to be severely anaemic. The prevalence of any anaemia in women varies by regions, with the lowest level in the Eastern and Southern re- gions (43 percent each) and the highest level in the Western Region (50 percent). HIV/AIDS The HIV/AIDS pandemic is one of the most serious health concerns in the world today be- cause of its high case-fatality rate and the lack of a cure. Awareness of AIDS is relatively high Summary of Findings | xxvii among Sierra Leonean adults age 15-49, with 69 percent of women and 83 percent of men saying that they have heard about AIDS. Nevertheless, only 14 percent of women and 25 percent of men are classified as having ‘comprehensive knowl- edge’ about AIDS, i.e., knowing that consistent use of condoms during sexual intercourse and having just one faithful, HIV-negative partner can reduce the chances of getting HIV/AIDS, knowing that a healthy-looking person can have HIV (the virus that causes AIDS), and knowing that HIV cannot be transmitted by sharing food/utensils with someone who has HIV/AIDS, or by mosquito bites. Such a low level of knowledge about HIV/AIDS implies that a concerted effort is needed to address misconceptions about the transmission of HIV in Sierra Leone. Compre- hensive knowledge is substantially lower among respondents with no education and those who live in the poorest households. Programmes could be targeted to populations in rural areas, and especially women in the Northern and Southern regions and men in the Eastern Region, where comprehensive knowledge is lowest. A composite indicator on stigma towards people who are HIV positive shows that only 5 percent of women and 15 percent of men age 15-49 ex- pressed accepting attitudes towards persons liv- ing with HIV/AIDS. Regarding condom use, only 7 percent of women who had more than one partner in the 12 months before the survey said they used a con- dom during the most recent sexual intercourse, far lower than the 15 percent reported by men. Among women who reported having higher-risk sexual intercourse in the past 12 months, only 7 percent used a condom at the last higher-risk sexual intercourse. For men, the comparable fig- ure is three times higher—22 percent. Overall, only about one-quarter of women age 15-49 years and one-third of men age 15-49 know where to get an HIV test. Even fewer have ever been tested; only 13 percent of women and 8 percent of men have ever had an HIV test, and only 4 percent of women and 3 percent of men have been tested and received their test results in the 12 months before the survey. Several recent studies have shown that male circumcision may have a protective effect against transmission of HIV. The results of the 2008 SLDHS indicate that male circumcision is widespread in Sierra Leone, with almost all men age 15-49 being circumcised (96 percent). This is seen for all age groups, residential areas, and levels of education. One of the most important elements in the 2008 SLDHS was the inclusion of HIV testing for adults who were interviewed. Overall, HIV tests were conducted for 88 percent of the 3,954 eligible women age 15-49 and 85 percent of the 3,541 eligible men age 15-59 interviewed in every second household selected for the SLDHS. The test results indicate that overall, 1.5 per- cent of Sierra Leonean adults age 15-49 are HIV positive. HIV prevalence is slightly higher among women (1.7 percent) than men (1.2 per- cent). There are few differentials in HIV preva- lence by socio-economic, demographic, and sex- ual behaviour characteristics. FEMALE CIRCUMCISION The 2008 SLDHS collected data on the prac- tice of female circumcision (or female genital cutting) in Sierra Leone. Awareness of the prac- tice is universally high. Almost all (99 percent) of Sierra Leonean women and 96 percent of men age 15-49 have heard of the practice. The preva- lence of female circumcision is high (91 per- cent). Most women (82 percent) reported that the cutting involves the removal of flesh. The most radical procedure, infibulation—when vagina is sewn closed during the circumcision—is re- ported by only 3 percent of women. The survey results indicate that almost all of the women were circumcised by traditional practitioners (95 percent); only a small proportion of circumci- sions were performed by a trained health profes- sional (0.3 percent). Among Sierra Leonean adults age 15-49 who have heard of female circumcision, more men than women oppose the practice (41 and 26 percent, respectively), which is similar to pat- terns in other West African countries. Contributors to the Sierra Leone Demographic and Health Survey | xxix CONTRIBUTORS TO THE SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY Professor Joseph A.L. Kamara Statistician General, Statistics Sierra Leone Mohamed K. Koroma Deputy Statistician General, Statistics Sierra Leone Moses L.J. Williams Director of Demographic and Social Statistics Andrew Bob Johnny Director of Geographic Information System Paul Sengeh Monitoring and Evaluation Specialist - UNICEF Dr. Edward Magbity Monitoring and Evaluation Specialist - MOHS Dr. Francis Smart Programme Manager, RH and Family Planning Programme - MOHS Dr. Duramani Conteh Ag. Director, Hospitals and Laboratory Services - MOHS Alhaji Vandy Sovula National Professional Project Personnel, Data and Development - UNFPA Mr. Samuel O. Weekes Institute for Population Studies - USL Mrs. Elizabeth Sam Institute for Population Studies - USL Samuel Ogunlade SLDHS Consultant - UNFPA Other Contributors to the SLDHS Ade Renner Health Economist - World Health Organization James L. Kamara Monitoring and Evaluation Office - National AIDS Secretariat Gbogboto B. Musa Senior Statistician - Statistics Sierra Leone Sahr E. Yambasu Senior Statistician - Statistics Sierra Leone Sonnia Magba Bu-Buakei Jabbi Senior Statistician - Statistics Sierra Leone Ibrahim G. Kargbo Statistician - Statistics Sierra Leone Francis Tommy Statistician - Statistics Sierra Leone Peter Bangura Statistician - Statistics Sierra Leone Andrew Kamara Statistician - Statistics Sierra Leone Wogba Kamara Statistician - Statistics Sierra Leone Alusine Kamara Statistician - Statistics Sierra Leone Bridget Moseray (Mrs) Statistician - Statistics Sierra Leone Yeabu Tholley (Mrs) Statistician - Statistics Sierra Leone Mohamed Kamara Statistician - Statistics Sierra Leone Yalice Bangura (Mrs) Statistician - Statistics Sierra Leone Harriet Farmer (Mrs) Asst. Statistician - Statistics Sierra Leone Alimatu Musa (Ms) Asst. Statistician - Statistics Sierra Leone Millennium Development Goal Indicators | xxxi Millennium Development Goal Indicators Goal Indicator Value (percent) Male Female Total 1. Eradicate extreme poverty and hunger 4. Prevalence of underweight children under five years1 23.6 18.8 21.1 2. Achieve universal primary education 6. Net attendance ratio in primary education2 60.6 62.9 61.7 7. Percentage of pupils starting grade 1 who reach grade 53 96.2 95.4 95.8 7b. Primary completion rate4 14.5 11.3 12.9 8. Literacy rate for those age 15-24 years 69.6 43.5 na 3. Promote gender equality and empower women 9. Ratio of girls to boys in primary, secondary, and tertiary education5 na na 84.9 10. Ratio of literate women to men age 15-24 years na na 62.5 11. Share of women in wage employment in the non- agricultural sector6 na na 28.3 4. Reduce child mortality 13. Under-five mortality rate7 na na 140.0 14. Infant mortality rate7 na na 56.0 15. Percentage of children age one year immunized against measles8 58.8 60.7 59.7 5. Improve maternal health 16. Maternal mortality ratio9 na na 857.0 17. Percentage of births attended by skilled health personnel10 na na 42.4 6. Combat HIV/AIDS, malaria and other diseases 19. Percentage of current users of contraception using condoms11 49.3 7.5 na 19A. Condom use at last higher-risk sex12 22.4 9.6 na 19B. Percentage of population age 15-24 years with comprehensive correct knowledge of HIV/AIDS13 27.6 17.3 na 19C. Contraceptive prevalence rate14 na 8.2 na 20. Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years15 0.7 0.6 0.6 22. Percentage of population in malaria-risk areas using effective malaria prevention and treatment measures16 na na 38.2 22A. Percentage of children under five sleeping under ITN 25.5 26.0 25.8 22B. Percentage of children under five with fever appropriately treated with antimalarial drugs 30.1 30.1 30.1 Urban Rural Total 7. Ensure environmental sustainability 29. Percentage of population using solid fuels17 98.9 99.7 99.4 30. Percentage of population with sustainable access to an improved water source, urban and rural18 81.7 35.2 50.5 31. Percentage of population with access to improved sanitation, urban and rural19 26.1 6.6 13.0 32. Percentage of households with access to secure tenure na na na na = Not applicable 1 Based on children who slept in the household the night before the interview (de facto). 2 Based on de facto population. Numerator is children age 6-11 currently attending school; denominator is children age 6-11 years. 3 Based on de facto population. This indicator is calculated using rates of promotion, dropout, and repetition for a given school year. The rates are used to project an estimate for the percentage of students attending grade 1 who are expected to reach grade 5, with or without repetition. 4 Based on de facto population. Numerator is children who completed grade 6 or higher; denominator is children age 11-13 years. 5 Based on de facto population age 6-24 years 6 Numerator is all women working in the non-agricultural sector who received payment in cash, or in cash and in kind; denominator is all women and all men with non-agricultural occupation. 7 Mortality rates refer to a 5-year period before the survey. 8 In Sierra Leone, the measles vaccinations are given at the age of 9 months. The values presented in the table are for children age 12-23 months who have been vaccinated at any time against measles. 9 Per 100,000 live births; calculated as maternal mortality rate divided by the general fertility rate (for the period 2001-2008) 10 Skilled health personnel includes: doctor, nurse, midwife, and MCH aid. 11 The number of women age 15-49 in marital or consensual unions who report they are using a condom to avoid pregnancy (regardless of whether they are also using additional methods) is divided by the total number of women age 15-49 in union who are practicing, or whose sexual partners are practicing, contraception. The indicator is not equivalent to condom use prevalence as a main method of contraception). 12 Based on de facto population age 15-24. Higher-risk sex is sexual intercourse with a non-marital, non-cohabiting partner. 13 Respondents with “comprehensive correct knowledge” of AIDS are those who say that using a condom every time for sexual intercourse and having just one uninfected and faithful partner can reduce the chances of getting the AIDS virus, and furthermore say that a healthy-looking person can have the AIDS virus, and who reject the common misconception that HIV can be spread by mosquito bites and by sharing food with someone with AIDS. 14 Based on women age 15-49 in marital or consensual unions 15 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent. Note that these indicators do not take into account children who live outside of households, e.g., in institutions or on the street, because the SLDHS includes only households in its sample. 16 Based on de facto population with at least one insecticide-treated bednet (ITN) 17 Solid fuel includes: coal, charcoal, wood, straw, crops, animal dung and other. 18 Improved drinking water source includes: water from pipe/tap, from protected well, protected spring and rainwater. 19 Improved sanitary means of excreta disposal includes: flush toilet, improved pit latrine, and latrine with a slab. xxxii | Summary of Findings ATLANTIC OCEAN GUINEA LIBERIA NORTHERN SOUTHERN EASTERNWESTERN Bo Koinadugu Kono Bombali Tonkolili Kenema Moyamba Port Loko Pujehun Kailahun Bonthe Kambia Bonthe Western Area SIERRA LEONE 0 50 10025 Kilometres ± Freetown Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY Sierra Leone is located on the west coast of Africa and covers an area of about 72,000 square kilometres (28,000 square miles). It extends from latitude 7 degrees north to 10 degrees north, and from longitude 10 degrees west to 14 degrees west. The Republic of Guinea borders it on the north and northeast, and the Republic of Liberia borders it on the east and southeast. On the west and southwest, the Atlantic Ocean extends approximately 340 kilometres (211 miles). Administratively, Sierra Leone is divided into 4 provinces. Each province is subdivided into districts, and each district is divided into chiefdoms. Overall, there are 14 districts and 149 chiefdoms. Among the 14 districts, there are 5 city councils and 14 district councils, including Freetown, the capital, for a total of 19 local councils (SSL, 2006). Sierra Leone has four main physical regions: the Freetown Peninsula raised beaches and hills, the Coastal Plains, the Interior Lowlands, and the Interior Plateau. The Freetown peninsula consists of three roughly parallel ranges of highlands that are narrow but extend about 30km south of Freetown. The hills and mountains in these highlands rise impressively from 200 to 1000m above the low-lying narrow coastal area. The Interior Lowlands region makes up about half of the country. Most of the area, which is largely swamp, is less than 150m above sea level. The Interior Plateau region makes up the eastern half of the country. It is the most extensive physical region and includes the greatest variety of land forms. It is 300 to 450m above sea level. The Interior Plateau is dissected by the main rivers flowing westward towards the sea. Rising above the general level of this region are a number of hills and mountains, including the Kambui, Nimini, and Gori hills and the Sula, Kangari, Loma, Tingi, and Wara Wara mountains. Climate in Sierra Leone is determined mainly by the seasonal movements of two air masses: the north-easterly Continental Tropical Winds (commonly called North-East Trade Winds) and the south-westerly Maritime Tropical Winds (commonly called South-West Monsoon). The country experiences two main seasons: the dry season, which is between November and May, and the wet/raining season, which lasts from April/May to November. The present distribution of vegetation in Sierra Leone has been influenced not only by factors of climate and soil, but also by man. At present the following vegetation communities can be distinguished: forest, savanna, grassland, and swamp. The country has eight main river systems. The Great Scarcies, Little Scarcies, Rokel, Jong, Sewa, Wanjei, Moa, and Mano. The rivers typically flow from north east to south west, eventually reaching the Atlantic Ocean. 1.2 HISTORY Sierra Leone’s earliest known contact with Europe was in the fifteenth century during the Portuguese voyages of exploration. One such voyage to discover a sea route to India resulted in the Portuguese reaching the Sierra Leone Peninsula. Because the high coastal ranges resembled lions to the explorers, the area was called Sierra Lyoa, meaning Lion Mountains. Contact stimulated trade, with manufactured goods coming from Europe, in return for fruit, carvings, and gold from Sierra Leone. However, in the sixteenth century, there was the added dimension of the introduction of the slave trade. In 1562 the earliest known shipment of slaves was 2 | Introduction taken from the country to the Americas. There was a further strengthening of the European link in 1789 with the founding of settlements for freed slaves. The first group of 411 freed slaves was settled on land bought from King Tom of the Sierra Leone Peninsula. The settlement was under the administration of the Sierra Leone Company, which was founded in 1791 with the aim of re-establishing legitimate trade with the inhabitants. With the abolition of the slave trade and pressure from individuals and organizations in Britain, the British Government took direct responsibility for the new settlement. In 1808 the British Government declared the new settlement to be a Crown Colony. This move was intended to facilitate the enforcement of the Slave Trade Abolition Act. British rule covered only the colony, which was then the Freetown Peninsula and Bonthe Island. The largest part of the country, referred to as the hinterland, was in the hands of traditional rulers. However, in 1896, the rest of the country was declared a protectorate, followed two years later by the Hut Tax War. Today, Sierra Leone is a republic within the British Commonwealth of Nations, having gained independence from Britain on 27 April, 1961. It gained the status of republic in April 1971 and adopted a one-party system of government in 1978. In 1991, however, the country reverted to a multiparty state, with two main political parties: the Sierra Leone Peoples Party (SLPP) and the All Peoples Congress (APC). The country then went through a 10-year civil conflict that began in 1991 and ended in 2002. English is the official language of the country, which has about 15 ethnic groups. The major tribes include the Mende, Temne, Limba, and Creole. The main religions are Christianity and Islam. 1.3 ECONOMY According to the results of the 2004 Sierra Leone Population and Housing Census (SSL, 2006), the population of Sierra Leone is estimated at about 4.9 million in an estimated 819,854 households. For the period 1985-2004, the population growth rate was estimated at 1.8 percent. About 64 percent of the population resides in rural areas. Sierra Leone was ranked last among the 177 countries surveyed globally in the 2007/2008 United Nations Human Development Index, with a per capita GDP of about US$806, a life expectancy of 41.8 years, and an adult literacy rate of 34.8 percent. The UNDP 2007/2008 Human Development Report estimates that in 2005 about 52 percent of the population lived on less than US$1 a day (UNDP, 2007). In 2007, Sierra Leone’s real GDP grew by 6.4 percent, or about 0.9 percentage points below the 2006 growth rate of 7.3 percent. Of the total 2007 GDP, the contribution of agriculture declined to 46 percent; industry and services (less FISIM1) remained unchanged at 10 percent and 37 percent, respectively; while the Net-Tax contribution went up by 1 percent to 7 percent. The economy has been unable to create jobs at a rate to match the rising labour force demand. The most recent household income and expenditure survey (2003-04) showed that about 70 percent of the population lives below the poverty line according to the National Poverty Line of Le2 2,111 per day (SSL, 2004). Overall, poverty is highest in rural areas, with 79 percent of the rural population living below the poverty line. The most acute form of poverty, insufficient food, is concentrated mainly in rural areas. About 68 percent of the population cannot afford enough food to eat. Three out of four people (75 percent) in rural areas outside Freetown do not attain the minimum daily calorie intake (2700 calories). The poor in Sierra Leone can meet only about 71 percent of their 1 FISIM is Financial Intermediation Services Indirectly Measured. The SNA 93 recommends that it should be treated as Intermediate Consumption and therefore deducted from the output of sectors that incur them; or appears in the account but deducted from the total. 2 National currency is Sierra Leonean leone (Le): 1 Le = 0.000324 U.S. dollars (as per March 2009) Introduction | 3 basic needs. The rebel war resulted in a substantial reduction in the standard of living and, for many people, reduced access to food. A poor and undernourished population is more susceptible to various diseases. Thus, rising maternal and child mortality rates, increasing rates of illiteracy, and rising unemployment levels characterize the living conditions in many parts of Sierra Leone. The HIV/AIDS pandemic has also had a major impact on all sectors of the economy through loss of production and labour force. Against this background, the government of Sierra Leone in 2005 launched the Economic Recovery Strategy, aimed at restoring economic growth, generating employment opportunities, and reducing poverty levels (Poverty Reduction Strategy Paper, March 2005). 1.4 POPULATION The population of Sierra Leone increased from 2,180,355 in 1963 to 4,976,871 in 2004 (Central Statistics Office, 1963; SSL, 2006). The results of the previous censuses indicate that the annual population growth rate was 1.8 percent per annum during the 1985-2004 period, down from 2.3 percent reported during the 1974-1985 period, and 2.0 percent during the 1963-1974 inter-censual period. 1.5 POPULATION AND FAMILY PLANNING POLICIES AND PROGRAMMES In 1993, the Government of Sierra Leone launched the National Population Policy for Development, Progress and Welfare (Ministry of Development, 1993). The population policy is being revised, and a first draft will be completed later in 2009. The 1993 National Population Policy for Development, Progress and Welfare sought to be humane and responsible, respecting individual freedoms and rights as well as religious beliefs and cultural values. It also recognizes that all couples and individuals have the basic right to make decisions freely and responsibly on the number and the spacing of their children and to receive the information, education, and the means to do so. Only those means or methods deemed morally acceptable, scientifically sound, culturally appropriate, and economically feasible were made available in the implementation of the policy. The population policy reinforces and enriches national development, especially human resource development, improves the quality of life of the people, and enhances human welfare and dignity. Special emphasis was placed on regulating population quantity, enhancing population quality, and improving the health and welfare of women and children. The interplay between population and development was a constant consideration in the preparation of the 1993 policy. In more specific terms, the goals of the national population policy include the following: • To make development planning and policy more comprehensive and effective, by the incorporation of the demographic dimension. • To achieve a rate of growth of the population that is sustainable by the economy. • To contribute towards meeting the basic needs of the people and enhancing the quality and utilization of the nation’s human resources. • To promote the health and welfare of the people especially those in the high risk groups of mothers and children. • To moderate initially the expected rise in population, and later to progressively reduce population growth rates through the promotion of voluntary family planning and small family norms, so as to facilitate the attainment of national economic and social targets. • To guide rural-urban migration, so as to minimize socio-economic problems and to optimize benefits to migrants and non-migrants alike in rural as well as urban areas. 4 | Introduction In order to achieve the above mentioned goals, the 1993 population policy set the following objectives: • To improve the demographic knowledge base (i.e., data collection, processing, analysis, projections, and research on population and development interaction) on a regular basis. • To actively promote and facilitate utilization of the knowledge base in social and economic planning, policies and projects, etc. • To promote, clarify, and sharpen awareness and understanding amongst leaders and the public at large of population and development problems and issues. • To provide men and women with information and education on the value of reasonable family size and child spacing to improve the welfare of the family and its members, the community, and the nation • To pay special attention to selected groups such as young persons, women of reproductive age, and members of organized groups, in providing information and education relating to family life, fertility regulation, etc. • To improve the quality and availability of maternal and child health care services so as to reduce infant, child, and maternal morbidity and mortality. • To make family planning services easily accessible and affordable to couples and individuals, and to actively promote the acceptance of contraceptive practice. • To design and implement programmes on integrated rural and urban development, to moderate and orient rural-urban migration. • To review existing legislation as it pertains to key areas of population policy, and to provide for the improved quality of life, so as to enhance the welfare of men, women, and children. 1.6 HEALTH POLICIES AND PROGRAMMES The Ministry of Health and Sanitation launched the National Health Policy in October 2002 (Ministry of Health and Sanitation, 2002). This document sets out the policy of the Government of Sierra Leone motivating and guiding the health sector. The previous health policy was written in 1993, nearly 17 years ago. Since then there have been a number of changes that have led to the need for updating health sector policy. Most important, the civil war suffered by the country caused major disruptions of the health system, including damage to the physical infrastructure, loss of skilled professionals and, through the wider economic effects, reduction in the resources available to the health sector. It has also resulted in changes in population patterns, and specific health problems ranging from mental trauma to physical disability. In addition to these war-related effects, there are wider changes that many countries in sub-Saharan Africa are facing that have implications for health policy. These include changing patterns of disease distribution such as the spread of HIV/AIDS, the escalating of TB and malaria, as well as the more general problems associated with the epidemiological and demographic transition. They also include a general recognition of the need to re- examine the way in which the health care sector is structured, particularly regarding increased decentralization, more partnership between the public and private sectors, and greater transparency in decision-making, including involvement of communities and other key stakeholders in the decision- making and accountability processes. Introduction | 5 The 2002 National Health Policy is set against this varied background and has been developed to provide clear direction for the health sector in the medium term (Ministry of Health and Sanitation, 2002). It includes policies related to both the reconstruction of the health sector and the reform and development of the sector. It also fully recognizes the existence of specific policies in defined technical areas. The goals, objectives and national health priorities are as follows: • The overall goal of the health sector is to maintain and improve the health of all Sierra Leonean residents within the country. • The Government of Sierra Leone is committed to pursuing such a goal in an equitable manner. It will work towards ensuring that all citizens have access to basic good quality health care. It has special responsibility to ensure the health of those citizens who are particularly vulnerable as a result of poverty, conflict, gender, or specific health problems. • The Government of Sierra Leone also has responsibility for ensuring the provision of adequate public health services (including sanitation), for food safety, and for effective action against specific communicable diseases. • The health of a country is not the result of health services alone, but can be affected both positively and negatively by the activities of a number of other sectors. The Ministry of Health and Sanitation has a responsibility to provide leadership and health-related advocacy to such sectors to ensure their activities are health promoting. • Sierra Leone faces a number of major health problems. However, resource constraints, particularly regarding the availability of finance and health care professionals, means that priorities have to be set for the key health problems that will be the focus of the health sector. This does not imply that other health problems will be ignored, but rather that they will not receive targeted national investment. It is also recognized that there are differences between districts in the prevalence and incidence of specific health problems (such as Lassa fever). As such, there will be opportunities during the planning processes for local setting of priorities within the national framework. National health priorities have been set on the basis of a number of criteria. These are: the severity of the disease in terms of its contribution to the overall burden of disease in the country, the distribution of the health problem within the country as a national problem, the feasibility and cost-effectiveness of interventions concerning the health problem, public expectations concerning the problem, and compliance with international regulations. On the basis of the above criteria, the current national priority health problems are: • Malaria • Sexually transmitted infections including HIV/AIDS • Tuberculosis • Unsatisfactory reproductive health including maternal and neo-natal mortality • Acute respiratory infections • Childhood immunizable diseases • Nutrition-related disease 6 | Introduction • Water, food, and sanitation-borne diseases • Disability • Mental illness Technical policies exist for a number of these health priorities; they set specific objectives, targets, strategies and, where appropriate, treatment protocols. In August 2002, these were policies on environmental health, immunization, drugs, health education, malaria, and HIV/AIDS (draft), and a national strategy for the development of prosthetics and orthotics services (Ministry of Health and Sanitation, 2002). Further technical policies will be developed in each of the remaining priority areas, and the existing ones will be updated as necessary. 1.7 OBJECTIVES AND ORGANIZATION OF THE 2008 SLDHS The 2008 Sierra Leone Demographic and Health Survey (SLDHS) is a nationally representative sample survey designed to provide information on population and health issues in Sierra Leone. This is the first Demographic and Health Survey conducted in Sierra Leone and was carried out by Statistics Sierra Leone (SSL) in collaboration with the Ministry of Health and Sanitation. The 2008 SLDHS was funded by the Sierra Leone government, UNFPA, UNDP, UNICEF, DFID, USAID, and The World Bank. WHO, WFP and UNHCR provided logistical support. ICF Macro, an ICF International Company, provided technical support for the survey through the MEASURE DHS project. MEASURE DHS is sponsored by the United States Agency for International Development (USAID) to assist countries worldwide in obtaining information on key population and health indicators. The purpose of the SLDHS is to collect national- and regional-level data on fertility and contraceptive use, marriage and sexual activity, fertility preferences, breastfeeding practices, nutritional status of women and young children, childhood and adult mortality, maternal and child health, female genital cutting, awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections, adult health, and other issues. The survey obtained detailed information on these topics from women of reproductive age and, for certain topics, from men as well. The 2008 SLDHS was carried out from late April 2008 to late June 2008, using a nationally representative sample of 7,758 households. The survey results are intended to assist policymakers and planners in assessing the current health and population programmes and in designing new strategies for improving reproductive health and health services in Sierra Leone. 1.8 SAMPLE DESIGN The SLDHS sample was designed to provide most of the indicators for the country as a whole, for urban and rural areas separately, and for each of four regions that were formed by grouping the 14 districts. The regional groups are as follows: Eastern: Kailahun, Kenema, Kono districts Northern: Bombali, Kambia, Koinadugu, Port Loko, Tonkolili districts Southern: Bo, Bonthe, Moyamba, Pujehun districts Western: Western Area Urban and Western Area Rural districts A representative probability sample of households was selected for the 2008 SLDHS sample. The sample was selected in two stages. In the first stage, 353 clusters were selected from a list of enumeration areas in the master sample frame that was designed for the 2004 Sierra Leone Population Introduction | 7 and Housing Census (SSL, 2006). In the second stage, a complete listing of households was carried out in each selected cluster. Twenty-two households were then systematically selected from each cluster for participation in the survey. This design resulted in a final sample of 7,758 households. All women age 15-49 who were either permanent residents of the households or visitors present in the household on the night before the survey were eligible to be interviewed. In addition, all men age 15-59 in half of the households selected for the survey were eligible to be interviewed if they were either permanent residents or visitors present in the household on the night before the survey. Height and weight measurements of female respondents and children under the age of five years were done only in the households selected for the male survey. Eligible adults and children age 6-59 months in the households selected for the male survey were tested for anaemia, and women and men were asked to provide blood samples for HIV testing. The blood samples were dried and transported to the National Reference Laboratory of the Ministry of Health and Sanitation at Lakka, where they were tested for the human immunodeficiency virus (HIV). 1.9 QUESTIONNAIRES Three types of questionnaires were administered for the 2008 SLDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. The contents of these questionnaires were based on the model questionnaires developed by the MEASURE DHS programme for use in countries with low levels of contraceptive use. The SSL, in collaboration with other stakeholders and ICF Macro staff, held a series of meetings to adapt the model questionnaires to the situation in Sierra Leone regarding relevant issues in population, family planning, HIV/AIDS, and other health issues in Sierra Leone. Given that there are many local languages in Sierra Leone—most of which have no accepted written script, and are not taught in the schools—and given that English is widely spoken, it was decided not to attempt to translate the questionnaires into vernaculars. However, many of the questions were ‘broken down’ to generate a list of key words and translated into the main languages using Roman script. A list with the key words was provided to each interviewer with suggestions for using it during data collection to standardize the translation; this aspect was emphasized during the main training. The household and individual questionnaires were pretested in February 2008. The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire also collected information on the characteristics of the household dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor and roof, ownership of various durable goods, and ownership and use of mosquito nets. The Household Questionnaire was also used to record height and weight measurements of women age 15- 49 and children under the age of 5 years, and women’s and men’s voluntary consent to give blood samples for testing. The HIV and anaemia testing procedures are described in detail in the next section. The Women’s Questionnaire was used to collect information from all women age 15-49 years and covered the following topics: • Background characteristics (education, residential history, media exposure, etc.) • Reproductive history and child mortality • Knowledge and use of family planning methods • Fertility preferences • Antenatal and delivery care 8 | Introduction • Breastfeeding and infant feeding practices • Vaccinations and childhood illnesses • Marriage and sexual activity • Woman’s work and husband’s background characteristics • Infant and child feeding practices • Awareness and behaviour about AIDS and other sexually transmitted infections (STIs) • Other health issues • Female genital cutting • Adult mortality including maternal mortality The Men’s Questionnaire was administered to all men age 15-59 living in every second household in the 2008 SLDHS sample. The Men’s Questionnaire collected much the same information found in the Women’s Questionnaire, but was shorter because it did not contain questions on reproductive history or maternal and child health and nutrition. 1.10 ANAEMIA AND HIV TESTING 1.10.1 Haemoglobin Testing Haemoglobin testing is the primary method of anaemia diagnosis. Reliable measures are obtained using the HemoCue system (Hb 201+). In half of the households selected for the 2008 SLDHS, men age 15-59, women age 15-49, and children age 6-59 months were tested for anaemia. A consent statement was read to all eligible respondents or to the parent or responsible adult for children and young women age 15-17. This statement explained the purpose of the test, informed them that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Before taking any blood, the finger was wiped with an alcohol swab and allowed to air dry. Then, the palm side of the end of a finger was punctured with a sterile, single-use, self-retracting lancet. A drop3 of blood was collected in a HemoCue microcuvette, which also serves as a measuring device, and placed in a HemoCue photometer where the results are displayed. An informative brochure was given to each household explaining what anaemia is, the symptoms, and measures people can take to prevent anaemia. Each person whose haemoglobin level was lower than the recommended cut-off point was given a written referral recommending immediate follow-up with a health professional. 1.10.2 HIV Testing All eligible women age 15-49 and men age 15-59 (in every second household) who were interviewed were asked to voluntarily provide three drops of blood for HIV testing. The protocol for the blood specimen collection and analysis was based on the anonymous linked protocol developed by the DHS programme and approved by ICF Macro’s Institutional Review Board. The protocol for the SLDHS was also reviewed and approved by the Sierra Leone National Ethics Committee on Bio- Medical Research. The protocol allows for the merging of the HIV results with the socio-demographic data collected in the individual questionnaires, provided that information which could potentially identify an individual is destroyed before the linking is effected. This requires that identification codes 3 From consenting adults, the blood was first collected for the HIV test, followed by the anaemia test. Introduction | 9 be deleted from the data file and that the back page of the Household Questionnaire, which contains the bar code labels and names of respondents, be destroyed prior to merging the HIV results with the individual data file. For the purposes of blood sample collection, to obtain informed consent for collecting blood for HIV testing, interviewers explained the procedures, the confidentiality of the data, the fact that test results could not be linked or made available to the subject, and informed respondents how they could establish their HIV status through voluntary counselling and testing (VCT) services. Interviewers then collected a dried blood spot sample on a filter paper card from a finger prick using a single-use, spring-loaded, sterile lancet. Each blood sample was given a bar code label, with a duplicate label attached to the Household Questionnaire on the line showing consent for that respondent. A third copy of the same bar code label was affixed to a Blood Sample Transmittal Form to track the blood sample from the field to the laboratory. The filter papers were dried overnight in a plastic drying box, after which they were packed in individual ziploc bags with desiccants and a humidity indicator card, then placed in a larger airtight bag for each sample point. Blood samples were periodically collected in the field along with the completed questionnaires and transported to SSL headquarters in Freetown to be logged in. After this, they were taken to the National Reference Laboratory of the Ministry of Health and Sanitation at Lakka Hospital for HIV testing. At the laboratory, the bar code labels on the dried blood spot samples were scanned into the computer using a programme specially developed by ICF Macro that pre-assigns to each sample a sequential number for ease in tracking. The blood spots were kept refrigerated or frozen depending on how long it would be until they could be tested. After the samples were allowed to attain room temperature, a circle—i.e., a completely filled and well-saturated spot without blood clot—at least 6.3 mm in diameter was taken from each filter paper using a hole punch. Each blot was placed into its pre-assigned well in the elution plate that contained 200 µl of phosphate buffered saline (PBS, pH 7.3- 7.4) and left in the refrigerator overnight at 2-8°C. These eluates were then diluted and tested with Vironostika HIV Uniform II Plus O (BioMerieux). All positive samples and 10 percent of negative samples were then tested with Murex HIV 1.2.O test kit (Abbott). Finally, any discordant samples were tested on Western Blot 2.2 (Abbott) to resolve the discrepancies. Prior to the survey, the National Reference Laboratory (NRL) had experience using its ELISA machine for testing for HIV. ICF Macro supplied the NRL staff with the necessary equipment and reagents. ICF Macro consultants visited and worked with the NRL staff and trained seven laboratory technicians in how to run the various tests and use the software. The HIV test results were merged with the individual questionnaire records after the questionnaires were destroyed and the cluster numbers scrambled. 1.11 TRAINING OF FIELD STAFF Two hundred qualified candidates were recruited for training by Statistics Sierra Leone to serve as supervisors, field editors, interviewers, bio-marker technicians, and quality control personnel. Efforts were made to recruit high-calibre personnel nationwide to ensure appropriate linguistic and cultural diversity. The main survey training was conducted by Statistics Sierra Leone during a four- week period from 17 March to 15 April, 2008. The training was conducted by senior staff from Statistics Sierra Leone, who participated in the pretest, with support from UNFPA, UNICEF, the Ministry of Health and Sanitation, and ICF Macro. Training consisted of lectures, demonstrations, practice interviews in small groups, and examinations. The last week of training provided instruction on how to take anthropometric measurements and the procedures for anaemia and HIV testing—how to administer informed consent, how to take blood spot samples, how to dry the filter papers, and how to pack them up the next morning. During the final week of training, participants had two days of field practice. The final day of training consisted of a session with the team supervisors and field editors to train them on how to supervise the fieldwork and how to edit completed questionnaires. 10 | Introduction 1.12 MAIN FIELDWORK (DATA COLLECTION) Fieldwork for the 2008 SLDHS took place over a two-month period from the end of April to the end of June 2008. Twenty-four teams carried out the data collection. Each team consisted of a team supervisor, one field editor, one bio-marker technician, two female interviewers, and one male interviewer. Senior DHS technical staff visited teams regularly to review the work and monitor data quality. Eight SSL staff and members of the Technical Committee coordinated fieldwork activities and visited the teams at regular intervals to monitor the work. The SSL Director in charge of the project, ICF Macro staff, and the DHS resident consultant monitored fieldwork in addition to SSL top management and the UN interagency team. 1.13 DATA PROCESSING The processing of the SLDHS results began shortly after fieldwork commenced. Completed questionnaires were returned regularly from the field to SSL headquarters in Freetown, where they were entered and edited by data processing personnel recruited and trained for this task. The data processing personnel included two supervisors, five office editors, 15 data entry editors, 23 data entry operators, and four secondary editors. Data were entered using the CSPro computer package. All data were entered twice for 100 percent verification. The concurrent processing of data was a distinct advantage for assessing data quality because SSL was able to advise field teams of errors detected during data entry. The data entry and editing phase of the survey was completed in October 2008. 1.14 RESPONSE RATES Table 1.1 shows response rates for the 2008 SLDHS. A total of 7,758 households were selected in the sample, of which 7,461 were found occupied at the time of the fieldwork. The shortfall is largely due to households that were away for an extended period of time and structures that were found to be vacant or destroyed. Of the existing households, 7,284 were successfully interviewed, yielding a household response rate of 98 percent. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Sierra Leone 2008 Result Residence Total Urban Rural Household interviews Households selected 3,184 4,574 7,758 Households occupied 3,068 4,393 7,461 Households interviewed 2,956 4,328 7,284 Household response rate1 96.3 98.5 97.6 Interviews with women age 15-49 Number of eligible women 3,385 4,460 7,845 Number of eligible women interviewed 3,160 4,214 7,374 Eligible women response rate2 93.4 94.5 94.0 Interviews with men age 15-59 Number of eligible men 1,559 1,982 3,541 Number of eligible men interviewed 1,403 1,877 3,280 Eligible men response rate2 90.0 94.7 92.6 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents In the households interviewed in the survey, a total of 7,845 eligible women were identified, of whom 7,374 were successfully interviewed, yielding a response rate of 94 percent. With regard to the male survey results, 3,541 eligible men were identified, of whom 3,280 were successfully interviewed, yielding a response rate of 93 percent. The response rates are lower in the urban than rural sample, especially for men. Introduction | 11 The principal reason for non-response among eligible men and women was the failure to find individuals at home despite repeated visits to the household, followed by refusal to be interviewed. The slightly lower response rate for men reflects the more frequent and longer absences of men from the households. Household Population and Housing Characteristics | 13 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 2.1 INTRODUCTION This chapter presents a description of the demographic and socio-economic characteristics of the population in households1 sampled and interviewed in the 2008 Sierra Leone Demographic and Health Survey (SLDHS). All usual residents and visitors were listed in the Household Questionnaire. The Household Questionnaire collected information on characteristics of the household population, such as age, sex, education, and survivorship of biological parents. This chapter also describes the characteristics of the household dwelling, including source of drinking water, availability of electricity, sanitation facilities, building materials, and possession of household durable goods. The information presented in this chapter is intended to facilitate the interpretation of key demographic, socio-economic, and health indicators presented later in this report. It is also intended to assist in the measurement of the representativeness of the survey sample. 2.2 HOUSEHOLD POPULATION BY AGE, SEX AND RESIDENCE Age and sex are the most important demographic variables upon which the needs and services of a population are based. Age and sex structure have a major impact on the population’s fertility, mortality, and nuptiality (marriage) patterns. Table 2.1 shows the percent distribution of the de facto household population by five-year age groups according to age, sex, and residence. The household population totals 41,608 persons, of which 49 percent are males and 51 percent are females. Just over two-thirds of the population live in rural areas. The population of Sierra Leone is youthful, with about 49 percent under 15 years of age, an indication of a population with high fertility. Approximately 36 percent of the population is age 15-49. Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Sierra Leone 2008 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 13.3 12.6 13.0 17.7 16.7 17.2 16.2 15.4 15.8 5-9 14.7 14.8 14.8 19.5 16.6 18.0 17.9 16.0 17.0 10-14 18.2 17.9 18.0 16.2 14.5 15.3 16.9 15.6 16.2 15-19 10.5 8.5 9.5 6.0 4.9 5.4 7.5 6.1 6.7 20-24 7.8 7.9 7.9 4.0 5.1 4.5 5.2 6.0 5.6 25-29 6.4 8.1 7.2 4.9 8.4 6.7 5.4 8.3 6.9 30-34 4.7 5.4 5.1 4.0 5.0 4.5 4.2 5.1 4.7 35-39 5.0 5.8 5.4 5.9 5.6 5.7 5.6 5.6 5.6 40-44 4.2 3.1 3.6 3.6 3.3 3.5 3.8 3.3 3.5 45-49 3.6 2.1 2.8 3.9 2.8 3.3 3.8 2.6 3.2 50-54 2.1 4.9 3.5 2.2 6.5 4.4 2.2 5.9 4.1 55-59 1.8 2.5 2.1 2.2 2.7 2.5 2.0 2.6 2.3 60-64 3.4 2.6 3.0 3.7 2.9 3.3 3.6 2.8 3.2 65-69 1.7 1.4 1.6 2.4 1.9 2.2 2.2 1.8 2.0 70-74 1.1 1.0 1.1 1.7 1.3 1.5 1.5 1.2 1.4 75-79 0.8 0.6 0.7 1.2 0.7 0.9 1.0 0.7 0.8 80 + 0.5 0.7 0.6 0.9 0.9 0.9 0.7 0.9 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 6,657 6,985 13,642 13,545 14,421 27,966 20,202 21,406 41,608 1 In this survey, a household is defined as a person or a group of persons, related or unrelated, who live together and share a common source of food and livelihood, and recognize one person as head. 14 | Household Population and Housing Characteristics Figure 2.1 shows the age and sex structure of the population. The population pyramid has a wide base, indicating that a large proportion of the population is made up of children under age 15. Figure 2.1 Population Pyramid Sierra Leone, 2008 80 + 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 Age 0246810 0 2 4 6 8 10 Percent Male Female 2.2.1 Household Composition Table 2.2 shows the composition of households in the survey. Overall, 22 percent of households are headed by females. Female-headed households are more common in urban than in rural areas (26 and 21 percent, respectively). The average household size in Sierra Leone is 5.9 persons. The household size is slightly larger in rural areas than in urban areas (6.0 persons, compared with 5.7 persons). Urban households are more likely than rural households to have just one or two members (13 percent, compared with 8 percent). Overall, one in six households (16 percent) have nine or more members. Almost four in ten households (39 percent) include children whose mother and father are not present (foster children), and 43 percent of households include foster children and/or orphans. Urban households are much more likely than rural households to have foster children (45 and 36 percent, respectively). Consequently, urban households are more likely than rural households to have foster children and/or orphans (49 and 41 percent, respectively). There are more households with single orphans than with double orphans (17 and 4 percent, respectively). Household Population and Housing Characteristics | 15 Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18 years of age, according to residence, Sierra Leone 2008 Characteristic Residence Total Urban Rural Household headship Male 74.3 79.3 77.6 Female 25.7 20.7 22.4 Total 100.0 100.0 100.0 Number of usual members 0 0.0 0.0 0.0 1 6.6 2.8 4.1 2 6.0 4.9 5.3 3 11.7 9.7 10.4 4 14.4 14.7 14.6 5 15.0 17.1 16.4 6 14.6 15.8 15.4 7 9.5 11.3 10.7 8 6.5 7.0 6.9 9+ 15.8 16.5 16.2 Total 100.0 100.0 100.0 Mean size of households 5.7 6.0 5.9 Percentage of households with orphans and foster children under 18 years of age Foster children1 45.0 35.6 38.8 Double orphans 5.0 3.5 4.0 Single orphans 18.3 15.9 16.8 Foster and/or orphan children 48.6 40.6 43.3 Number of households 2,469 4,815 7,284 Note: Table is based on de jure household members, i.e., usual residents. 1 Children under 18 years of age living in households with neither their mother nor their father present. 2.2.2 Children’s Living Arrangement and Orphanhood Detailed information on living arrangements and orphanhood for children under 18 years of age is presented in Table 2.3. Of the 22,280 children under age 18 reported in the 2008 SLDHS, about half live with both parents, 10 percent live with their mother only and their father is living, 9 percent live with their father only and their mother is living, and 26 percent live with neither of their natural parents although both parents are living. The table also provides information on type of orphanhood, that is, the proportion of children who have lost one or both parents. Eleven percent of children under 18 years of age have lost one parent, while 2 percent have lost both parents. 16 | H ou se ho ld P op ul at io n an d H ou sin g C ha ra ct er ist ic s T ab le 2 .3 C hi ld re n’ s liv in g ar ra ng em en ts a nd o rp ha nh oo d P er ce nt d ist rib ut io n of d e ju re c hi ld re n un de r 18 y ea rs o f ag e by li vi ng a rr an ge m en ts a nd s ur vi va l s ta tu s of p ar en ts , th e pe rc en ta ge o f ch ild re n no t liv in g w ith a b io lo gi ca l p ar en t, an d th e pe rc en ta ge o f c hi ld re n w ith o ne o r b ot h pa re nt s de ad , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Li vi ng w ith b ot h pa re nt s Li vi ng w ith m ot he r bu t n ot w ith fa th er Li vi ng w ith fa th er bu t n ot w ith m ot he r N ot li vi ng w ith e ith er p ar en t To ta l Pe rc en ta ge no t l iv in g w ith a bi ol og ic al pa re nt Pe rc en ta ge w ith o ne or b ot h pa re nt s de ad N um be r o f ch ild re n Fa th er al iv e Fa th er de ad M ot he r al iv e M ot he r de ad Bo th a liv e O nl y fa th er al iv e O nl y m ot he r al iv e Bo th d ea d In fo rm at io n m iss in g on fa th er o r m ot he r A ge 0- 4 62 .3 14 .1 2. 6 5. 2 0. 4 11 .3 0. 8 1. 0 0. 7 1. 7 10 0. 0 15 .4 5. 5 6, 70 9 < 2 68 .2 18 .7 3. 0 3. 0 0. 1 4. 1 0. 4 0. 6 0. 4 1. 5 10 0. 0 7. 1 4. 6 2, 69 1 2- 4 58 .4 11 .0 2. 3 6. 6 0. 7 16 .1 1. 1 1. 2 0. 9 1. 8 10 0. 0 21 .0 6. 2 4, 01 7 5- 9 51 .7 7. 7 3. 2 9. 2 1. 1 19 .6 1. 3 2. 7 1. 8 1. 7 10 0. 0 27 .1 10 .1 7, 14 3 10 -1 4 41 .4 7. 2 5. 0 11 .0 1. 9 21 .8 1. 5 4. 7 2. 9 2. 5 10 0. 0 33 .6 16 .1 6, 83 7 15 -1 7 36 .9 7. 8 6. 6 8. 8 2. 4 19 .9 1. 7 8. 1 3. 4 4. 5 10 0. 0 37 .5 22 .1 1, 59 1 S ex M al e 51 .8 9. 1 3. 6 9. 3 1. 5 16 .7 1. 1 3. 1 1. 8 2. 0 10 0. 0 24 .7 11 .2 11 ,3 42 Fe m al e 49 .6 9. 9 3. 9 7. 6 0. 9 18 .9 1. 4 3. 3 2. 0 2. 4 10 0. 0 28 .0 11 .6 10 ,9 38 R es id en ce U rb an 40 .4 13 .0 3. 5 8. 0 0. 9 22 .4 1. 5 4. 5 2. 7 3. 0 10 0. 0 34 .1 13 .2 7, 06 4 Ru ra l 55 .5 7. 8 3. 9 8. 7 1. 4 15 .7 1. 1 2. 6 1. 6 1. 8 10 0. 0 22 .7 10 .6 15 ,2 16 R e g io n Ea st er n 58 .0 9. 4 4. 0 6. 7 0. 9 13 .5 1. 0 2. 8 1. 8 1. 8 10 0. 0 21 .0 10 .6 3, 98 6 N or th er n 51 .0 8. 3 4. 3 9. 7 1. 4 16 .9 1. 1 3. 1 2. 0 2. 1 10 0. 0 25 .4 12 .1 10 ,4 21 So ut he rn 53 .1 9. 2 2. 4 8. 1 1. 2 19 .5 1. 1 2. 5 1. 4 1. 5 10 0. 0 26 .0 8. 6 4, 23 2 W es te rn 39 .1 13 .2 3. 8 7. 5 1. 1 23 .1 1. 9 4. 5 2. 3 3. 4 10 0. 0 35 .3 13 .7 3, 64 0 W ea lth q ui nt ile Lo w es t 56 .8 7. 0 4. 7 7. 4 1. 6 15 .0 1. 2 2. 4 1. 3 2. 6 10 0. 0 22 .5 11 .2 4, 34 5 Se co nd 53 .9 8. 7 3. 8 9. 7 1. 4 15 .3 1. 2 2. 5 1. 8 1. 7 10 0. 0 22 .5 10 .8 4, 63 2 M id dl e 55 .4 7. 6 3. 9 8. 4 1. 1 15 .8 1. 0 2. 9 2. 3 1. 6 10 0. 0 23 .6 11 .1 4, 65 7 Fo ur th 47 .2 11 .5 3. 8 8. 8 1. 1 19 .4 1. 1 3. 4 2. 0 1. 6 10 0. 0 27 .6 11 .5 4, 54 8 H ig he st 39 .0 12 .8 2. 6 8. 1 1. 0 24 .2 1. 7 5. 0 2. 1 3. 4 10 0. 0 36 .4 12 .6 4, 09 7 To ta l < 15 51 .8 9. 6 3. 6 8. 5 1. 1 17 .6 1. 2 2. 8 1. 8 2. 0 10 0. 0 25 .5 10 .6 20 ,6 89 To ta l < 18 50 .7 9. 5 3. 8 8. 5 1. 2 17 .8 1. 2 3. 2 1. 9 2. 2 10 0. 0 26 .3 11 .4 22 ,2 80 N ot e: T ab le is b as ed o n de ju re m em be rs , i .e ., us ua l r es id en ts . 16 | Household Population and Housing Characteristics Household Population and Housing Characteristics | 17 2.3 SCHOOL ATTENDANCE BY SURVIVORSHIP OF PARENTS AND BY ORPHANHOOD STATUS Children who are orphaned or live in a house with chronically ill adults may be at a greater risk of dropping out of school because of lack of money to pay school fees or the need to stay at home to care for the sick relative. The SLDHS included information to monitor such situations. Table 2.4 presents data on school attendance of children age 10-14 by parental survival according to background characteristics. The first panel of the table shows the proportion of children attending school whose parents are both dead and the proportion whose parents are both living and the child is residing with at least one parent. The last panel of the table compares school attendance of orphans and non-orphans. The overall ratio of school attendance of children whose parents are dead to those whose parents are living and the child resides with at least one parent is 0.62. This indicates that six in ten children whose parents are dead have access to school, compared with all children whose parents are living and the child resides with at least one parent. The gap in school attendance between children whose parents are living and children whose parents are dead is wider for girls, children in rural areas, and among children in the lower wealth quintiles. There are large differentials in the ratio by region. In the Eastern and Southern regions the ratio is less than 0.4, while in the Northern and Western regions it is 0.7. Table 2.4 also shows that 61 percent of orphans are attending school, compared with 74 percent of non-orphans. This brings the school attendance ratio of orphans to non-orphans to 0.83, which means that orphans are less likely to attend school compared with non-orphans. The disparity in school attendance between orphans and non-orphans is greater among girls, children in rural areas, and children in households in the lower wealth quintiles. The ratio also varies by region. In the Eastern and Southern regions the ratio is less than 0.8, while in the Northern and Western regions it is 0.84 and 0.87, respectively. Table 2.4 School attendance by survivorship of parents and by orphanhood status For de jure children 10-14 years of age, the percentage attending school by parental survival and by orphanhood status and the ratios of the percentages attending, by parental survival and orphanhood status according to background characteristics, Sierra Leone 2008 Background characteristic Percentage attending school by survivorship of parents Ratio1 Percentage attending school by orphanhood status Ratio2 Both parents dead Number Both parents living and child resides with at least one parent Number Orphan Non-orphan Percentage Number Percentage Number Sex Male 53.1 92 77.7 2,121 0.68 66.4 544 75.8 2,912 0.88 Female 42.4 109 74.3 1,951 0.57 56.2 556 71.9 2,824 0.78 Residence Urban 62.9 101 92.0 1,283 0.68 76.7 435 88.3 2,060 0.87 Rural 31.4 100 68.8 2,789 0.46 51.2 665 65.8 3,676 0.78 Region Eastern (28.2) 23 77.8 671 0.36 60.2 160 76.4 867 0.79 Northern 50.3 101 71.3 2,064 0.70 58.4 560 69.6 2,786 0.84 Southern (24.9) 33 72.2 696 0.35 48.6 149 67.6 1,007 0.72 Western 66.8 44 93.7 641 0.71 77.0 232 88.8 1,077 0.87 Wealth quintile Lowest * 22 50.8 716 0.39 39.5 186 49.7 939 0.79 Second (18.2) 40 70.8 874 0.26 50.9 221 67.0 1,146 0.76 Middle (51.9) 43 74.6 863 0.70 63.3 222 71.0 1,139 0.89 Fourth (57.4) 56 88.1 879 0.65 65.8 251 82.8 1,237 0.79 Highest (72.2) 40 94.1 740 0.77 82.8 221 91.6 1,275 0.90 Total 47.3 201 76.1 4,072 0.62 61.2 1,101 73.8 5,736 0.83 Note: Table is based only on children who usually live in the household. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. 1 Ratio of the percentage with both parents dead to the percentage with both parents living and child resides with at least one parent 2 Ratio of the percentage for orphans to the percentage for non-orphans 18 | Household Population and Housing Characteristics 2.4 EDUCATION OF THE HOUSEHOLD POPULATION Education is a key determinant of the lifestyle and status an individual enjoys in a society. Studies have consistently shown that educational attainment has a strong effect on health behaviours and attitudes. In general, the higher the level of education a woman has attained, the more knowledgeable she is about the use of health facilities, family planning methods, and the health of her children. Results from the 2008 SLDHS can be used to look at educational attainment and current school attendance among household members. Sierra Leone’s education system has been unstable for more than 10 years because of the civil crisis; however, a major restructuring of the infrastructure and educational programme is being undertaken by the government. The government of Sierra Leone has adopted a policy of free primary education in all government schools for all children. The government is undertaking massive renovation of infrastructure damaged during the war, and it is revising and expanding programmes in the educational system. For purposes of this analysis, age six is used as the age for entry into the primary level. Because of the war, however, many children who should have started school when they reached school-going age never got to start school. Officially, primary school consists of six years of education; junior secondary school and senior secondary school each consist of three years of education. Tables 2.5.1 and 2.5.2 show the percent distribution of the female and male household population age six years and over by the highest level of schooling attended or completed, and the median grade completed, according to background characteristics. Overall, 58 percent of women and 46 percent of men have no education. Only one in four women (25 percent) and 28 percent of men have some primary education. Men are almost twice as likely as women to have attended secondary school (22 and 12 percent, respectively). Age is negatively associated with education attainment; younger people are more likely to have received education than older people. While 41 percent of girls and 43 percent of boys age 6-9 have no education, for women age 25 or older the proportion is 70 percent or higher, and for men age 25 or older the proportion is 54 percent or higher. Tables 2.5.1 and 2.5.2 show that younger people are more likely to be educated than older people. Whereas about 57 percent of girls age 6-14 years have some primary education, the corresponding proportions for women age 15-19 and 20-24 are 21 and 12 percent, respectively. The proportion is even lower for older women. The same pattern is observed for men. Household Population and Housing Characteristics | 19 Table 2.5.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 40.6 57.5 0.3 0.2 0.0 0.0 1.4 100.0 2,883 0.0 10-14 26.0 57.4 5.3 10.5 0.0 0.1 0.7 100.0 3,333 2.3 15-19 33.8 21.1 8.7 34.9 0.4 0.3 0.9 100.0 1,299 4.4 20-24 57.3 12.0 2.6 20.1 3.4 3.3 1.4 100.0 1,287 0.0 25-29 73.1 8.8 2.2 9.3 1.7 3.4 1.5 100.0 1,781 0.0 30-34 70.2 7.4 3.4 11.7 2.6 3.6 1.1 100.0 1,098 0.0 35-39 74.8 6.2 3.6 10.1 1.7 2.2 1.4 100.0 1,207 0.0 40-44 74.7 5.5 2.8 10.2 2.4 3.0 1.3 100.0 699 0.0 45-49 80.1 4.7 3.0 8.4 0.9 1.6 1.3 100.0 554 0.0 50-54 85.3 1.9 1.9 5.6 1.0 1.4 2.9 100.0 1,271 0.0 55-59 88.2 2.1 0.9 3.0 0.9 1.7 3.2 100.0 564 0.0 60-64 90.1 1.8 1.8 1.9 1.1 1.2 2.2 100.0 603 0.0 65+ 93.1 0.9 0.7 1.0 0.2 0.7 3.4 100.0 964 0.0 Residence Urban 37.0 28.6 5.0 21.4 2.8 3.9 1.3 100.0 5,946 1.9 Rural 68.8 23.5 2.0 3.8 0.1 0.1 1.6 100.0 11,612 0.0 Region Eastern 61.5 27.0 2.9 6.6 0.2 0.5 1.3 100.0 3,082 0.0 Northern 64.6 24.9 2.4 5.7 0.2 0.3 1.8 100.0 7,747 0.0 Southern 64.4 23.4 2.9 7.0 0.4 0.7 1.2 100.0 3,489 0.0 Western 32.2 26.3 5.0 25.3 4.5 5.5 1.3 100.0 3,239 3.3 Wealth quintile Lowest 77.5 17.0 1.2 2.1 0.0 0.0 2.2 100.0 3,390 0.0 Second 68.0 25.4 1.8 3.2 0.0 0.1 1.6 100.0 3,528 0.0 Middle 65.7 26.1 2.5 4.6 0.1 0.1 1.0 100.0 3,426 0.0 Fourth 53.0 29.2 4.2 11.0 0.5 0.8 1.3 100.0 3,562 0.0 Highest 28.0 28.2 5.4 26.8 4.3 5.8 1.4 100.0 3,652 3.7 Total 58.0 25.2 3.1 9.7 1.0 1.4 1.5 100.0 17,558 0.0 Note: Total includes 16 women with information missing on age 1 Completed grade 6 at the primary level 2 Completed grade 3 at the senior secondary school level More than two-thirds (69 percent) of women in the rural areas have no education and only about one-quarter (24 percent) have some primary education. The situation is worse for secondary education; only about 4 percent of women in rural areas have some secondary education. This pattern is seen across all regions except in the Western Region, where 25 percent of women have some secondary education, and 10 percent have completed secondary education. 20 | Household Population and Housing Characteristics Table 2.5.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 43.4 54.5 0.1 0.2 0.0 0.0 1.9 100.0 3,061 0.0 10-14 21.8 59.1 6.3 11.8 0.0 0.0 1.0 100.0 3,412 2.7 15-19 23.1 23.0 6.7 45.1 0.7 0.5 0.8 100.0 1,507 5.3 20-24 33.1 9.4 3.4 42.4 7.1 4.1 0.7 100.0 1,058 6.5 25-29 53.7 8.4 2.7 20.7 6.5 6.5 1.5 100.0 1,082 0.0 30-34 55.7 9.7 4.0 15.6 4.5 8.7 1.8 100.0 852 0.0 35-39 58.9 8.4 3.9 18.0 3.8 6.3 0.7 100.0 1,141 0.0 40-44 55.2 6.2 2.4 19.4 7.5 8.3 0.9 100.0 768 0.0 45-49 63.7 8.2 2.3 15.2 4.0 5.5 1.1 100.0 767 0.0 50-54 60.9 5.0 2.6 17.0 5.8 7.5 1.2 100.0 440 0.0 55-59 63.8 6.9 2.8 12.9 6.0 5.6 2.0 100.0 414 0.0 60-64 78.4 1.8 2.4 8.6 2.4 4.5 2.0 100.0 734 0.0 65+ 85.4 3.1 0.9 4.9 1.4 2.6 1.8 100.0 1,108 0.0 Residence Urban 23.8 27.7 5.0 29.3 5.7 7.3 1.2 100.0 5,641 4.6 Rural 57.2 28.4 2.5 8.9 0.8 0.8 1.4 100.0 10,720 0.0 Region Eastern 51.5 28.5 3.6 12.6 1.4 1.5 0.9 100.0 2,866 0.0 Northern 50.1 30.2 3.2 12.2 1.1 1.2 1.9 100.0 7,122 0.0 Southern 54.1 26.9 2.2 12.7 1.5 1.8 0.8 100.0 3,335 0.0 Western 20.6 24.3 4.9 31.4 7.8 10.1 0.9 100.0 3,038 5.8 Wealth quintile Lowest 69.2 22.4 1.8 4.3 0.2 0.1 2.1 100.0 3,191 0.0 Second 57.2 31.0 2.1 7.6 0.5 0.2 1.3 100.0 3,233 0.0 Middle 50.7 31.7 3.1 11.5 1.1 0.8 1.3 100.0 3,203 0.0 Fourth 35.7 32.3 4.8 21.3 2.5 2.5 0.9 100.0 3,258 1.8 Highest 18.2 23.7 4.9 33.5 7.8 10.9 1.0 100.0 3,477 6.2 Total 45.7 28.2 3.4 16.0 2.5 3.0 1.3 100.0 16,361 0.1 Note: Total includes 19 men with information missing on age 1 Completed grade 6 at the primary level 2 Completed grade 3 at the senior secondary school level There are differentials in education attainment by urban-rural residence. In general, urban residents have higher levels of education than rural residents. For instance, the median years of schooling completed for urban women and men are two and five years, respectively, whereas for rural women and men, the corresponding proportions are zero years. As expected, men and women in the Western Region (which includes Freetown, the capital) are better educated than their counterparts in the other regions. As expected, educational attainment is highly correlated with household wealth. The proportion of women with no education increases from 28 percent among those in the highest quintile to 78 percent among those in the lowest wealth quintile, and only 2 percent women in the lowest quintile have at least some secondary education, compared with 27 percent of women in the highest quintile. Similarly, only 4 percent of men in the lowest quintile have at least some secondary education, compared with 34 percent of men in the highest quintile. Figure 2.2 shows the educational attainment of women and men in the 2008 SLDHS. Household Population and Housing Characteristics | 21 Figure 2.2 Age-specific Attendance Rates for the de facto Population Age 5-24 Sierra Leone, 2008 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Female Male 2.5 SCHOOL ATTENDANCE RATIOS Table 2.6 presents net attendance ratios (NARs) and gross attendance ratios (GARs) for the household population by level of schooling and sex, according to background characteristics The NAR for primary school measures the proportion of children of primary school age who are attending primary school, while the GAR represents the total number of primary school pupils age 5-24 as a percentage of children of primary school age. In Sierra Leone, the levels refer to 6-11 years for primary and 12-17 years for secondary. The GAR is usually higher than the NAR because the GAR includes participation of those who may be older or younger than the official age range for that level. Pupils who are over age for a given level of school may have started school late, may have repeated one or more classes in school, or may have dropped out of school and later returned. The NAR indicates that 62 percent of children of primary school age are attending primary school. The NARs for primary school are higher in urban (76 percent) than in the rural areas (56 percent), and highest in the Western Region (79 percent). The NAR in other regions ranges from 57 percent in the Northern Region to 63 percent in the Eastern Region. The GAR indicates that overall, there are children in primary school who are not of primary school age, with ratios of 92 for males and 93 for females. The Gender Parity Index (GPI) shows the ratio of female to male GARs. The overall GPI at the primary level is about 1.00, which indicates equality in the participation rates for males and females in primary school. At the primary school level, the (GPI) varies slightly across subgroups. At the secondary level, the overall GPI is 0.67. GPI is higher in urban (0.73) than in rural areas (0.55) and ranges from 0.57 in the Northern Region to 0.74 in the Western Region. 22 | Household Population and Housing Characteristics Table 2.6 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Sierra Leone 2008 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index (GPI)3 Male Female Total Gender Parity Index (GPI)3 PRIMARY SCHOOL Residence Urban 75.7 76.4 76.1 1.01 114.9 113.0 113.9 0.98 Rural 54.5 56.5 55.5 1.04 83.4 83.3 83.3 1.00 Region Eastern 61.4 64.5 63.0 1.05 93.6 96.5 95.1 1.03 Northern 56.2 56.9 56.5 1.01 87.6 85.8 86.8 0.98 Southern 58.9 64.0 61.3 1.09 87.5 87.9 87.7 1.00 Western 79.9 78.1 78.7 0.99 117.1 116.1 116.6 0.99 Wealth quintile Lowest 43.9 42.7 43.3 0.97 66.6 62.6 64.7 0.94 Second 54.8 60.3 57.4 1.10 85.0 85.8 85.4 1.01 Middle 58.8 60.3 59.5 1.03 90.4 88.7 89.6 0.98 Fourth 72.2 70.4 71.3 0.97 108.7 107.9 108.3 0.99 Highest 79.4 80.7 80.1 1.02 120.2 119.1 119.6 0.99 Total 60.6 62.9 61.7 1.04 92.4 92.8 92.6 1.00 SECONDARY SCHOOL Residence Urban 48.1 43.4 45.8 0.90 93.0 67.7 80.5 0.73 Rural 19.2 12.7 16.0 0.66 31.7 17.3 24.7 0.55 Region Eastern 23.5 20.6 22.1 0.87 47.5 33.4 40.5 0.70 Northern 27.9 18.8 23.6 0.68 48.2 27.7 38.5 0.57 Southern 18.5 19.7 19.1 1.07 42.5 28.8 35.6 0.68 Western 52.3 45.0 48.5 0.86 91.4 67.9 79.4 0.74 Wealth quintile Lowest 10.7 8.3 9.6 0.78 17.7 11.9 15.0 0.67 Second 15.4 9.7 12.7 0.63 25.8 13.6 20.0 0.53 Middle 22.6 17.2 20.0 0.76 37.4 23.0 30.4 0.61 Fourth 35.8 27.5 31.7 0.77 70.3 41.5 56.0 0.59 Highest 56.7 48.8 52.7 0.86 105.0 76.4 90.6 0.73 Total 30.6 25.1 27.9 0.82 56.0 37.8 47.1 0.67 1 The NAR for primary school is the percentage of the primary-school-age (6-11 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (12-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary- school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100.0. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. 2.6 GRADE REPETITION AND DROP-OUT RATE Repetition and drop-out rates describe the flow of pupils through the educational system in Sierra Leone. Repetition rates indicate the percentage of pupils who attended a particular class during the 2006-2007 academic year who attended the same class again during the 2007-2008 academic year. Drop-out rates show the percentage of pupils who attended class during the 2006-2007 academic year but did not attend school the following year. Repetition and drop-out rates approach zero when pupils nearly always progress to the next grade at the end of the school year. Repetition and drop-out rates often vary across grades, indicating points in the school system where pupils are not regularly promoted to the next grade or they decide to drop out of school. Household Population and Housing Characteristics | 23 Table 2.7 shows the repetition and drop-out rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics. The repetition rate declines from 5 percent in grade 1 to 2 percent in grade 5, then rises to 3 percent in grade 6. There are small variations by gender and urban-rural residence; however, larger differentials are observed by region, especially in grade 1. While 9 percent of students in the Eastern Region repeat grade 1, only 2 percent of first graders in the Northern Region repeat the grade. Drop- out rates vary less than repetition rates; in all grades the drop-out rate is around 1 percent. Table 2.7 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics, Sierra Leone 2008 Background characteristic School grade 1 2 3 4 5 6 REPETITION RATE1 Sex Male 4.4 3.1 1.3 2.9 2.1 3.0 Female 5.1 2.9 3.2 2.4 1.6 3.7 Residence Urban 3.7 3.3 2.0 1.6 2.4 3.4 Rural 5.2 2.9 2.5 3.4 1.5 3.2 Region Eastern 9.2 1.7 3.4 3.5 2.5 5.0 Northern 2.2 4.0 1.2 3.4 1.5 1.5 Southern 5.6 2.3 4.6 1.8 2.2 8.5 Western 5.0 2.6 2.3 1.1 2.0 2.9 Wealth quintile Lowest 7.6 2.4 2.1 5.6 2.0 3.6 Second 4.2 3.1 2.7 3.6 1.9 4.1 Middle 3.0 4.7 3.1 2.0 0.7 3.2 Fourth 5.6 1.7 1.5 2.4 2.6 3.5 Highest 4.0 3.1 2.1 1.5 2.0 2.8 Total 4.7 3.0 2.3 2.7 1.9 3.3 DROPOUT RATE2 Sex Male 0.8 0.5 0.8 1.1 1.8 0.8 Female 1.2 0.8 1.3 0.9 1.9 2.0 Residence Urban 0.7 0.3 0.5 0.3 1.7 0.6 Rural 1.1 0.9 1.4 1.5 2.0 2.2 Region Eastern 1.5 1.6 0.6 1.9 0.2 2.7 Northern 1.1 0.5 1.5 1.5 2.0 1.8 Southern 0.2 0.0 0.0 0.0 2.7 0.0 Western 1.1 0.8 1.2 0.3 2.2 0.0 Wealth quintile Lowest 1.3 1.9 0.0 4.2 1.8 0.9 Second 1.1 0.3 2.1 1.1 3.5 7.4 Middle 1.6 0.9 1.4 0.7 0.7 1.5 Fourth 0.3 0.4 0.6 0.8 1.9 0.5 Highest 0.9 0.3 0.9 0.3 1.4 0.4 Total 1.0 0.7 1.1 1.0 1.9 1.3 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school in the current school year. 2.7 HOUSEHOLD DRINKING WATER To assess the socio-economic conditions under which the population lives, respondents were asked to give specific information about their household environment. The 2008 SLDHS collected information about drinking water, including the source, time taken to collect water, persons who 24 | Household Population and Housing Characteristics usually collect the water, and any water treatment prior to drinking. The source of drinking water is an indicator of whether or not the water is suitable for drinking. Sources of water believed to be relatively free of disease are improved sources such as piped water into dwelling/yard/plot; public taps/standpipes, tube wells or bore holes, protected dug wells, protected spring, and rainwater. Non- improved sources, like unprotected dug wells, unprotected springs, and surface water are more likely to have disease-causing agents that have a negative impact on health. Table 2.8 presents information on the drinking water of households in the 2008 SLDHS. More than half (51 percent) of households obtain drinking water from improved sources: 22 percent from protected dug wells and 14 percent from public taps/standpipes. Similar proportions are seen for the population; half of the population obtains drinking water from an improved source: 23 percent from protected dug wells and 13 percent from public taps. There is a substantial difference in access to improved water sources between urban and rural households. More than four-fifths (83 percent) of urban households have access to improved sources of water, compared with 34 percent of rural households. The most common source of water in rural areas is surface water (40 percent), while in urban areas 28 percent of households obtain water from protected dug wells, 27 percent from public stand pipes, and 20 percent have water piped into their dwelling or yard. Only 13 percent of households in Sierra Leone have water on their premises. More than half of households take less than 30 minutes to get water, while 29 percent require 30 minutes or more to obtain drinking water. Urban households are much more likely than rural households to have the water close to home; 30 percent of urban households have the water source on their premises, compared with 4 percent of households in rural areas. Water is most often collected by adult female household members (57 percent), followed by female children under age 15 (14 percent). This pattern is more typical in rural areas (68 percent) than in urban areas (36 percent). Nine in ten households do not treat water prior to drinking. The most popular way to treat water is by adding bleach or chlorine (6 percent). Urban households are more likely than rural households to treat the water; 14 percent of households in urban areas use appropriate treatment of water, compared with 4 percent of households in rural areas. Household Population and Housing Characteristics | 25 Table 2.8 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and de jure population by treatment of drinking water, according to residence, Sierra Leone 2008 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 82.9 34.3 50.8 81.3 35.1 50.3 Piped water into dwelling/yard/plot 20.4 1.0 7.6 19.3 1.0 7.1 Public tap/standpipe 26.5 7.1 13.7 24.3 6.9 12.7 Tube well or borehole 6.3 6.4 6.4 5.9 6.3 6.2 Protected dug well 28.0 18.8 21.9 30.1 19.9 23.3 Protected spring 1.6 0.9 1.1 1.6 0.9 1.2 Non-improved source 16.1 65.5 48.7 18.0 64.6 49.2 Unprotected dug well 9.4 15.3 13.3 10.8 15.1 13.7 Unprotected spring 2.6 9.5 7.1 2.8 9.0 6.9 Tanker truck/cart with small tank 0.1 0.4 0.3 0.1 0.4 0.3 Surface water 4.0 40.2 27.9 4.3 40.1 28.3 Bottled water, improved source for cooking/ washing1 0.6 0.1 0.2 0.4 0.1 0.2 Bottled water, non- improved source for cooking/washing1 0.2 0.0 0.1 0.1 0.0 0.0 Missing 0.2 0.2 0.2 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 83.4 34.4 51.0 81.7 35.2 50.5 Time to obtain drinking water (round trip) Water on premises 30.3 4.0 13.0 30.7 4.5 13.1 Less than 30 minutes 32.9 60.5 51.2 33.0 58.5 50.1 30 minutes or longer 33.1 26.8 28.9 32.0 28.2 29.5 Don’t know/missing 3.7 8.7 7.0 4.2 8.7 7.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 35.5 68.0 57.0 35.6 68.2 57.5 Adult male 15+ 14.0 6.0 8.7 10.7 3.9 6.2 Female child under age 15 11.9 14.7 13.7 14.2 16.0 15.4 Male child under age 15 6.2 6.0 6.0 6.6 6.2 6.3 Other 1.5 0.8 1.0 1.4 0.6 0.8 Water on premises 30.3 4.0 13.0 30.7 4.5 13.1 Missing 0.7 0.6 0.6 0.7 0.6 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 1.6 0.2 0.7 1.5 0.2 0.6 Bleach/chlorine 11.1 2.8 5.6 12.9 2.9 6.2 Strained through cloth 2.2 0.9 1.4 2.1 0.9 1.3 Ceramic, sand or other filter 0.7 0.2 0.4 1.1 0.3 0.6 Solar disinfection 0.0 0.1 0.0 0.0 0.0 0.0 Other 1.3 1.2 1.2 1.2 1.1 1.1 No treatment 83.3 92.9 89.7 81.5 92.7 89.0 Percentage using an appropriate treatment method3 14.4 4.2 7.6 16.1 4.2 8.2 Number 2,469 4,815 7,284 14,104 28,701 42,805 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 2.8 SANITATION FACILITIES Poor sanitation coupled with unsafe water sources increases the risk of water-borne diseases and illnesses due to poor hygiene. Studies have shown that the absence of proper toilet facilities and improper disposal of faecal material increases exposure to the risk of diseases like dysentery, diarrhoea, and typhoid fever. Members of households with improved sanitation facilities are less likely to contract these communicable diseases. Table 2.9 shows that overall, 11 percent of households have improved, not shared toilet facility. Urban households are much more likely than rural households to have this type of facility (21 26 | Household Population and Housing Characteristics and 6 percent, respectively). The most common toilet facility is the open pit (29 percent), which is much more likely to be used in rural areas (35 percent) than in urban areas (15 percent). Overall, one in four households have no toilet facilities, 33 percent in rural areas and 5 percent in urban areas. Table 2.9 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Sierra Leone 2008 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 21.4 5.8 11.1 26.1 6.5 13.0 Flush/pour flush to piped sewer system 0.1 0.0 0.0 0.3 0.0 0.1 Flush/pour flush to septic tank 7.6 0.1 2.6 8.0 0.1 2.7 Flush/pour flush to pit latrine 1.3 0.0 0.5 1.3 0.0 0.5 Ventilated improved pit (VIP) latrine 5.1 2.2 3.2 6.5 2.3 3.7 Pit latrine with slab 7.3 3.5 4.8 10.0 4.1 6.0 Non-improved facility 78.6 94.2 88.9 73.9 93.5 87.0 Any facility shared with other households 52.5 21.8 32.2 47.9 21.8 30.4 Flush/pour flush not to sewer/septic tank/ pit latrine 0.8 0.0 0.3 0.6 0.0 0.2 Pit latrine without slab/open pit 15.3 35.2 28.5 16.1 37.5 30.5 Bucket 0.4 0.1 0.2 0.4 0.1 0.2 Hanging toilet/hanging latrine 2.8 3.0 2.9 2.7 3.0 2.9 No facility/bush/field/stream/river 4.9 33.2 23.6 4.6 30.1 21.7 Other 0.6 0.3 0.4 0.5 0.3 0.4 Missing 1.3 0.6 0.9 1.2 0.7 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,469 4,815 7,284 14,104 28,701 42,805 2.9 OTHER HOUSEHOLD CHARACTERISTICS Table 2.10 provides information on other characteristics of household dwellings, such as access to electricity, construction materials used for the floor, number of rooms used for sleeping, and cooking practices. Only 12 percent of households in Sierra Leone have access to electricity for lighting, with a very large disparity between urban and rural households (33 and 1 percent, respectively) (Table 2.10). The type of flooring material in the dwelling can be viewed as an indicator of the quality of housing, a dimension of wealth, as well as an indicator of health risk. Floor materials like earth, sand, and animal dung pose a health problem because they can act as breeding grounds for pests and may be a source of dust. They are also more difficult to keep clean. Table 2.10 shows that over 61 percent of households have floors made of earth, sand, or animal dung. In general, rural households have poorer quality floors than urban households; 81percent of rural households have earth, sand or dung floors, compared with only 22 percent of the urban households. On the other hand, urban households are more likely to have cement, tile, carpet, or wooden floors (75 percent), compared with rural households (17 percent). The number of rooms used for sleeping gives an indication of the extent of crowding in households. Overcrowding increases the risks of contracting infectious diseases like acute respiratory infections and skin diseases, especially among children. In the survey, a room in which three or more persons sleep is considered to be over crowded. Overall, more than half (52 percent) of the households have three or more rooms for sleeping. Households in rural areas are more likely than urban households to have three or more rooms for sleeping (58 and 39 percent, respectively). Cooking is commonly done outdoors (58 percent) or in a separate building (35 percent). This is observed in both urban and rural areas. Eight in ten households use wood for cooking. While almost all households (97 percent) in rural areas use wood for cooking, 56 percent of urban households use wood and 39 percent use charcoal. Use of solid fuels for cooking is almost universal in Sierra Leone (99 percent). Household Population and Housing Characteristics | 27 The 2008 SLDHS shows that 91 percent of the households that use solid fuel cook without a chimney or hood; 86 percent in urban areas and 94 percent in rural areas. An open fire or stove with hood is used in 6 percent of households. Urban households are more likely than rural households to use an open fire or stove with hood (11 and 3 percent, respectively). Table 2.10 Household characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Sierra Leone 2008 Housing characteristic Households Population Urban Rural Total Urban Rural Total Electricity Yes 33.1 1.4 12.1 31.0 1.3 11.1 No 66.8 98.5 87.8 68.9 98.6 88.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 19.8 74.7 56.1 20.1 74.2 56.3 Dung 2.1 6.0 4.7 2.0 6.0 4.7 Stone 2.1 2.6 2.4 1.9 2.3 2.2 Wood/planks/palm/bamboo/ parquet or polished wood 0.7 0.2 0.3 0.7 0.2 0.3 Ceramic tiles 7.8 0.3 2.9 9.0 0.3 3.2 Cement 65.4 16.2 32.9 64.7 17.0 32.7 Carpet 1.5 0.0 0.5 1.2 0.0 0.4 Other 0.4 0.0 0.1 0.2 0.0 0.1 Missing 0.2 0.1 0.1 0.2 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 31.3 14.7 20.3 19.9 9.0 12.6 Two 28.4 26.3 27.0 26.9 22.4 23.9 Three or more 39.0 58.0 51.6 51.8 67.4 62.3 Missing 1.3 1.0 1.1 1.4 1.2 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 6.4 4.5 5.2 5.9 4.1 4.7 In a separate building 35.2 35.5 35.4 40.1 36.5 37.7 Outdoors 54.8 58.9 57.5 52.6 58.7 56.7 Other 0.2 0.2 0.2 0.1 0.1 0.1 Missing 3.5 0.9 1.8 1.3 0.6 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.1 0.0 0.0 0.0 0.0 0.0 Kerosene 0.4 0.1 0.2 0.2 0.1 0.1 Coal/lignite 1.5 0.0 0.5 1.3 0.0 0.4 Charcoal 38.9 1.2 14.0 35.2 1.2 12.4 Wood 56.0 97.2 83.2 62.4 97.6 86.0 Straw/shrubs/grass 0.1 0.9 0.6 0.1 0.8 0.6 Other fuel 0.1 0.0 0.1 0.0 0.0 0.0 No food cooked in household 2.6 0.3 1.1 0.7 0.1 0.3 Missing 0.2 0.2 0.2 0.2 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 96.5 99.4 98.4 98.9 99.7 99.4 Number of households 2,469 4,815 7,284 14,104 28,701 42,805 Type of fire/stove among households using solid fuel1 Closed stove with chimney 0.7 0.1 0.3 0.6 0.2 0.3 Open fire/stove with chimney 0.8 0.7 0.8 1.0 0.8 0.9 Open fire/stove with hood 11.1 3.0 5.7 9.7 3.1 5.3 Open fire/stove without chimney or hood 86.1 93.8 91.3 87.4 93.7 91.6 Other 0.2 0.9 0.7 0.1 0.9 0.6 Missing 1.2 1.4 1.3 1.1 1.4 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/ population using solid fuel 2,383 4,787 7,171 13,945 28,618 42,563 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 28 | Household Population and Housing Characteristics 2.10 HOUSEHOLD DURABLE GOODS Information was collected in the 2008 SLDHS on the availability of household durable goods such as household effects, means of transportation, and ownership of agricultural land and farm animals. Table 2.11 shows that 55 percent of households own a radio, 28 percent own a mobile telephone, 10 percent own a television set, and 6 percent own a refrigerator. Urban households are much more likely than rural households to own these goods. For instance, 78 percent of urban households own a radio, compared with 43 percent of rural households. Mobile telephones are available in 64 percent of households in urban areas and 10 percent of rural households. While 28 percent of urban households have a television set, this item is almost non-existent in rural areas (less than 1 percent). Eleven percent of households own a bicycle. Bicycles are the most common means of transportation and are owned almost equally by rural and urban households (11 and 10 percent, respectively). Urban households are three times more likely than rural households to own a motorcycle/scooter (6 and 2 percent, respectively). Sixty percent of households own agricultural land and 50 percent have farm animals. Table 2.11 shows that rural households are almost four times as likely to own agricultural land as urban households (80 and 22 percent, respectively). Similarly, 59 percent of rural households own farm animals, compared with 33 percent of urban households. Table 2.11 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Sierra Leone 2008 Possession Households Population Urban Rural Total Urban Rural Total Household effects Radio 78.2 43.2 55.1 79.6 45.6 56.8 Television 27.9 0.9 10.1 27.5 1.1 9.8 Mobile telephone 63.5 9.9 28.1 67.3 11.1 29.6 Non-mobile telephone 2.3 0.1 0.8 2.2 0.1 0.8 Refrigerator 16.8 0.3 5.9 17.1 0.3 5.8 Means of transport Bicycle 10.1 10.7 10.5 12.4 12.6 12.5 Animal drawn cart 0.4 0.1 0.2 0.3 0.1 0.2 Motorcycle/scooter 6.4 1.6 3.3 7.8 2.1 4.0 Car/truck 4.6 0.4 1.8 5.0 0.5 2.0 Boat with a motor 0.6 1.0 0.9 0.6 1.0 0.9 Ownership of agricultural land 22.2 79.5 60.1 27.0 81.6 63.6 Ownership of farm animals1 32.5 58.6 49.8 39.4 61.8 54.4 Number 2,469 4,815 7,284 14,104 28,701 42,805 1 Cattle, cows, bulls, horses, donkeys, mules, pigs, goats, sheep, rabbits, fowl, rodents for breed or birds for sale 2.11 WEALTH QUINTILES The 2008 SLDHS provided an opportunity to obtain information about the distribution of Sierra Leone’s population by wealth quintiles. Table 2.12 shows the percent distribution of the jure population by wealth quintiles, according to residence and region. It is not surprising that more than half of urban residents (56 percent) live in households that are in the highest wealth quintile, compared with only 2 percent of the rural population; 56 percent of residents in rural households are in the two lowest quintiles. Table 2.12 also shows that three in four residents of the Western Region (which includes Freetown, the capital) are in the highest quintile, while three in four residents of the other regions are in the three lowest quintiles. Household Population and Housing Characteristics | 29 Table 2.12 Wealth quintiles Percent distribution of the jure population by wealth quintiles, according to residence and region, Sierra Leone 2008 Residence/region Wealth quintile Total Number of population Lowest Second Middle Fourth Highest Residence Urban 2.0 4.4 9.2 28.4 56.0 100.0 14,104 Rural 28.8 27.6 25.3 15.9 2.3 100.0 28,701 Region Eastern 24.1 21.9 23.8 20.0 10.2 100.0 7,878 Northern 19.4 25.2 26.3 21.9 7.2 100.0 18,730 Southern 34.9 24.0 17.1 16.3 7.7 100.0 8,531 Western 0.7 0.9 3.9 19.5 75.0 100.0 7,667 Total 20.0 20.0 20.0 20.0 20.0 100.0 42,805 2.12 BIRTH REGISTRATION According to the 2007 Child Rights Act of Sierra Leone, parents are required to give their children a name and to register the child because the child has a right to know who his or her parents are and to have a nationality through registration (SLG, 2007). The birth registration policy in Sierra Leone is being reviewed to ensure that parents and caretakers of children take responsibility for ensuring this child right. Table 2.13 shows the percentage of children under five years of age by registration status. Just over half (51 percent) of children were reported to have been registered; 31 percent have a birth certificate and 20 percent did not. Coverage of birth registration varies little by the child’s age and sex, but varies widely across regions, with the Western Re- gion reporting the highest coverage (61 per- cent) and the Northern Region reporting the lowest coverage (42 percent). In the Eastern and Southern regions, the proportions are 56 and 59 percent, respectively. Births in urban areas are more likely than those in rural areas to be registered (59 and 48 percent, respectively). There is a positive relationship between wealth status and birth registration, with birth registration increasing with wealth quintile. Forty-three percent of births in the lowest wealth quintile are registered, compared with 62 percent of births in the highest quintile. 2.13 CHILD LABOUR Sierra Leone is a signatory to the Convention on the Rights of the Child (SLG, 2007). The SLDHS Household Questionnaire asked a number of questions to obtain information about the prevalence of child labour in Sierra Leone. Child labour is defined as the involvement of children age 5-14 in labour activities. A child is considered to be involved in child labour activities if he or she meets the following criteria: Table 2.13 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of children whose births are registered Number of children Had a birth certificate Did not have a birth certificate Total registered Age <2 31.2 21.8 52.9 2,691 2-4 30.0 19.4 49.4 4,017 Sex Male 30.9 21.1 52.0 3,334 Female 30.1 19.6 49.7 3,374 Residence Urban 40.4 18.8 59.1 1,803 Rural 26.9 20.9 47.8 4,906 Region Eastern 34.0 21.7 55.8 1,372 Northern 18.2 23.3 41.6 2,994 Southern 40.8 18.6 59.4 1,343 Western 48.6 11.9 60.5 1,000 Wealth quintile Lowest 25.5 17.5 43.0 1,526 Second 24.8 22.0 46.8 1,410 Middle 26.6 24.1 50.6 1,463 Fourth 34.4 22.0 56.4 1,285 Highest 46.5 15.0 61.5 1,025 Total 30.5 20.4 50.9 6,709 30 | Household Population and Housing Characteristics • Children age 5-11: at least one hour of economic work or 28 hours of domestic work during the week preceding the survey. • Children age 12-14: at least 14 hours of economic work or 28 hours of domestic work during the week preceding the survey. These definitions make it possible to differentiate child labour from child work, which in turn allows organizations working in child protection to identify and advocate the types of work that should be eliminated if the rights of the children are to be preserved. The discussion below provides a minimum estimate of the prevalence of child labour in Sierra Leone because some children may be involved in other labour activities (and thus be performing child labour) for a smaller number of hours than the criteria specified above. Table 2.14 shows that 31 percent of children are involved in child labour. Of these children, less than 1 percent receive payment for their work, 11 percent work without pay, and 26 percent work for a family business. Surprisingly, children age 5-11 are much more likely than children age 12-14 to be involved in child labour (43 and 6 percent, respectively). Small variations in child labour activities Table 2.14 Child labour Percentage of children age 5-14 years who were involved in child labour activities in the past week, by type of work, Sierra Leone 2008 Background characteristic Worked outside household in the past week1 Household chores for 28+ hours/ week Worked for family business in past week1 Total child labour2 Number of children age 5-14 Paid work Unpaid work Age 5-11 years 1.0 15.1 0.4 37.2 42.9 9,617 12-14 years 0.2 0.4 1.0 2.9 6.2 4,447 Sex Male 1.0 10.8 0.4 27.9 32.8 7,149 Female 0.4 10.1 0.8 24.8 29.8 6,914 Residence Urban 0.3 9.0 0.7 15.4 20.7 4,562 Rural 0.9 11.2 0.6 31.7 36.5 9,501 Region Eastern 0.6 12.6 1.8 26.1 34.2 2,353 Northern 0.9 7.8 0.3 28.7 31.1 6,829 Southern 0.9 17.2 0.6 38.3 45.6 2,586 Western 0.4 8.6 0.2 6.2 13.0 2,296 Orphan (mother and/or father deceased) Yes 0.7 8.4 0.6 22.7 26.6 1,833 No 0.7 10.8 0.6 26.9 32.0 12,230 School participation Yes 0.6 10.6 0.6 25.1 30.5 8,853 No 1.0 10.2 0.5 28.5 32.8 5,210 Wealth quintile Lowest 0.7 14.7 0.6 37.2 42.5 2,605 Second 1.3 10.9 0.3 33.0 37.1 2,970 Middle 0.4 10.0 0.8 28.5 33.2 2,945 Fourth 1.0 8.8 0.7 21.9 27.2 2,924 Highest 0.2 8.1 0.6 10.8 16.2 2,619 Total 0.7 10.5 0.6 26.4 31.3 14,063 Note: Equivalent to UNICEF MICS Indicator 71. 1 Defined as any such work for children age 5-11 and 14 hours or more of such work for those age 12-14 2 The numerator for the child labour estimate includes: (a) children age 5-11 who during the past week did at least one hour of economic activity or at least 28 hours of domestic chores and (b) children age 12-14 who during the past week did at least 14 hours of economic activity or at least 28 hours of domestic chores. Household Population and Housing Characteristics | 31 are observed by sex, urban-rural residence, orphanhood status, and whether the child is attending school. However, there are large variations between regions. Whereas only 13 percent of children in the Western Region are involved in child labour, the corresponding proportion in the Southern Region is 46 percent. The level of child labour reported in the 2008 SLDHS (31 percent) is much lower than that reported in the 2005 Multiple Indicator Cluster Survey (MICS) (48 percent) (SSL and UNICEF/Sierra Leone, 2007). Characteristics of Respondents | 33 CHARACTERISTICS OF RESPONDENTS 3 This chapter provides a profile of the respondents interviewed in the 2008 SLDHS: women age 15-49 and men age 15-59. Information is presented on a number of basic characteristics such as age, marital status, place of residence, ethnicity, religion, literacy, and access to mass media. The chapter also explores adults’ employment status, occupation, and earnings. An analysis of these variables provides the socio-economic context within which demographic and reproductive health issues are examined in subsequent chapters. 3.1 BACKGROUND CHARACTERISTICS OF SURVEY RESPONDENTS Information on the basic characteristics of women and men interviewed in the survey is essential for the interpretation of findings presented later in the report. Background characteristics of the 7,374 women and 3,280 men interviewed in the 2008 SLDHS are presented in Table 3.1. Weighted and unweighted numbers are shown. Unweighted numbers indicate the actual number of women and men interviewed, while weighted figures show the parameters of the population. The distribution of respondents according to age shows that 32 percent of women and men are age 15-24. In the 25-29 age group, the proportion of women is notably larger than the proportion of men (22 and 15 percent, respectively). The proportion of women and men age 30-34 is 14 and 13 percent, respectively. In successive age groups thereafter, the proportion of men is larger than the proportion of women. Nearly eight in ten respondents are Muslim. The respondents are almost equally divided among three ethnic groups, Temne, Mende, and other groups. Less than one-fifth (19 percent) of women have never married compared with 37 percent of men. Seventy-five percent of women are currently married or living in an informal marital union, compared with 60 percent of men. This is possibly because men marry later in life than women. While women are as likely as men to be divorced or separated, women are much more likely than men to be widowed (3 percent and less than 1 percent, respectively). Almost two-thirds of respondents (64 percent of women and 62 percent of men) live in rural areas. The distribution of respondents by region shows that four in ten live in the Northern Region (41 percent of women and 38 percent of men), while the Eastern Region has the lowest proportion (18 percent of women and 19 percent of men). Two in three (66 percent) of women have never been to school, compared with 48 percent of men. Men are much more likely than women to complete secondary education (32 percent compared with 19 percent). Similarly, the proportion who go beyond secondary education is higher among men than women (5 and 3 percent, respectively). 34 | Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Sierra Leone 2008 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 16.2 1,198 1,263 17.9 526 549 20-24 16.1 1,186 1,195 13.7 403 414 25-29 22.3 1,643 1,578 15.2 446 440 30-34 14.1 1,043 1,066 12.7 373 380 35-39 15.3 1,131 1,094 17.8 525 512 40-44 8.8 652 658 11.4 336 337 45-49 7.0 520 520 11.4 335 329 Marital status Never married 19.0 1,399 1,531 36.8 1,085 1,122 Married 65.0 4,794 4,677 54.6 1,607 1,568 Living together 9.9 732 696 5.4 160 171 Divorced/separated 3.5 256 269 2.7 81 87 Widowed 2.6 194 201 0.4 11 13 Residence Urban 36.0 2,655 3,160 38.1 1,123 1,295 Rural 64.0 4,719 4,214 61.9 1,822 1,666 Region Eastern 18.0 1,325 1,759 18.9 557 740 Northern 40.7 3,001 2,165 38.4 1,131 819 Southern 20.9 1,542 1,835 21.0 617 746 Western 20.4 1,506 1,615 21.7 639 656 Education No education 65.9 4,860 4,609 48.4 1,426 1,332 Primary 13.0 960 1,004 14.1 414 442 Secondary 18.6 1,372 1,558 32.4 953 1,017 More than secondary 2.5 182 203 5.1 151 170 Ethnicity Temne 34.8 2,564 2,096 36.0 1,060 868 Mende 31.6 2,331 2,721 30.6 901 1,070 Other 33.6 2,479 2,557 33.4 984 1,023 Religion Christian 22.0 1,625 1,933 21.8 642 739 Muslim 76.8 5,665 5,370 77.7 2,289 2,204 Other 1.1 84 71 0.5 14 18 Wealth quintile Lowest 18.7 1,382 1,323 18.9 558 543 Second 18.6 1,368 1,228 17.7 520 463 Middle 19.4 1,428 1,309 18.0 530 497 Fourth 20.0 1,472 1,560 20.3 597 636 Highest 23.4 1,723 1,954 25.1 739 822 Total 15-49 100.0 7,374 7,374 100.0 2,944 2,961 50-59 na na 0 na 336 319 Total 15-59 na na 0 na 3,280 3,280 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable 3.2 EDUCATIONAL ATTAINMENT Tables 3.2.1 and 3.2.2 present the distribution of female and male respondents by the highest level of education attended according to background characteristics. The results show that the proportion of respondents who have never been to school is higher for women than for men (66 and 48 percent, respectively). For both women and men, younger respondents are more likely than older respondents to have received education. For instance, 5 percent of women age 15-24 have completed primary school, compared with 3 percent women age 45-49. Men show similar proportions. The Characteristics of Respondents | 35 median years of schooling completed by women age 15-19 is five, whereas for older women (age 20-49) it is zero years. The median years completed for men age 15-19 is six, and for older men (age 25-49) it is zero years. Level of education varies by residence. Women and men in rural areas are less likely to be educated than their urban counterparts. For women, 38 percent of those in urban areas have never been to school, compared with 81 percent in rural areas. The gap in educational attainment between urban and rural residents widens with higher education levels. Whereas 6 percent of women in urban areas completed secondary school, the corresponding proportion in rural areas is less than 1 percent. There is wide variation in education across regions: 77 percent of women in the Northern Region have not attended school, compared with 32 percent of women in the Western Region. In the Southern and Eastern regions, the proportions who have no education are 73 and 71 percent, respectively. Further, the Western Region has the highest proportion of women who go beyond secondary school, 9 percent, compared with about 1 percent in other regions. As expected, the level of education increases with household wealth (wealth index). For example, 4 percent of women in the lowest quintile have attained some secondary education, compared with 40 percent of women in the highest quintile. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 46.1 15.6 4.5 29.0 3.0 1.8 100.0 2.6 2,384 15-19 34.1 20.0 6.3 37.6 1.7 0.2 100.0 4.6 1,198 20-24 58.2 11.1 2.7 20.4 4.2 3.4 100.0 0.0 1,186 25-29 75.3 8.4 1.9 9.5 1.9 3.1 100.0 0.0 1,643 30-34 70.5 7.4 3.9 11.8 2.7 3.7 100.0 0.0 1,043 35-39 76.6 6.1 3.3 10.3 1.8 1.8 100.0 0.0 1,131 40-44 76.3 4.5 2.7 10.9 2.2 3.4 100.0 0.0 652 45-49 81.4 5.0 3.1 7.9 1.2 1.5 100.0 0.0 520 Residence Urban 38.3 10.8 4.8 33.7 6.0 6.3 100.0 5.1 2,655 Rural 81.4 9.0 2.6 6.4 0.3 0.3 100.0 0.0 4,719 Region Eastern 70.8 11.8 3.8 12.2 0.5 0.9 100.0 0.0 1,325 Northern 77.1 8.5 2.2 10.6 0.9 0.6 100.0 0.0 3,001 Southern 72.6 9.6 4.2 11.4 0.9 1.3 100.0 0.0 1,542 Western 32.4 10.0 4.5 36.1 8.2 8.8 100.0 6.3 1,506 Wealth quintile Lowest 87.6 6.9 1.8 3.7 0.0 0.0 100.0 0.0 1,382 Second 82.3 9.6 2.7 5.1 0.1 0.1 100.0 0.0 1,368 Middle 79.1 10.4 2.4 7.7 0.2 0.2 100.0 0.0 1,428 Fourth 61.1 11.5 5.4 19.1 1.5 1.3 100.0 0.0 1,472 Highest 28.7 9.6 4.3 39.9 8.4 9.2 100.0 6.7 1,723 Total 65.9 9.6 3.4 16.3 2.3 2.5 100.0 0.0 7,374 1 Completed 6 grades at the primary level 2 Completed 3 grades at the senior secondary school level Table 3.2.2 shows that the differentials in education for men are similar to those for women. Younger men, men in urban areas, those who live in the Western Region, and men in the highest wealth quintile are more likely than other men to have education. 36 | Characteristics of Respondents Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 25.0 14.5 5.1 44.9 8.6 1.9 100.0 6.2 929 15-19 20.8 18.7 7.8 47.8 4.8 0.0 100.0 5.9 526 20-24 30.4 8.9 1.6 41.3 13.5 4.4 100.0 7.1 403 25-29 56.5 10.4 3.2 14.0 8.6 7.3 100.0 0.0 446 30-34 61.1 8.7 3.5 14.5 3.9 8.3 100.0 0.0 373 35-39 60.6 7.7 4.8 19.6 3.3 4.0 100.0 0.0 525 40-44 51.4 5.7 1.9 17.4 12.2 11.4 100.0 0.0 336 45-49 66.4 7.7 2.5 15.5 4.6 3.3 100.0 0.0 335 Residence Urban 21.3 6.8 4.5 41.6 14.9 11.0 100.0 7.9 1,123 Rural 65.2 12.2 3.5 15.4 2.1 1.5 100.0 0.0 1,822 Region Eastern 57.1 14.7 5.2 18.2 2.5 2.3 100.0 0.0 557 Northern 58.2 10.3 2.9 24.1 2.4 2.1 100.0 0.0 1,131 Southern 55.3 10.6 4.3 22.7 3.9 3.3 100.0 0.0 617 Western 17.0 5.4 4.2 36.4 22.2 14.7 100.0 9.1 639 Wealth quintile Lowest 76.1 12.8 2.8 7.8 0.5 0.0 100.0 0.0 558 Second 68.9 11.6 4.4 13.5 1.4 0.4 100.0 0.0 520 Middle 57.1 15.0 3.0 20.3 3.2 1.4 100.0 0.0 530 Fourth 42.0 7.2 6.3 31.8 6.9 5.8 100.0 5.0 597 Highest 12.2 6.0 3.1 45.4 18.7 14.5 100.0 9.1 739 Total 15-49 48.4 10.2 3.9 25.4 7.0 5.1 100.0 1.2 2,944 50-59 64.8 8.0 3.2 14.6 5.1 4.4 100.0 0.0 336 Total 15-59 50.1 9.9 3.8 24.3 6.8 5.1 100.0 0.0 3,280 1 Completed 6 grades at the primary level 2 Completed 3 grades at the senior secondary school level 3.3 LITERACY The 2008 SLDHS assessed the ability to read and write among women and men who had never been to school or who had attended only the primary level. This was done by asking respondents to read all or part of a short, simple sentence to establish literacy. The sample sentences were written in simple English1. Tables 3.3.1 and 3.3.2 show the percent distribution of women and men, respectively, by level of schooling, level of literacy, and percentage literate, according to background characteristics. The data show that 74 percent of women and 55 percent of men are illiterate. The gender gap in literacy varies by age, ranging from 10 percentage points in age 30-34 to 33 percentage points in age 20-24. The urban-rural differential follows the expected pattern; rural respondents are more likely to be illiterate than their urban counterparts. The proportion of illiterate rural men is almost three times that of urban men (73 and 26 percent, respectively). For women, the proportion is 89 and 47 percent, respectively. The Eastern Region has the highest illiteracy rate among men (68 percent), while the Northern Region has the highest rate among women (84 percent). As expected, illiteracy decreases as wealth increases. For women, the poorest have the highest rate of illiteracy (94 percent), while the richest are the least likely to be illiterate (37 percent). Men show a similar pattern. 1 These sentences include the following: 1) Parents love their children; 2) Farming is hard work; 3) The child is reading a book; 4) Children work hard at school; 5) The rains came late this year. Characteristics of Respondents | 37 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Sierra Leone 2008 Background characteristic Secondary school or higher No schooling, or primary school only Missing Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Age 15-19 39.6 3.7 11.4 43.9 0.1 0.1 1.2 100.0 54.7 1,198 20-24 28.0 0.1 4.0 67.2 0.2 0.1 0.3 100.0 32.2 1,186 25-29 14.5 0.0 2.5 82.6 0.2 0.0 0.2 100.0 17.0 1,643 30-34 18.2 0.2 3.1 78.3 0.0 0.1 0.2 100.0 21.5 1,043 35-39 14.0 0.2 2.7 82.2 0.5 0.0 0.3 100.0 16.9 1,131 40-44 16.4 0.1 2.0 80.8 0.3 0.0 0.3 100.0 18.6 652 45-49 10.5 0.6 3.6 84.1 0.7 0.0 0.5 100.0 14.7 520 Residence Urban 46.1 1.1 5.6 46.3 0.2 0.1 0.6 100.0 52.8 2,655 Rural 7.0 0.5 3.6 88.2 0.3 0.0 0.3 100.0 11.2 4,719 Region Eastern 13.6 0.9 3.6 81.3 0.0 0.1 0.5 100.0 18.1 1,325 Northern 12.1 0.4 3.9 82.4 0.6 0.0 0.5 100.0 16.5 3,001 Southern 13.6 1.1 5.6 79.4 0.0 0.1 0.2 100.0 20.3 1,542 Western 53.1 0.9 4.5 40.9 0.0 0.1 0.4 100.0 58.6 1,506 Wealth quintile Lowest 3.7 0.2 2.6 92.7 0.3 0.0 0.5 100.0 6.5 1,382 Second 5.4 0.8 4.3 88.8 0.6 0.0 0.2 100.0 10.4 1,368 Middle 8.1 0.5 4.6 86.2 0.3 0.1 0.2 100.0 13.2 1,428 Fourth 22.0 1.3 5.1 71.0 0.1 0.0 0.4 100.0 28.4 1,472 Highest 57.5 0.9 4.8 35.9 0.1 0.1 0.7 100.0 63.2 1,723 Total 21.1 0.8 4.3 73.1 0.2 0.0 0.4 100.0 26.2 7,374 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Sierra Leone 2008 Background characteristic Secondary school or higher No schooling, or primary school only Missing Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Age 15-19 52.6 7.7 12.9 25.2 0.8 0.1 0.8 100.0 73.3 526 20-24 59.1 1.4 4.3 34.3 0.1 0.2 0.6 100.0 64.8 403 25-29 29.8 0.9 4.7 62.5 0.4 0.2 1.4 100.0 35.4 446 30-34 26.7 1.1 3.8 67.4 0.5 0.0 0.5 100.0 31.6 373 35-39 26.9 1.4 3.8 67.0 0.4 0.0 0.6 100.0 32.0 525 40-44 41.0 0.6 2.3 55.8 0.2 0.0 0.1 100.0 43.9 336 45-49 23.4 0.2 2.3 73.5 0.0 0.0 0.5 100.0 26.0 335 Residence Urban 67.5 2.0 4.3 25.1 0.1 0.1 0.9 100.0 73.7 1,123 Rural 19.0 2.4 5.9 71.6 0.5 0.1 0.5 100.0 27.3 1,822 Region Eastern 23.0 2.3 6.3 67.6 0.0 0.1 0.7 100.0 31.6 557 Northern 28.6 2.2 6.2 62.4 0.5 0.0 0.1 100.0 37.0 1,131 Southern 29.9 2.9 5.4 59.1 0.9 0.2 1.6 100.0 38.2 617 Western 73.3 1.4 2.7 21.9 0.0 0.0 0.7 100.0 77.5 639 Wealth quintile Lowest 8.3 2.1 5.8 82.7 0.4 0.2 0.5 100.0 16.2 558 Second 15.2 2.1 6.8 75.0 0.3 0.0 0.6 100.0 24.1 520 Middle 24.9 3.2 5.4 65.4 0.6 0.2 0.4 100.0 33.4 530 Fourth 44.5 2.0 5.8 46.4 0.6 0.0 0.6 100.0 52.4 597 Highest 78.6 1.8 3.3 15.0 0.2 0.0 1.0 100.0 83.7 739 Total 15-49 37.5 2.2 5.3 53.9 0.4 0.1 0.7 100.0 45.0 2,944 50-59 24.0 1.9 4.1 68.1 1.0 0.0 0.9 100.0 30.0 336 Total men 15-59 36.1 2.2 5.2 55.3 0.4 0.1 0.7 100.0 43.5 3,280 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 38 | Characteristics of Respondents 3.4 ACCESS TO MASS MEDIA The 2008 SLDHS collected information on the exposure of respondents to common print and electronic media. Respondents were asked how often they read a newspaper, listen to the radio, and watch television. These data are important because they provide an indication of the extent to which Sierra Leoneans are regularly exposed to mass media, which are often used to disseminate messages on family planning and other health issues. Tables 3.4.1 and 3.4.2 show that the most popular media is radio; 46 percent of women and 63 percent of men age 15-49 listen to the radio at least once a week. Eleven percent of women and 17 percent of men age 15-49 watch television weekly. Because of the low literacy rate, readership of newspapers among women is low (7 percent), while 18 percent of men read a newspaper at least once a week. Urban residents are more likely to have access to mass media than rural residents: 8 percent of urban women are exposed to all three media at least once a week, compared with less than 1 percent of rural women; the difference for men is more pronounced, 22 percent of urban men, compared with 1 percent of rural men are exposed to all three media at least once a week. Similarly, the Western Region has the highest proportion of women and men who have access to all three media. There is a positive relationship between level of education and wealth status and exposure to mass media. For instance, 77 percent of women in the lowest wealth quintile have no weekly exposure to any mass media source, compared with 22 percent of women in the highest wealth quintile. The corresponding figures for men are 64 and 9 percent, respectively. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Sierra Leone 2008 Background characteristic At least once a week: Not exposed to any media Number of women Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 12.3 15.1 48.0 5.1 48.7 1,198 20-24 7.7 14.8 47.5 4.4 48.9 1,186 25-29 3.7 8.1 45.5 1.6 53.1 1,643 30-34 6.8 11.3 46.8 3.7 51.3 1,043 35-39 4.4 7.5 43.7 1.7 55.1 1,131 40-44 7.4 8.0 44.0 2.8 54.2 652 45-49 3.5 6.8 39.6 1.8 58.6 520 Residence Urban 15.7 24.7 64.8 7.9 30.7 2,655 Rural 1.5 2.6 34.8 0.3 64.4 4,719 Region Eastern 2.4 6.0 40.0 1.0 58.4 1,325 Northern 4.2 5.9 42.2 1.9 56.2 3,001 Southern 4.2 6.1 34.9 1.4 63.7 1,542 Western 17.6 28.5 68.3 9.1 27.3 1,506 Education No education 0.0 3.7 34.4 0.0 64.5 4,860 Primary 2.8 11.6 53.2 0.7 44.5 960 Secondary or higher 29.5 31.3 75.9 14.1 18.7 1,554 Wealth quintile Lowest 0.5 0.7 23.1 0.0 76.6 1,382 Second 1.0 2.0 32.5 0.3 67.2 1,368 Middle 2.0 3.1 39.6 0.1 59.0 1,428 Fourth 6.0 8.3 53.4 1.9 44.3 1,472 Highest 20.3 33.4 72.3 11.2 22.1 1,723 Total 6.6 10.6 45.6 3.1 52.3 7,374 Characteristics of Respondents | 39 Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Sierra Leone 2008 Background characteristic At least once a week: Not exposed to any media Number of men Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 19.2 25.6 62.0 11.5 33.9 526 20-24 27.6 22.5 68.3 14.1 27.7 403 25-29 17.9 18.2 60.8 9.1 36.7 446 30-34 16.9 13.9 62.8 7.5 35.1 373 35-39 12.3 11.4 62.3 4.8 36.5 525 40-44 23.9 15.6 70.3 10.5 27.9 336 45-49 11.7 8.8 55.2 4.8 42.9 335 Residence Urban 37.5 38.5 80.8 21.6 14.9 1,123 Rural 6.5 3.7 52.0 1.0 46.5 1,822 Region Eastern 9.3 4.2 59.6 2.4 39.1 557 Northern 11.2 9.5 55.7 3.2 41.7 1,131 Southern 8.4 9.4 54.8 2.3 44.0 617 Western 48.2 48.7 86.8 31.0 8.2 639 Education No education 0.6 5.2 46.4 0.1 52.0 1,426 Primary 5.3 12.9 67.9 1.4 29.9 414 Secondary or higher 46.0 33.7 82.6 23.0 13.4 1,104 Wealth quintile Lowest 1.6 2.0 35.3 0.5 64.1 558 Second 4.8 3.6 48.2 0.5 51.0 520 Middle 9.0 6.0 59.9 0.8 37.1 530 Fourth 18.3 15.1 74.5 7.0 21.4 597 Highest 47.0 47.1 87.2 28.5 9.0 739 Total 15-49 18.3 17.0 63.0 8.9 34.4 2,944 50-59 12.6 7.8 61.2 2.8 37.7 336 Total 15-59 17.7 16.0 62.8 8.3 34.8 3,280 3.5 EMPLOYMENT Like education, employment can also be a source of empowerment for women, especially if it puts them in control of income. It is difficult however to measure women’s employment because most of the work that women do, especially on family farms, at home, in family businesses, or in the informal sector, is often not perceived by women themselves as employment. Cash payment is not attached to these types of work; therefore, they do not report it as such. To avoid underestimating women’s employment, the DHS questionnaire asked women several probing questions on their employment status to ensure complete coverage of employment in any sector, formal or informal. Women are defined as employed if they are currently working or worked at any time during the 12 months preceding the survey. Additional information was obtained on the type of work, such as whether they worked continuously throughout the year, who they worked for, and the form in which they received their earnings. Men were also asked questions on employment. 40 | Characteristics of Respondents Table 3.5.1 and Figure 3.1 show the percent distribution of women age 15-49 by employment status, according to background characteristics. Overall, 77 percent of women were employed in the 12 months preceding the survey; 72 percent were currently employed while 5 percent, although not currently employed, had worked in the 12 months preceding the survey. Twenty-three percent of women did not work at all in the 12 months before the survey. For men age 15-49, 86 percent were employed in the 12 months preceding the survey (84 percent currently employed and 2 percent not currently employed but worked in the 12 months preceding the survey) (Table 3.5.2 and Figure 3.2). Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Sierra Leone 2008 Background characteristic Employed in the past 12 months Not employed in the past 12 months Missing Total Number of women Currently employed1 Not currently employed Age 15-19 46.6 4.0 49.2 0.2 100.0 1,198 20-24 60.3 5.0 34.5 0.2 100.0 1,186 25-29 79.3 4.5 15.7 0.5 100.0 1,643 30-34 78.5 7.3 13.9 0.3 100.0 1,043 35-39 81.6 5.5 12.5 0.3 100.0 1,131 40-44 83.2 4.1 12.2 0.4 100.0 652 45-49 84.0 4.4 11.1 0.4 100.0 520 Marital status Never married 41.5 3.3 55.1 0.1 100.0 1,399 Married/ living together 78.9 5.6 15.1 0.4 100.0 5,525 Divorced/separated/widowed 79.7 3.5 16.9 0.0 100.0 450 Number of living children 0 49.2 3.9 46.7 0.2 100.0 1,592 1-2 73.6 5.1 20.9 0.4 100.0 2,639 3-4 80.3 5.6 13.9 0.2 100.0 1,954 5+ 84.5 5.4 9.7 0.4 100.0 1,189 Residence Urban 57.7 4.0 38.1 0.2 100.0 2,655 Rural 79.8 5.6 14.2 0.4 100.0 4,719 Region Eastern 66.4 9.0 24.4 0.3 100.0 1,325 Northern 78.8 4.6 16.2 0.5 100.0 3,001 Southern 75.6 3.9 20.3 0.3 100.0 1,542 Western 59.0 3.6 37.2 0.2 100.0 1,506 Education No education 79.6 5.5 14.5 0.3 100.0 4,860 Primary 68.3 5.0 26.2 0.5 100.0 960 Secondary or higher 49.8 3.5 46.5 0.2 100.0 1,554 Wealth quintile Lowest 80.3 6.7 12.4 0.7 100.0 1,382 Second 81.1 5.3 13.2 0.3 100.0 1,368 Middle 79.1 4.8 15.9 0.2 100.0 1,428 Fourth 69.2 5.2 25.3 0.3 100.0 1,472 Highest 54.0 3.4 42.3 0.2 100.0 1,723 Total 71.9 5.0 22.8 0.3 100.0 7,374 1 ‘Currently employed’ is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Respondents | 41 Figure 3.1 Women’s Employment Status in the Past 12 Months Sierra Leone, 2008 72% 5% 23% Currently employed Not employed in the past 12 months Not currently employed, but worked in the past 12 months Tables 3.5.1 and 3.5.2 show that for both women and men current employment increases with the respondent’s age. Almost all men age 30 or older (97 percent or higher) were employed in the past year. Women who are married or divorced, separated, or widowed are more likely to be currently employed than unmarried women (79-80 percent, compared with 42 percent). Men show a similar pattern; married men are the most likely to be currently employed (97 percent), while never-married men are the least likely to be currently employed (63 percent). The two tables also show that the proportion of women and men who are currently working increases with the number of living children they have. While less than half of women with no children are currently employed, at least 74 percent of women with children are employed. Similarly, at least 91 percent of men with one or more living children are currently employed, compared with 66 percent of men with no living children. The percentage of men and women who are currently employed is substantially higher in rural areas (80 percent for women and 94 percent for men) than in urban areas (58 percent for women and 67 percent for men). There is also a substantial difference in levels of employment by region; the Northern Region has the highest level of employment for men (90 percent) and women (79 percent), while the Western Region has the lowest level of employment for the two sexes (68 percent of men and 59 percent of women). Employment has a negative relationship with education level and wealth status. For example, 97 percent of men and 80 percent of women with no education are employed, compared with 67 percent of men and 50 percent of women with secondary or higher education. 42 | Characteristics of Respondents Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Sierra Leone 2008 Background characteristic Employed in the past 12 months Not employed in the past 12 months Missing Total Number of men Currently employed1 Not currently employed Age 15-19 51.8 3.4 44.8 0.0 100.0 526 20-24 70.6 3.0 26.4 0.0 100.0 403 25-29 90.6 1.3 8.0 0.1 100.0 446 30-34 96.3 1.3 1.9 0.5 100.0 373 35-39 95.3 2.2 2.5 0.0 100.0 525 40-44 95.4 1.9 2.4 0.3 100.0 336 45-49 97.0 0.4 2.6 0.0 100.0 335 Marital status Never married 62.8 3.3 33.9 0.0 100.0 1,085 Married/ living together 96.5 1.2 2.2 0.1 100.0 1,767 Divorced/separated/widowed 86.8 4.0 9.2 0.0 100.0 92 Number of living children 0 66.0 2.9 31.0 0.0 100.0 1,137 1-2 91.1 1.9 6.8 0.1 100.0 715 3-4 96.8 1.6 1.4 0.1 100.0 551 5+ 98.1 0.8 0.9 0.2 100.0 541 Residence Urban 66.9 3.9 28.9 0.2 100.0 1,123 Rural 94.2 0.9 4.9 0.0 100.0 1,822 Region Eastern 89.5 1.5 9.0 0.0 100.0 557 Northern 90.0 1.3 8.6 0.1 100.0 1,131 Southern 83.9 1.3 14.8 0.0 100.0 617 Western 67.6 4.6 27.5 0.4 100.0 639 Education No education 97.2 0.5 2.2 0.1 100.0 1,426 Primary 83.4 2.1 14.4 0.0 100.0 414 Secondary or higher 66.6 4.0 29.3 0.2 100.0 1,104 Wealth quintile Lowest 94.5 0.6 4.7 0.1 100.0 558 Second 95.5 0.0 4.5 0.0 100.0 520 Middle 94.6 1.5 3.9 0.0 100.0 530 Fourth 83.7 3.0 13.0 0.2 100.0 597 Highest 59.7 4.1 36.0 0.1 100.0 739 Total 15-49 83.8 2.0 14.1 0.1 100.0 2,944 50-59 95.1 0.9 3.7 0.3 100.0 336 Total 15-59 84.9 1.9 13.0 0.1 100.0 3,280 1 ‘Currently employed’ is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 3.6 OCCUPATION Tables 3.6.1 and 3.6.2 show the distribution of women and men who were employed in the 12 months preceding the survey by occupation and background characteristics. Data in these tables show that the agriculture sector employs 57 percent of women and 59 percent of men. The next most common occupation for women is sales and services (34 percent). Six percent of women are in professional, technical, and managerial work. Very few women are engaged in other occupations (2 percent or less). Similar proportions of men work in professional, technical, managerial occupations (14 percent) and sales and services jobs (13 percent). Characteristics of Respondents | 43 Women who work in agriculture are more likely to be older, married, live in rural areas, have no education, and live in the poorest households. Professional, technical and managerial sectors are more likely to attract younger women, women who have never married, women with no children, urban women, women with secondary or higher education, and women from the wealthiest households. There are no substantial differences in occupation by region; 66-72 percent of women and men in the Northern, Eastern and Southern regions work in agriculture and 19-27 percent of women work in the sales and services sector. One in three men (33 percent) in the Western Region work in professional, technical and managerial jobs. Women with no education or with primary education work mainly in agricultural jobs (42-69 percent), while 51 percent of women with secondary or higher education work in the sales and services sector. For men, the relationship between education and occupation follows a similar pattern. Tables 3.6.1 and 3.6.2 show that women (85 percent) and men (86 percent) in the lowest wealth quintile are most likely to work in the agriculture sector, while those in the highest wealth quintile (71 and 31 percent, respectively) are most likely to work in the sales and service sector. Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Sierra Leone 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agri- culture Missing Total Number of women Age 15-19 19.6 0.0 24.2 2.5 0.1 1.0 48.9 3.7 100.0 606 20-24 7.0 0.2 36.8 2.3 0.5 0.4 50.8 2.0 100.0 775 25-29 3.2 0.3 34.4 1.9 0.1 0.2 59.0 1.0 100.0 1,377 30-34 3.9 0.4 36.8 1.7 0.3 0.0 56.0 0.8 100.0 895 35-39 4.0 0.3 33.5 0.8 0.0 0.0 60.1 1.2 100.0 986 40-44 5.3 0.6 34.0 0.4 0.2 0.0 58.8 0.7 100.0 570 45-49 3.5 0.3 31.9 0.4 0.0 0.0 63.7 0.2 100.0 460 Marital status Never married 29.9 0.6 36.7 3.5 0.3 0.7 24.2 4.2 100.0 627 Married/ living together 2.9 0.2 32.4 1.3 0.2 0.2 61.9 0.9 100.0 4,668 Divorced/separated/widowed 3.7 0.4 44.0 1.3 0.3 0.0 48.7 1.6 100.0 374 Number of living children 0 20.2 0.5 31.2 2.4 0.4 0.7 41.6 3.0 100.0 845 1-2 4.7 0.5 35.6 2.4 0.1 0.3 55.0 1.4 100.0 2,077 3-4 2.7 0.1 34.2 0.7 0.2 0.0 61.2 0.8 100.0 1,678 5+ 2.3 0.1 30.7 0.2 0.1 0.0 65.7 0.8 100.0 1,069 Residence Urban 13.3 1.0 66.2 3.4 0.1 0.5 13.2 2.4 100.0 1,637 Rural 3.0 0.0 20.4 0.8 0.2 0.1 74.6 0.9 100.0 4,032 Region Eastern 5.7 0.1 18.9 1.6 0.5 0.1 72.3 0.7 100.0 998 Northern 3.8 0.0 27.2 0.8 0.1 0.3 67.0 0.8 100.0 2,502 Southern 3.1 0.1 27.2 1.0 0.2 0.0 65.6 2.8 100.0 1,225 Western 15.6 1.4 74.6 3.9 0.1 0.2 2.5 1.6 100.0 944 Education No education 1.3 0.0 28.0 0.9 0.2 0.2 68.6 0.9 100.0 4,137 Primary 6.1 0.0 46.6 2.7 0.0 0.5 42.4 1.7 100.0 703 Secondary or higher 29.2 2.0 50.8 3.5 0.4 0.2 10.7 3.2 100.0 829 Wealth quintile Lowest 1.5 0.0 11.5 0.3 0.3 0.0 85.3 1.2 100.0 1,201 Second 3.1 0.1 16.9 0.4 0.2 0.0 78.2 1.1 100.0 1,183 Middle 3.1 0.0 26.2 1.2 0.1 0.4 67.6 1.3 100.0 1,199 Fourth 6.1 0.1 50.2 2.0 0.2 0.4 39.4 1.5 100.0 1,095 Highest 18.1 1.5 71.1 4.2 0.1 0.2 3.3 1.5 100.0 990 Total 6.0 0.3 33.6 1.5 0.2 0.2 56.9 1.3 100.0 5,669 44 | Characteristics of Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Sierra Leone 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agri- culture Missing Total Number of men Age 15-19 33.1 0.3 3.0 3.6 1.4 0.0 55.0 3.4 100.0 290 20-24 22.7 2.7 10.4 9.2 3.6 0.5 48.8 2.2 100.0 296 25-29 11.1 3.0 12.7 9.3 3.8 0.0 58.8 1.4 100.0 410 30-34 9.4 1.7 15.5 8.4 4.4 0.4 59.8 0.3 100.0 364 35-39 7.4 1.5 13.9 6.7 4.4 0.2 65.2 0.7 100.0 512 40-44 15.7 1.2 17.7 5.8 4.9 0.0 54.0 0.8 100.0 327 45-49 9.0 0.7 13.4 8.4 5.0 0.0 62.9 0.6 100.0 326 Marital status Never married 26.6 1.8 8.2 7.1 3.2 0.2 50.2 2.7 100.0 717 Married/ living together 9.3 1.4 14.6 7.3 4.2 0.1 62.4 0.7 100.0 1,726 Divorced/separated/widowed 13.1 3.7 13.2 11.9 7.4 0.0 50.7 0.0 100.0 84 Number of living children 0 23.1 2.0 9.1 5.8 3.4 0.2 54.2 2.2 100.0 784 1-2 12.4 1.9 13.2 11.1 6.2 0.2 53.7 1.3 100.0 665 3-4 9.9 1.7 15.7 6.8 3.4 0.2 61.5 0.8 100.0 543 5+ 8.3 0.6 14.3 5.9 2.8 0.0 68.0 0.1 100.0 535 Residence Urban 29.2 4.3 26.6 16.9 4.4 0.5 15.2 2.8 100.0 796 Rural 7.5 0.4 6.3 3.0 3.8 0.0 78.5 0.5 100.0 1,731 Region Eastern 9.8 0.6 6.1 3.0 10.7 0.0 69.6 0.2 100.0 506 Northern 12.2 0.6 9.4 3.9 1.3 0.1 72.1 0.4 100.0 1,033 Southern 6.3 1.3 13.7 4.3 5.8 0.0 66.5 2.2 100.0 526 Western 33.3 5.4 26.1 23.6 0.6 0.7 7.1 3.1 100.0 462 Education No education 2.7 0.7 9.1 5.7 4.3 0.0 77.1 0.4 100.0 1,393 Primary 11.3 2.0 12.1 10.3 5.2 0.0 57.9 1.2 100.0 354 Secondary or higher 36.5 3.1 19.3 9.2 3.0 0.5 25.6 2.8 100.0 779 Wealth quintile Lowest 4.4 0.1 3.8 1.4 4.3 0.0 85.5 0.6 100.0 530 Second 4.6 0.3 7.8 1.3 2.8 0.0 83.2 0.0 100.0 497 Middle 10.1 0.4 7.9 5.3 4.7 0.0 71.1 0.6 100.0 509 Fourth 18.9 1.4 14.7 10.8 6.9 0.5 45.2 1.7 100.0 518 Highest 35.4 6.2 30.9 19.3 1.0 0.3 3.5 3.4 100.0 472 Total 15-49 14.3 1.6 12.7 7.4 4.0 0.2 58.5 1.2 100.0 2,526 50-59 9.9 1.2 15.1 4.2 4.8 0.0 64.5 0.3 100.0 322 Total 15-59 13.8 1.6 13.0 7.1 4.1 0.1 59.2 1.1 100.0 2,849 3.7 EARNINGS, EMPLOYERS, AND CONTINUITY OF EMPLOYMENT Table 3.7 presents information on women’s employment, including type of earnings, type of employer, and continuity of employment. Because the employment variables in the table are strongly influenced by the sector in which a woman is employed, the table takes into account whether the woman is involved in agricultural or non-agricultural work. The data show that 83 percent of women employed in agricultural work are not paid, 74 percent are self-employed, and 24 percent are employed by a family member; 44 percent work all year and 53 percent work seasonally. Characteristics of Respondents | 45 Women who work in non-agricultural jobs are slightly better off than women employed in agricultural work; 54 percent of these women are not paid, but 37 percent are paid in cash only. Among women who work in agriculture, 84 percent are not paid and 5 percent are paid in cash only. Eighty-one percent of women are self-employed, and most women work all year (71 percent). Table 3.7 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Sierra Leone 2008 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 4.5 36.8 18.2 Cash and in-kind 5.6 5.0 5.3 In-kind only 5.9 2.9 4.6 Not paid 83.4 54.2 71.0 Missing 0.6 1.1 0.9 Total 100.0 100.0 100.0 Type of employer Employed by family member 24.3 9.8 18.1 Employed by non-family member 1.4 8.3 4.4 Self-employed 74.1 81.3 77.1 Missing 0.2 0.6 0.5 Total 100.0 100.0 100.0 Continuity of employment All year 44.2 70.7 55.1 Seasonal 53.1 17.6 37.8 Occasional 2.0 11.0 6.3 Missing 0.7 0.7 0.8 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 3,225 2,368 5,669 Note: The total column includes women with information missing on type of employment who are not shown separately. 3.8 HEALTH INSURANCE Health insurance is largely unknown in Sierra Leone; almost no one is covered by a health insurance scheme (data not shown). 3.9 KNOWLEDGE AND ATTITUDES CONCERNING TUBERCULOSIS The 2008 SLDHS collected information on the respondent’s knowledge and attitudes concerning tuberculosis (TB). Tables 3.8.1 and 3.8.2 show that knowledge of TB in Sierra Leone is widespread (86 percent of women and 90 percent of men). Younger respondents and those who live in rural areas are less likely than other respondents to have heard of TB. Almost all women and men in the Western Region have heard of TB (99 and 98 percent, respectively). Knowledge of TB increases with education and wealth status. Women and men with less than primary education and in the lowest wealth quintile are the least likely to know about TB. 46 | Characteristics of Respondents Among women and men who have heard of TB, more than half know that TB is spread through the air by coughing (57 percent of women and 68 percent of men). Knowledge that TB can be cured is also widespread (77 percent of women and 85 percent of men). In general, urban residents, more educated respondents, and those in the wealthiest households are more aware that TB is transmitted through the air by coughing and that it can be completely cured. In Sierra Leone, there is little stigma attached to TB. Only about one-quarter of women (24 percent) and 17 percent of men said that they would want to keep secret the fact that a family member had TB. Stigma generally increases with level of education and wealth quintile, and is higher among urban than rural residents. Table 3.8.1 Knowledge and attitudes concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentage who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Sierra Leone 2008 Background characteristic Among all women: Among respondents who have heard of TB: Percentage who have heard of TB Number of women Percentage who reported that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of women Age 15-19 81.3 1,198 55.8 72.8 28.9 974 20-24 88.5 1,186 56.9 75.3 28.5 1,050 25-29 85.1 1,643 55.9 77.4 21.1 1,398 30-34 85.7 1,043 58.1 79.1 22.9 894 35-39 86.0 1,131 59.9 79.6 22.7 973 40-44 88.7 652 59.8 80.0 20.2 578 45-49 88.9 520 56.7 81.0 18.3 462 Residence Urban 94.8 2,655 62.7 82.9 33.8 2,518 Rural 80.8 4,719 53.9 73.8 17.1 3,812 Region Eastern 85.2 1,325 56.4 67.9 18.3 1,129 Northern 81.5 3,001 60.4 80.1 15.6 2,445 Southern 82.2 1,542 46.2 72.0 19.0 1,268 Western 98.7 1,506 62.9 84.9 45.3 1,487 Education No education 82.0 4,860 52.6 74.2 18.7 3,985 Primary 89.5 960 60.3 74.2 26.0 859 Secondary or higher 95.6 1,554 68.8 88.1 36.0 1,486 Wealth quintile Lowest 78.7 1,382 53.9 71.1 15.9 1,087 Second 81.2 1,368 53.2 74.3 18.3 1,112 Middle 80.9 1,428 54.0 73.0 17.0 1,155 Fourth 88.7 1,472 58.8 78.6 22.9 1,306 Highest 96.9 1,723 63.7 85.7 37.8 1,670 Total 85.8 7,374 57.4 77.4 23.7 6,330 Characteristics of Respondents | 47 Table 3.8.2 Knowledge and attitudes concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentage who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Sierra Leone 2008 Background characteristic Among all men: Among respondents who have heard of TB: Percentage who have heard of TB Number of men Percentage who reported that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of men Age 15-19 80.7 526 71.1 80.5 22.2 424 20-24 90.0 403 73.1 86.1 24.7 362 25-29 90.2 446 62.2 82.9 17.5 402 30-34 91.9 373 65.3 81.7 9.8 343 35-39 92.9 525 63.2 84.3 14.2 488 40-44 93.0 336 72.0 89.3 17.3 313 45-49 93.1 335 71.6 88.8 11.9 312 Residence Urban 96.1 1,123 78.4 88.9 21.7 1,079 Rural 86.0 1,822 60.8 81.5 13.7 1,566 Region Eastern 89.0 557 48.9 75.8 8.5 495 Northern 87.5 1,131 72.5 87.4 11.8 990 Southern 86.0 617 66.9 83.3 18.6 531 Western 98.4 639 76.8 87.8 30.4 629 Education No education 88.1 1,426 57.3 79.5 12.7 1,256 Primary 80.1 414 60.7 81.0 15.2 332 Secondary or higher 95.7 1,104 82.9 91.5 22.6 1,057 Wealth quintile Lowest 83.5 558 52.2 77.0 14.8 466 Second 85.3 520 61.3 80.8 10.6 444 Middle 87.8 530 65.1 84.0 11.7 465 Fourth 92.3 597 72.6 87.4 16.7 551 Highest 97.2 739 80.6 89.7 26.0 719 Total 15-49 89.8 2,944 68.0 84.5 17.0 2,645 50-59 92.1 336 67.1 88.8 12.5 309 Total 15-59 90.1 3,280 67.9 84.9 16.5 2,954 3.10 SMOKING To measure the extent of smoking among Sierra Leonean adults, women and men who were interviewed in the 2008 SLDHS were asked if they currently smoked cigarettes or used other forms of tobacco. Twelve percent of women reported that they use tobacco; 6 percent smoke cigarettes and 6 percent use other types of tobacco (Table 3.9.1). Men are more likely to use tobacco than women. Overall, 37 percent of men age 15-49 smoke cigarettes (Table 3.9.2). Among men, the proportion of smokers is highest in rural areas, among those with no education, and among those in the poorest households. Four in ten men who smoke cigarettes had at least 10 cigarettes in the 24 hours before the survey. While there are large differences in the proportion cigarette smokers by wealth quintile (50 percent for men in the lowest quintile and 17 percent for men in the highest quintile), among men who smoke 10 or more cigarettes there is little variation by wealth status (34-42 percent). 48 | Characteristics of Respondents Table 3.9.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, by background characteristics and maternity status, Sierra Leone 2008 Background characteristic Uses tobacco Does not use tobacco Number of women Cigarettes Pipe Other tobacco Age 15-19 0.8 0.0 0.8 98.2 1,198 20-24 3.4 0.0 2.0 95.2 1,186 25-29 6.5 0.2 4.1 90.3 1,643 30-34 9.2 0.4 7.0 85.0 1,043 35-39 7.8 0.2 8.2 85.0 1,131 40-44 8.5 0.9 10.7 82.2 652 45-49 9.0 0.5 13.6 78.5 520 Maternity status Pregnant 4.5 0.0 5.2 91.3 598 Breastfeeding (not pregnant) 6.0 0.2 4.8 90.2 2,091 Neither 6.2 0.3 5.9 88.6 4,685 Residence Urban 5.0 0.3 1.7 93.4 2,655 Rural 6.6 0.2 7.7 87.0 4,719 Region Eastern 8.5 0.2 6.9 85.4 1,325 Northern 5.0 0.3 3.4 92.6 3,001 Southern 6.2 0.0 13.2 82.3 1,542 Western 5.7 0.5 0.8 93.2 1,506 Education No education 6.9 0.3 7.5 86.7 4,860 Primary 6.1 0.0 3.4 90.6 960 Secondary or higher 3.1 0.1 0.7 96.4 1,554 Wealth quintile Lowest 6.6 0.0 9.9 84.7 1,382 Second 6.5 0.3 8.1 86.5 1,368 Middle 6.2 0.1 6.0 89.0 1,428 Fourth 6.8 0.5 4.0 90.1 1,472 Highest 4.2 0.3 0.8 94.7 1,723 Total 6.0 0.2 5.5 89.3 7,374 Characteristics of Respondents | 49 Table 3.9.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in past 24 hours, according to background characteristics, Sierra Leone 2008 Background characteristic Uses tobacco Does not use tobacco Number of men Number of cigarettes in the past 24 hours Total Number of cigarette smokers Cigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 9.0 0.0 0.9 90.9 526 (2.4) (13.2) (41.8) (15.3) (25.4) (2.0) 100.0 47 20-24 25.5 0.0 2.4 74.4 403 0.0 8.6 45.3 14.1 25.7 6.3 100.0 103 25-29 38.6 0.5 5.0 60.2 446 0.9 9.4 38.4 17.7 30.6 3.0 100.0 172 30-34 43.9 0.6 6.2 54.9 373 1.1 6.5 33.2 14.7 43.2 1.3 100.0 164 35-39 47.5 0.1 4.2 51.9 525 0.5 7.1 32.3 13.9 43.1 3.1 100.0 249 40-44 49.6 0.8 3.8 50.0 336 0.4 2.8 27.3 19.8 48.7 1.1 100.0 167 45-49 52.5 1.4 6.1 46.4 335 0.0 6.5 37.7 14.9 39.6 1.3 100.0 176 Residence Urban 22.5 0.1 2.7 76.6 1,123 0.8 8.1 31.4 14.2 43.4 2.1 100.0 253 Rural 45.3 0.6 4.6 54.2 1,822 0.6 6.7 36.3 16.3 37.6 2.5 100.0 825 Region Eastern 42.4 0.2 5.2 56.7 557 0.0 6.9 54.6 19.6 18.1 0.8 100.0 236 Northern 41.3 0.7 1.9 58.4 1,131 0.4 6.5 26.8 14.1 48.6 3.7 100.0 467 Southern 37.6 0.6 6.9 61.3 617 0.4 4.6 31.9 17.5 44.2 1.4 100.0 232 Western 22.3 0.0 3.3 76.9 639 2.7 13.0 35.9 12.3 33.4 2.7 100.0 143 Education No education 50.0 0.8 5.0 49.5 1,426 0.4 5.0 33.7 16.1 42.1 2.7 100.0 713 Primary 31.8 0.0 3.2 67.6 414 0.0 12.3 35.7 18.4 31.5 2.1 100.0 132 Secondary or higher 21.1 0.1 2.8 78.0 1,104 1.6 10.1 39.5 13.4 33.6 1.8 100.0 233 Wealth quintile Lowest 50.2 0.2 5.7 49.0 558 0.4 5.5 38.0 18.5 34.2 3.4 100.0 280 Second 43.0 1.3 5.6 56.2 520 0.4 7.0 35.6 13.6 40.9 2.4 100.0 224 Middle 44.7 0.2 3.7 54.6 530 0.0 7.5 34.1 14.9 41.6 1.9 100.0 237 Fourth 35.1 0.4 2.0 64.8 597 0.3 5.6 34.9 15.9 40.4 2.8 100.0 210 Highest 17.2 0.1 3.0 81.9 739 3.0 11.7 30.6 15.0 38.8 0.8 100.0 127 Total 15-49 36.6 0.4 3.9 62.7 2,944 0.6 7.0 35.2 15.8 39.0 2.5 100.0 1,078 50-59 41.6 1.4 5.0 55.8 336 1.0 4.3 19.8 25.0 46.9 3.0 100.0 140 Total 15-59 37.1 0.5 4.0 62.0 3,280 0.6 6.7 33.4 16.8 39.9 2.5 100.0 1,217 Note: Figures in parentheses are based on 25-49 unweighted cases. Fertility Levels, Trends, and Differentials | 51 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4 Fertility is one of the principal components of population dynamics that determine the size and structure of the population of a country. Fertility, unlike mortality and migration, has remained the most crucial factor associated with population change in Sierra Leone because of its persistent high levels. For over a generation, the total fertility rate (TFR) in Sierra Leone has been six children or more per woman. These high TFR levels are strongly tied to social, economic, and cultural factors that are yet to be fully understood. The UN fertility estimates also indicate that there has been little or no change in fertility levels in Sierra Leone since the early 1950s (United Nations, 2009). The increasing number of births per woman has come to be seen as the driving force behind the country’s population increases. The government of Sierra Leone recognized the potential drawbacks of high levels of fertility on the economy in its First National Development Plan (Sierra Leone Government, 1974). These efforts culminated in the formulation of a National Population Policy in 1988, government’s earliest population policy framework to address development issues, including fertility. The 2008 SLDHS was undertaken at a time when this long-standing trend of high fertility in Sierra Leone was well established. However, the survey provides information on fertility differentials that is essential for understanding the dynamics of fertility in Sierra Leone and the potential impact on population change. This chapter looks at a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women initiate childbearing. Information on current and cumulative fertility is essential in monitoring population growth. The data on birth intervals are important because short intervals are strongly associated with childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the mother and the child. Data on fertility were collected in several ways. Each woman interviewed was asked about all of the births she had had in her lifetime. To ensure completeness of responses, the duration of the pregnancy, the month and year the pregnancy ended, and the result of the pregnancy were recorded for each pregnancy. In addition, questions were asked separately about sons and daughters who live with the mother, those who live elsewhere, and those who have died. Subsequently, a list of all births was recorded along with the name of the child, age if still living, and age at death if dead. Finally, information was collected on whether women were pregnant at the time of the survey. 4.1 CURRENT FERTILITY The level of current fertility is one of the most important demographic indicators for determining the status of women and for health and family planning policy-makers because of its direct relevance to population policy and programmes. Current fertility is measured for the three-year period prior to the survey (mid-2005 to mid-2008). A three-year period was chosen because it reflects the most current information, while having a sufficient number of cases to allow statistical calculation of rates. The results by urban-rural residence are presented in Table 4.1. 52 | Fertility Levels, Trends, and Differentials Several measures of fertility are shown in this chapter. Age-specific fertility rates (ASFRs) are defined as the number of live births per thousand women in a specific age group. These rates were calculated by dividing the number of live births among women in a specific age group by the number of woman-years lived in that age group. The total fertility rate (TFR) is the sum of the ASFRs and is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed age- specific fertility rates. The general fertility rate (GFR) is the number of live births occurring during a specified period per 1,000 women age 15-49. The crude birth rate (CBR) is the number of births per 1,000 population during a specified period. The data in Table 4.1 show that the total fertility rate in Sierra Leone for the three years preceding the 2008 SLDHS survey was 5.1 births per woman. The results indicate that women in rural areas have an average of two more births (5.8) than women in urban areas (3.8). Overall, the fertility of rural women is almost 14 percent higher than the national average. The age pattern of fertility as reflected in the ASFRs indicates that childbearing begins early. Figure 4.1 shows that for the entire sample of women, fertility is relatively high among adolescents age 15-19 (146 births per 1,000 women). Fertility peaks at age 20-24 (222 births per 1,000 women) followed by a steady decline, which is expected. Figure 4.1 also shows that, when looking at residence, fertility reaches its peak in urban areas at age 25-29, while the peak in rural areas is at age 20-24. This indicates a slight delay in childbearing in urban areas. The data also show that for each age group, fertility is higher in rural areas than in urban areas. The urban-rural difference in fertility is most pronounced for women age 15-19 (94 births per 1,000 women in urban areas, compared with 185 births per 1,000 women in rural areas). Table 4.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Sierra Leone 2008 Age group Residence Total Urban Rural 15-19 94 185 146 20-24 187 244 222 25-29 192 229 217 30-34 148 208 187 35-39 99 167 145 40-44 35 88 71 45-49 4 48 36 TFR 3.8 5.8 5.1 GFR 138 202 179 CBR 27.3 33.4 31.5 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Fertility Levels, Trends, and Differentials | 53 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence Sierra Leone, 2008 , , , , , , ,) ) ) ) ) ) ) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 50 100 150 200 250 300 Births per 1,000 women Urban Rural Total) , Table 4.1 provides estimates of the General Fertility Rate (GFR) and the Crude Birth Rate (CBR). The general fertility rate (GFR), which refers to the number of live births occurring during a specified period per 1,000 women age 15-49, is estimated at 179 births per woman for the entire sample. There is considerable difference between rural and urban areas in the GFR. Rural areas have a GFR that is 46 percent higher than the GFR in urban areas (202 births per 1,000 women in rural areas, compared with 138 births per 1,000 women in urban areas). Finally, the crude birth rate (CBR) is the number of births per 1,000 population during a specified period. The overall CBR is 31.5 births. As with the other fertility rates, there is an urban- rural differential, with the rural rate being higher than the urban rate (33.4 births per 1,000 population, compared with 27.3 births per 1,000 population, respectively). 4.2 FERTILITY DIFFERENTIALS In this section, fertility is examined in terms of residence, region, education, and household wealth status (wealth quintile). Table 4.2 and Figure 4.2 present these differentials for three measures of fertility: total fertility rate, percentage of women who are currently pregnant, and mean number of children ever born to women age 40-49. 54 | Fertility Levels, Trends, and Differentials Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Sierra Leone 2008 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 3.8 6.5 4.9 Rural 5.8 9.0 5.8 Region Eastern 5.6 7.8 5.2 Northern 5.8 8.6 6.2 Southern 5.0 10.4 5.1 Western 3.4 5.1 4.7 Education No education 5.8 8.9 5.7 Primary 5.1 8.1 5.5 Secondary or higher 3.1 5.6 4.4 Wealth quintile Lowest 6.3 9.1 5.6 Second 5.8 10.2 5.9 Middle 5.8 9.4 5.7 Fourth 4.9 7.4 5.7 Highest 3.2 5.1 4.7 Total 5.1 8.1 5.5 Note: Total fertility rates are for the period 1-36 months preceding the survey. Figure 4.2 Total Fertility Rate by Background Characteristics Sierra Leone, 2008 5.1 3.8 5.8 5.6 5.8 5 3.4 5.8 5.1 3.1 6.3 5.8 5.8 4.9 3.2 SIERRA LEONE RESIDENCE Urban Rural REGION Eastern Northern Southern Western EDUCATION No education Primary Secondary or higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 1 2 3 4 5 6 7 Total fertility rate The Northern Region reported the highest TFR (5.8 births per woman), followed by the Eastern Region, which has a slightly lower TFR (5.6 births per woman), and then the Southern Region (5.0 births per woman). The Western Region has the lowest TFR (3.4 births per woman). In effect, women in the Northern Region have an average of 2.4 more children than their counterparts in the Fertility Levels, Trends, and Differentials | 55 Western Region. The disparity in childbearing between women in the Western Region and women in other regions may be the result of a number of social, cultural, and economic factors such as greater access to family planning services in the Western Region (which includes Freetown, the capital), compared with other regions. As expected, there is an inverse relationship between fertility and education, with uneducated women having almost twice as many births (5.8) as their counterparts with secondary or higher education (3.1). In other words, the fertility of women with no education is 87 percent higher that of women with secondary or higher education. Fertility levels are also related to household wealth status. The data suggest that women in the lowest wealth quintile have much higher fertility than those in the highest wealth quintile (6.3 births per woman, compared with 3.2 births per woman). Regarding the level of current pregnancy among women age 15-49, Table 4.2 shows that 8 percent of women reported being pregnant at the time of the survey. The variation in pregnancy levels by background characteristics is similar to that observed for total fertility rates. Table 4.2 also provides a rough assessment of trends in the various sub-groups by comparing current fertility with a measure of completed fertility: the mean number of children ever born to women age 40-49. The mean number of children ever born to older women who are nearing the end of their reproductive period is an indicator of average completed fertility for women who began childbearing during the three decades preceding the survey. If fertility remained constant over time and the reported data on both children ever born and children born during the three years preceding the survey are reasonably accurate, the TFR and the mean number of children ever born are expected to be similar. When fertility levels have been falling, the TFR will be substantially lower than the mean number of children ever born. The results show a completed fertility rate of 5.5 births per woman. Comparing the TFR with completed fertility reveals a slight decrease in fertility over the past few decades, from 5.5 to 5.1 births per woman. Whilst most of the results for sub-groups are consistent with this trend, fertility has increased somewhat among women in the Eastern Region, those with no education, and women in the lowest and middle wealth quintiles. The biggest increase is observed among women in the lowest wealth quintile who reported a 13 percent increase in fertility, from 5.6 to 6.3 births per woman. 4.3 FERTILITY TRENDS Trends in fertility over time can be examined by comparing age-specific fertility rates from the 2008 SLDHS for successive five-year periods preceding the survey, as shown in Table 4.3. Because women 50 years and over were not interviewed in the survey, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 35-39 for the period 15-19 years before the survey because these women would have been over age 50 at the time of the survey and therefore not eligible to be interviewed. The results in Table 4.3 show that fertility has declined among all age groups over the past ten years. However, fertility increased among all age groups between the period 15-19 years before the survey and the period 10-14 years before the survey, with the largest increase observed among women who were age 25-29 at the time of the birth. Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother’s age at the time of the birth, Sierra Leone 2008 Mother’s age at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 15-19 143 172 170 152 20-24 214 259 242 228 25-29 210 252 267 203 30-34 185 233 226 [232] 35-39 142 194 [218] 40-44 78 [146] 45-49 [35] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 56 | Fertility Levels, Trends, and Differentials 4.4 CHILDREN EVER BORN AND CHILDREN SURVIVING The number of children ever born, the mean number of children ever born, and the mean number of surviving children for all women and for those currently married, are presented in Table 4.4. Table 4.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born; and mean number of children ever born and mean number of living children, according to age group, Sierra Leone 2008 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 72.2 21.9 5.5 0.3 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,198 0.34 0.30 20-24 27.4 28.8 26.7 12.8 3.7 0.6 0.1 0.0 0.0 0.0 0.0 100.0 1,186 1.39 1.19 25-29 7.9 16.9 27.4 20.5 15.0 7.9 3.5 0.7 0.3 0.0 0.0 100.0 1,643 2.61 2.16 30-34 3.8 8.9 15.0 21.1 18.8 15.0 10.0 4.4 1.8 0.6 0.5 100.0 1,043 3.69 3.01 35-39 3.3 5.8 9.6 13.7 15.5 13.7 14.9 11.4 7.7 2.7 1.6 100.0 1,131 4.69 3.76 40-44 2.0 5.3 6.9 10.4 12.0 15.3 12.9 13.2 9.2 6.9 5.7 100.0 652 5.41 4.16 45-49 3.0 3.1 8.4 9.5 13.6 9.7 12.4 12.9 10.2 6.5 10.8 100.0 520 5.70 4.32 Total 19.3 14.8 16.1 13.4 11.0 8.1 6.5 4.6 3.0 1.6 1.6 100.0 7,374 2.98 2.40 CURRENTLY MARRIED WOMEN 15-19 38.3 46.5 14.1 1.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 100.0 359 0.78 0.72 20-24 13.0 29.7 33.7 17.7 4.9 0.9 0.1 0.0 0.0 0.0 0.0 100.0 812 1.75 1.50 25-29 5.2 15.2 27.4 22.1 16.2 8.7 4.0 0.8 0.3 0.0 0.0 100.0 1,429 2.77 2.30 30-34 2.1 7.9 14.1 21.3 20.2 16.1 10.8 4.4 1.9 0.6 0.5 100.0 899 3.84 3.14 35-39 2.9 5.2 9.3 14.3 15.6 13.9 14.7 11.3 8.2 2.9 1.6 100.0 1,022 4.75 3.82 40-44 1.8 4.3 6.7 10.2 12.4 15.6 12.8 13.5 9.1 7.8 5.8 100.0 572 5.52 4.25 45-49 3.0 2.6 8.9 10.1 13.4 9.3 11.9 12.4 10.6 6.1 11.6 100.0 431 5.72 4.39 Total 7.1 14.2 18.4 16.3 13.4 9.9 7.8 5.4 3.7 1.9 1.9 100.0 5,525 3.55 2.86 Data on the number of children ever born reflect the accumulation of births over the past 30 years and, therefore have limited relevance to current fertility levels, particularly when the country has experienced a decline in fertility. Moreover, the data are subject to recall error, which is typically greater for older than younger women. Nevertheless, the information on children ever born (or parity) is useful in looking at a number of issues. The parity data show how average family size varies across age groups. The percentage of women in their forties who have never had children provides an indicator of the level of primary infertility (the inability to bear children). Comparison of differences in the mean number of children ever born and surviving reflects the cumulative effects of mortality during the period in which women have been bearing children. The data show that 72 percent of young women age 15-19 have never given birth. This implies that about 28 percent of these teenagers have already had at least one birth. The percentage of women with no children decreases rapidly to 8 percent among women age 25-29, and by age 40 only about 2 percent of women are childless. This indicates that childbearing is nearly universal among women in Sierra Leone. At the time of the survey, 19 percent of all women were childless. On average, women nearing the end of their reproductive years have attained a parity of 5.7 children, which is higher than the total fertility rate of 5.1 births per woman. Similar patterns are observed for currently married women. At the time of the survey, less than one in ten currently married women (7 percent) were childless. Again, this suggests that childbearing is universal among Sierra Leonean women. The mean number of children ever born is higher for currently married women (3.6 children) than for all women (3.0 children). This difference is due to the substantial proportion of young and unmarried women in the latter group. Fertility Levels, Trends, and Differentials | 57 Table 4.4 shows that the mean number of children surviving increases with age for both all women and currently married women, a pattern similar to that observed for children ever born. The mean number of children surviving is also similar for both groups of women. 4.5 BIRTH INTERVALS Birth interval is the length of time between two successive live births. Information on birth intervals provides insight into birth spacing patterns, which affect fertility as well as maternal, infant and childhood mortality. Studies have shown that short birth intervals are associated with increased risk of death for mother and child, particularly when the birth interval is less than 24 months. The Sierra Leone National Population Policy recommends a birth interval of at least 24 months for Sierra Leonean women. Table 4.5 shows the percent distribution of non-first births in the five years preceding the survey by number of months since the preceding birth, according to various background characteristics. Table 4.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth; and median number of months since preceding birth, according to background characteristics, Sierra Leone 2008 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 10.3 19.4 35.7 17.6 9.1 7.9 100.0 67 30.3 20-29 6.4 12.6 34.4 20.1 12.6 13.9 100.0 2,148 35.0 30-39 4.7 10.4 31.4 20.0 11.5 22.1 100.0 1,921 38.1 40-49 7.0 14.3 22.9 20.4 9.7 25.7 100.0 511 39.3 Sex of preceding birth Male 6.4 12.4 31.1 19.5 11.9 18.8 100.0 2,365 36.1 Female 5.2 11.5 32.8 20.6 11.7 18.2 100.0 2,282 36.4 Survival of preceding birth Living 4.2 11.2 32.4 20.6 12.3 19.4 100.0 3,889 37.2 Dead 14.1 15.9 29.5 17.2 9.2 14.0 100.0 758 31.0 Birth order 2-3 5.0 12.0 31.5 19.4 12.8 19.3 100.0 2,150 36.9 4-6 5.8 11.5 32.0 20.3 12.2 18.2 100.0 1,857 36.4 7+ 8.2 13.3 33.0 21.5 7.3 16.8 100.0 641 34.2 Residence Urban 5.8 8.3 27.5 20.3 13.2 24.9 100.0 1,166 40.1 Rural 5.8 13.2 33.4 20.0 11.3 16.4 100.0 3,481 35.3 Region Eastern 7.0 10.8 33.6 20.4 10.3 17.9 100.0 929 35.6 Northern 5.0 11.7 33.2 20.4 12.3 17.3 100.0 2,177 36.1 Southern 7.5 15.8 31.5 19.9 9.8 15.4 100.0 963 33.8 Western 3.8 8.5 24.9 18.2 15.4 29.2 100.0 579 43.6 Education No education 6.2 12.5 32.7 20.2 12.1 16.4 100.0 3,731 35.6 Primary 4.5 12.8 31.7 20.9 9.1 21.1 100.0 524 36.6 Secondary or higher 3.8 6.1 25.0 17.6 12.4 35.1 100.0 393 45.9 Wealth quintile Lowest 5.9 14.4 34.1 21.0 10.8 13.9 100.0 1,101 34.8 Second 5.6 13.1 34.5 17.9 12.0 16.9 100.0 1,006 35.0 Middle 7.2 12.0 32.3 21.4 10.4 16.6 100.0 1,073 35.5 Fourth 4.5 11.2 31.7 19.7 12.2 20.7 100.0 861 37.1 Highest 5.2 6.6 23.2 19.9 15.2 30.0 100.0 606 44.7 Total 5.8 12.0 31.9 20.0 11.8 18.5 100.0 4,648 36.2 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 58 | Fertility Levels, Trends, and Differentials The overall median birth interval in Sierra Leone is 36.2 months, 12.2 months higher than the birth interval of 24 months recommended in the National Population Policy. The median number of months since a preceding birth increases steadily with age, from a low of 30.0 months among mothers age 15-19 to a high of 39.3 months among mothers age 40-49. There is no marked difference in the length of the median birth interval by birth order or sex of the preceding birth. The data indicate that the longest birth intervals occur among women with secondary or higher education (45.9 months) and women in households in the highest wealth quintile (44.7 months). Table 4.5 also shows that urban women have longer birth intervals than their rural counterparts (40.1 and 35.3 months, respectively). Looking at regions, the shortest birth interval is reported by women in the Southern Region (33.8 months), while the longest interval is reported by women in the Western Region (43.6 months). Finally, Table 4.5 shows that less than one in five (18 percent) non-first births in the past five years were born less than 24 months after the preceding births. 4.6 AGE AT FIRST BIRTH Concerns about age at first birth have been raised by demographers and health providers not only because of its implications for fertility and reproductive health, but also for its implications regarding the overall health of both mother and child. Early exposure to childbearing can lead to increased fertility, especially in environments with low contraceptive prevalence. Early childbearing can also lead to clinical complications such as vesico-vaginal fistula. Table 4.6 shows the median age at first birth and the percentage of women who gave birth by exact ages, by five-year age groups. Table 4.6 Age at first birth Percentage of women age 15-49 who gave birth by specific exact ages, percentage who have never given birth, and median age at first birth, according to current age, Sierra Leone 2008 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 5.7 na na na na 72.2 1,198 a 20-24 12.8 39.9 57.9 na na 27.4 1,186 19.2 25-29 12.2 40.7 59.9 74.5 87.9 7.9 1,643 19.0 30-34 13.3 39.3 59.3 73.2 86.0 3.8 1,043 19.0 35-39 11.8 38.4 50.9 64.4 79.3 3.3 1,131 19.8 40-44 12.3 37.1 54.4 66.5 79.1 2.0 652 19.5 45-49 11.7 36.9 52.0 64.9 73.4 3.0 520 19.7 20-49 12.4 39.2 56.5 na na 9.1 6,176 19.2 25-49 12.3 39.0 56.2 69.9 82.9 4.7 4,990 19.3 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Childbearing begins early in Sierra Leone. The median age at first birth for women age 25-49 is 19.3 years, comparable to the median age at first birth for women age 20-49 (19.2 years). Further analysis of the data in Table 4.6 suggests that the median age at first birth is slightly lower among younger women (under 35 years) compared with older women (35 years and over), implying that more women are having births at younger ages. It should be noted that almost four in ten Sierra Leonean women have given birth before age 18, while over half (56 percent) have had a birth by age 20. Variation in the median age at first birth by background characteristics is presented in Table 4.7. Fertility Levels, Trends, and Differentials | 59 Table 4.7 Median age at first birth Median age at first birth among women age 20-49 years, according to background characteristics, Sierra Leone 2008 Background characteristic Age Women age 20-49 Women age 25-49 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban a 20.1 19.3 18.7 18.9 19.3 19.7 19.3 Rural 18.2 18.6 18.8 20.3 19.7 20.0 19.0 19.2 Region Eastern 18.7 19.1 20.2 20.3 20.3 19.2 19.5 19.7 Northern 18.5 18.5 18.5 19.8 19.7 20.1 18.9 19.0 Southern 18.0 18.8 19.0 20.2 19.2 20.5 19.0 19.2 Western a 20.6 19.2 18.7 19.2 19.2 19.9 19.5 Education No education 18.0 18.6 18.7 20.1 19.5 19.9 18.9 19.1 Primary 17.9 19.1 19.3 20.5 19.0 18.7 19.1 19.3 Secondary or higher a 22.0 20.0 18.4 20.1 19.7 a 20.2 Wealth quintile Lowest 18.2 19.0 19.2 20.4 21.2 20.0 19.3 19.5 Second 17.8 18.8 19.1 20.6 19.6 19.4 19.0 19.3 Middle 18.0 18.2 18.7 19.7 19.5 20.9 18.8 19.0 Fourth 19.4 18.9 17.7 19.6 19.0 19.5 19.0 18.9 Highest a 20.6 19.7 18.6 19.0 19.0 a 19.6 Total 19.2 19.0 19.0 19.8 19.5 19.7 19.2 19.3 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group The results indicate that there are no major differences in the median age at first birth by urban-rural residence. With respect to region, the onset of childbearing is earliest in the Northern Region (19.0 years), which is characterized by large family size, and the latest is in the Eastern Region (19.7 years). Increasing education leads to a delay in childbearing; the most profound effect was observed for women with secondary or higher education. No consistent pattern was seen regarding the effect of wealth on the onset of childbearing. 4.7 ADOLESCENT FERTILITY AND MOTHERHOOD Adolescent pregnancy and motherhood were identified by the Government of Sierra Leone as serious social, economic, and health risks for young girls (Sierra Leone Government, 1993). Early teenage pregnancy can cause severe health problems for both the mother and child. Moreover, an early start to childbearing greatly reduces the educational and employment opportunities of women and is associated with higher levels of fertility. There is ongoing concern about this matter on the part of the Sierra Leone Government and its partners involved in the reproductive health of young people. The government has formulated the National Reproductive Health Policy, which identifies the complications of pregnancy, child birth, and unsafe abortion as major causes of death among women age 15-19. Table 4.8 shows the percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and the total percentage who have begun childbearing, by background characteristics. The results indicate that 34 percent of all adolescent women age 15-19 have already had a birth or were pregnant with their first child at the time of the survey (28 percent had had a live birth and 6 percent were pregnant with their first child). Figure 4.3 shows the variation in adolescent childbearing by background characteristics. 60 | Fertility Levels, Trends, and Differentials Table 4.8 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Sierra Leone 2008 Background characteristic Percentage who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 7.1 4.2 11.3 230 16 15.7 5.1 20.8 230 17 25.7 3.2 28.9 168 18 39.1 8.0 47.2 339 19 45.1 9.1 54.2 231 Residence Urban 17.1 5.4 22.6 551 Rural 36.8 7.0 43.8 647 Region Eastern 32.2 5.7 37.9 229 Northern 32.6 6.9 39.6 460 Southern 29.5 7.8 37.4 239 Western 14.2 4.2 18.4 270 Education No education 46.3 8.1 54.4 409 Primary 27.6 6.3 33.9 315 Secondary or higher 11.9 4.6 16.5 474 Wealth quintile Lowest 42.5 6.9 49.4 182 Second 37.9 8.8 46.8 184 Middle 34.3 9.1 43.4 212 Fourth 25.9 5.7 31.6 257 Highest 12.8 3.3 16.1 363 Total 27.8 6.2 34.0 1,198 Figure 4.3 Percentage of Adolescent Women Who Have Begun Childbearing by Background Characteristics Sierra Leone, 2008 34 23 44 54 34 17 49 47 43 32 16 SIERRA LEONE RESIDENCE Urban Rural EDUCATION No education Primary Secondary or higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 10 20 30 40 50 60 70 Percentage of women age 15-19 Fertility Levels, Trends, and Differentials | 61 Adolescent childbearing is positively related to age, with 11 percent of women age 15 having begun childbearing compared with 54 percent of women age 19. Adolescent childbearing in rural areas is about twice as high as in urban areas (44 and 23 percent, respectively). By region, the proportion of teenagers who have begun childbearing ranges from 18 percent in the Western Region to 40 percent in the Northern Region. Education is negatively associated with adolescent fertility, with uneducated teenagers being more than three times as likely to have begun childbearing as those with secondary or higher education. Household wealth status is also negatively associated with adolescent fertility; teenagers in the poorest households are most likely to have begun childbearing. Family Planning | 63 FAMILY PLANNING 5 This chapter presents results from the 2008 SLDHS regarding aspects of contraceptive knowledge and past and current prevalence. Special attention is focused on the source of contraception, informed choice, non-use, and intention to use contraceptive methods in the future. The chapter also contains information on exposure to family planning messages through the media, contact with family planning providers, and husband’s knowledge of wife’s use of contraception. These topics are of practical use to policy-makers and programme administrators in formulating effective family planning strategies. Although the focus of this chapter is on women, some results from the male survey are discussed because men play an important role in the realization of reproductive goals. To get an indication of interspousal communication and the decision-making process regarding family planning in the household, the study compares the responses of men, where possible, with those of their wives. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS One major objective of the 2008 SLDHS was to assess the level of knowledge of contraceptive methods among women and men. Individuals who have adequate information about the available methods of contraception are better able to develop a rational approach to planning their families. Information on knowledge of contraception was collected in the survey by asking female and male respondents to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent had heard of it. Contraceptive methods are grouped into two types in the tables in this chapter: modern and traditional. Modern methods include female sterilization, male sterilization, the pill, intrauterine device (IUD), injectables, implants, male condom, female condom, foam/jelly, lactational amenorrhoea method (LAM), and emergency contraception. Traditional methods include the rhythm method (periodic abstinence) and withdrawal. Provision was made in the questionnaire to record any other methods, including folk methods named spontaneously by the respondent. Table 5.1 shows data on the level of knowledge of contraceptive methods among all women and men age 15-49, as well as among those who are currently married and those who are sexually active but not married, by specific methods. According to Table 5.1, 74 percent of all women have heard of a method of contraception, compared with 83 percent of all men. Knowledge of a modern method is more widespread than knowledge of traditional methods. For example, 69 percent of all women have heard of a modern method, compared with just 44 percent who have heard of a traditional method. Among all groups of women and men, the three best known methods are the pill, injectables, and the male condom. About six in ten women (61 percent) have heard of the pill, compared with about half (49 percent) of men. However, nearly six in ten women have heard of the male condom, compared with eight in ten men. The least well-known methods are implants, foam/jelly, emergency contraception, male sterilization, and LAM. In general, women are more likely to know about female- oriented methods such as the pill, IUD, and injectables and men are more likely to know about male- oriented methods such as male sterilization and male condoms. Exceptions are female sterilization, implants, foam/jelly, emergency contraception, and female condoms, which are better known to men than women. Men are more aware of the rhythm method and withdrawal (20 and 36 percent, respectively) than women (11 and 12 percent, respectively). However, sexually active unmarried women are more aware of the rhythm method than sexually active unmarried men (29 and 24 percent, 64 | Family Planning respectively). Women are much more likely to mention folk methods than men: 34 percent of all women, compared with 18 percent of all men. Awareness of specific family planning methods is similar for all women and for currently married women, but awareness of methods is markedly higher sexually active unmarried women. Similarly, sexually active unmarried men are generally more likely to have heard of specific methods, compared with all men and currently married men. Table 5.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who know any contraceptive method, by sex and specific method, Sierra Leone 2008 Method Women Men All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 74.4 72.8 91.1 83.3 85.3 87.6 Any modern method 68.7 66.2 88.1 82.1 83.7 87.0 Female sterilization 22.5 21.7 29.5 27.1 31.1 25.0 Male sterilization 6.7 5.9 13.0 14.6 15.9 16.9 Pill 60.8 58.7 81.4 49.1 52.0 54.3 IUD 26.1 22.4 52.0 19.4 20.3 21.1 Injectables 59.4 57.6 79.3 48.7 51.8 52.9 Implants 3.7 3.1 9.5 5.3 6.0 4.3 Male condom 58.4 54.7 83.1 80.1 81.6 85.6 Female condom 17.4 14.3 39.4 22.1 23.4 26.4 Foam/jelly 4.1 3.0 11.6 11.4 13.1 11.2 Lactational amenorrhoea method (LAM) 8.5 8.3 13.6 8.7 10.7 7.1 Emergency contraception 6.2 4.7 17.2 13.7 13.9 17.7 Any traditional method 44.4 45.4 55.1 44.5 48.8 50.8 Rhythm 10.6 8.3 28.9 20.0 20.6 23.7 Withdrawal 12.2 9.9 30.0 35.9 38.7 44.2 Folk method 34.3 37.7 29.5 17.6 21.2 16.3 Mean number of methods known by respondents 15-49 3.3 3.1 5.2 3.7 4.0 4.1 Number of respondents 7,374 5,525 551 2,944 1,767 402 Mean number of methods known by respondents 15-59 na na na 3.7 4.0 4.1 Number of respondents na na na 3,280 2,077 411 na = Not applicable 1 Respondent had sexual intercourse in the 30 days preceding the survey The mean number of methods known is a rough indicator of the breadth of knowledge of family planning methods. On average, currently married women, who have the greatest exposure to the risk of pregnancy, know at least three methods of contraception. Currently married men know at least four methods of contraception. Table 5.2 shows differentials in knowledge of any contraceptive method and any modern contraceptive method among currently married women and men by background characteristics. Knowledge of at least one method is high among men and moderately high among women. It is lower among currently married women and men in rural areas (68 and 81 percent, respectively) than among those in urban areas (85 and 96 percent, respectively). By region, knowledge of at least one method is lowest among women in the Northern Region (67 percent) and among men in the Northern and Southern regions (80 percent, each). Knowledge of at least one contraceptive method increases with level of education and wealth quintile for both women and men. For example, only 65 percent of women in the lowest wealth quintile have heard of any method of family planning, compared with 89 percent of those in the highest wealth quintile. Variation in knowledge of any modern method follows similar patterns to variation in knowledge of any method. Family Planning | 65 Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method, by background characteristics, Sierra Leone 2008 Background characteristic Women Men Has heard of any method Has heard of any modern method1 Number of women Has heard of any method Has heard of any modern method1 Number of men Age 15-19 58.2 48.6 359 * * 5 20-24 76.3 70.3 812 87.5 85.8 79 25-29 73.6 67.8 1,429 87.0 87.0 283 30-34 74.4 67.4 899 80.6 79.8 308 35-39 73.3 66.3 1,022 88.9 85.9 479 40-44 73.4 68.2 572 87.5 85.6 303 45-49 70.8 62.5 431 80.6 78.8 310 Residence Urban 84.8 81.3 1,561 95.7 95.0 517 Rural 68.1 60.2 3,965 81.0 79.0 1,250 Region Eastern 72.3 70.8 1,028 90.9 89.5 382 Northern 66.5 56.1 2,434 80.1 78.8 689 Southern 75.3 67.6 1,206 79.5 75.7 388 Western 87.8 87.4 858 97.5 97.5 308 Education No education 68.3 60.4 4,280 79.0 76.8 1,081 Primary 85.5 82.3 601 89.1 88.4 203 Secondary or higher 91.1 90.0 644 97.9 97.1 483 Wealth quintile Lowest 65.0 57.7 1,178 72.2 67.2 391 Second 63.7 55.3 1,144 80.8 79.1 370 Middle 69.2 58.9 1,186 85.8 85.3 350 Fourth 80.3 75.7 1,051 93.8 93.5 353 Highest 89.4 88.0 967 97.4 97.1 303 Total 15-49 72.8 66.2 5,525 85.3 83.7 1,767 50-59 na na na 77.7 77.3 310 Total 15-59 na na na 84.2 82.7 2,077 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed na = Not applicable 1 Female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, diaphragm, foam or jelly, lactational amenorrhoea method (LAM), and emergency contraception 5.2 EVER USE OF CONTRACEPTION Data on ever use of contraception has special significance because it shows the cumulative success of programmes promoting the use of family planning among couples. Ever use refers to use of a method at any time, with no distinction between past and present use. All respondents interviewed in the 2008 SLDHS who said that they had heard of a method of family planning were asked whether they had ever used that method. Men were only asked about ever use of methods that require male participation, i.e., male sterilization, male condom, rhythm method, and withdrawal. Table 5.3.1 shows the percentage of all women, currently married women, and sexually active unmarried women who have ever used specific methods of family planning, by age. Table 5.3.2 presents comparable information for men. Table 5.3.1 shows that only 21 percent of currently married women have ever used a contraceptive method, 19 percent have used a modern method, and 6 percent have used a traditional method. The methods most commonly used by currently married women are the pill (9 percent) and injectables (8 percent), followed by the male condom, LAM, and folk methods (each used by 4 percent of women). 66 | F am ily P la nn in g T ab le 5 .3 .1 E ve r u se o f c on tra ce pt io n: W om en P er ce nt ag e of a ll w om en , c ur re nt ly m ar rie d w om en a nd s ex ua lly a ct iv e un m ar rie d w om en a ge 1 5- 49 w ho h av e ev er u se d an y co nt ra ce pt iv e m et ho d by m et ho d, a cc or di ng to a ge , S ie rr a Le on e 20 08 A ge An y m et ho d An y m od er n m et ho d M od er n m et ho d An y tra di - tio na l m et ho d Tr ad iti on al m et ho d N um be r of w om en Fe m al e st er ili za - tio n M al e st er ili za - tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om Fo am / je lly LA M Em er - ge nc y co nt ra - ce pt io n Rh yt hm W ith - dr aw al Fo lk m et ho d AL L W O M EN 1 5- 19 13 .2 10 .7 0. 0 0. 0 4. 3 0. 4 1. 9 0. 0 4. 8 0. 5 0. 1 1. 2 0. 9 4. 3 1. 7 1. 6 2. 1 1, 19 8 2 0- 24 25 .5 21 .9 0. 0 0. 0 9. 2 0. 8 7. 0 0. 0 9. 2 0. 2 0. 2 2. 8 2. 1 10 .0 4. 0 5. 0 3. 0 1, 18 6 2 5+ 25 .6 22 .5 0. 1 0. 0 10 .8 1. 3 9. 6 0. 1 5. 1 0. 2 0. 1 3. 7 0. 9 7. 1 2. 0 1. 9 4. 2 4, 99 0 T ot al 23 .6 20 .5 0. 0 0. 0 9. 5 1. 1 7. 9 0. 1 5. 7 0. 2 0. 1 3. 1 1. 1 7. 1 2. 3 2. 3 3. 6 7, 37 4 C U RR EN TL Y M A RR IE D W O M EN 1 5- 19 6. 0 5. 7 0. 0 0. 0 1. 9 0. 0 0. 3 0. 0 1. 6 0. 5 0. 0 1. 5 0. 0 1. 0 0. 1 0. 5 0. 4 35 9 2 0- 24 17 .0 14 .1 0. 0 0. 0 5. 8 0. 7 5. 2 0. 0 4. 1 0. 2 0. 0 3. 3 0. 6 5. 7 1. 4 2. 3 3. 0 81 2 2 5+ 23 .5 20 .5 0. 0 0. 1 9. 7 1. 1 8. 9 0. 1 4. 4 0. 1 0. 1 3. 8 0. 7 6. 3 1. 4 1. 4 4. 2 4, 35 5 T ot al 21 .4 18 .6 0. 0 0. 0 8. 6 1. 0 7. 8 0. 1 4. 1 0. 1 0. 1 3. 5 0. 6 5. 9 1. 3 1. 4 3. 8 5, 52 5 SE XU A LL Y AC TI V E U N M A RR IE D W O M EN 1 1 5- 19 40 .9 31 .9 0. 0 0. 0 14 .6 0. 4 7. 7 0. 0 15 .5 2. 4 0. 0 1. 8 4. 9 18 .4 7. 7 7. 2 9. 6 18 6 2 0- 24 62 .1 55 .0 0. 0 0. 4 29 .6 0. 4 14 .8 0. 0 29 .2 0. 6 0. 0 0. 8 8. 7 29 .7 16 .9 15 .1 4. 8 15 7 2 5+ 53 .8 48 .7 0. 5 0. 0 26 .4 3. 1 16 .0 0. 7 15 .4 1. 0 0. 0 2. 6 3. 3 17 .9 9. 5 8. 1 5. 3 20 8 T ot al 51 .8 44 .8 0. 2 0. 1 23 .3 1. 4 12 .8 0. 3 19 .3 1. 4 0. 0 1. 8 5. 4 21 .4 11 .0 9. 8 6. 6 55 1 L A M = L ac ta tio na l a m en or rh oe a m et ho d 1 W om en w ho h ad s ex ua l i nt er co ur se in th e 30 d ay s pr ec ed in g th e su rv ey 66 | Family Planning Family Planning | 67 Ever use of any method is markedly higher among sexually active unmarried women than other women, with 52 percent of sexually active unmarried women having used a contraceptive method at some time, compared with 24 percent of all women. Sexually active unmarried women are much more likely to have used the male condom (19 percent) than either all women (6 percent) or currently married women (4 percent). They are also more likely to have used traditional methods, especially the rhythm method and withdrawal. Table 5.3.2 shows that less than one-third of all men between the ages of 15 and 49 have ever used a male-oriented method of contraception. Ever use is highest among sexually active unmarried men, 47 percent of whom have used a method, compared with 28 percent of currently married men and 30 percent of all men. As expected, the male condom is the most common method ever used among the male-oriented methods. It was used at some time by 21 percent of currently married men and 42 percent of sexually active unmarried men. Interestingly, higher proportions of men than women report having used the rhythm method and withdrawal. Table 5.3.2 Ever use of contraception: Men Percentage of all men, currently married men and sexually active unmarried men age 15-49 who have ever used any contraceptive method by method, according to age, Sierra Leone 2008 Age Any method Any modern method Modern method Any traditional method Traditional method Number of men Male sterili- zation Male condom Rhythm With- drawal ALL MEN 15-19 13.4 10.1 0.4 10.0 6.1 2.4 5.4 526 20-24 40.4 34.3 0.7 34.2 24.0 11.0 21.2 403 25+ 32.4 27.1 1.1 26.4 17.9 8.3 14.4 2,016 Total 15-49 30.1 25.1 0.9 24.6 16.6 7.6 13.7 2,944 50-59 19.9 13.9 1.8 12.8 13.4 6.4 9.5 336 Total 15-59 29.1 23.9 1.0 23.4 16.3 7.5 13.3 3,280 CURRENTLY MARRIED MEN 15-19 * * * * * * * 5 20-24 29.2 23.4 0.0 23.4 18.2 8.1 16.8 79 25+ 29.3 23.7 1.1 23.1 16.7 7.6 13.3 1,683 Total 15-49 29.4 23.7 1.1 23.1 16.8 7.7 13.5 1,767 50-59 18.7 12.9 1.9 11.7 12.5 6.7 8.6 310 Total 15-59 27.8 22.1 1.2 21.4 16.2 7.6 12.8 2,077 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 30.8 26.2 0.0 26.2 16.0 9.4 12.8 84 20-24 53.4 46.0 1.0 45.8 35.9 18.2 30.1 134 25+ 48.7 45.0 0.2 45.0 26.0 11.6 22.2 184 Total 15-49 46.5 41.4 0.4 41.3 27.2 13.3 22.9 402 50-59 65.1 56.1 0.0 56.1 49.5 9.0 40.5 10 Total 15-59 46.9 41.7 0.4 41.7 27.7 13.2 23.3 411 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Men who had sexual intercourse in the 30 days preceding the survey 5.3 CURRENT USE OF CONTRACEPTIVE METHODS This section presents information on the prevalence of contraceptive use among all women, currently married women, and sexually active unmarried women age 15-49. The level of current use is the most widely used and valuable measure of the success of a family planning programme. Furthermore, it can be used to estimate the reduction in fertility attributable to contraception. The contraceptive prevalence rate (CPR) is usually defined as the percentage of currently married women who are currently using a method of contraception. 68 | Family Planning Table 5.4 shows the percent distribution of all women, currently married women, and sexually active unmarried women who are currently using specific family planning methods by age. Table 5.4 Current use of contraception by age Percent distribution of all women, currently married women and sexually active unmarried women age 15-49 by contraceptive method currently used, according to age, Sierra Leone 2008 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Not currently using Total Number of women Female sterili- zation Pill IUD Inject- ables Male condom LAM Rhythm With- drawal Folk method ALL WOMEN 15-19 8.4 5.9 0.0 2.8 0.3 1.1 1.5 0.3 2.4 0.9 0.1 1.4 91.6 100.0 1,198 20-24 12.5 10.0 0.0 3.5 0.3 3.2 2.5 0.6 2.5 1.3 0.4 0.9 87.5 100.0 1,186 25-29 9.4 8.2 0.0 2.8 0.3 3.1 1.1 0.9 1.2 0.4 0.1 0.7 90.6 100.0 1,643 30-34 10.9 8.7 0.0 3.9 0.2 3.8 0.3 0.6 2.2 0.3 0.2 1.7 89.1 100.0 1,043 35-39 11.5 9.6 0.1 3.3 0.3 4.7 0.6 0.6 1.9 0.4 0.0 1.4 88.5 100.0 1,131 40-44 11.6 9.0 0.1 2.6 1.0 4.0 0.8 0.5 2.6 0.2 0.0 2.4 88.4 100.0 652 45-49 6.3 4.1 0.2 0.5 0.2 2.5 0.4 0.4 2.2 0.0 0.0 2.2 93.7 100.0 520 Total 10.2 8.2 0.0 2.9 0.3 3.2 1.1 0.6 2.0 0.6 0.1 1.3 89.8 100.0 7,374 CURRENTLY MARRIED WOMEN 15-19 1.2 1.2 0.0 1.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 98.8 100.0 359 20-24 5.5 4.8 0.0 1.7 0.1 1.5 0.6 0.8 0.7 0.2 0.0 0.5 94.5 100.0 812 25-29 7.7 6.8 0.0 2.1 0.2 2.7 0.8 1.0 0.8 0.1 0.0 0.7 92.3 100.0 1,429 30-34 9.8 7.7 0.0 3.5 0.2 2.9 0.4 0.6 2.1 0.2 0.2 1.7 90.2 100.0 899 35-39 10.9 9.2 0.0 3.3 0.3 4.8 0.4 0.5 1.6 0.4 0.0 1.2 89.1 100.0 1,022 40-44 11.7 8.8 0.0 2.7 0.7 3.9 0.9 0.6 2.9 0.2 0.0 2.7 88.3 100.0 572 45-49 6.6 4.1 0.2 0.3 0.2 2.6 0.5 0.4 2.4 0.0 0.0 2.4 93.4 100.0 431 Total 8.2 6.7 0.0 2.3 0.2 2.9 0.6 0.7 1.5 0.2 0.0 1.2 91.8 100.0 5,525 SEXUALLY ACTIVE UNMARRIED WOMEN1 15-19 31.4 20.5 0.0 10.1 0.4 4.0 6.1 0.0 10.9 3.5 0.0 7.4 68.6 100.0 186 20-24 46.3 33.7 0.0 13.7 0.0 11.5 8.5 0.0 12.6 8.0 1.3 3.4 53.7 100.0 157 25+ 26.0 21.1 0.5 9.6 2.1 6.7 2.3 0.0 4.9 2.6 0.5 1.7 74.0 100.0 208 Total 33.6 24.5 0.2 11.0 0.9 7.1 5.3 0.0 9.1 4.5 0.5 4.1 66.4 100.0 551 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method 1 Women who had sexual intercourse in the 30 days preceding the survey Table 5.4 and Figure 5.1 show that only 8 percent of currently married women are currently using some method of contraception. Modern methods of contraception account for almost all the use, with 7 percent of currently married women reporting using a modern method, compared with only 2 percent who are using a traditional method. Injectables (3 percent) and the pill (2 percent) are the most widely used methods among currently married women, followed by male condoms and LAM (each used by less than 1 percent of married women). Family Planning | 69 Figure 5.1 Current Use of Contraception among Currently Married Women Age 15-49 Sierra Leone, 2008 8.2 6.7 0 2.3 0.2 2.9 0.6 0.7 1.5 0.2 0 1.2 ANY METHOD ANY MODERN METHOD Female sterilization Pill IUD Injectables Male condom LAM ANY TRADITIONAL METHOD Rhythm Withdrawal Folk method 0 2 4 6 8 10 Percent LAM = Lactational amenorrhoea method Current use of modern methods is slightly higher among all women than among those who are currently married. However, current use is more than three times as high among sexually active unmarried women (25 percent) as among currently married women (7 percent) or all women (8 percent). The proportion of currently married women currently using a method of contraception rises with age from 1 percent of those age 15-19 to 12 percent among those age 40-44, after which it declines to 7 percent for the 45-49 age group. It is interesting to note that among married women, the pill and injectables are the two most commonly used methods in every age group except women age 45-49, for whom folk methods are the second most commonly used method after injectables. Among sexually active unmarried women—most of whom are under age 25 (62 percent)—pills, injectables, and the male condom are the most commonly used methods. 5.4 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS The study of differentials in current use of contraception is important because it helps identify subgroups of the population to target for family planning services. Table 5.5 presents information on the prevalence of current contraceptive use among currently married women by background characteristics. The data show that some women in Sierra Leone are more likely to use contraceptive methods than others. The proportion of currently married women using a contraceptive method increases with the number of children they have, from only 2 percent among those with no children to 12 percent among those with five or more children. Women in urban areas are more likely to use contraception (16 percent) than those in rural areas (5 percent). 70 | Family Planning Table 5.5 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Sierra Leone 2008 Background characteristic Any method Any modern method Modern method Any tradi- tional method Traditional method Not currently using Total Number of women Female sterili- zation Pill IUD Inject- ables Male condom LAM Rhythm With- drawal Folk method Number of living children 0 1.8 1.4 0.0 1.3 0.0 0.1 0.0 0.0 0.4 0.2 0.0 0.2 98.2 100.0 516 1-2 6.9 6.1 0.0 2.6 0.2 1.6 0.8 0.8 0.8 0.3 0.1 0.4 93.1 100.0 2,136 3-4 9.2 7.9 0.0 2.8 0.5 3.5 0.5 0.6 1.3 0.2 0.1 1.1 90.8 100.0 1,793 5+ 12.3 8.7 0.0 1.7 0.1 5.7 0.5 0.7 3.6 0.0 0.0 3.5 87.7 100.0 1,080 Residence Urban 16.2 14.2 0.0 5.6 0.7 5.6 1.5 0.8 2.0 0.7 0.1 1.2 83.8 100.0 1,561 Rural 5.0 3.8 0.0 1.1 0.1 1.8 0.2 0.6 1.2 0.0 0.0 1.2 95.0 100.0 3,965 Region Eastern 6.2 5.4 0.1 2.7 0.0 1.8 0.4 0.3 0.8 0.1 0.1 0.6 93.8 100.0 1,028 Northern 4.4 3.1 0.0 0.7 0.1 1.9 0.4 0.0 1.3 0.0 0.0 1.3 95.6 100.0 2,434 Southern 8.4 6.8 0.0 2.4 0.1 2.3 0.1 1.9 1.6 0.1 0.0 1.5 91.6 100.0 1,206 Western 21.2 18.6 0.0 6.6 1.1 7.7 2.1 1.1 2.5 0.9 0.1 1.5 78.8 100.0 858 Education No education 5.7 4.4 0.0 1.3 0.1 2.3 0.2 0.5 1.3 0.0 0.0 1.3 94.3 100.0 4,280 Primary 10.8 9.5 0.0 4.2 0.0 3.4 0.3 1.5 1.4 0.1 0.0 1.3 89.2 100.0 601 Secondary or higher 22.3 19.5 0.0 7.7 1.2 6.1 3.5 1.1 2.7 1.6 0.3 0.9 77.7 100.0 644 Wealth quintile Lowest 4.4 3.0 0.0 0.7 0.0 1.1 0.2 1.0 1.4 0.0 0.0 1.4 95.6 100.0 1,178 Second 3.5 2.7 0.0 0.6 0.0 1.4 0.2 0.4 0.8 0.0 0.0 0.8 96.5 100.0 1,144 Middle 4.6 3.3 0.0 1.0 0.2 1.5 0.2 0.4 1.3 0.0 0.0 1.3 95.4 100.0 1,186 Fourth 10.6 8.9 0.1 3.3 0.1 4.2 0.6 0.6 1.7 0.2 0.0 1.5 89.4 100.0 1,051 Highest 20.2 18.0 0.0 6.9 1.0 7.1 2.0 1.0 2.2 0.9 0.2 1.1 79.8 100.0 967 Total 8.2 6.7 0.0 2.3 0.2 2.9 0.6 0.7 1.5 0.2 0.0 1.2 91.8 100.0 5,525 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method Contraceptive use among currently married women is highest in the Western Region (21 percent) and lowest in the Northern Region (4 percent). Use of both modern and traditional methods increases with educational attainment, from 6 percent among currently married women with no education to 11 percent among those with primary education; more than one-fifth (20 percent) of currently married women with secondary or higher education are using a contraceptive method. Use of contraception also rises with wealth status, from 4 percent among married women in the two lowest wealth quintiles to 20 percent among those in the highest wealth quintile (Figure 5.2). 5.5 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION Couples generally use family planning methods to either limit family size or delay the next birth. Those who use family planning as a way to control family size (i.e., to stop having children) adopt contraception when they have reached the number of children they want. Those who see family planning as a way to delay the next birth use contraception to space births. Couples may start using family planning early, with the intention of delaying a pregnancy. This may be done before a couple has had their desired number of children. In a culture where smaller family size is becoming the norm, young women adopt family planning at an earlier age than their older counterparts. Family Planning | 71 Figure 5.2 Contraceptive Use among Currently Married Women by Residence, Level of Education, and Wealth Quintile Sierra Leone, 2008 16 5 6 11 22 4 4 5 11 20 RESIDENCE Urban Rural EDUCATION No education Primary Secondary or higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 5 10 15 20 25 Percent Women interviewed in the 2008 SLDHS were asked how many children they had at the time they first used a method of family planning. Table 5.6 shows the percent distribution of women by number of living children at the time of first use of contraception, according to current age. The results indicate that more women in Sierra Leone are adopting family planning at lower parities (i.e., fewer children) than before. This can be seen from younger women reporting first use of contraception when they have fewer children than older women. For example, 15 percent of women age 20-24 reported first using contraception before they had any children, compared with only 3 percent of women age 45-49. Older women are far more likely to have waited until they had children before using contraception, with the largest proportions starting to use contraception only when they had four or more children. Table 5.6 Number of children at first use of contraception Percent distribution of women age 15-49 by number of living children at the time of first use of contraception, according to current age, Sierra Leone 2008 Current age Has not used contra- ception Number of living children at first use of contraception Total Number of women 0 1 2 3 4+ Missing 15-19 86.8 10.3 2.4 0.1 0.0 0.0 0.5 100.0 1,198 20-24 74.5 15.1 6.0 3.3 0.6 0.0 0.6 100.0 1,186 25-29 77.2 6.5 6.3 5.1 2.5 1.7 0.7 100.0 1,643 30-34 70.0 7.2 6.2 5.5 4.5 5.9 0.7 100.0 1,043 35-39 73.6 3.4 3.9 4.2 4.0 10.5 0.4 100.0 1,131 40-44 71.5 3.8 4.6 2.1 3.2 14.2 0.6 100.0 652 45-49 79.7 2.6 3.0 2.5 2.4 8.8 1.0 100.0 520 Total 76.4 7.6 4.8 3.5 2.4 4.7 0.6 100.0 7,374 72 | Family Planning 5.6 KNOWLEDGE OF THE FERTILE PERIOD A basic knowledge of reproductive physiology provides a useful background for the successful practice of coitus-associated methods such as withdrawal and condoms. Such knowledge is particularly critical for the successful use of the rhythm method. The 2008 SLDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during the menstrual cycle. All women were asked, ‘From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual intercourse?’ If the answer was ‘yes,’ the respondent was further asked whether that time was just before her period begins, during her period, right after her period ends, or halfway be- tween two periods. Table 5.7 shows the results of those questioned for all women and for women who reported they were currently using the rhythm method. Among all women, about one in seven (14 percent) understand that a woman is most likely to conceive halfway between her menstrual periods. Nine percent wrongly identified the fertile period as right after a woman’s period has ended, and one-quarter of women said that there is no specific fertile time. Slightly less than half of women (46 percent) reported they do not know when the fertile period falls. As expected, women who are using the rhythm method are more likely than non-users to know that the fertile time in a woman’s menstrual cycle is halfway between periods, and less likely to say that there is no specific fertile time; however, the number of rhythm users is too small to draw meaningful conclusions. 5.7 SOURCE OF CONTRACEPTION Information on where women obtain their contraceptive methods is useful for family planning programme managers and implementers to enable proper logistics planning. In the 2008 SLDHS, women who reported using a modern contraceptive method at the time of the survey were asked where they obtained the method the last time they acquired it. Because some women may not know in which category the source they used falls (e.g., government or private, health centre or clinic), interviewers were instructed to write down the full name of the source or facility. Supervisors and field editors were told to verify that the name and source type were consistent, asking informants in the clusters for the names of local family planning outlets, if necessary. This practice was designed to improve the accuracy of source reporting. Table 5.7 Knowledge of fertile period Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Sierra Leone 2008 Perceived fertile period Users of rhythm method Non-users of rhythm method All women Just before menstrual period begins (9.9) 3.6 3.6 During menstrual period (0.0) 1.1 1.1 Right after menstrual period has ended (13.0) 9.4 9.4 Halfway between two menstrual periods (73.4) 13.7 14.1 Other (0.0) 0.1 0.1 No specific time (2.0) 24.9 24.8 Don’t know (1.7) 46.1 45.9 Missing (0.0) 1.1 1.1 Total 100.0 100.0 100.0 Number of women 42 7,332 7,374 Note: Figures in parentheses are based on 25 to 49 unweighted cases. Family Planning | 73 Table 5.8 shows that half of contraceptive users obtain their methods from the public sector. Government health centres are the most common public source (18 percent), followed by government family planning clinics (15 percent) and government hospitals (14 percent). Table 5.8 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of the method, according to method, Sierra Leone 2008 Source Pill Injectables Male condom Total Public sector 37.8 71.0 19.2 50.4 Government hospital 9.3 17.4 11.7 13.7 Government health centre 12.0 29.5 2.6 18.1 Family planning clinic 14.7 18.8 2.1 15.0 Mobile clinic 1.2 0.8 0.0 1.0 Fieldworker 0.6 4.1 2.9 2.4 Other public 0.0 0.4 0.0 0.2 Private medical sector 56.9 25.7 31.4 38.9 Private hospital/ clinic 6.8 9.3 2.2 8.4 Pharmacy 44.2 12.4 26.7 26.2 Private doctor 0.5 0.4 0.0 0.4 Private mobile clinic 1.5 1.1 2.0 1.3 Private fieldworker 0.7 0.9 0.5 0.7 Other private medical 3.3 1.7 0.0 2.0 Other source 1.7 0.0 39.1 6.4 Shop 1.2 0.0 0.3 0.5 Friend/relative 0.6 0.0 38.7 5.9 Other 0.5 0.5 6.6 1.4 Missing 3.1 2.8 3.7 2.9 Total 100.0 100.0 100.0 100.0 Number of women 217 233 82 560 1 Total includes 3 users of female sterilization, 25 users of the IUD and users of other modern methods, but excludes lactational amenorrhoea method (LAM). Thirty-nine percent of women use the private medical sector to obtain their contraceptive methods. Pharmacies (26 percent) account for the largest group of providers in the medical private sector. Eight percent of women obtain their methods from private hospitals and clinics. Six percent of women using a modern method of contraception get their method from other sources, mostly from friends or relatives. The type of source differs by method. Whereas over two-thirds of injectable users obtain their method from a government source, condom users are more likely to use ‘other’ sources (39 percent) or the private medical sector (31 percent) than a government source (19 percent). Over half of pill users get their method from private facilities (57 percent), but a sizeable portion (38 percent) depend on the public sector for this method. 5.8 INFORMED CHOICE Informed choice is an important tool for monitoring the quality of family planning services. Users of modern methods should be informed about the choices they have and the methods available to them. Family planning providers should inform all method users of potential side effects and what to do if they experience a problem. This information assists users in coping with side effects and decreases unnecessary discontinuation of temporary methods. 74 | Family Planning Current users of modern methods who are well informed about the side effects and problems associated with contraceptive methods and know the range of method options available are better placed to make an informed choice about the method they would like to use. Current users of modern contraceptive methods were asked whether, at the time they adopted the particular method, they were informed about the side effects or problems they might encounter with the method. Table 5.9 shows the percentage of current users of modern methods who were informed about the side effects of the method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed of other contraceptive methods they could use. Table 5.9 Informed choice Among current users of selected modern methods of contraception age 15-49 who started the last episode of use in the five years preceding the survey, the percentage who were informed about possible side effects or problems of the method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods they could use, by method and by initial source of method, Sierra Leone 2008 Method/source Among women who started last episode of use of modern contraceptive method in the past five years, percentage who were: Number of women Informed about side effects or problems of method used Informed about what to do if experienced side effects Informed by a health or family planning worker of other methods that could be used Method Pill 44.7 43.5 57.7 187 IUD * * * 16 Injectables 63.9 65.6 57.8 205 Initial source of method1 Public medical sector 64.8 66.0 64.1 246 Private medical sector 39.1 38.8 51.1 122 Other private sector * * * 21 Total 54.9 55.2 57.6 408 Note: Table includes only the contraceptive methods shown. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 19 women with information missing on initial source of method. 1 Source at start of current episode of use Over half (55 percent) of users of modern contraceptive methods were informed of the side effects or health problems that can be associated with the method they were provided and what to do if they experienced side effects. About six in ten (58 percent) users of modern methods were told of other methods that were available. The results indicate that injectable users are more likely than pill users to be told about side effects of the method (64 and 45 percent, respectively) and what to do if they experienced side effects (66 and 44 percent, respectively). An equal proportion (58 percent each) of pill users and injectables users were informed about other methods they might use. Regarding the source of supply, users who obtained their methods from public facilities— especially government health clinics—were more likely to be informed about the side effects or problems associated with their methods than were users who obtained their methods from the private medical sector. 5.9 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which non-users of contraception plan to use family planning in the future. Women who were not currently using a method of contraception were asked about their intention to use family planning in the future. The results are presented in Table 5.10. Family Planning | 75 Twenty-eight percent of currently married non-users say they intend to use family planning in the future. On the other hand, 48 percent do not intend to use family planning and 23 percent are unsure. The proportion of those intending to use varies with the number of living children, increasing from 16 percent for those with no child to a peak of 33 percent for those with four or more children. The proportion of currently married women who are not using any contraception and who do not intend to use in the future is highest among those with no children (61 percent). Table 5.10 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Sierra Leone 2008 Intention to use contraception Number of living children1 Total 0 1 2 3 4+ Intends to use 15.8 23.1 25.2 29.5 32.7 27.5 Unsure 21.2 24.6 26.2 22.0 21.0 23.0 Does not intend to use 60.9 51.3 47.7 47.2 45.0 48.3 Missing 2.1 1.0 0.8 1.3 1.4 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 386 920 1,076 925 1,766 5,072 1 Includes current pregnancy 5.10 REASONS FOR NOT INTENDING TO USE CONTRACEPTION Understanding the reasons women give for not using family planning methods is critical to designing programmes that improve the quality of services. Table 5.11 presents the main reasons for not intending to use contraception as reported by currently married women who are not using a method and who do not intend to use a contraceptive method in the future. Fourteen percent of non-users said they do not in- tend to use a contraceptive method in the future because they are opposed to family planning, and a similar proportion said that their husband or partner was opposed to family planning. The next most common reasons given for not intending to use contraception were fear of side ef- fects, desire for more children, and lack of knowledge of any method (11 percent, each). Other reasons given were infecundity/subfecundity (10 percent), religious prohibition (9 percent), menopause/hysterectomy (6 percent), and health concerns (3 percent). Interestingly, very few women cited lack of access to family planning or cost of family planning methods as the main reason they do not intend to use family planning. Table 5.11 Reason for not intending to use contraception in the future Percent distribution of currently married women age 15-49 who are not using contraception and who do not intend to use in the future by main reason for not intending to use, Sierra Leone 2008 Reason Percent Fertility-related reasons Infrequent sex/no sex 1.4 Menopausal/had hysterectomy 6.0 Subfecund/infecund 9.5 Wants as many children as possible 10.8 Opposition to use Respondent opposed 13.5 Husband/partner opposed 14.4 Others opposed 0.2 Religious prohibition 9.3 Lack of knowledge Knows no method 11.3 Knows no source 0.7 Method-related reasons Health concerns 3.4 Fear of side effects 10.8 Lack of access/too far 0.3 Costs too much 1.3 Inconvenient to use 0.5 Interfere with body’s normal process 1.3 Other 3.1 Don’t know 2.2 Total 100.0 Number of women 2,450 76 | Family Planning 5.11 PREFERRED METHOD FOR FUTURE USE Demand for specific methods can be assessed by asking non-users which method they intend to use in the future. Table 5.12 presents information on method preferences among currently married women who are not using contraception but say they intend to use in the future. Half of women who intend to use contraception in the future say they intend to use injectables, and around one- fourth (24 percent) plan to use the pill. Twelve percent of women intend to use folk methods, 3 percent intend to use female sterilization, and 2 percent intend to use male condoms. 5.12 EXPOSURE TO FAMILY PLANNING MESSAGES The mass media can be a powerful vehicle for conveying family planning messages. Information about the level of public exposure to a particular type of mass media allows policy-makers to use the most effective type of media for targeting specific groups in the population. To assess the effectiveness of such media on the dissemination of family planning information, all respondents in the SLDHS were asked whether they had heard or seen a family planning message in the past six months on the radio, on television, or in a newspaper or magazine. Women were also asked if they had seen family planning messages on billboards and posters. Table 5.13 shows that less than half of all women (47 percent) were recently exposed to family planning messages through at least one type of mass media, compared with 54 percent of men. There are large differences in exposure by type of media; for example, radio messages reach 46 percent of women and 54 percent of men, compared with television messages that reach only 6 percent of women and 9 percent of men. Coverage of family planning messages in the print media (newspapers and magazines) is intermediate between radio and television, reaching 6 percent of women and 14 percent of men. For all three media types, coverage is higher among those in urban areas than in rural areas. For example, women in urban areas are almost twice as likely as those in rural areas to have been exposed to family planning messages on the radio (64 and 36 percent, respectively). Regional differences highlight large differentials in exposure to family planning messages in the media, particularly on the radio, which is widely used in Sierra Leone. Slightly over one-third of women in the Eastern and Southern regions reported exposure to family planning messages on the radio, compared with more than two-thirds (73 percent) of women in the Western Region. Among men, exposure to family planning messages on the radio ranges from 42 percent in the Southern Region to 87 percent in the Western Region. Women and men in the Western Region are the most likely to report exposure to family planning messages on the television (24 and 33 percent, respectively). In the other regions the proportions are 3 percent or less. For both women and men, there are large differentials in exposure to family planning messages through the media by level of education. For example, 25 percent of women with at least some secondary school say they recently saw a family planning message in a newspaper or magazine, compared with less than 1 percent of those with no education. Similarly, striking differences in exposure to family planning messages occur by wealth quintile. Only 29 percent of women in the lowest wealth quintile heard a family planning message on the radio, compared with 72 percent of those in the highest wealth quintile. Differences are almost equally as strong for the other types of media. Similar patterns are observed for men. Table 5.12 Preferred method of contraception for future use Percent distribution of currently married women age 15-49 who are not using a contraceptive method but who intend to use in the future by preferred method, Sierra Leone 2008 Method Percent Female sterilization 2.6 Male sterilization 0.1 Pill 24.2 IUD 1.4 Injectables 50.3 Male condom 2.2 Female condom 0.1 Lactation amenorrhoea method (LAM) 0.2 Rhythm 0.4 Withdrawal 0.1 Folkloric method 11.8 Unsure 6.5 Total 100.0 Number of women 1,395 Family Planning | 77 Table 5.13 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on radio or television or in a newspaper/ magazine in the past few months, according to background characteristics, Sierra Leone 2008 Background characteristic Women Men Radio Television Newspaper/ magazine None of the three media Number of women Radio Television Newspaper/ magazine None of the three media Number of men Age 15-19 45.1 6.5 8.5 53.7 1,198 42.8 9.5 9.5 56.8 526 20-24 51.4 8.0 8.7 47.8 1,186 53.8 11.3 21.1 44.2 403 25-29 44.5 4.7 4.1 55.2 1,643 56.9 9.9 13.2 42.8 446 30-34 46.8 8.0 5.5 53.0 1,043 53.8 8.6 16.0 45.6 373 35-39 43.7 4.8 4.8 55.9 1,131 56.9 7.8 11.7 42.7 525 40-44 48.4 7.6 7.6 51.1 652 65.6 9.7 22.5 34.0 336 45-49 43.1 5.1 3.7 56.9 520 50.2 5.9 9.6 49.5 335 Residence Urban 63.7 15.1 14.5 35.2 2,655 73.7 21.7 32.6 24.8 1,123 Rural 36.3 1.3 1.4 63.5 4,719 41.5 1.2 3.1 58.4 1,822 Region Eastern 36.1 1.6 2.0 63.8 1,325 45.2 1.3 5.0 54.5 557 Northern 41.5 1.9 3.0 58.3 3,001 45.9 2.3 5.4 54.0 1,131 Southern 38.2 1.6 2.6 61.5 1,542 42.1 3.3 7.6 57.4 617 Western 72.5 23.8 19.7 25.8 1,506 86.6 33.1 44.8 11.6 639 Education No education 35.6 1.9 0.7 64.3 4,860 39.0 1.7 0.9 60.9 1,426 Primary 54.3 5.0 2.8 44.9 960 46.8 5.9 4.6 52.7 414 Secondary or higher 74.2 20.8 25.1 24.2 1,554 75.5 19.6 35.3 23.0 1,104 Wealth quintile Lowest 28.9 0.4 0.5 70.8 1,382 28.3 1.4 1.7 71.6 558 Second 34.5 0.5 1.1 65.5 1,368 40.7 1.1 2.0 58.9 520 Middle 35.5 1.3 1.8 63.9 1,428 51.3 0.7 3.2 48.7 530 Fourth 53.2 3.8 4.8 46.6 1,472 60.3 6.3 13.7 39.7 597 Highest 72.0 21.8 19.4 26.6 1,723 78.7 28.4 41.2 19.1 739 Total 15-49 46.2 6.3 6.1 53.3 7,374 53.8 9.0 14.4 45.6 2,944 50-59 na na na na na 48.4 8.0 10.6 51.6 336 Total 15-59 na na na na na 53.2 8.9 14.0 46.2 3,280 na = Not applicable All women in the 2008 SLDHS were asked if they had seen the following specific family planning messages on billboards and posters in the past 12 months: ‘Boku Born, Boku Losis’; ‘Have self control, value your body, respect yourself, avoid teenage pregnancy’; ‘Space the birth of your children,’ and ‘Children by choice, not by chance’. Figure 5.3 shows that, overall, less than half of all women (47 percent) have been exposed to at least one of these family planning messages during the past year (data not shown). The most frequently cited message is ‘Boku Born, Boku Losis’ (41 percent), followed by ‘Have self control, value your body, respect yourself, avoid teenage pregnancy’ (37 percent) and ‘Space the birth of your children’ (34 percent) messages. The least known message is ‘Children by choice, not by chance’ (27 percent). Fifty-three percent of women reported that they had seen none of these messages (data not shown). 78 | Family Planning Figure 5.3 Exposure to Specific Family Planning Messages Sierra Leone, 2008 41 37 34 27 Boku Born, Boku Losis Have self control Space the births Children by choice 0 10 20 30 40 50 Percentage of women 5.13 CONTACT OF NON-USERS WITH FAMILY PLANNING PROVIDERS In the 2008 SLDHS, women who were not using any family planning method were asked if they had visited a health facility in the past 12 months to obtain care for themselves or their children and, if so, whether any health worker at the facility spoke to them about family planning. These questions can assess the level of so-called ‘missed opportunities’ to inform women about contraception. The results shown in Table 5.14 indicate that only 14 percent of non-users visited a health facility where someone discussed family planning with them. Less than one in ten (7 percent) non- users discussed family planning with a health worker outside of a health facility, when the fieldworker visited them at home. These results imply that the majority of women (83 percent) who were not using a method of contraception had no discussion about family planning with a health professional during the 12 months preceding the survey, neither inside nor outside of a health facility, and 23 percent visited a facility in which no one discussed family planning with them. Family Planning | 79 Table 5.14 Contact of non-users with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the past 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who neither discussed family planning with a fieldworker nor with someone at a health facility, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who were visited by a fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who neither discussed family planning with a fieldworker nor with someone at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 4.0 8.4 17.3 89.4 1,098 20-24 8.5 16.5 26.7 79.1 1,039 25-29 8.0 18.3 23.2 78.4 1,490 30-34 6.9 14.3 26.4 81.7 930 35-39 6.0 13.6 22.7 83.5 1,001 40-44 6.0 9.1 21.8 87.0 577 45-49 7.4 7.4 21.8 88.0 487 Residence Urban 7.6 13.6 24.7 82.2 2,168 Rural 6.3 13.4 22.1 83.4 4,452 Region Eastern 6.2 11.3 30.1 85.1 1,238 Northern 5.9 14.4 17.6 83.5 2,823 Southern 7.9 13.4 24.6 81.9 1,391 Western 8.0 13.6 26.1 81.2 1,168 Education No education 5.7 13.0 21.9 84.1 4,576 Primary 9.0 16.2 25.6 79.6 854 Secondary or higher 9.3 13.5 24.8 81.3 1,191 Wealth quintile Lowest 5.6 10.6 22.5 87.0 1,317 Second 6.6 13.5 23.9 83.3 1,318 Middle 6.2 15.2 19.3 81.5 1,351 Fourth 8.0 16.2 22.3 79.6 1,292 Highest 7.4 11.9 26.5 83.7 1,343 Total 6.7 13.5 22.9 83.0 6,620 5.14 HUSBAND/PARTNER’S KNOWLEDGE OF WOMEN’S CONTRACEPTIVE USE Use of family planning methods is facilitated when couples discuss and agree on the issue. To assess the extent to which women use contraception without telling their partners, the 2008 SLDHS asked currently married women whether their husband/partner knew that they were using a method of family planning. Table 5.15 shows that nearly two-thirds (64 percent) of women reported that their husband or partner knows about their use of contraception, while about one-fifth (19 percent) said that their husband/partner did not know. Seventeen percent of married women using contraception said that they were not sure whether their spouse knows about their use of family planning. 80 | Family Planning Table 5.15 Husband/partner’s knowledge of women’s use of contraception Percent distribution of currently married women age 15-49 who are using a method of contraception by whether their husband/partner knows about their use of contraception, according to background characteristics, Sierra Leone 2008 Background characteristic Husband/partner’s knowledge of women’s use of contraception Total Number of women Knows1 Does not know Unsure whether knows/ missing Age 15-19 * * * 100.0 4 20-24 61.9 24.0 14.1 100.0 44 25-29 70.4 13.8 15.7 100.0 110 30-34 63.5 23.5 13.0 100.0 88 35-39 59.6 16.1 24.3 100.0 111 40-44 63.9 27.2 8.9 100.0 67 45-49 (60.6) (14.4) (24.9) 100.0 28 Residence Urban 66.6 16.1 17.3 100.0 254 Rural 59.6 23.0 17.4 100.0 200 Region Eastern 65.1 21.4 13.5 100.0 63 Northern 67.8 19.8 12.5 100.0 107 Southern 55.2 24.7 20.1 100.0 102 Western 65.1 14.9 20.0 100.0 181 Education No education 57.2 23.8 19.1 100.0 245 Primary 61.8 18.9 19.3 100.0 65 Secondary or higher 75.1 11.4 13.5 100.0 144 Wealth quintile Lowest 52.9 21.7 25.4 100.0 52 Second (62.9) (28.4) (8.7) 100.0 40 Middle 56.9 25.0 18.1 100.0 54 Fourth 63.0 23.1 13.9 100.0 112 Highest 68.6 12.7 18.7 100.0 195 Total 63.5 19.1 17.3 100.0 453 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. 1 Includes women who reported use of male sterilization, male condoms or withdrawal Communication about use of family planning appears to be somewhat better among urban couples than rural couples. A smaller proportion of rural women than urban women reported that their husband or partner was aware of their use of a contraceptive method (60 percent, compared with 67 percent). Similarly, a smaller proportion of women in the Southern Region (55 percent) reported that their spouse is aware of their use of contraception, compared with women in other regions (65 to 68 percent). In general, women with more education and those in the higher wealth quintiles are more likely than other women to say that their husband/partner knows that they are using a contraceptive method. 5.15 MEN’S ATTITUDES TOWARDS CONTRACEPTION The 2008 SLDHS assessed men’s attitudes toward contraception by asking male respondents whether they agreed or disagreed with two statements about family planning use: 1) contraception is women’s business and a man should not have to worry about it; and 2) women who use contraception may become promiscuous. This information is useful in formulating family planning programmes and policies targeted toward men because they play a key role in women’s reproductive health. Men’s attitudes towards family planning and specific contraceptive methods are important in developing educational activities designed to address some of their misconceptions and fears. The results are shown in Table 5.16. Family Planning | 81 Overall, men in Sierra Leone think they should take some responsibility regarding family planning, with slightly over half (58 percent) rejecting the statement that contraception is a woman’s business and men should not have to worry about it. However, more than one-fifth (22 percent) of men agree with the statement, and around one-fifth (19 percent) say they don’t know. Older men and those with at least some secondary education are more likely than other men to disagree with the statement that contraception is only a woman’s business. Similarly, urban men (64 percent) and those in the Western Region (67 percent) are more likely to disagree with the statement than men in rural areas or in other regions. The proportion of men who do not think that women alone should deal with family planning increases steadily as wealth quintile increases. With regard to the statement that women who use contraception may become promiscuous, almost one-third (32 percent) of men reject the statement; however, more than four in ten (42 percent) agree that women who use contraception may become promiscuous. Table 5.16 Male attitudes towards contraceptive use Percent distribution of men age 15-49 by two common attitudes regarding women’s use of contraception: ‘Contraception is women’s business’ and ‘Women who use contraception may become promiscuous,’ and by whether the man agrees with the attitudes, according to background characteristics, Sierra Leone 2008 Background characteristic Contraception is women’s business Total Women who use contraception may become promiscuous Total Number of men Agree Disagree Don’t know Missing Agree Disagree Don’t know Missing Age 15-19 14.9 40.8 44.2 0.1 100.0 24.3 26.6 48.9 0.2 100.0 526 20-24 19.5 58.6 21.9 0.0 100.0 40.8 29.8 29.4 0.0 100.0 403 25-29 24.2 61.5 14.3 0.0 100.0 49.1 32.9 17.8 0.1 100.0 446 30-34 25.0 60.8 14.2 0.0 100.0 45.0 33.9 20.9 0.2 100.0 373 35-39 25.7 60.8 13.2 0.3 100.0 44.1 32.2 23.4 0.3 100.0 525 40-44 26.1 67.5 6.1 0.3 100.0 46.9 38.0 15.0 0.1 100.0 336 45-49 22.0 65.5 11.2 1.3 100.0 46.6 34.0 17.9 1.5 100.0 335 Residence Urban 20.8 64.2 14.9 0.1 100.0 37.0 42.3 20.5 0.2 100.0 1,123 Rural 23.1 54.8 21.8 0.3 100.0 44.5 25.7 29.4 0.4 100.0 1,822 Region Eastern 27.4 57.5 15.0 0.1 100.0 42.1 31.7 26.2 0.1 100.0 557 Northern 17.8 58.3 23.3 0.6 100.0 46.2 23.4 29.7 0.7 100.0 1,131 Southern 24.9 50.3 24.8 0.0 100.0 33.6 34.0 32.2 0.2 100.0 617 Western 23.1 66.9 10.0 0.0 100.0 40.8 45.8 13.4 0.0 100.0 639 Education No education 25.1 55.4 19.4 0.2 100.0 44.6 27.9 27.2 0.3 100.0 1,426 Primary 21.6 42.6 34.8 0.9 100.0 36.3 21.2 41.6 0.9 100.0 414 Secondary or higher 18.8 68.1 13.1 0.1 100.0 39.7 41.5 18.7 0.1 100.0 1,104 Wealth quintile Lowest 25.3 49.6 25.0 0.1 100.0 39.6 28.4 31.9 0.0 100.0 558 Second 24.7 54.5 20.4 0.4 100.0 48.1 22.0 29.4 0.5 100.0 520 Middle 21.3 56.6 21.6 0.4 100.0 44.5 26.6 28.5 0.5 100.0 530 Fourth 21.1 60.8 17.8 0.2 100.0 39.1 35.3 25.1 0.5 100.0 597 Highest 19.8 66.9 13.2 0.1 100.0 38.5 43.1 18.3 0.1 100.0 739 Total 15-49 22.2 58.3 19.2 0.2 100.0 41.6 32.0 26.0 0.3 100.0 2,944 Proximate Determinants of Fertility | 83 PROXIMATE DETERMINANTS OF FERTILITY 6 Fertility levels in most populations can be affected by a number of factors that define a woman’s risk of becoming pregnant. These factors are marriage, sexual intercourse, postpartum amenorrhoea and abstinence from sexual relations, onset of menopause, and contraceptive use. This chapter addresses all of these determinants of a woman’s fertility except for contraception. Marriage is a principal indicator of women’s exposure to risk of pregnancy. Early age at marriage is usually associated with a longer period of exposure to the risk of pregnancy and higher fertility levels. The duration of postpartum amenorrhoea and postpartum abstinence that affect the length of time a woman is insusceptible to pregnancy determine birth spacing. Finally, the onset of menopause marks the end of a woman’s reproductive life. These factors taken together determine the length and pace of reproduction and are important in understanding fertility levels and differences. 6.1 CURRENT MARITAL STATUS The percent distribution of women and men by marital status at the time of the survey is presented in Table 6.1. The categories ‘married’ and ‘living together’ when combined are referred to as ‘currently married,’ while those who are divorced, separated, or widowed are referred to as ‘formerly married.’ Overall, 19 percent of women of childbearing age have never been married; 75 percent are either married or living together with a man; and the remaining 6 percent are divorced, separated, or widowed. The low proportion (1 percent) of women age 45-49 who have never been married indicates that marriage is largely universal in Sierra Leone. Divorce and separation (4 percent) are uncommon in Sierra Leone. Among men age 15-49 interviewed in the 2008 SLDHS, 37 percent have never been married; 60 percent are currently married or living with a woman; and 3 percent are separated, divorced, or widowed. Compared with women, a greater proportion of men have never been married (18 percentage points higher for men), while a somewhat smaller proportion are formerly married (3 percent of men, compared with 6 percent of women). Although women enter into marriage earlier than men, by age 35 a higher proportion of men are in a marital union then women. Women (10 percent) are more likely than men (5 percent) to report living together (informal union). 84 | Proximate Determinants of Fertility Table 6.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Sierra Leone 2008 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed WOMEN 15-19 69.0 23.7 6.2 0.1 0.7 0.2 100.0 29.9 1,198 20-24 28.5 57.6 10.8 0.3 2.1 0.6 100.0 68.4 1,186 25-29 7.2 75.8 11.2 0.9 3.9 1.0 100.0 87.0 1,643 30-34 6.8 76.8 9.4 0.6 4.6 1.8 100.0 86.2 1,043 35-39 1.8 79.3 11.0 0.7 3.6 3.5 100.0 90.3 1,131 40-44 2.6 76.4 11.4 0.3 2.4 7.0 100.0 87.8 652 45-49 1.3 73.9 9.2 0.5 3.0 12.1 100.0 83.0 520 Total 19.0 65.0 9.9 0.5 3.0 2.6 100.0 74.9 7,374 MEN 15-19 99.1 0.6 0.3 0.0 0.0 0.0 100.0 0.9 526 20-24 78.6 13.8 5.9 0.3 1.4 0.0 100.0 19.7 403 25-29 34.8 55.1 8.2 0.6 0.9 0.4 100.0 63.3 446 30-34 13.2 73.7 8.9 1.8 2.2 0.2 100.0 82.6 373 35-39 3.8 85.1 6.0 0.7 3.9 0.4 100.0 91.1 525 40-44 4.1 85.4 4.8 1.4 3.1 1.3 100.0 90.2 336 45-49 2.6 87.6 5.1 1.2 2.8 0.7 100.0 92.7 335 Total 15-49 36.8 54.6 5.4 0.8 2.0 0.4 100.0 60.0 2,944 50-59 2.5 89.6 2.7 1.7 2.0 1.6 100.0 92.3 336 Total 15-59 33.3 58.1 5.2 0.9 2.0 0.5 100.0 63.3 3,280 6.2 POLYGYNY Polygyny (the practice of having more than one wife) has implications for the frequency of exposure to sexual activity and, therefore, fertility. The extent of polygyny was measured by asking married women the question, ‘Does your husband/partner have any other wives besides yourself?’ For currently married men, the question was, ‘Do you have one wife or more than one wife?’ If more than one, he was asked, ‘How many wives do you have?’ Table 6.2.1 shows the distribution of women by number of co-wives, and Table 6.2.2 shows the distribution of men by number of wives, according to background characteristics. Overall, 37 percent of currently married women are in polygynous unions. Older women are more likely to be in polygynous unions than younger women. Polygyny is more prevalent in rural areas (42 percent) than in urban areas (27 percent). The regional distribution shows substantial variation in the prevalence of polygyny, with the Northern Region having the highest proportion (almost half) of women in polygynous unions, and the Western Region having the lowest proportion (18 percent). The proportion of women living in polygynous unions declines as level of education increases. Women with no education and those in the middle and fourth wealth quintiles are more likely to be in polygynous marriages than women in other sub-groups. Table 6.2.2 shows that 17 percent of men age 15-49 and 20 percent of men age 15-59 have two or more wives. In general, the variations in polygyny among men by background characteristics are similar to those observed for women. Proximate Determinants of Fertility | 85 Table 6.2.1 Number of women’s co-wives Percent distribution of currently married women age 15-49 by number of co- wives, according to background characteristics, Sierra Leone 2008 Background characteristic Number of co-wives Total Number of women 0 1 2+ Missing Age 15-19 69.3 26.8 2.9 1.0 100.0 359 20-24 69.6 24.9 3.4 2.1 100.0 812 25-29 64.3 26.9 6.8 2.0 100.0 1,429 30-34 58.3 28.6 10.7 2.4 100.0 899 35-39 56.3 29.7 11.7 2.3 100.0 1,022 40-44 53.7 28.9 15.1 2.3 100.0 572 45-49 47.6 31.2 19.1 2.2 100.0 431 Residence Urban 70.4 21.9 4.9 2.9 100.0 1,561 Rural 56.7 30.3 11.2 1.8 100.0 3,965 Region Eastern 66.3 26.3 6.4 1.0 100.0 1,028 Northern 50.0 35.0 13.6 1.5 100.0 2,434 Southern 65.0 23.6 8.6 2.8 100.0 1,206 Western 77.5 16.0 2.3 4.2 100.0 858 Education No education 57.0 30.1 11.0 1.9 100.0 4,280 Primary 66.9 25.9 4.8 2.4 100.0 601 Secondary or higher 78.3 15.2 3.4 3.2 100.0 644 Wealth quintile Lowest 62.6 29.8 5.8 1.8 100.0 1,178 Second 57.1 29.4 11.1 2.4 100.0 1,144 Middle 53.7 32.2 12.7 1.5 100.0 1,186 Fourth 55.9 30.1 12.3 1.6 100.0 1,051 Highest 75.6 16.3 4.5 3.6 100.0 967 Total 60.6 27.9 9.4 2.1 100.0 5,525 Table 6.2.2 Number of men’s wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Sierra Leone 2008 Background characteristic Number of wives Total Number of men 1 2+ Age 15-19 * * 100.0 5 20-24 97.8 2.2 100.0 79 25-29 94.2 5.8 100.0 283 30-34 87.4 12.6 100.0 308 35-39 79.1 20.9 100.0 479 40-44 78.0 22.0 100.0 303 45-49 72.8 27.2 100.0 310 Residence Urban 91.5 8.5 100.0 517 Rural 78.9 21.1 100.0 1,250 Region Eastern 85.2 14.8 100.0 382 Northern 75.1 24.9 100.0 689 Southern 83.2 16.8 100.0 388 Western 95.4 4.6 100.0 308 Education No education 78.1 21.9 100.0 1,081 Primary 83.7 16.3 100.0 203 Secondary or higher 92.2 7.8 100.0 483 Wealth quintile Lowest 81.9 18.1 100.0 391 Second 77.1 22.9 100.0 370 Middle 79.0 21.0 100.0 350 Fourth 81.0 19.0 100.0 353 Highest 96.1 3.9 100.0 303 Total 15-49 82.6 17.4 100.0 1,767 50-59 64.9 35.1 100.0 310 Total 15-59 79.9 20.1 100.0 2,077 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed 86 | Proximate Determinants of Fertility 6.3 AGE AT FIRST MARRIAGE Marriage in Sierra Leonean communities defines the point in a woman’s life when childbearing becomes socially acceptable. Women who marry early will have, on average, a longer period of exposure to pregnancy, often leading to a higher number of lifetime births. Information on age at first marriage was obtained by asking respondents the month and year, or age, when they started living with their first husband or wife. Table 6.3 shows the percentage of women and men who have married by specific ages, according to current age group. Over one-fifth of women age 20-49 are married by age 15, about six in ten are married by age 18 and seven in ten enter marriage by age 20. The median age at first marriage among women age 20-49 is 17.2 years. Women age 20-24 reported the highest age at first marriage (18.2 years), which is about one year later than for women in the other age groups. Among men age 20-49 years, there are no reported marriages by age 15, and only 9 percent are married by age 18; about one-fifth (19 percent) of men marry by age 20. The median age at first marriage among men age 25-49 years is 24.5 years, 7 years later than the median age for women, indicating a considerable time lag in marriage between women and men in Sierra Leone. The median age at first marriage among men does not vary much by age, but it appears to be somewhat higher among older men age 45-49 (25.8 years). Table 6.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Sierra Leone 2008 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 10.3 na na na na 69.0 1,198 a 20-24 19.3 47.9 62.2 na na 28.5 1,186 18.2 25-29 22.4 57.1 71.7 82.1 89.8 7.2 1,643 17.1 30-34 25.4 58.8 71.8 78.6 85.7 6.8 1,043 16.9 35-39 23.3 59.3 70.6 79.7 85.4 1.8 1,131 16.9 40-44 20.3 57.0 71.3 81.7 86.9 2.6 652 17.1 45-49 22.0 57.4 71.0 79.5 84.9 1.3 520 17.2 20-49 22.2 56.0 69.6 na na 9.3 6,176 17.2 25-49 22.9 57.9 71.3 80.5 87.0 4.7 4,990 17.0 MEN 15-19 0.0 na na na na 99.1 526 a 20-24 0.0 5.1 11.4 na na 78.6 403 a 25-29 0.0 9.7 22.2 35.4 53.6 34.8 446 24.4 30-34 0.0 11.6 20.6 38.7 58.5 13.2 373 23.6 35-39 0.0 9.1 22.5 34.9 56.4 3.8 525 24.2 40-44 0.0 8.9 16.8 30.9 51.2 4.1 336 24.8 45-49 0.0 8.9 19.4 29.8 42.4 2.6 335 25.8 20-49 0.0 8.9 19.1 na na 23.3 2,418 a 25-49 0.0 9.6 20.6 34.2 53.0 12.3 2,016 24.5 20-59 0.0 8.4 18.5 na na 20.8 2,754 a 25-59 0.0 8.9 19.7 32.9 51.4 10.9 2,351 24.8 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women or men married for the first time before reaching the beginning of the age group Proximate Determinants of Fertility | 87 Table 6.4.1 shows the median age at first marriage for women age 20-49 and age 25-49 by five-year age groups, according to background characteristics. Urban women marry about two years later than their rural counterparts; the difference varies from half a year among women age 35-39 to two and a half years among women age 25-29. As expected, marriage among women in the Western Region (19.6 years) occurs three and a half years later than among women in the Northern Region (16.1 years). Education is positively associated with age at first marriage, largely because women who are more educated spend a longer period of time in school. There is a difference of five years between age at first marriage among women with no education (16.4 years) and age at first marriage among women with secondary or higher education (21.4 years). Wealth appears to have no major effect on age at first marriage, except for women in the highest quintile, who have a much higher age at first marriage (19.4 years) than women in other wealth quintiles (16.3 to 16.9 years). Much of the variation in age at first marriage among women is also seen among men, especially when comparing five-year age groups, with men in the younger age groups marrying earlier than those in the older age groups. Men in rural areas marry at a somewhat younger age than men in urban areas, although the difference is not as pronounced as among women. Men in the Western Region have the highest age at first marriage, while men in the Northern Region have the lowest age at first marriage. There is a positive correlation between median age at marriage and level of education. For example, among men age 45-49, the difference in the age at first marriage between men with no education (25.4 years) and those with secondary or higher education (27.6 years) is more than two years. Table 6.4.1 Median age at first marriage: Women Median age at first marriage among women by five-year age groups, age 20-49 and age 25-49, according to background characteristics, Sierra Leone 2008 Background characteristic Age Women age 20-49 Women age 25-49 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban a 19.0 18.7 17.2 18.6 18.3 18.9 18.4 Rural 16.6 16.4 16.0 16.7 16.6 16.8 16.5 16.5 Region Eastern 18.3 17.1 17.2 17.2 16.6 17.3 17.3 17.1 Northern 16.7 16.1 15.9 16.2 16.3 16.4 16.2 16.1 Southern 16.9 16.9 16.4 17.5 17.6 17.8 17.1 17.1 Western a 21.4 19.8 17.6 18.9 18.9 a 19.6 Education No education 16.5 16.6 16.1 16.2 16.6 16.8 16.4 16.4 Primary 17.7 17.9 17.5 18.3 17.0 17.9 17.8 17.8 Secondary or higher a 22.8 22.8 19.0 21.2 20.7 a 21.4 Wealth quintile Lowest 16.9 16.8 16.0 16.8 17.0 16.6 16.6 16.6 Second 16.5 16.1 16.5 17.0 16.4 17.4 16.5 16.6 Middle 16.0 16.3 16.0 16.3 16.0 16.9 16.2 16.3 Fourth 18.4 17.4 16.3 16.9 17.5 16.5 17.3 16.9 Highest n 20.4 20.0 17.7 19.5 18.7 a 19.4 Total 18.2 17.1 16.9 16.9 17.1 17.2 17.2 17.0 Note: The age at first marriage is defined as the age at which the respondent began living with her first husband/partner. a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group 88 | Proximate Determinants of Fertility Table 6.4.2 Median age at first marriage: Men Median age at first marriage among men by five-year age groups, age 25-49 and age 25-59, according to background characteristics, Sierra Leone 2008 Background characteristic Age Men age 25-49 Men age 25-59 25-29 30-34 35-39 40-44 45-49 50-59 Residence Urban a 25.5 24.6 25.1 27.3 25.9 a a Rural 22.9 22.7 24.0 24.7 25.5 25.8 23.8 24.2 Region Eastern 22.4 24.5 24.1 25.2 26.0 24.9 24.4 24.5 Northern 23.6 22.3 23.2 23.1 25.1 25.4 23.2 23.6 Southern 24.7 23.0 24.4 24.6 27.7 29.5 24.6 a Western a 26.4 26.1 26.2 28.6 24.6 a a Education No education 22.7 22.7 23.9 24.9 25.4 25.8 23.8 24.2 Primary 24.2 24.2 23.9 25.6 25.7 27.0 24.5 24.8 Secondary or higher a 25.6 24.9 24.6 27.6 24.9 a a Wealth quintile Lowest 23.8 23.1 25.0 25.9 25.9 27.0 24.9 a Second 23.0 22.5 23.7 23.6 25.3 27.2 23.4 24.0 Middle 21.9 22.9 23.2 24.1 25.7 25.4 23.2 23.6 Fourth a 23.6 23.9 24.7 25.8 23.9 24.7 24.7 Highest a 26.0 25.8 25.7 28.5 24.7 a a Total 24.4 23.6 24.2 24.8 25.8 25.8 24.5 24.8 Note: The age at first marriage is defined as the age at which the respondent began living with his first wife/partner. a = Omitted because less than 50 percent of the men married for the first time before reaching the beginning of the age group 6.4 AGE AT FIRST SEXUAL INTERCOURSE Although age at marriage is often used as a proxy for first exposure to intercourse and the beginning of exposure to the risk of pregnancy, some women engage in sexual activity before marriage. The 2008 SLDHS gathered information on the timing of first sexual intercourse for both men and women, irrespective of marital status. Table 6.5 shows the proportion of women and men who had first sexual intercourse by specific ages. Twenty-seven percent of women age 20-49 had sexual intercourse by age 15, more than two- thirds were sexually active by age 18, and almost eight in ten women had experienced intercourse by age 20. The median age at first sexual intercourse among women age 20-49 is 16.1 years, which is more than one year below the median age at first marriage (17.2 years), suggesting that Sierra Leonean women generally have first sexual intercourse before their first marriage. Median age at first sexual intercourse does not vary much by women’s age. Overall, 8 percent of men age 20-49 had sexual intercourse by age 15, 39 percent by age 18, and 64 percent by age 20. The median age at first sexual intercourse among men age 20-49 (18.6 years) is two and a half years higher than the median age among women the same age (16.1 years). The median age at first sexual intercourse among men age 25-49 (18.7 years) is almost six years below the median age at first marriage (24.5 years), indicating that many Sierra Leonean men initiate sexual intercourse before marriage. Tables 6.6.1 and 6.6.2 show the median age at first sex by background characteristics for women and men. Women age 25-49 in rural areas begin sexual activity about one year earlier than their urban counterparts (15.8 years, compared with 16.9 years). Sexual activity among women begins earliest in the Northern Region (15.8 years) and latest in the Western Region (17.2 years). With respect to education, women with secondary or higher education begin sexual activity more than two years later (18.1 years) than those with no education (15.8 years). Likewise, women in the highest wealth quintile begin sexual activity about two years later (17.5 years) than women in the other wealth quintiles (15.7 to 16.0 years). Proximate Determinants of Fertility | 89 Table 6.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first intercourse, according to current age, Sierra Leone 2008 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number of respondents Median age at first intercourse 15 18 20 22 25 WOMEN 15-19 22.3 na na na na 34.6 1,198 a 20-24 26.8 66.8 83.0 na na 4.5 1,186 16.2 25-29 29.2 69.7 81.3 86.4 88.5 0.4 1,643 16.0 30-34 27.9 67.6 80.1 84.2 85.4 0.0 1,043 16.0 35-39 27.0 68.2 79.3 83.6 84.8 0.0 1,131 16.1 40-44 24.2 61.9 73.8 81.6 82.9 0.0 652 16.5 45-49 27.1 64.5 76.1 81.8 83.0 0.0 520 16.3 20-49 27.4 67.2 79.8 na na 1.0 6,176 16.1 25-49 27.6 67.4 79.1 84.2 85.7 0.1 4,990 16.1 15-24 24.6 na na na na 19.6 2,384 a MEN 15-19 11.4 na na na na 57.1 526 a 20-24 10.5 44.8 70.8 na na 14.9 403 18.3 25-29 8.8 43.4 69.1 87.0 91.2 4.0 446 18.4 30-34 8.2 42.6 68.1 86.9 91.6 0.0 373 18.5 35-39 7.9 40.7 65.1 82.8 89.6 0.0 525 18.6 40-44 4.5 30.8 57.4 78.7 85.5 0.9 336 18.9 45-49 4.3 29.2 52.2 76.7 83.0 0.5 335 19.7 20-49 7.6 39.2 64.4 na na 3.4 2,418 18.6 25-49 7.0 38.1 63.1 82.8 88.6 1.1 2,016 18.7 15-24 11.0 na na na na 38.8 929 a 20-59 7.1 37.5 62.2 na na 3.0 2,754 18.8 25-59 6.6 36.3 60.7 80.5 86.8 1.0 2,351 18.9 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Table 6.6.1 Median age at first intercourse: Women Median age at first sexual intercourse among women by five-year age groups, age 20-49 and age 25-49, according to background characteristics, Sierra Leone 2008 Background characteristic Age Women age 20-49 Women age 25-49 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban 17.3 16.7 17.2 16.5 18.1 16.9 17.0 16.9 Rural 15.6 15.7 15.7 15.9 15.9 16.0 15.8 15.8 Region Eastern 15.8 15.9 16.4 16.0 16.1 16.5 16.0 16.1 Northern 15.7 15.7 15.6 16.0 15.9 16.0 15.8 15.8 Southern 16.0 15.9 15.9 16.0 16.8 16.5 16.0 16.0 Western 17.7 17.0 17.7 16.6 18.1 16.7 17.3 17.2 Education No education 15.7 15.7 15.7 15.8 16.0 16.0 15.8 15.8 Primary 15.5 16.2 16.7 16.9 16.9 16.8 16.3 16.7 Secondary or higher 18.2 18.0 18.1 17.8 18.8 18.3 18.2 18.1 Wealth quintile Lowest 15.8 15.7 15.6 15.8 15.8 16.0 15.7 15.7 Second 15.7 15.8 15.9 16.1 16.0 16.0 15.9 15.9 Middle 15.5 15.7 15.9 15.8 15.9 16.4 15.8 15.8 Fourth 16.0 15.9 15.7 16.3 17.1 15.9 16.0 16.0 Highest 17.8 17.3 17.7 16.9 18.2 17.9 17.6 17.5 Total 16.2 16.0 16.0 16.1 16.5 16.3 16.1 16.1 a = Omitted because less than 50 percent of the women had intercourse for the first time before reaching the beginning of the age group 90 | Proximate Determinants of Fertility The data for men on median age at first intercourse show a different pattern from that observed for women, with almost no difference in the timing of first sexual activity between men in rural areas and those in urban areas. The lowest median age at first sexual intercourse among men age 25-49 is in the Southern Region (18.2 years) and the highest is in the Eastern and Northern regions (19 years each). No definite pattern is seen in the median age at first intercourse among men by level of education or wealth quintile. Table 6.6.2 Median age at first intercourse: Men Median age at first sexual intercourse among men by five-year age groups, age 20-59, age 25-49 and age 25-59, according to background characteristics, Sierra Leone 2008 Background characteristic Age Men age 20-59 Men age 25-49 Men age 25-59 20-24 25-29 30-34 35-39 40-44 45-49 50-59 Residence Urban 18.1 18.4 18.3 18.4 18.7 19.5 20.4 18.6 18.6 18.8 Rural 18.5 18.4 18.5 18.8 19.4 20.0 20.1 18.9 18.8 18.9 Region Eastern 18.9 18.5 18.8 19.3 19.5 19.8 20.3 19.1 19.0 19.1 Northern 18.6 18.7 18.7 18.7 19.7 20.0 20.3 19.1 19.0 19.3 Southern 17.6 18.0 17.8 18.1 18.3 19.2 19.0 18.3 18.2 18.4 Western 17.8 18.1 17.9 18.0 18.7 19.3 20.9 18.4 18.4 18.6 Education No education 18.2 18.4 18.6 18.3 19.8 19.8 20.2 18.8 18.7 18.9 Primary 18.7 18.1 18.6 18.2 19.2 19.1 20.4 18.8 18.6 18.8 Secondary or higher 18.3 18.4 18.1 19.3 18.7 19.7 19.9 18.7 18.7 18.8 Wealth quintile Lowest 17.6 18.0 18.6 19.1 19.4 19.2 19.9 18.8 18.8 18.9 Second 19.5 18.7 18.8 18.1 20.1 20.3 20.4 19.1 18.9 19.0 Middle 18.1 18.3 18.1 19.2 19.1 19.2 19.9 18.7 18.7 18.8 Fourth 18.3 18.5 19.0 18.6 18.8 19.6 20.6 18.8 18.8 18.9 Highest 18.2 18.5 18.1 18.4 18.6 19.8 20.2 18.5 18.6 18.7 Total 18.3 18.4 18.5 18.6 18.9 19.7 20.2 18.8 18.7 18.9 a = Omitted because less than 50 percent of the men had intercourse for the first time before reaching the beginning of the age group 6.5 RECENT SEXUAL ACTIVITY In the absence of contraception, the chances of becoming pregnant are related to the frequency of sexual intercourse. Thus, the information on sexual activity can be used to refine measures of exposure to pregnancy. All women and men were asked how long ago their last sexual intercourse occurred. Tables 6.7.1 and 6.7.2 show the percent distribution of women and men, respectively, by timing of last sexual intercourse, according to background characteristics. Forty-seven percent of women age 15-49 and 54 percent of men age 15-49 had sexual intercourse in the four weeks before the survey; 24 percent of women and 22 percent of men had been sexually active in the year before the survey but not in the month before to the interview; and 19 percent of women and 7 percent of men had not been sexually active for one or more years. A total of 6 percent of women and 13 percent of men reported that they had never had sexual intercourse. The proportion of women who were sexually active during the four weeks preceding the survey increases with age, from 30 percent among women age 15-19 to 57 percent among women age 40-44, and then decreases to 48 percent at age 45-49. As expected, women currently in union were much more likely to be sexually active in the four weeks preceding the survey than women who were formerly married or have never been married. Differences among women in the level of recent sexual activity by marital duration, residence, region, level of education, and wealth quintile are generally small; the largest differential is observed between women residing in the Southern Region (53 percent) and those in the Northern Region (42 percent). Proximate Determinants of Fertility | 91 Table 6.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Sierra Leone 2008 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years ago Missing Age 15-19 29.5 23.1 11.3 1.5 34.6 100.0 1,198 20-24 46.2 25.9 21.3 2.0 4.5 100.0 1,186 25-29 48.6 25.5 21.2 4.2 0.4 100.0 1,643 30-34 49.5 25.4 19.7 5.4 0.0 100.0 1,043 35-39 53.0 22.2 19.9 4.9 0.0 100.0 1,131 40-44 56.8 19.9 18.9 4.4 0.0 100.0 652 45-49 48.1 21.2 24.2 6.4 0.0 100.0 520 Marital status Never married 31.7 23.9 9.0 1.4 34.0 100.0 1,399 Married or living together 52.2 23.5 19.9 4.3 0.0 100.0 5,525 Divorced/separated/ widowed 24.1 27.9 42.0 6.0 0.0 100.0 450 Marital duration2 Married only once 51.2 23.5 20.7 4.5 0.0 100.0 4,219 0-4 years 45.6 28.1 22.6 3.7 0.0 100.0 905 5-9 years 51.4 21.4 23.7 3.6 0.0 100.0 1,051 10-14 years 52.2 24.1 19.0 4.8 0.0 100.0 851 15-19 years 52.1 23.5 18.9 5.4 0.0 100.0 637 20-24 years 54.9 20.2 19.4 5.6 0.0 100.0 430 25+ years 56.7 21.2 16.1 5.9 0.0 100.0 346 Married more than once 55.5 23.5 17.3 3.7 0.0 100.0 1,306 Residence Urban 47.2 25.7 13.9 3.0 10.2 100.0 2,655 Rural 46.3 22.8 22.2 4.4 4.3 100.0 4,719 Region Eastern 48.2 26.6 16.4 3.0 5.8 100.0 1,325 Northern 41.9 23.2 25.0 5.0 4.9 100.0 3,001 Southern 53.4 20.1 18.1 2.8 5.5 100.0 1,542 Western 47.6 26.7 11.3 3.5 11.0 100.0 1,506 Education No education 48.4 22.8 22.3 4.4 2.1 100.0 4,860 Primary 41.4 23.8 17.9 3.3 13.6 100.0 960 Secondary or higher 44.2 27.4 10.4 2.5 15.5 100.0 1,554 Wealth quintile Lowest 46.1 22.4 22.1 4.9 4.4 100.0 1,382 Second 43.7 24.1 24.1 4.2 3.8 100.0 1,368 Middle 46.5 23.0 21.5 4.5 4.5 100.0 1,428 Fourth 46.4 24.2 20.4 2.9 6.2 100.0 1,472 Highest 49.5 25.3 10.1 3.1 11.9 100.0 1,723 Total 46.6 23.9 19.2 3.9 6.4 100.0 7,374 1 Excludes women who had sexual intercourse within the past 4 weeks 2 Excludes women who are not currently married 92 | Proximate Determinants of Fertility Table 6.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Sierra Leone 2008 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the past 4 weeks Within 1 year1 One or more years ago Missing Age 15-19 16.3 20.2 6.5 0.0 57.1 100.0 526 20-24 44.8 30.0 8.0 2.3 14.9 100.0 403 25-29 58.5 24.6 5.3 7.6 4.0 100.0 446 30-34 67.1 19.2 7.0 6.7 0.0 100.0 373 35-39 68.4 19.9 5.9 5.8 0.0 100.0 525 40-44 65.4 18.3 7.6 7.8 0.9 100.0 336 45-49 67.3 19.0 6.6 6.5 0.5 100.0 335 Marital status Never married 32.4 24.1 6.7 1.6 35.3 100.0 1,085 Married or living together 66.8 19.8 6.5 6.9 0.0 100.0 1,767 Divorced/separated/ widowed 55.1 30.0 7.9 6.9 0.0 100.0 92 Marital duration2 Married only once 67.4 19.0 6.5 7.2 0.0 100.0 1,324 0-4 years 64.4 20.2 6.8 8.6 0.0 100.0 266 5-9 years 62.7 23.6 7.6 6.1 0.0 100.0 333 10-14 years 69.1 16.8 7.2 7.0 0.0 100.0 331 15-19 years 67.9 20.0 5.8 6.4 0.0 100.0 220 20-24 years 74.8 11.6 3.3 10.3 0.0 100.0 107 25+ years 80.3 10.9 3.0 5.8 0.0 100.0 67 Married more than once 65.1 22.1 6.6 6.2 0.0 100.0 443 Residence Urban 49.6 25.5 5.6 4.7 14.6 100.0 1,123 Rural 56.3 19.3 7.2 5.2 12.1 100.0 1,822 Region Eastern 55.4 21.4 8.1 4.1 11.0 100.0 557 Northern 50.6 20.8 6.5 5.5 16.6 100.0 1,131 Southern 63.5 14.4 4.4 5.8 11.9 100.0 617 Western 48.5 30.5 7.4 4.0 9.5 100.0 639 Education No education 60.3 19.5 7.5 6.1 6.6 100.0 1,426 Primary 47.4 17.2 4.4 3.7 27.4 100.0 414 Secondary or higher 47.7 26.1 6.3 4.0 15.9 100.0 1,104 Wealth quintile Lowest 57.1 18.5 8.6 5.0 10.7 100.0 558 Second 56.0 19.7 6.4 5.8 12.1 100.0 520 Middle 58.5 17.9 6.8 4.0 12.7 100.0 530 Fourth 53.3 21.4 5.7 6.1 13.5 100.0 597 Highest 46.6 28.3 5.8 4.1 15.2 100.0 739 Total 15-49 53.7 21.7 6.6 5.0 13.0 100.0 2,944 50-59 63.9 19.9 8.1 7.8 0.3 100.0 336 Total 15-59 54.8 21.5 6.7 5.3 11.7 100.0 3,280 1 Excludes men who had sexual intercourse within the past 4 weeks 2 Excludes men who are not currently married The proportion of men who were sexually active in the four weeks preceding the survey is higher than the proportion of women (54 percent, compared with 47 percent). The likelihood of recent sexual activity increases with age, peaking at 68 percent among men age 35-39. As with women, men who are currently in union are more likely to have been sexually active in the past four weeks than those who are not in union. Men who have been married for 20 years or more are more likely to have had recent sexual intercourse than those married for shorter durations. Men in urban areas are less likely to have had sexual intercourse in the recent past than those in rural areas (50 and 56 percent, respectively). The largest differentials in recent sexual activity are observed by region; 49 percent of men in the Western Region reported that they had had sexual intercourse in the four weeks preceding the survey, compared with 64 percent of men in the Southern Region. Men with no education are more likely to have had sexual intercourse recently than men with primary education or secondary or higher Proximate Determinants of Fertility | 93 education. By wealth quintile, recent sexual activity is lowest among men in the highest (richest) wealth quintile (47 percent); proportions for the other wealth quintiles range from 53 to 59 percent. 6.6 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea is defined as the period between childbirth and the re- turn of ovulation, generally approximated by the resumption of menstruation follow- ing childbirth. This period is largely deter- mined by the duration and intensity of breastfeeding. The risk of conception during this period is low. The duration of post- partum amenorrhoea and sexual abstinence following a birth jointly determine the length of the period of insusceptibility. Thus, women are considered insusceptible to the risk of pregnancy if they are amenorrhoeic and/or abstaining from sex following childbirth. Women who gave birth three years preceding the survey were asked about the duration of their amenorrhoea and sexual abstinence following each birth. Table 6.8 shows the percentage of births in the three years preceding the survey for which mothers were still postpartum amenor- rhoeic, abstaining, and insusceptible, by number of months since the birth. The results show that Sierra Leonean women are amenorrhoeic for a median of 10.8 months; they abstain from sexual intercourse for a median of 18.9 months, and they are insusceptible to pregnancy for a median of 19.2 months. In general, the proportion of women who are amenorrhoeic or abstaining decreases as time since the birth increases. The proportion of women who are amenorrhoeic drops from 85 percent in the first two months after the birth, to 38 percent at 12-13 months, and finally to 5 percent at 28-29 months after the birth. Almost all Sierra Leonean women (95 percent) abstain from sex during the first two months after a birth. Table 6.9 shows the median duration of postpartum amenorrhoea, abstinence, and insusceptibility by background characteristics. Younger women (under age 30) have a slightly longer median period of insusceptibility, mainly because of their longer duration of postpartum abstinence. Women living in urban areas have a shorter median duration of postpartum amenorrhoea than rural women, and a shorter median duration of postpartum abstinence; thus, their period of insusceptibility is shorter than that of rural women. There are slight variations by regions in the period of insusceptibility, with the longest period observed in the Northern Region (21.5 months) and the shortest period in the Southern Region (16.5 months). There is an inverse relationship between level of education and postpartum insusceptibility. The duration of postpartum insusceptibility is the longest among women with no education (19.6 months) and shortest among women with secondary or higher education (16.4 months). Similarly, the median duration of postpartum insusceptibility is longest among women in the four lowest wealth quintiles (18.5 to 20.3 months) and shortest among women in the highest wealth quintile (17.9 months). Table 6.8 Postpartum amenorrhoea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Sierra Leone 2008 Months since birth Percentage of births for which the mother is: Number of births Amenorrhoeic Abstaining Insusceptible1 <2 84.5 94.9 96.1 185 2-3 80.0 92.1 94.9 295 4-5 73.2 89.7 92.9 255 6-7 69.1 84.3 89.6 218 8-9 61.4 80.3 83.7 237 10-11 54.5 83.3 86.8 214 12-13 38.2 71.8 75.3 240 14-15 36.0 68.8 72.1 247 16-17 30.1 69.1 70.5 201 18-19 14.0 43.0 46.8 158 20-21 9.9 42.9 43.3 138 22-23 11.4 25.8 28.7 140 24-25 6.8 18.0 21.0 248 26-27 10.3 17.1 21.1 251 28-29 4.7 16.0 17.7 175 30-31 2.1 8.1 8.1 123 32-33 3.5 5.1 8.6 120 34-35 1.1 3.7 4.2 125 Total 37.6 56.3 59.1 3,569 Median 10.8 18.9 19.2 na Mean 12.1 18.6 19.5 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are still amenorrhoeic or still abstaining (or both) following the birth 94 | Proximate Determinants of Fertility Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Sierra Leone 2008 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother’s age 15-29 9.7 19.1 19.3 30-49 12.3 18.5 18.8 Residence Urban 8.6 18.7 18.8 Rural 11.7 19.1 19.4 Region Eastern 10.0 18.4 18.7 Northern 12.6 21.1 21.5 Southern 11.4 15.6 16.5 Western 6.7 18.7 18.7 Mother’s education No education 11.6 19.3 19.6 Primary 10.7 18.4 18.7 Secondary or higher 8.1 16.0 16.4 Wealth quintile Lowest 10.8 18.4 19.0 Second 11.5 20.0 20.3 Middle 11.3 19.0 19.3 Fourth 10.2 18.5 18.5 Highest 7.7 17.8 17.9 Total 10.8 18.9 19.2 Note: Medians are based on the status at the time of the survey (current status). 1 Includes births for which mothers are still amenorrhoeic or still abstaining (or both) following the birth 6.7 MENOPAUSE The risk of becoming pregnant declines with age. The term infecundity denotes a process rather than a well-defined event, and although the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a group of women. Table 6.10 presents data on menopause, an indicator of decreasing exposure to the risk of pregnancy (infecundity) for women age 30 and over. In the context of the available survey data, women are considered menopausal if they are neither pregnant nor postpartum amenorrhoeic and have not had a menstrual period for at least six months preceding the survey. The proportion of women who are menopausal increases with age from 4 percent among women age 30-34, to 57 percent among women age 48-49. Overall, 13 percent of women age 30-49 in Sierra Leone are menopausal. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Sierra Leone 2008 Age Percentage menopausal1 Number of women 30-34 3.7 1,043 35-39 5.1 1,131 40-41 12.9 399 42-43 23.5 174 44-45 31.6 335 46-47 33.5 123 48-49 57.2 142 Total 12.5 3,346 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 95 FERTILITY PREFERENCES 7 Information on fertility preferences is important for family planning programmes because it allows an assessment of the need for contraception, whether for spacing or limiting births, the extent of unwanted mistimed pregnancies, and the overall attitudes of women towards childbearing. Data on fertility preferences can also be a useful indicator of the future direction of fertility. In the 2008 Sierra Leone Demographic and Health Survey (SLDHS) currently married women and men were asked about their fertility preferences, including their desire to have another child, the length of time they would like to wait before having another child, and what they consider to be the ideal number of children. These data make it possible to quantify fertility preferences and, in combination with the data on contraceptive use, permit estimation of the unmet need for family planning, for both spacing and limiting births. However, caution should be exercised in the interpretation of data on fertility preferences because respondents’ reported preferences are, in most cases, hypothetical. They may be influenced by social pressure, and they are subject to change and rationalization. Nevertheless, information on future reproductive intentions is of fundamental importance in the development of population policies and in refining and modifying existing family planning programmes. 7.1 DESIRE FOR MORE CHILDREN In the 2008 SLDHS currently married women and men were asked whether they want to have another child, and if so how soon. Pregnant women, or men whose wives were pregnant at the time of the survey, were asked the same question but phrased differently to ensure that they understood that the question was not about the desire for the current pregnancy but for subsequent children. Table 7.1 shows fertility preferences and future reproductive intentions of currently married women and men by the number of living children. Twenty-eight percent of women want to have another child soon (within two years), 25 percent want another child after two or more years, and 3 percent say they want to have another child, but are undecided as to when. Thirty percent of currently married women want no more children, 8 percent are undecided about having another child, and a very small proportion (close to 0 percent) are sterilized. Four percent of women declared themselves to be infecund (Figure 7.1). These results indicate that there is a strong need for family planning services either for child spacing or limiting births. Table 7.1 also shows that there are differences in fertility preferences between men and women. Overall, 36 percent of currently married men want another child soon (within two years), compared with 28 percent of currently married women. Conversely, men are less likely than women to want no more children (17 and 30 percent, respectively); only 1 percent of men have been sterilized. The desire to stop (limit) childbearing—which includes those who want no more children and the small proportion sterilized—increases with the number of living children a woman has, from 2 percent among women with no children to 77 percent among women with six or more children. Women are more likely to want to limit childbearing at lower parities than men. For example, 14 percent of women with two children want to stop childbearing or are sterilized, compared with 7 percent of men. Similarly, 77 percent of women with six or more children want to stop childbearing or are sterilized, compared with 32 percent of men with six or more children. 96 | Fertility Preferences Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Sierra Leone 2008 Desire for children Number of living children1 Total 15-49 Total 50-59 Total 15-59 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 74.1 46.1 32.3 24.4 15.3 6.5 3.3 28.0 na na Have another later3 5.4 34.8 35.5 29.3 20.3 13.0 6.4 24.5 na na Have another, undecided when 1.6 5.0 4.2 3.6 2.6 1.3 1.0 3.2 na na Undecided 7.4 6.0 9.5 8.3 11.1 8.4 6.7 8.3 na na Want no more 2.1 4.2 13.5 29.2 45.2 62.8 76.5 30.3 na na Sterilized4 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 na na Declared infecund 6.2 2.8 3.4 2.8 4.2 5.3 3.9 3.8 na na Missing 3.1 1.0 1.6 2.4 1.2 2.7 2.1 1.8 na na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 0.0 Number 395 971 1,171 1,011 849 530 598 5,525 0 0 MEN5 Have another soon2 74.6 45.2 41.5 35.6 28.6 27.7 24.3 36.0 30.1 35.1 Have another later3 5.1 35.0 33.1 30.8 28.6 17.2 19.4 26.4 10.9 24.1 Have another, undecided when 0.0 3.2 5.1 4.6 5.0 4.7 3.5 4.1 2.8 3.9 Undecided 7.9 9.3 9.5 9.9 13.9 14.5 17.7 12.2 17.2 13.0 Want no more 4.0 2.8 5.7 15.6 20.4 31.9 30.7 16.9 31.4 19.1 Sterilized4 0.0 1.4 0.8 1.8 0.0 1.7 1.3 1.1 1.9 1.2 Declared infecund 0.0 0.3 0.3 0.0 0.7 0.0 0.0 0.2 1.8 0.4 Missing 8.5 2.8 4.0 1.7 2.8 2.3 3.1 3.1 3.8 3.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 90 253 324 297 255 221 328 1,767 310 2,077 Na = Not applicable 1 Includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 5 Number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Figure 7.1 Fertility Preferences among Married Women Sierra Leone, 2008 Have another soon 28% Have another later 25% Have another, undecide 3% Undecided 8% Want no more 30% Declared Infecund 4% Missing 2% Have another, undecided when Fertility Preferences | 97 7.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS Tables 7.2.1 and 7.2.2 show the desire to limit childbearing among currently married women and men by background characteristics. Table 7.2.1 shows that urban women are slightly more likely to want to limit childbearing than their urban counterparts (33 percent, compared with 29 percent). The desire to limit childbearing is highest among women in the Eastern Region (36 percent), followed closely by those in the Western Region (32 percent). Table 7.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children and background characteristics, Sierra Leone 2008 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 0.6 3.5 15.4 39.9 54.2 74.4 78.5 32.8 Rural 2.8 4.6 12.6 25.0 41.9 58.9 75.9 29.4 Region Eastern 8.0 5.6 16.6 34.4 52.6 73.8 86.2 35.8 Northern 2.0 4.3 9.7 22.5 38.4 58.7 75.0 28.7 Southern 0.0 3.9 13.8 25.4 45.4 57.9 71.1 27.6 Western 1.0 3.4 18.4 45.2 55.7 72.6 79.0 32.3 Education No education 1.8 4.8 12.3 26.7 42.8 60.0 74.7 30.2 Primary 3.1 2.6 13.3 34.3 44.1 79.6 87.8 29.5 Secondary or higher 3.0 3.4 20.1 39.9 66.3 76.4 85.1 32.5 Wealth quintile Lowest 2.7 2.3 11.0 23.5 44.8 55.4 77.3 26.9 Second 3.8 4.8 13.2 27.5 38.3 62.2 70.7 30.6 Middle 0.0 4.7 10.4 27.4 39.4 54.8 83.9 29.1 Fourth 3.8 4.3 15.8 28.9 45.5 73.4 70.0 32.5 Highest 0.8 5.6 17.5 41.1 64.5 72.9 87.0 33.5 Total 2.1 4.3 13.5 29.2 45.2 62.8 76.5 30.4 Note: Women who have been sterilized are considered to want no more children. 1 Includes current pregnancy Table 7.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Sierra Leone 2008 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 2.4 6.2 14.9 33.6 31.7 46.8 42.4 25.6 Rural 4.9 3.1 2.7 9.3 16.0 28.1 29.7 14.8 Region Eastern 0.0 4.5 5.3 10.6 21.1 35.7 43.6 18.4 Northern 6.2 0.0 2.0 6.7 11.1 22.4 20.6 11.5 Southern 4.2 3.3 2.9 17.4 21.3 32.6 46.2 18.9 Western 3.3 10.1 21.6 39.9 39.5 66.8 48.8 30.9 Education No education 4.9 1.3 3.7 7.2 16.7 24.1 25.1 13.0 Primary 0.0 0.0 2.9 14.2 36.3 57.3 39.7 21.2 Secondary or higher 4.3 10.7 13.4 37.3 22.5 41.4 53.2 27.9 Wealth quintile Lowest 3.6 0.0 3.7 5.2 21.0 18.5 32.0 12.6 Second 0.0 0.0 0.0 10.5 20.6 18.9 25.5 13.5 Middle 0.0 5.2 5.1 16.7 10.2 40.9 36.6 18.2 Fourth 16.0 4.6 1.5 10.2 18.7 44.6 30.9 17.3 Highest 3.6 9.7 21.8 45.8 35.8 56.7 49.7 30.9 Total 15-49 4.0 4.2 6.5 17.4 20.4 33.6 32.0 18.0 Note: Men who have been sterilized or who state in response to the question about desire for children that their wife has been sterilized are considered to want no more children. 1 Number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 98 | Fertility Preferences Table 7.2.2 shows that a much higher proportion of men in urban areas would like to limit childbearing (26 percent) than men in rural areas (15 percent). Men in the Northern Region were the least likely to want to limit childbearing (12 percent), while men in the Western Region were the most likely to want to limit childbearing (31 percent). Education has a role in the desire of women and men to limit childbearing. The proportion of women and men who want to stop childbearing is highest among those with secondary or higher education (33 percent of women and 28 percent of men); for women and men with no education, the proportions are 30 percent for women and 13 percent for men. Likewise, women and men in the highest (richest) wealth quintile are more likely than those in lower wealth quintiles to want to limit childbearing. 7.3 NEED FOR FAMILY PLANNING SERVICES The proportion of women who want to stop childbearing or who want to space their next birth is a crude measure of the extent of the need for family planning, given that not all of these women are exposed to the risk of pregnancy and some of them may already be using contraception. This section discusses the extent of the need for family planning and the potential demand for family planning services in Sierra Leone. Currently married fecund women who want to postpone their next birth for two or more years or who want to stop childbearing altogether but are not using a contraceptive method are considered to have an unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted. Similarly, amenorrhoeic women who are not using family planning and whose last birth was mistimed are considered to have an unmet need for spacing, and those whose last child was unwanted have an unmet need for limiting. Women who are currently using a family planning method are said to have a met need for family planning. The total demand for family planning consists of those who fall into the met need and unmet need categories. Table 7.3 shows the need for family planning among currently married women by background characteristics. Overall, 28 percent of married women in Sierra Leone have an unmet need for family planning, with a higher proportion with an unmet need for spacing births than with an unmet need for limiting births. Only 8 percent of women in Sierra Leone have a met need for family planning. If all currently married women who say they want to space or limit their children were to use a family planning method, the contraceptive prevalence rate would increase to 36 percent. Currently, 23 percent of the family planning needs of currently married women are being satisfied. Unmet need for family planning shows an inverted U-shaped pattern by age, increasing from 22 percent in age group 15-19 to a peak in age group 30-34 (34 percent), then declining steadily thereafter, reaching the lowest level in age group 45-49 (19 percent). Unmet need for spacing is generally higher among younger women, while unmet need for limiting is generally higher among older women. Unmet need is slightly higher among urban women (29 percent) than among rural women (27 percent), but both groups of women have higher levels of unmet need for spacing than for limiting. Because met need is substantially higher among urban women than rural women (16 percent, compared with 5 percent), the total demand for family planning is higher among urban women (45 percent) than among rural women (32 percent). Fertility Preferences | 99 Table 7.3 Unmet need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage for the demand for contraception that is satisfied, by background characteristics, Sierra Leone 2008 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 19.8 2.4 22.2 0.9 0.3 1.2 20.7 2.7 23.4 5.1 359 20-24 25.1 3.0 28.1 5.1 0.3 5.5 30.2 3.3 33.6 16.3 812 25-29 22.1 6.1 28.2 6.1 1.6 7.7 28.2 7.7 35.9 21.4 1,429 30-34 18.2 15.5 33.8 5.6 4.2 9.8 23.9 19.7 43.6 22.5 899 35-39 11.4 18.0 29.4 4.1 6.8 10.9 15.5 24.8 40.3 27.0 1,022 40-44 3.8 18.6 22.3 2.0 9.7 11.7 5.7 28.3 34.0 34.4 572 45-49 3.2 15.5 18.7 1.0 5.6 6.6 4.1 21.2 25.3 26.0 431 Residence Urban 16.1 12.5 28.6 9.0 7.3 16.2 25.1 19.7 44.8 36.3 1,561 Rural 16.5 10.7 27.2 2.5 2.5 5.0 19.0 13.2 32.2 15.6 3,965 Region Eastern 17.0 14.8 31.8 3.2 2.9 6.2 20.2 17.8 38.0 16.2 1,028 Northern 17.1 9.9 27.1 1.7 2.7 4.4 18.8 12.6 31.5 14.0 2,434 Southern 14.9 9.5 24.3 5.0 3.4 8.4 19.9 12.9 32.8 25.8 1,206 Western 15.8 12.8 28.5 12.3 8.8 21.2 28.1 21.6 49.7 42.6 858 Education No education 15.6 11.2 26.7 2.9 2.9 5.7 18.4 14.0 32.5 17.6 4,280 Primary 20.5 9.9 30.5 5.9 4.9 10.8 26.4 14.9 41.3 26.3 601 Secondary or higher 17.9 12.5 30.4 12.8 9.5 22.3 30.7 22.0 52.7 42.3 644 Wealth quintile Lowest 16.1 10.4 26.5 2.3 2.1 4.4 18.4 12.5 30.9 14.3 1,178 Second 16.8 10.9 27.8 1.6 1.9 3.5 18.4 12.9 31.3 11.3 1,144 Middle 16.3 11.4 27.7 2.3 2.3 4.6 18.5 13.7 32.3 14.1 1,186 Fourth 17.5 11.9 29.4 5.3 5.3 10.6 22.8 17.2 40.0 26.6 1,051 Highest 15.2 11.4 26.5 11.6 8.6 20.2 26.7 20.0 46.7 43.2 967 Total 16.4 11.2 27.6 4.3 3.9 8.2 20.7 15.0 35.8 22.9 5,525 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose current pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. Looking at regional differences, unmet need for family planning is highest in the Eastern Region (32 percent) and lowest in the Southern Region (24 percent). Women with primary and secondary or higher education have a higher unmet need (31 and 30 percent, respectively) than women with no education (27 percent). No pattern was seen in the relationship between unmet need for family planning and wealth quintile; however, women in the fourth quintile have the highest level of unmet need. 100 | Fertility Preferences 7.4 IDEAL FAMILY SIZE In the 2008 SLDHS, ideal family size was measured in two ways. Respondents who did not have any children were asked the number of children they would like to have if they could choose the exact number to have, and respondents who had living children were asked how many children they would like to have if they could go back to the time when they did not have any children and choose exactly the number of children to have. Even though these questions are based on hypothetical situations, they provide two measures. First, for men and women who have not yet started a family, the data provide an idea of future fertility. Second, for older and high parity women, the excess of past fertility over the ideal family size provides a measure of unwanted fertility. The results are presented in Table 7.4 for both women and men age 15-49. Table 7.4 Ideal number of children Percent distribution of women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to number of living children, Sierra Leone 2008 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN1 0 4.4 0.8 0.2 0.6 0.6 0.0 0.9 1.3 1 0.2 1.0 0.2 0.1 0.3 0.0 0.0 0.3 2 13.3 7.7 5.3 2.1 1.5 1.4 1.8 5.7 3 20.3 16.2 10.6 10.2 3.4 4.8 2.5 11.3 4 35.4 37.4 39.4 27.4 30.3 15.1 17.0 31.4 5 8.3 10.6 15.2 16.3 14.3 21.5 9.0 13.1 6+ 14.1 21.5 25.1 37.2 42.9 50.3 60.0 31.4 Non-numeric responses 4.0 4.7 4.0 6.2 6.9 7.0 8.8 5.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,426 1,338 1,347 1,103 921 589 650 7,374 Mean ideal number of children for:2 All women 3.9 4.5 4.8 5.2 5.6 6.1 6.5 5.0 Number 1,370 1,276 1,293 1,035 857 548 593 6,972 Currently married women 4.6 4.8 4.9 5.3 5.6 6.2 6.5 5.3 Number 379 917 1,121 945 787 496 546 5,190 MEN3 0 10.8 1.2 0.9 1.3 1.9 2.9 2.1 5.0 1 0.4 1.1 0.8 0.0 0.0 0.0 0.0 0.4 2 12.1 8.8 4.2 1.3 1.6 0.6 0.7 6.5 3 12.7 17.7 11.6 8.8 1.3 0.4 0.9 9.4 4 30.6 31.6 32.8 27.7 19.2 15.4 13.2 26.5 5 11.0 15.1 16.3 18.0 21.1 17.9 6.9 13.8 6+ 20.7 20.3 30.0 39.5 50.2 60.1 66.9 34.6 Non-numeric responses 1.8 4.3 3.4 3.4 4.8 2.8 9.3 3.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,101 352 356 313 264 228 329 2,944 Mean ideal number of children for men 15-49:2 All men 4.1 4.7 5.2 5.6 6.7 7.2 9.2 5.5 Number 1,081 337 344 302 252 222 299 2,837 Currently married men 4.8 5.0 5.4 5.6 6.7 7.3 9.2 6.4 Number 83 242 311 287 242 214 297 1,678 Mean ideal number children for men 15-59:2 All men 4.1 4.7 5.2 5.6 6.7 7.2 9.9 5.8 Number 1,086 346 363 331 280 252 444 3,128 Currently married men 4.9 5.0 5.3 5.6 6.7 7.3 10.0 6.8 Number 88 251 330 316 271 244 443 1,943 1 Includes current pregnancy 2 Respondents who gave non-numeric responses were excluded from the calculation of means 3 Number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Fertility Preferences | 101 The vast majority of women and men were able to provide a numeric response; only 5 percent of women and 4 percent of men did not give a numeric response but provided answers such as ‘any number,’ ‘it’s up to God,’ or ‘do not know.’ The data reflect a strong desire for large families among Sierra Leonean women and men. More respondents reported six or more children as ideal than any other number of children (31 percent of women and 35 percent of men). The next most common number reported as ideal is four children. Overall, the mean ideal number of children is higher for men (5.5 children) than for women (5.0 children). The 2008 SLDHS data show that the preferred family size for both sexes in Sierra Leone is higher than the four children suggested in the National Population Policy. Table 7.4 shows that the mean ideal family size increases with the number of living children for both women and men, from about four children among women with no children to almost seven children among those with six or more children, indicating the positive association between actual and ideal number of children. For men, ideal family size increases from four children among men with no children to at least nine children among those with six or more living children. Interestingly, more men than women with no children want to keep their status childless (11 percent of men, compared with 4 percent of women). This positive association between actual and ideal number of children may be due to two factors. First, to the extent that women and men are able to implement their fer- tility desires, those who want smaller families will tend to achieve smaller families. Second, some women and men may have difficulty admitting their desire for fewer children (if they could go back in time and begin childbearing again), and may report their actual number of children as their preferred number of children. Despite this tendency to rationalize the ideal number of children, the SLDHS data provide evidence of unwanted fertility, with nearly one- third of women (31 percent) and one-fourth of men (24 percent) who have six or more children wanting an ideal family size of less than six children. Similarly, among women with five children, one in five said they would prefer to have fewer children than they actually have. 7.5 MEAN IDEAL NUMBER OF CHILDREN BY BACKGROUND CHARACTERISTICS Table 7.5 shows the mean ideal number of children for all women age 15-49 by background characteristics. The mean ideal number of children increases with age from 4.1 children among women age 15-19 to 6.1 children among women age 45-49. Ideal family size is higher in rural areas (5.4 children) than urban areas (4.2 children); it is highest in the Northern Region (5.4 children) and the Southern Region (5.3 children), and lowest in the Western Region (3.8 children). Ideal family size decreases with increasing level of education; there is nearly a two-child difference between women with no education (5.5 children) and women with secondary or higher education (3.7 children). Like education, there is an inverse relationship between mean ideal number of children and household wealth status (wealth quintile), with women in the lowest (poorest) wealth quintile having the highest ideal number of children (5.7 children) and women in the highest (richest) wealth quintile having the lowest ideal number of children (3.9 children). Table 7.5 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Sierra Leone 2008 Background characteristic Mean ideal number of children Number of women1 Age 15-19 4.1 1,153 20-24 4.5 1,154 25-29 4.8 1,557 30-34 5.1 989 35-39 5.6 1,050 40-44 5.8 604 45-49 6.1 466 Residence Urban 4.2 2,551 Rural 5.4 4,421 Region Eastern 4.9 1,302 Northern 5.4 2,786 Southern 5.3 1,442 Western 3.8 1,442 Education No education 5.5 4,543 Primary 4.5 909 Secondary or higher 3.7 1,521 Wealth quintile Lowest 5.7 1,306 Second 5.5 1,255 Middle 5.3 1,352 Fourth 4.8 1,406 Highest 3.9 1,653 Total 5.0 6,972 1 Women who gave a numeric response 102 | Fertility Preferences 7.6 FERTILITY PLANNING STATUS The issue of unplanned and unwanted fertility was further investigated in the 2008 SLDHS by asking women age 15-49 a series of questions about each child born to them in the past five years, as well as any current pregnancy, to determine whether the birth or pregnancy was wanted then (planned), wanted later (mistimed), or not wanted at all (unplanned) at the time of conception. In assessing these results, it is important to recognize that women may declare a previously unwanted birth or current pregnancy as wanted; such rationalizations can result in an underestimate of the true extent of unwanted births. Table 7.6 shows the percent distribution of births (including current pregnancy) in the five years preceding the survey by planning status of the birth, according to birth order and age of mother at birth. The results indicate that 26 percent of births in Sierra Leone were not planned; 16 percent were mistimed (wanted later); and 10 percent were unwanted. There are no definite patterns in the proportion of births that are mistimed or unwanted by birth order, although the percentage of unwanted births is highest for births of order four and above. Among women, the percentage of unwanted births increases with age, from a low of 5 percent among mothers age 20-24 to a high of 42 percent among mothers age 45-49. As expected, mistimed births are most common among younger mothers. Eighteen percent of births to young women age 15-19 were mistimed and 11 percent were unwanted. Table 7.6 Fertility planning status Percent distribution of births among women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Sierra Leone 2008 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 71.3 15.9 10.5 2.3 100.0 1,285 2 80.3 13.9 4.7 1.1 100.0 1,289 3 77.7 14.5 5.2 2.6 100.0 1,087 4+ 65.3 16.7 15.0 3.0 100.0 2,748 Mother’s age at birth <20 69.8 17.7 10.9 1.6 100.0 1,073 20-24 77.2 15.3 5.3 2.2 100.0 1,737 25-29 73.2 17.1 7.1 2.6 100.0 1,578 30-34 67.8 14.4 14.2 3.5 100.0 1,100 35-39 68.5 12.4 17.2 1.9 100.0 659 40-44 56.7 14.7 25.3 3.2 100.0 228 45-49 (52.8) (5.2) (42.0) (0.0) 100.0 35 Total 71.6 15.6 10.4 2.4 100.0 6,409 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 7.7 WANTED FERTILITY RATES Using information on whether births occurring in the five years before the survey were wanted or not, a total ‘wanted’ fertility rate has been calculated. The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. The wanted fertility rate is calculated in the same manner as the conventional total fertility rate (TFR), except that unwanted births are excluded. A birth is considered wanted if the number of living children at the time of conception was less than the ideal number of children reported by the respondent. Women who did not report a numeric ideal family size were assumed to want all their births. These rates represent the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been prevented. A comparison of the total wanted fertility rate and the actual total fertility rate suggests the potential demographic impact of eliminating unwanted births (Table 7.7). Fertility Preferences | 103 Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Sierra Leone 2008 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 3.4 3.8 Rural 5.2 5.8 Region Eastern 5.0 5.6 Northern 5.1 5.8 Southern 4.5 5.0 Western 3.0 3.4 Education No education 5.1 5.8 Primary 4.6 5.1 Secondary or higher 2.8 3.1 Wealth quintile Lowest 5.7 6.3 Second 5.2 5.8 Middle 5.0 5.8 Fourth 4.3 4.9 Highest 2.9 3.2 Total 4.5 5.1 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. The total wanted fertility rate for Sierra Leone is 4.5 children, with is 0.6 children lower than the actual total fertility rate of 5.1 children. This implies that the total fertility rate could be reduced by 12 percent if unwanted births are eliminated. The gap between wanted and observed fertility is greatest among women living in rural areas, those in the Northern Region, women with no education, and those in the middle quintile. Infant and Child Mortality | 105 INFANT AND CHILD MORTALITY 8 This chapter presents information on levels, trends, and differentials in neonatal, post- neonatal, infant, child and under-five mortality The information provides mortality statistics to policymakers, programme managers and researchers for use in assessing the impact of health policies and programmes, and to identify sectors of the population that are at high risk. Estimates of infant and child mortality also serve as necessary parameters for population projections, particularly if the level of adult mortality can be inferred with reasonable confidence. Finally, indices of childhood mortality are widely accepted as indicators of the overall living conditions of a population. These rates are also crucial for monitoring progress towards the United Nations Millennium Development Goal (MDG) of reducing child mortality. 8.1 DEFINITION, METHODOLOGY, AND DATA QUALITY The primary causes of childhood mortality change as children age. A large component of early infant mortality is the result of congenital diseases and other biological factors related to conditions in early infancy. Child mortality (1-4 years), on the other hand, is primarily the result of environmental causes that are more susceptible to control, such as infectious diseases, malnutrition, and accidents. As under-five mortality declines over time, it is often observed that child mortality declines to a greater degree than infant mortality; this phenomenon is mainly the result of improvements in children’s environments brought about by public health interventions or general improvements in living standards (Sullivan et al., 1994). In this chapter, age-specific mortality measures are defined as follows: Neonatal mortality: the probability of dying in the first month of life. Post-neonatal mortality: the probability of dying between the neonatal period and the first birthday; calculated as the difference between infant and neonatal mortality. Infant mortality: the probability of dying before the first birthday. Child mortality: the probability of dying between the first and fifth birthdays. Under-five mortality: the probability of dying before the fifth birthday. All measures are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. There are several methods that can be used for the direct calculation of infant and child mortality rates, e.g., period approach, true cohort approach, and synthetic cohort approach. It is beyond the scope of this report to describe the differences between the main approaches, but a technical explanation can be found in the Guide to DHS Statistics (Rutstein and Rojas, 2003). DHS uses the synthetic cohort approach, which calculates mortality probabilities for small age segments, and then combines these component probabilities for the full age segment of interest. The advantage to this method is that mortality rates can be calculated for time periods close to the survey date while still respecting the principle of correspondence. The data needed for the calculations are in the birth history section of the Woman’s Questionnaire and include the month and year of birth for all of a woman’s children, their sex and survival status, and the current age at the time of the interview if the child is alive, or age at death if the child has died. The quality of mortality estimates calculated from retrospective birth histories depends on the completeness with which births and deaths are reported and recorded. Potentially the most serious data quality problem is the selective omission from the birth history of children who did not survive, which can lead to underestimation of mortality rates. Other potential problems include displacement 106 | Infant and Child Mortality of birth dates, which may cause a distortion of mortality trends, and misreporting of age at death, which may distort the age pattern of mortality. When selective omission of childhood deaths occurs, the impact is usually most severe for deaths in early infancy. If early neonatal deaths are selectively underreported, the result is an unusually low ratio of deaths occurring in the first seven days to all neonatal deaths, and an unusually low ratio of neonatal to infant deaths. Underreporting of early infant deaths is seen most commonly for births that occurred long before the survey; hence it is useful to examine the ratios over time. An examination of the ratios (see Appendix Tables C.5 and C.6) shows that no significant number of early infant deaths was omitted in the 2008 SLDHS over the 15 years preceding the survey. The proportions of neonatal deaths are roughly constant (between 70 and 76 percent). However, for the period 15-19 years preceding the survey, the proportion was much higher (84 percent). The proportions of infant deaths that occur during the first month of life are entirely plausible over the 15 years preceding the survey (varying between 43 and 46 percent). This inspection of the mortality data reveals no evidence of selective underreporting or misreporting of age at death that would significantly compromise the quality of the SLDHS rates for childhood mortality. 8.2 LEVELS AND TRENDS Table 8.1 shows the variation in neonatal, post-neonatal, infant, child, and under-five mor- tality rates for three successive five-year periods preceding the survey. For the most recent five-year period, infant mortality is 89 deaths per 1,000 live births, and under-five mortality is 140 deaths per 1,000 live births. This means that about one in eleven children born in Sierra Leone dies before the first birthday, and one in seven children dies before attaining the fifth birthday. Neonatal mortality is 36 deaths per 1,000 live births in the most recent five-year period, while post-neonatal mortality is 53 deaths per 1,000 live births. This pattern shows that about 40 percent of deaths under one year of age occur in the neonatal period, and more than one-quarter of child deaths under five years occur in the neonatal period. Table 8.1 Early childhood mortality rates Neonatal, post-neonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Sierra Leone 2008 Years preceding the survey Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 36 53 89 56 140 5-9 61 71 132 73 195 10-14 51 70 120 80 190 1 Computed as the difference between the infant and neonatal mortality rates Figure 8.1 shows in more detail the trends in infant and under-five mortality over the 15 years preceding the survey. Infant mortality and under-five mortality rates decreased between the mid- 1990s and the mid-2000s by 26 percent (for both). However, the figure also shows that infant and under-five mortality rates were highest during the period 1998-2002. The increase in mortality during this time can be explained in two ways: 1) the impact of the peak period of the civil war; and/or 2) by the transfer of births, in particular dead children, from the 5th year to the 6th year preceding the survey, as shown in Appendix Table C4. Infant and Child Mortality | 107 Figure 8.1 Trends in Infant and Under-five Mortality in the 15 Years Preceding the Survey + + +120 132 83 & & &190 195 140 1995 2000 2005 2008 0 50 100 150 200 250 Deaths per 1,000 Infant mortality (1q0) Under-five mortality (5q0)& + Year (1q0) (5q0) Sierra Leone, 2008Note: Data are centred on mid-point of period covered by estimate. The infant and child mortality estimates from the SLDHS cannot be compared with estimates from other sources. No other survey undertaken in Sierra Leone used the same methodology as the 2008 SLDHS. This is the first national survey in the country that has collected data on infant and child mortality based on the retrospective reproductive histories of women age 15-49. 8.3 DIFFERENTIALS IN INFANT AND CHILD MORTALITY 8.3.1 Socio-economic Differentials in Infant and Child Mortality Mortality differentials by residence, region, mother’s level of education, and wealth quintile are presented in Table 8.2 and Figure 8.2. To have a sufficient number of births to analyse mortality differentials across population subgroups, period-specific rates are presented for the ten-year period preceding the survey (mid-1995 to mid-2005). Differentials by residence show similar under-five mortality rates for both rural and urban areas (168 and 167 deaths per 1,000 live births, respectively).There is very little difference in mortality levels in urban and rural areas among children who are less than one year of age. The 2008 SLDHS data show wide variations in mortality levels by region. The Southern Region has the highest mortality rates for all mortality indicators except for neonatal mortality and child mortality. Child mortality and neonatal mortality are highest in the Northern Region. Under-five mortality is highest in the Southern Region (180 deaths per 1,000 live births), followed by the Northern Region (173 per 1,000) and the Western Region (162 per 1,000), and lowest in the Eastern Region (147 per 1,000). This implies that a child born in the Southern or Northern regions is at greater risk of dying before the fifth birthday than a child born in the Eastern or Western regions. 108 | Infant and Child Mortality Table 8.2 Early childhood mortality rates by background characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10- year period preceding the survey, by background characteristic, Sierra Leone 2008 Background characteristic Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 49 56 106 68 167 Rural 49 65 113 62 168 Region Eastern 39 56 95 57 147 Northern 54 60 113 67 173 Southern 45 77 122 66 180 Western 51 58 109 59 162 Mother’s education No education 49 65 114 63 170 Primary 49 65 114 83 187 Secondary or higher 45 41 85 49 130 Wealth quintile Lowest 68 80 148 74 211 Second 45 56 101 58 154 Middle 41 64 105 59 158 Fourth 45 55 99 69 161 Highest 41 52 93 57 144 1 Computed as the difference between the infant and neonatal mortality rates Similar patterns are seen for infant mortality. Neonatal mortality is highest in the Northern Region (54 deaths per 1,000 live births), followed by the Western Region (51 per 1,000), while post- neonatal mortality is highest in the Southern Region (77 per 1,000), followed by the Northern Region (60 per 1,000). Mortality rates by region should be interpreted with caution because of district variations within regions and because of the high level of sampling errors (Appendix B). Empirical evidence from several studies have shown that mother’s level of education is inversely related to her child’s risk of dying. Higher levels of educational attainment are generally associated with lower mortality rates, because education exposes mothers to information about good nutrition, use of contraceptives to limit and space births, and knowledge about childhood illnesses and treatment. The 2008 SLDHS results show large differentials in mortality between children of mothers with primary education or no education and children of mothers with secondary or higher education (see Table 8.2). The under-five mortality rate is highest for children of mothers with primary education (187 per 1,000), followed by children of mothers with no education (170 per 1,000). Children whose mothers have secondary or higher education experience the lowest under-five mortality rate (130 per 1,000). They also experience the lowest infant mortality rate; the chances of a child dying at under one year are lower for mothers with secondary or higher education than those with primary or no education (85, 114, and 114 deaths per 1,000 live births, respectively). Mortality risk for children is associated with the economic status of the household. Childhood mortality rates are highest for children living in households in the lowest wealth quintile. With the exception of the second quintile, under-five mortality decreases gradually with improving economic status of the household, falling from a high of 211 deaths per 1,000 live births in households in the lowest wealth quintile to 144 per 1,000 in households in the highest wealth quintile. Infant and Child Mortality | 109 Figure 8.2 Under-five Mortality by Mother’s Background Characteristics Sierra Leone, 2008 167 168 170 187 130 211 154 158 161 144 RESIDENCE Urban Rural EDUCATION No education Primary Secondary or higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 50 100 150 200 250 Deaths per 1,000 live births 8.3.2 Demographic Differentials in Infant and Child Mortality This section examines differentials in mortality among children under five years by age, sex of child, age of mother at birth, birth order, previous birth interval, and birth size. The results are presented in Table 8.3 for the ten-year period preceding the survey. The results show that male children experience higher mortality than female children at all ages up to five years. No likely explanation has been suggested for the gender differences in mortality between male and female children. The relationship between mother’s age at birth and childhood mortality presents a U-shaped pattern, with children of the youngest and oldest mothers experiencing the highest mortality risks. That is, mortality is higher among children born to women below 20 years and those between 30-39 years and lowest among children whose mothers are age 20-29 years at the time of birth. Childhood mortality rates also exhibit a U-shaped relationship with birth order of the child; however, this association applies only to neonatal, infant, and under-five mortality. In general, mortality is higher for first-order births (with the exception of post-neonatal mortality), compared with second- to sixth-order births. Birth order seven and above shows higher mortality risks than births of order one. Birth intervals have a considerable impact on children’s chances of survival. Short birth intervals are associated with an increased risk of dying. As the birth interval increases in length, the mortality risk is reduced considerably. Children born less than two years after a prior sibling have substantially higher risk of death than children born after intervals of two or more years. For example, the infant mortality rate is 182 deaths per 1,000 live births for children born after an interval of less than two years, compared with 80 per 1,000 for a birth interval of three years, and 54 per 1,000 for a birth interval of four or more years. 110 | Infant and Child Mortality Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10- year period preceding the survey, by demographic characteristics, Sierra Leone 2008 Demographic characteristic Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Sex of child Male 53 65 118 67 177 Female 45 60 105 61 159 Mother’s age at birth <20 56 77 133 86 208 20-29 46 57 104 57 154 30-39 50 60 110 57 161 40-49 (34) (57) (91) * * Birth order 1 65 60 125 66 183 2-3 36 59 95 57 147 4-6 47 61 108 67 168 7+ 68 82 150 77 215 Previous birth interval2 <2 years 83 98 182 86 252 2 years 39 64 103 75 170 3 years 25 55 80 48 124 4+ years 24 30 54 29 81 Birth size3 Small/very small 56 64 120 na na Average or larger 29 42 71 na na Note: Numbers in parentheses are based on 250-499 unweighted children exposed to the risk of death, and an asterisk represents a rate based on fewer than 250 children that has been suppressed. na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey The size of a child at birth is related to childhood mortality rates. Children whose birth size is described by the mother as ‘small’ or ‘very small’ have a 40 percent greater risk of dying before their first birthday than children whose birth size is described as ‘average or larger.’ The size of the child at birth appears to strongly affect the neonatal mortality rate but has little effect during the post-neonatal period. 8.4 PERINATAL MORTALITY Pregnancy deaths that are pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths within seven days of birth (early neonatal deaths) constitute perinatal deaths. The perinatal death rate is calculated by dividing the total number of perinatal deaths by the total number of pregnancies reaching seven months of gestation. The distinction between a stillbirth and an early neonatal death may be a fine one, depending often on the observed presence or absence of some faint signs of life after delivery. The causes of stillbirths and early neonatal deaths are overlapping, and examining just one or the other can understate the true level of mortality around delivery. Table 8.4 presents the number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey by residence and region, and for selected demographic and socio-economic characteristics. The survey results show 5,860 reported pregnancies of at least seven months gestation during the five years preceding the survey, 49 stillbirths and 147 early neonatal deaths, yielding an overall perinatal mortality rate of 34 deaths per 1,000 pregnancies. Infant and Child Mortality | 111 Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Sierra Leone 2008 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother’s age at birth <20 7 29 36 984 20-29 26 66 31 3,003 30-39 14 46 37 1,627 40-49 3 6 * 247 Previous pregnancy interval in months4 First pregnancy 9 41 44 1,111 <15 5 4 * 228 15-26 12 31 36 1,185 27-38 9 39 35 1,372 39+ 15 33 24 1,965 Residence Urban 20 48 43 1,605 Rural 29 99 30 4,255 Region Eastern 1 31 27 1,170 Northern 16 60 29 2,640 Southern 14 26 33 1,200 Western 19 30 58 850 Mother’s education No education 30 109 31 4,473 Primary 7 17 34 720 Secondary or higher 12 21 50 667 Wealth quintile Lowest 9 49 44 1,336 Second 9 25 28 1,228 Middle 6 23 22 1,294 Fourth 12 21 30 1,114 Highest 14 29 48 888 Total 49 147 34 5,860 Note: An asterisk represents a rate based on fewer than 250 unweighted pregnancies of 7+ months duration that has been suppressed. 1 Stillbirths are foetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration, expressed per 1,000. 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. By mother’s age, perinatal mortality is highest among women under age 20 (36 deaths per 1,000 pregnancies) and women age 30-39 (37 deaths per 1,000 pregnancies). However, first pregnancies and pregnancies that occur within an interval of less than 15 months are more likely to end in perinatal death than pregnancies that occur after an interval of at least 15 months. There are wide differences in perinatal mortality by residence, with rural women more likely to experience perinatal loses than urban women. Large differences are also seen by region; the Western Region has the highest perinatal mortality rate (58 deaths per 1,000 pregnancies), and the Eastern Region has the lowest rate (27 deaths per 1,000 pregnancies). Surprisingly, perinatal mortality is highest among women with secondary or higher education (50 deaths per 1,000 pregnancies), compared with women who have primary education (34 deaths per 1,000 pregnancies) or no education (31 deaths per 1,000 pregnancies). The relationship between perinatal mortality and household wealth status (wealth quintiles) shows a U-shaped pattern, with women in the lowest and highest wealth quintiles experiencing more perinatal losses than women in the middle wealth quintiles. 112 | Infant and Child Mortality 8.5 HIGH-RISK FERTILITY BEHAVIOUR Several studies have documented that survival of children partly depends on demographic and biological characteristics of the mothers. In general, the probability of dying in early childhood is much greater among children born to mothers who are too young or too old, children born after a short birth interval, and children born to mothers with high parity. The risk is elevated if a child is born to a mother who has more than one of these risk characteristics. It is apparent that young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. Similarly, older women may also experience age-related problems during pregnancy and delivery. In the analysis, a mother is classified as ‘too young’ if she is less than 18 years of age and ‘too old’ if she is over 34 years of age at the time of delivery; a ‘short birth interval’ is defined as a birth occurring within 24 months of a previous birth; and a ‘high-order’ birth is one occurring after three or more previous births (i.e., birth order four or higher). First-order births may be at increased risk of dying, relative to births of other orders; however, this distinction is not included in the risk categories in the table because it is not considered avoidable fertility behaviour. For the short birth interval category, only children with a preceding interval of less than 24 months are included. Table 8.5 presents the distribution of children born in the five years preceding the survey by categories of elevated risk of dying. The second column shows the percentage of children falling into specific categories. The third column shows the risk ratio for children, calculated by comparing the proportion dead among children in each high-risk category with the proportion dead among children not in any high-risk category. This implies children whose mothers were age 18-34 at delivery, children born 24 or more months after the previous birth, or children who are of birth order two or three). Fifty-eight percent of children in Sierra Leone fall into a high-risk category, with 39 percent in a single high-risk category and 19 percent in a multiple high-risk category. High risks are associated with birth intervals of less than 24 months, births to mothers older than 34 years, births above order three and intervals of less than 24 months to mothers younger than 18 years under the single high-risk category. In general, risk ratios are higher for children in a multiple high-risk category than for children in a single high-risk category. The highest risk (3.3) is associated with fourth and higher births that occur less than 24 months after a previous birth to mothers who are over age 34 years; however, only 2.2 percent of births fall into this multiple high-risk category. Six percent of births in Sierra Leone occur after a short birth interval to mothers who have had three or more births, with these children three times as likely to die in early childhood as children who are not in any high- risk category. The last column of Table 8.5 shows the distribution of currently married women who have the potential for a high-risk birth. This column is purely hypothetical and does not take into consideration the protection provided by family planning, postpartum insusceptibility, and the effects of prolonged abstinence. While several women are protected from conception (because of family planning, postpartum insusceptibility, and prolonged abstinence), only those who have been sterilized are included in the ‘not in any high-risk category.’ Generally, 76 percent of currently married women have the potential for having a high-risk birth, with 32 percent falling into a single high-risk category and 45 percent into a multiple high-risk category. Infant and Child Mortality | 113 Table 8.5 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of dying and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Sierra Leone 2008 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high risk category 28.7 1.0 18.2a Unavoidable risk category First order births between ages 18 and 34 years 13.3 1.7 5.4 Single high-risk category Mother’s age <18 7.3 1.9 0.8 Mother’s age >34 1.5 0.7 5.5 Birth interval <24 months 5.5 2.1 8.8 Birth order >3 24.5 1.2 16.5 Subtotal 38.7 1.5 31.6 Multiple high-risk category Age <18 & birth interval <24 months2 0.7 2.1 0.6 Age >34 & birth interval <24 months 0.1 0.0 0.3 Age >34 & birth order >3 10.6 1.4 25.7 Age >34 & birth interval <24 months & birth order >3 2.2 3.3 6.3 Birth interval <24 months & birth order >3 5.7 2.7 11.8 Subtotal 19.3 2.1 44.8 In any avoidable high-risk category 58.0 1.7 76.4 Total 100.0 na 100.0 Number of births/women 5,811 na 5,525 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women Maternal Health | 115 MATERNAL HEALTH 9 The health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child. One of the priorities of the Ministry of Health and Sanitation is the provision of medical care and services during pregnancy and at delivery that impact the survival of both the mother and infant. The results of the 2008 Demographic and Health Survey conducted in Sierra Leone provide an evaluation of the utilization of these health care services, as well as information useful in assessing the need for service expansion. The information can be used to identify women whose babies are at risk due to non-use of maternal health services. This chapter presents findings on several areas related to maternal health—antenatal, delivery, and postnatal care—as well as problems in accessing medical care. These findings are important to policymakers and programme implementers in formulating programmes and policies and in designing appropriate strategies and interventions to improve maternal and child health care services. 9.1 ANTENATAL CARE The major objective of antenatal care (ANC) is to identify and treat problems during pregnancy such as anemia, pregnancy induced hypertension and infections. It is during antenatal care visits that screening for complications and advice on a range of issues including place of delivery and referral of mothers with complications occur. Information on antenatal care is important for identifying subgroups of women who do not use these services and for planning improvements in services. The data on antenatal care from the 2008 Sierra Leone Demographic and Health Survey (SLDHS) provide information on the type of service provider, the number of antenatal care visits, the stage of pregnancy at the time of the first and last visits, and the services and information provided during antenatal care, including whether tetanus toxoid immunization was received. Table 9.1 shows the percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by the type of antenatal care provider consulted during the pregnancy for the most recent birth, according to background characteristics. If a woman received antenatal care from more than one provider, the provider with the highest qualifications was recorded. The survey shows that more than eight in ten women (87 percent) received antenatal care from a health professional (doctor, nurse, midwife, or MCH aid); 5 percent received antenatal care from a tradi- tional midwife or a community health worker; and 7 percent did not receive any antenatal care. Differences in antenatal care coverage by women’s age at the time of the birth are not large. There are some differences by birth order; mothers in Sierra Leone are more likely to receive antenatal care from a doctor for the first birth (10 percent) than for second- or higher-order births (4-6 percent), and high parity women are slightly more likely than low parity women to see MCH aides for antenatal care. There are notable differences in the use of antenatal care services by women in urban and rural areas. Health professionals provide ANC services for 94 percent of urban mothers, compared with 84 percent of rural mothers. The difference is even larger for women who received antenatal care from a doctor (17 percent in urban areas and 2 percent in rural areas). There are also notable differences in antenatal care coverage by region; 94 percent of women in the Western Region received ANC services from health professionals, compared with only 82 percent of women in the Northern Region. Of particular note is that women in the Western Region are substantially more likely to receive antenatal care from a doctor (25 percent), than women in other regions (2-4 percent). 116 | Maternal Health The survey results show that use of ANC services is positively related to women’s level of education. Ninety-five percent of women with secondary or higher education received antenatal care services from a health professional, compared with 85 percent of women with no education. Similarly, more educated women are substantially more likely to receive antenatal care from a doctor (27 percent) than women with no education (3 percent). Household wealth status also shows a positive relationship between receipt of professional antenatal care, with women in the highest wealth quintile more likely to receive antenatal care from health professionals than those in the lowest wealth quintile (96 and 82 percent, respectively). This relationship is even stronger among women who received antenatal care services from a doctor; only 2 to 4 percent of women in the lower wealth quintiles have access to doctors for antenatal care, compared with 25 percent of women in the highest wealth quintile. Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth, and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Sierra Leone 2008 Background characteristic Doctor Nurse/ midwife MCH aid Community health worker Traditional birth attendant Other No one Missing Total Percentage receiving antenatal care from a skilled provider Number of women Mother’s age at birth <20 4.1 56.9 27.3 2.4 3.1 0.0 5.2 1.0 100.0 88.3 669 20-34 6.9 53.0 27.0 1.9 3.3 0.1 6.7 1.2 100.0 86.8 2,780 35-49 5.4 48.7 31.8 1.7 3.1 0.0 8.2 1.1 100.0 85.8 654 Birth order 1 10.1 51.9 27.1 1.4 3.1 0.1 5.4 0.9 100.0 89.1 781 2-3 6.3 54.7 25.1 2.5 3.8 0.0 6.5 1.1 100.0 86.1 1,506 4-5 4.5 51.9 29.1 1.7 3.5 0.1 7.7 1.6 100.0 85.4 985 6+ 4.4 51.8 32.0 1.7 2.0 0.0 7.1 1.0 100.0 88.2 831 Residence Urban 16.7 63.7 13.6 2.0 1.4 0.1 1.7 0.8 100.0 93.9 1,183 Rural 1.9 48.6 33.6 1.9 4.0 0.0 8.7 1.3 100.0 84.1 2,920 Region Eastern 4.0 46.2 39.3 1.4 3.9 0.1 3.5 1.4 100.0 89.6 809 Northern 1.5 55.5 24.9 1.9 3.1 0.0 12.2 1.0 100.0 81.9 1,869 Southern 4.3 49.2 36.8 2.8 4.5 0.0 0.8 1.7 100.0 90.3 783 Western 24.8 58.4 10.9 1.9 1.3 0.2 1.7 0.8 100.0 94.1 642 Mother’s education No education 2.6 50.8 31.1 2.2 3.9 0.0 8.2 1.1 100.0 84.5 3,051 Primary 6.2 62.3 24.1 1.3 2.0 0.3 2.3 1.4 100.0 92.7 515 Secondary or higher 26.7 55.7 12.6 1.3 0.5 0.0 2.1 1.1 100.0 95.0 537 Wealth quintile Lowest 1.9 39.4 40.9 1.7 5.3 0.0 9.8 1.1 100.0 82.1 885 Second 1.7 47.9 33.7 1.3 4.0 0.0 10.7 0.8 100.0 83.2 849 Middle 2.2 57.0 26.7 2.7 3.1 0.1 6.7 1.5 100.0 85.9 893 Fourth 4.4 60.7 24.3 2.7 2.5 0.2 4.1 1.1 100.0 89.4 793 Highest 24.8 62.3 9.0 1.4 0.6 0.0 0.6 1.2 100.0 96.1 683 Total 6.2 52.9 27.8 2.0 3.2 0.1 6.7 1.2 100.0 86.9 4,103 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, and MCH aid. Maternal Health | 117 9.2 NUMBER AND TIMING OF ANTENATAL CARE VISITS Antenatal care is most beneficial when it is sought early in pregnancy and is continued through to delivery. Under nor- mal circumstances, the World Health Orga- nization (WHO) recommends that a woman without complications have at least four ANC visits, the first of which takes place during the first trimester. Table 9.2 presents information on antenatal care including the number of visits and the timing of the first visit. In Sierra Leone, more than half of women (56 percent) have four or more an- tenatal care visits. Almost two in ten women have one to three ANC visits, but 7 percent of women have no antenatal care visits. The survey also shows that women in Sierra Leone do not receive antenatal care services early during pregnancy. Only 30 percent of women obtained antenatal care in the first three months of pregnancy, while 41 percent made their first visit in the fourth or fifth month, and 17 percent made the first ANC visit in the six or seventh month; 1 percent of women had their first antenatal care visit in the eighth month of pregnancy or later. There is a notable difference in antenatal care coverage between women in urban areas and women in rural areas. Sixty-six percent of women in urban areas made four or more antenatal care visits, compared with slightly over half (52 percent) of women in rural areas. Urban women also typically received first antenatal care earlier than rural women; 34 percent of urban women saw a provider for antenatal care early in pregnancy, compared with 29 percent of rural women. Overall, the median number of months pregnant at first ANC visit is 4.6 months. 9.3 COMPONENTS OF ANTENATAL CARE Describing the content of antenatal care is essential for assessing the quality of antenatal care services. Pregnancy complications are a primary source of maternal and child morbidity and mortality. Therefore, ensuring that pregnant women receive information on the signs of complications and testing them for complications should be routinely included in all antenatal care visits. To help assess antenatal care services, respondents were asked whether they had been advised of possible pregnancy complications and whether they had received certain screening tests during at least one of their ANC visits. Table 9.3 presents information on the percentage of women who took iron tablets or syrup, were informed of the signs of pregnancy complications, and received selected services during antenatal care visits for their most recent birth in the past five years. The data show that the majority (79 percent) of women with a recent birth took iron supplements during pregnancy, but less than half (44 percent) took drugs for intestinal parasites during the pregnancy. Variation by age at birth is minimal. There is a small decrease in the proportion of women who take iron supplements as birth order increases. However, substantial variations are Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Sierra Leone 2008 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 1.7 8.7 6.7 1 0.5 1.7 1.4 2-3 12.6 20.5 18.2 4+ 65.9 52.2 56.1 Don’t know/missing 19.3 16.9 17.6 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.7 8.7 6.7 <4 33.6 28.5 30.0 4-5 43.3 40.2 41.1 6-7 17.8 16.3 16.7 8+ 1.1 1.6 1.4 Don’t know/missing 2.5 4.7 4.0 Total 100.0 100.0 100.0 Number of women 1,183 2,920 4,103 Median months pregnant at first visit (for those with ANC) 4.6 4.7 4.6 Number of women with ANC 1,153 2,629 3,782 11 8 | M at er na l H ea lth Ta bl e 9. 3 C om po ne nt s of a nt en at al c ar e Am on g w om en a ge 1 5- 49 w ith a l iv e bi rth i n th e fiv e ye ar s pr ec ed in g th e su rv ey , th e pe rc en ta ge w ho t oo k iro n ta bl et s or s yr up a nd t he pe rc en ta ge w ho t oo k dr ug s fo r in te st in al p ar as ite s du rin g th e pr eg na nc y fo r th e m os t re ce nt b irt h, a nd a m on g w om en r ec ei vi ng a nt en at al c ar e (A N C ) fo r th e m os t re ce nt l iv e bi rt h in t he f iv e ye ar s pr ec ed in g th e su rv ey , th e pe rc en ta ge r ec ei vi ng s pe ci fic a nt en at al s er vi ce s, a cc or di ng t o ba ck gr ou nd c ha ra ct er ist ic s, S ie rr a Le on e 20 08 Ba ck gr ou nd ch ar ac te ris tic Am on g w om en w ith a liv e bi rth in th e pa st fiv e ye ar s, th e pe rc en ta ge w ho d ur in g th e pr eg na nc y fo r th ei r l as t b irt h: N um be r o f w om en w ith a liv e bi rth in th e pa st fiv e ye ar s Am on g w om en w ho re ce iv ed a nt en at al c ar e fo r t he ir m os t r ec en t b irt h in th e pa st fi ve y ea rs , th e pe rc en ta ge w ho re ce iv ed s pe ci fic s er vi ce s N um be r o f w om en w ith A N C fo r th ei r m os t re ce nt b irt h To ok ir on ta bl et s or sy ru p To ok in te st in al pa ra sit e dr ug s In fo rm ed o f sig ns o f pr eg na nc y co m pl ic a- tio ns W ei gh ed Bl oo d pr es su re m ea su re d U rin e sa m pl e ta ke n Bl oo d sa m pl e ta ke n M ot he r’ s ag e at b ir th < 20 80 .2 45 .8 66 9 57 .1 87 .0 83 .1 37 .9 42 .6 62 7 20 -3 4 78 .5 43 .2 2, 78 0 61 .3 89 .4 87 .8 41 .9 48 .2 2, 56 1 35 -4 9 79 .5 44 .6 65 4 61 .9 87 .9 87 .5 40 .4 45 .1 59 3 Bi rt h or de r 1 81 .3 44 .9 78 1 62 .7 87 .4 84 .3 46 .3 50 .7 73 2 2- 3 77 .2 44 .4 1, 50 6 60 .4 89 .2 87 .8 42 .0 47 .6 1, 39 2 4- 5 78 .2 40 .8 98 5 59 .0 88 .7 86 .6 39 .2 44 .5 89 4 6+ 80 .8 45 .4 83 1 61 .3 89 .4 88 .4 36 .2 44 .2 76 3 Re si de nc e U rb an 89 .0 45 .7 1, 18 3 71 .4 90 .0 91 .4 65 .4 67 .7 1, 15 3 Ru ra l 74 .9 43 .1 2, 92 0 56 .0 88 .2 85 .0 30 .3 37 .6 2, 62 9 Re gi on Ea st er n 86 .8 33 .3 80 9 61 .5 90 .0 87 .7 21 .9 23 .1 76 9 N or th er n 69 .2 39 .0 1, 86 9 58 .6 86 .7 83 .0 40 .7 49 .5 1, 62 2 So ut he rn 81 .0 62 .8 78 3 47 .6 89 .9 89 .1 28 .0 36 .1 76 4 W es te rn 94 .8 48 .3 64 2 80 .9 91 .2 93 .8 81 .1 81 .9 62 6 M ot he r’ s ed uc at io n N o ed uc at io n 75 .7 41 .5 3, 05 1 57 .6 87 .6 85 .2 34 .5 41 .1 2, 76 6 Pr im ar y 86 .0 49 .3 51 5 64 .7 90 .0 88 .6 44 .0 50 .0 49 6 Se co nd ar y or h ig he r 90 .8 52 .0 53 7 73 .1 93 .8 94 .9 72 .9 74 .1 52 0 W ea lth q ui nt ile Lo w es t 72 .9 40 .3 88 5 50 .3 85 .5 80 .1 21 .7 26 .0 78 9 Se co nd 71 .7 42 .4 84 9 58 .3 88 .4 84 .4 31 .4 37 .1 75 1 M id dl e 76 .0 43 .3 89 3 58 .2 90 .0 88 .1 36 .8 46 .2 82 0 Fo ur th 82 .8 45 .7 79 3 61 .7 88 .6 89 .5 44 .4 50 .9 75 1 H ig he st 95 .2 48 .8 68 3 77 .6 91 .7 93 .7 75 .8 78 .2 67 1 To ta l 79 .0 43 .8 4, 10 3 60 .7 88 .8 87 .0 41 .0 46 .8 3, 78 2 118 | Maternal Health Maternal Health | 119 noted by residence, region, education, and wealth quintile. For example, 89 percent of women in urban areas take iron tablets or syrup during pregnancy, compared with 75 percent of women in rural areas. Women in the Western and Eastern regions are most likely to have taken iron supplements, while women in the Northern Region are the least likely to have taken iron supplements during pregnancy. Women in the Southern and Western regions are more likely to receive drugs for intestinal parasites (63 and 48 percent, respectively), while women in the Eastern Region are the least likely to receive the drugs (33 percent). As expected, better educated women and those who live in households in the in the higher wealth quintiles are more likely than other women to have taken iron supplements and drugs for intestinal parasites during pregnancy. Regarding content of antenatal care services, the data show that 61 percent of women in Sierra Leone who received antenatal care reported that they were informed about the signs of pregnancy complications, and weight and blood pressure measurements were taken for 89 and 87 percent of women, respectively. Less than one in two women had a blood sample taken (47 percent) and an even smaller proportion of women had urine samples taken (41 percent). The quality of antenatal care received by women in Sierra Leone is related to level of education, wealth, residence, and region. Women with secondary or higher education, women in the highest wealth quintile, and women living in urban areas are more likely than other women to be informed about pregnancy complications. Regional variation in the proportion of women who were informed about the complications of pregnancy during ANC visits is marked, ranging from 48 percent in the Southern Region to 81 percent among women in the Western Region. Similar patterns are observed for receipt of routine components of antenatal care such as measuring weight and blood pressure, and taking blood and urine and blood samples for testing, although the difference between urban and rural areas in the proportion of women weighed is minimal. 9.4 TETANUS TOXOID INJECTIONS Neonatal tetanus is a leading cause of neonatal death in developing countries where a high proportion of deliveries are conducted at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) immunization is given to pregnant women to prevent neonatal tetanus. If a woman has received no previous TT injections, for full protection a pregnant woman needs two doses of TT during pregnancy. However, if a woman was immunized before she became pregnant, she may require one or no TT injections during pregnancy, depending on the number of injections she has ever received and the timing of the last injection. For a woman to have lifetime protection, a total of five doses is required. The 2008 SLDHS collected data on whether women who had a live birth in the five years preceding the survey received at least two TT injections, and whether the pregnancy for the most recent live birth in the past five years was protected against neonatal tetanus. Table 9.4 shows that most women (75 percent) in Sierra Leone received two or more tetanus injections during pregnancy and that 79 percent of births were protected against neonatal tetanus. There is little variation in tetanus toxoid coverage by age at birth and birth order; however, there are differences by residence. For example, 87 percent of births in urban areas are protected against tetanus, compared with 76 percent of births in rural areas. Regarding regional differences, the Northern Region has the lowest proportion of births protected against neonatal tetanus (69 percent), compared with other regions (87-88 percent). Education of the mother is positively related to tetanus toxoid coverage in Sierra Leone; 89 percent of births among women with secondary or higher education are protected against neonatal tetanus, compared with 76 percent of births among women with no education. Similarly, women in the highest (richest) wealth quintile are more likely to have received two or more TT injections during their last pregnancy, and to have had their last live birth be protected against neonatal tetanus, than women in the lower wealth quintiles. 120 | Maternal Health Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Sierra Leone 2008 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last live birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 74.6 78.0 669 20-34 74.2 78.9 2,780 35-49 75.5 80.7 654 Birth order 1 75.0 78.6 781 2-3 73.3 78.3 1,506 4-5 75.7 80.0 985 6+ 74.6 79.7 831 Residence Urban 82.5 87.3 1,183 Rural 71.2 75.7 2,920 Region Eastern 83.8 87.8 809 Northern 64.6 69.2 1,869 Southern 83.3 87.2 783 Western 80.8 86.8 642 Mother’s education No education 71.6 76.2 3,051 Primary 81.5 85.4 515 Secondary or higher 84.3 89.0 537 Wealth quintile Lowest 69.1 72.7 885 Second 74.4 77.8 849 Middle 70.7 76.8 893 Fourth 76.3 81.1 793 Highest 84.3 89.3 683 Total 74.5 79.0 4,103 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth. 9.5 PLACE OF DELIVERY The key objective of maternal and child health services is to provide safe delivery services. Increasing the number of babies delivered in health facilities is an important factor in reducing the health risks to both the mother and the baby. Another important component of efforts to reduce the health risks to mothers and children is to increase the proportion of babies delivered under the supervision of a trained health provider. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and infections that can cause sickness or death to either the mother or the baby. Table 9.5 shows the percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. The data show that the majority (72 percent) of births in Sierra Leone are delivered at home and 25 percent are delivered in health facilities, mostly public sector facilities. Delivery at a health facility is common for first births and for mothers who received antenatal care, especially if they had four or more ANC visits. It is also higher for births in urban areas than for births in rural areas; 40 percent of babies born in urban areas are delivered in a health facility, compared with 19 percent of those born in rural areas. The proportion of babies born in a health facility is generally low in most of Maternal Health | 121 Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Sierra Leone 2008 Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector Mother’s age at birth <20 24.8 2.1 69.9 1.5 1.7 100.0 26.9 977 20-34 22.0 2.8 71.5 0.8 2.9 100.0 24.8 4,002 35-49 19.8 1.0 75.5 0.2 3.5 100.0 20.8 832 Birth order 1 25.7 4.7 65.1 0.8 3.7 100.0 30.4 1,148 2-3 22.9 2.6 72.0 1.0 1.6 100.0 25.4 2,165 4-5 21.1 1.5 73.5 0.7 3.3 100.0 22.6 1,405 6+ 18.6 0.8 76.3 0.8 3.5 100.0 19.4 1,092 Antenatal care visits1 None 1.4 0.2 94.9 1.1 2.4 100.0 1.6 274 1-3 14.3 0.6 84.3 0.6 0.2 100.0 14.9 803 4+ 27.2 3.7 68.1 0.7 0.2 100.0 30.9 2,303 Don’t know/missing 27.7 3.4 62.3 1.3 5.2 100.0 31.1 723 Residence Urban 32.2 7.3 57.4 0.3 2.8 100.0 39.5 1,585 Rural 18.5 0.6 77.2 1.1 2.7 100.0 19.0 4,226 Region Eastern 27.4 1.1 69.2 0.0 2.4 100.0 28.5 1,170 Northern 15.1 0.3 80.2 1.0 3.4 100.0 15.5 2,623 Southern 31.5 2.1 62.8 1.8 1.8 100.0 33.6 1,187 Western 24.0 11.3 61.7 0.3 2.8 100.0 35.2 831 Mother’s education No education 19.0 0.9 76.1 1.0 3.0 100.0 19.9 4,443 Primary 32.0 1.8 63.7 0.4 2.1 100.0 33.7 713 Secondary or higher 33.5 13.0 51.1 0.5 1.9 100.0 46.5 655 Wealth quintile Lowest 16.4 0.5 79.3 1.4 2.4 100.0 16.9 1,327 Second 20.4 0.8 74.6 1.5 2.7 100.0 21.2 1,220 Middle 23.0 0.2 73.6 0.4 2.8 100.0 23.2 1,288 Fourth 25.5 2.1 69.2 0.3 2.9 100.0 27.6 1,102 Highest 28.0 11.3 57.2 0.4 3.1 100.0 39.3 873 Total 22.2 2.4 71.8 0.8 2.8 100.0 24.6 5,811 1 Includes only the most recent birth in the five years preceding the survey the regions (29 to 35 percent), with the Northern Region being considerably lower (16 percent of births). There is a strong association between mother’s level of education and place of delivery; the proportion of births delivered in a health facility is 47 percent among mothers with secondary or higher education, compared with 20 percent among mothers with no education. The association between household wealth status and delivery in a health facility is similarly strong, with the proportion of babies delivered in a health facility ranging from 17 percent in the lowest wealth quintile to 39 percent in the highest quintile. Regarding home deliveries, births to older women and higher parity women are more likely to occur at home. Similarly, rural births are more likely to be delivered at home than urban births. The proportion of deliveries that occur at home decreases as mother’s level of education increases, wealth quintile increases, and the number of ANC visits during pregnancy increases. Women in the Northern Region are substantially more likely to give birth at home (80 percent) than women in other regions (62 to 69 percent). 9.6 ASSISTANCE DURING DELIVERY In addition to place of delivery, type of assistance during delivery is an important variable influencing the birth outcome and the health of the mother and infant. A skilled birth attendant can reduce the likelihood of sepsis and other complications of delivery. Table 9.6 shows the percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, according to background characteristics. 122 | Maternal Health Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of birth assisted by a skilled provider, and the percentage delivered by caesarean-section, according to background characteristics, Sierra Leone 2008 Background characteristic Person providing assistance during delivery Percentage delivered by a skilled provider1 Percentage delivered by C-section Number of births Doctor Nurse/ midwife MCH aid Traditional birth attendant Relative/ other No one Don’t know/ missing Total Mother’s age at birth <20 1.2 29.6 14.1 43.4 9.2 0.9 1.7 100.0 44.8 1.6 977 20-34 1.8 29.5 11.7 44.4 9.2 0.9 2.4 100.0 43.1 1.6 4,002 35-49 1.4 25.9 9.4 48.5 11.0 1.3 2.6 100.0 36.6 1.0 832 Birth order 1 3.5 31.8 13.3 40.4 7.0 0.5 3.5 100.0 48.6 2.9 1,148 2-3 1.5 29.9 12.7 44.0 9.5 1.2 1.2 100.0 44.2 1.7 2,165 4-5 0.9 28.2 11.2 44.8 11.3 0.9 2.6 100.0 40.3 0.7 1,405 6+ 1.0 25.4 8.8 51.1 9.4 1.2 3.0 100.0 35.2 0.7 1,092 Place of delivery Health facility 6.3 67.0 25.4 1.1 0.0 0.1 0.1 100.0 98.6 6.1 1,430 Elsewhere 0.1 17.2 7.5 61.0 13.0 1.1 0.1 100.0 24.7 0.0 4,221 Missing 2.2 1.9 2.8 7.3 0.4 4.5 80.8 100.0 6.9 0.0 160 Residence Urban 4.7 52.0 10.3 24.9 4.7 0.8 2.7 100.0 66.9 3.2 1,585 Rural 0.5 20.4 12.3 52.3 11.2 1.0 2.2 100.0 33.2 0.9 4,226 Region Eastern 0.8 28.5 20.9 45.4 1.7 0.9 1.8 100.0 50.1 0.7 1,170 Northern 0.6 21.1 5.7 52.7 15.7 1.3 2.9 100.0 27.4 0.7 2,623 Southern 1.2 33.6 18.3 38.2 6.6 0.5 1.6 100.0 53.2 1.7 1,187 Western 6.9 48.2 8.6 28.8 4.3 0.9 2.4 100.0 63.7 4.7 831 Mother’s education No education 0.8 23.6 11.4 49.7 10.8 1.2 2.5 100.0 35.7 0.8 4,443 Primary 1.7 40.5 13.7 35.7 6.6 0.3 1.4 100.0 55.9 1.9 713 Secondary or higher 7.6 53.4 12.1 21.6 2.9 0.4 2.0 100.0 73.1 5.5 655 Wealth quintile Lowest 0.7 14.5 12.8 56.8 12.5 1.0 1.7 100.0 28.1 0.7 1,327 Second 0.3 22.7 12.4 48.4 13.0 1.0 2.2 100.0 35.4 0.8 1,220 Middle 0.5 26.6 11.6 48.8 9.2 0.9 2.5 100.0 38.6 0.9 1,288 Fourth 1.5 36.2 11.4 40.0 7.3 1.0 2.7 100.0 49.0 1.4 1,102 Highest 7.0 54.4 10.0 21.9 2.8 1.0 2.9 100.0 71.4 4.9 873 Total 1.7 29.0 11.7 44.8 9.4 1.0 2.3 100.0 42.4 1.5 5,811 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, and MCH aid. The data show that 42 percent of births in Sierra Leone are delivered with the assistance of a health professional (i.e., doctor, nurse/midwife, or MCH aid), and 45 percent are delivered by a traditional birth attendant. Nine percent of births (about one in ten) are attended by relatives, and 1 percent of all births are delivered without any assistance at all. Births to mothers younger than age 35 and first births are more likely to be assisted by trained health workers. Almost all births that occur in health facilities are assisted by trained providers. Women in urban areas (67 percent) and women in the Western Region (64 percent) are more likely than other women to be assisted by skilled health care workers at delivery. Women in the Northern Region are the least likely to be attended at delivery by a skilled provider (27 percent). As expected, mother’s education has a positive relationship with the type of delivery care received (Figure 9.1). Births to women with secondary or higher education are more than twice as likely to be assisted by health professionals as births to women with no education (73 and 36 percent, respectively). Similarly, delivery assistance varies by the economic status of women. Births to women in the highest wealth quintile are much more likely to be assisted by health professionals (71 percent) than births to women in the lowest wealth quintile (28 percent). Maternal Health | 123 Table 9.6 shows the prevalence of births by caesarean section. According to the World Health Organization and UNICEF, acceptable rates for caesarean section (C-section) delivery are between 5 and 15 percent. Above 15 percent is considered excessive, while rates below 5 percent indicate that not all women in need are receiving a C-section delivery (UNICEF/WHO/UNFPA, 1997; Althabe and Belizan, 2006). Sierra Leone’s C-section rate of 2 percent suggests that not all women in need of a C- section are receiving one. Births in health facilities, births in urban areas, births in the Western Region, and births to better educated and wealthier women are more likely than other births to be delivered by caesarean section. Figure 9.1 Assistance of Skilled Provider during Childbirth Sierra Leone, 2008 42 67 33 36 56 73 28 35 39 49 71 SIERRA LEONE RESIDENCE Urban Rural EDUCATION No education Primary Secondary or higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 20 40 60 80 100 Percent 9.7 POSTNATAL CARE A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Thus, postnatal care is important for both the mother and the child to treat possible complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. It is recommended that all women receive a check on their health within two days of delivery. To assess the prevalence of postnatal care, women who had a birth in the past five years were asked, for their most recent birth, whether they received a health check-up after the delivery, the timing of the first check-up, and the type of health provider performing the postnatal check-up. This information is presented in Tables 9.7 and 9.8 according to background characteristics. The data show that 58 percent of women in Sierra Leone receive postnatal care within two days after delivery: 38 percent within four hours of delivery, 8 percent 4 to 23 hours after delivery, and 12 percent one to two days after delivery. An additional 5 percent of women receive care 3 to 41 days after delivery, and one-third of mothers (33 percent) do not get any postnatal care. 124 | Maternal Health Table 9.7 Timing of first postnatal check-up Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution of the mother’s first postnatal check-up for the last live birth by time after delivery, according to background characteristics, Sierra Leone 2008 Background characteristic Time after delivery of mother’s first postnatal check-up No postnatal check-up1 Total Number of women Less than 4 hours 4-23 hours 1-2 days 3-41 days Don’t know/ missing Mother’s age at birth <20 39.3 7.2 11.4 5.1 4.8 32.1 100.0 669 20-34 37.5 7.9 12.0 5.3 4.0 33.3 100.0 2,780 35-49 36.6 7.8 13.0 6.2 4.3 32.0 100.0 654 Birth order 1 41.7 7.9 10.2 4.4 5.2 30.6 100.0 781 2-3 36.1 8.0 11.0 5.2 4.9 34.8 100.0 1,506 4-5 40.4 7.6 11.3 5.9 3.6 31.0 100.0 985 6+ 33.5 7.4 16.5 6.3 2.5 33.7 100.0 831 Place of delivery Health facility 55.3 12.6 11.2 2.7 6.8 11.4 100.0 1,061 Elsewhere 32.1 6.2 12.5 6.5 3.2 39.5 100.0 2,991 Residence Urban 49.6 6.5 12.8 3.2 4.2 23.6 100.0 1,183 Rural 32.9 8.3 11.7 6.4 4.1 36.6 100.0 2,920 Region Eastern 58.9 6.9 5.8 3.1 4.0 21.3 100.0 809 Northern 21.6 8.0 15.1 6.6 5.4 43.2 100.0 1,869 Southern 34.9 8.7 14.3 7.3 2.6 32.2 100.0 783 Western 61.1 7.2 8.2 2.8 2.5 18.3 100.0 642 Mother’s education No education 34.3 7.5 12.1 5.8 4.0 36.3 100.0 3,051 Primary 42.0 7.8 13.8 4.8 4.9 26.8 100.0 515 Secondary or higher 52.8 9.4 10.2 4.0 4.2 19.3 100.0 537 Wealth quintile Lowest 30.1 7.2 9.8 6.9 3.1 42.9 100.0 885 Second 31.1 9.5 14.3 6.1 4.3 34.7 100.0 849 Middle 36.0 7.7 11.7 6.1 5.1 33.4 100.0 893 Fourth 37.0 7.3 15.3 5.4 4.7 30.3 100.0 793 Highest 58.7 7.1 8.6 2.0 3.4 20.1 100.0 683 Total 37.7 7.8 12.0 5.4 4.1 32.9 100.0 4,103 Note: total includes 51 women with information missing on place of delivery 1 Includes women who received a check-up after 41 days Differences in receipt of postnatal care by age and parity are small; however, the majority (79 percent) of women who deliver in a health facility receive a postnatal check-up within two days of the birth, compared with just half of women who deliver elsewhere. There are variations in postnatal care by residence and region. Sixty-nine percent of mothers in urban areas receive postnatal care within two days of delivery, compared with only 53 percent of those in rural areas. By region, the proportion of mothers who receive timely postnatal care ranges from 45 percent in the Northern Region to 77 percent in the Western Region. Mother’s level of education and household wealth status are inversely related to the receipt of postnatal care. Seventy-two percent of mothers with secondary or higher education receive postnatal care within two days of delivery, compared with 54 percent of mothers with no education. There are also large differences by wealth quintile; 74 percent of women in the highest wealth quintile receive postnatal care within two days of delivery, compared with 47 percent of women in the lowest wealth quintile. Table 9.8 shows the distribution of mothers who gave birth in the five years preceding the survey by type of provider of mother’s first postnatal check-up for the last live birth, according to background characteristics. In Sierra Leone, 44 percent of mothers receive postnatal care from a Maternal Health | 125 health professional, 22 percent receive postnatal care from a traditional birth attendant, and less than 1 percent receive postnatal care from a community health worker. As mentioned above, 33 percent of women in Sierra Leone do not receive any postnatal care. Differentials for type of postnatal care provider are similar to those for postnatal care coverage in general. Mothers in urban areas and in the Western Region, mothers with secondary or higher education, and mothers in the highest wealth quintile are more likely to receive postnatal care from a health professional than other women. For example, 63 percent of mothers in urban areas receive postnatal care from health professionals, compared with 37 percent of mothers in the rural areas. Similarly, 68 percent of mothers with secondary or higher education receive postnatal care from health professionals, compared with 38 percent of those with no education. Finally, 67 percent of mothers in the highest wealth quintile receive postnatal care from health professionals, compared with 30 percent of mothers in the lowest quintile. Table 9.8 Type of provider of first postnatal check-up Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal check-up for the last live birth, according to background characteristics, Sierra Leone 2008 Background characteristic Type of health provider of mother’s first postnatal check-up No postnatal check- up1 Total Number of women Doctor/ nurse/ midwife MCH aid Community health worker Traditional birth attendant Other Don’t know/ missing Mother’s age at birth <20 29.5 13.9 1.0 22.7 0.0 0.7 32.1 100.0 669 20-34 31.4 13.1 0.5 21.1 0.1 0.6 33.3 100.0 2,780 35-49 27.7 16.4 0.6 22.6 0.0 0.6 32.0 100.0 654 Birth order 1 33.9 12.9 1.2 21.1 0.1 0.1 30.6 100.0 781 2-3 31.6 12.5 0.5 19.7 0.1 0.9 34.8 100.0 1,506 4-5 29.7 14.3 0.2 24.0 0.1 0.7 31.0 100.0 985 6+ 26.2 16.1 0.7 22.8 0.0 0.5 33.7 100.0 831 Place of delivery Health facility 65.1 20.8 0.3 1.4 0.0 1.1 11.4 100.0 1,061 Elsewhere 18.7 11.5 0.7 29.1 0.1 0.4 39.5 100.0 2,991 Residence Urban 53.9 8.9 0.0 12.3 0.2 1.0 23.6 100.0 1,183 Rural 21.0 15.7 0.8 25.4 0.0 0.5 36.6 100.0 2,920 Region Eastern 27.9 17.5 0.2 32.4 0.2 0.6 21.3 100.0 809 Northern 20.9 12.7 0.9 22.0 0.0 0.3 43.2 100.0 1,869 Southern 35.5 17.6 0.6 13.0 0.0 1.0 32.2 100.0 783 Western 55.7 7.4 0.1 17.2 0.1 1.1 18.3 100.0 642 Mother’s education No education 24.1 14.3 0.7 24.0 0.1 0.5 36.3 100.0 3,051 Primary 40.7 13.6 0.3 18.4 0.0 0.3 26.8 100.0 515 Secondary or higher 57.1 10.9 0.3 10.9 0.2 1.3 19.3 100.0 537 Wealth quintile Lowest 13.5 16.5 1.1 25.3 0.0 0.7 42.9 100.0 885 Second 23.2 17.6 0.2 24.0 0.0 0.4 34.7 100.0 849 Middle 28.0 12.4 0.9 25.0 0.0 0.3 33.4 100.0 893 Fourth 35.2 13.6 0.7 19.7 0.1 0.5 30.3 100.0 793 Highest 59.4 7.3 0.0 11.6 0.2 1.4 20.1 100.0 683 Total 30.5 13.7 0.6 21.6 0.1 0.6 32.9 100.0 4,103 Note: total includes 51 women with information missing on place of delivery 1 Includes women who received a check-up after 41 days 126 | Maternal Health 9.8 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers women may face in seeking care during pregnancy and at the time of delivery. In the 2008 SLDHS, women were asked whether each of the following factors would be a big problem or not a big problem in seeking medical care for themselves: getting permission to go for treatment, getting money for treatment, distance to a health facility, having to take transportation, concern that there may not be a health provider, and concern that there may be no drugs available. Table 9.9 shows that more than half of Sierra Leonean women reported that the major problem they face in accessing health care for themselves is getting money for treatment (80 percent). About half of women (49 to 53 percent) cited the problems: distance to health facility, the need to take transport, and concern that no drugs are available. More than one-third (37 percent) of women Table 9.9 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Sierra Leone 2008 Background characteristic Problems in accessing health care At least one problem accessing health care Number of women Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern no female provider available Concern no provider available Concern no drugs available Age 15-19 11.9 76.8 49.2 46.1 26.2 23.7 39.5 47.6 86.3 1,198 20-34 7.9 80.0 54.0 50.7 19.5 20.5 35.8 49.1 89.4 3,873 35-49 5.9 81.8 53.1 50.9 18.1 20.0 36.5 48.7 89.7 2,303 Number of living children 0 11.7 74.4 46.7 43.1 23.4 23.3 38.5 47.6 84.5 1,592 1-2 8.0 78.8 52.9 50.1 20.3 20.3 36.3 48.1 88.0 2,639 3-4 5.9 82.2 55.4 54.1 18.9 20.4 36.1 50.1 91.1 1,954 5+ 6.0 86.8 57.2 52.3 17.8 19.4 35.7 49.3 93.8 1,189 Marital status Never married 11.1 72.6 44.0 39.6 22.4 23.0 39.9 47.2 82.1 1,399 Married or living together 7.3 81.5 55.6 53.2 19.8 20.4 35.7 49.1 90.6 5,525 Divorced/separated/ widowed 5.6 84.6 47.7 43.7 17.6 19.0 38.2 49.1 89.8 450 Employed last 12 months Not employed 10.5 74.0 47.6 43.7 23.5 23.7 40.7 50.2 82.5 1,705 Employed for cash 6.4 72.8 44.8 41.6 15.0 17.1 34.5 45.1 84.5 1,330 Employed not for cash 7.3 84.8 57.7 55.1 20.5 20.9 35.7 49.3 93.1 4,286 Missing 12.0 66.6 39.7 55.0 11.4 17.7 34.7 45.4 77.7 53 Residence Urban 8.2 68.2 36.9 33.1 17.4 16.7 32.3 41.5 79.0 2,655 Rural 7.8 86.7 61.9 59.6 21.7 23.2 39.1 52.8 94.6 4,719 Region Eastern 10.8 83.8 58.4 57.5 25.6 20.4 48.8 59.0 92.2 1,325 Northern 6.1 88.0 59.7 56.3 17.9 20.7 32.9 47.6 94.2 3,001 Southern 8.5 79.9 51.8 49.9 24.2 32.2 46.5 61.1 92.8 1,542 Western 8.4 60.9 35.7 31.1 15.6 9.9 23.3 29.2 71.8 1,506 Education No education 7.6 85.5 59.5 57.1 20.7 22.0 37.8 51.4 93.2 4,860 Primary 9.3 80.1 44.9 42.2 21.9 22.3 35.7 44.9 88.5 960 Secondary or higher 7.9 62.6 37.3 32.6 17.3 16.4 33.7 42.6 76.0 1,554 Wealth quintile Lowest 8.3 89.5 68.0 65.4 26.3 27.3 43.0 56.3 96.2 1,382 Second 8.4 87.5 61.1 60.0 20.0 22.6 37.5 51.2 95.4 1,368 Middle 6.5 87.0 59.6 57.1 19.6 20.4 37.6 52.3 95.0 1,428 Fourth 8.6 80.7 46.8 42.7 20.3 20.5 36.1 48.1 89.9 1,472 Highest 7.8 60.1 34.1 30.2 15.8 14.9 30.4 38.1 72.3 1,723 Total 7.9 80.0 52.9 50.0 20.2 20.8 36.6 48.7 89.0 7,374 Note: Total includes 53 women with information missing on employment. Maternal Health | 127 mentioned concern that a health provider may not be available at a health facility as a serious problem. Only 8 percent of women reported that getting permission to go for treatment was a serious problem. The vast majority (89 percent) of women cited at least one of the specified factors as a serious problem in accessing health care. Younger women (age 15-19), women with no children, women who have never married, and women who are not employed are less likely to report any of the factors as a serious problem in accessing health care than other women. Women in urban areas and those in the Western Region are less likely than women in rural areas and women in other regions to cite at least one factor as a serious problem. The proportion of women who reported one or more of the factors as a serious problem in accessing health care decreases with increasing level of education and wealth quintile. Regarding specific problems, getting money for treatment appears to be a bigger issue in the Northern and Eastern regions and among the least educated and poorest women, while concern that there are no drugs available is cited particularly by women in the Southern and Eastern regions. Child Health | 129 CHILD HEALTH 10 This chapter, which deals with child health in Sierra Leone, presents the findings on neonatal conditions (birth weight and size at birth), children’s vaccination status, and treatment practices for the three major childhood illnesses: acute respiratory infection (ARI), fever, and diarrhoea. Information on children’s birth weight and size, treatment practices, and contact with health facilities when children are sick paves the way to strategic planning, designing, and implementation of programmes aimed at reducing morbidity and mortality among children under five years of age. 10.1 CHILD’S SIZE AT BIRTH A child’s birth weight and size at birth are important indicators of vulnerability to the risk of childhood illnesses and death. Children whose birth weight is less than 2.5 kilograms, or children reported to be ‘very small’ or ‘smaller than average’ are considered to have a higher than average risk of early childhood death. For births in the five years preceding the survey, birth weight, if available, was recorded in the questionnaire from either a written record or the mother’s recall. Because birth weight may not be known for many babies, the mother’s estimate of size at birth was also obtained. Although size estimate is subjective, it can be useful as a proxy for the weight of the child. Table 10.1 presents information on child’s weight and size at birth according to background characteristics. Birth weights were reported for only 33 percent of all births in the five years preceding the survey. Because these births are unlikely to be representative of all births (i.e., more urban, higher wealth status, etc.), the patterns of birth weight by background characteristics are likely to be biased. The data on reported size of child at birth show only small differences by background characteristics. Overall, births to the youngest women, births to women having their first child, births to women who smoke, and births in rural areas are less likely to be reported as ‘average or larger’ in size. The Southern Region has the lowest proportion of babies reported as ‘average or larger,’ and the Western Region has the highest proportion. The proportion of births reported as ‘average or larger’ size increases with level of education and household wealth quintile, although the differences are not large. 130 | Child Health Table 10.1 Child’s weight and size at birth Percent distribution of live births in the five years preceding the survey with a reported birth weight by birth weight; percentage of all births with a reported birth weight; and percent distribution of all live births in the five years preceding the survey by mother’s estimate of baby’s size at birth, according to background characteristics, Sierra Leone 2008 Background characteristic Percent distribution of births with a reported birth weight of: Total Number of births Percentage of all births with a reported birth weight Percent distribution of all live births by size of child at birth Total Number of births Less than 2.5 kg 2.5 kg or more Very small Smaller than average Average or larger Don’t know/ missing Mother’s age at birth <20 15.7 84.3 100.0 330 33.8 10.1 15.9 69.1 4.9 100.0 977 20-34 9.5 90.5 100.0 1,326 33.1 6.1 12.4 76.3 5.2 100.0 4,002 35-49 12.4 87.6 100.0 255 30.6 7.2 11.6 75.5 5.7 100.0 832 Birth order 1 15.8 84.2 100.0 412 35.9 9.3 16.6 68.2 5.9 100.0 1,148 2-3 8.7 91.3 100.0 730 33.7 6.6 12.0 76.6 4.8 100.0 2,165 4-5 9.9 90.1 100.0 440 31.3 6.5 12.2 76.5 4.8 100.0 1,405 6+ 11.4 88.6 100.0 330 30.2 5.8 11.6 76.9 5.7 100.0 1,092 Mother’s smoking status Smokes cigarettes/tobacco 10.3 89.7 100.0 194 34.0 7.2 13.9 71.9 7.0 100.0 571 Does not smoke 11.1 88.9 100.0 1,705 32.7 7.0 12.8 75.4 4.9 100.0 5,209 Residence Urban 9.5 90.5 100.0 696 43.9 5.2 11.6 78.5 4.6 100.0 1,585 Rural 11.8 88.2 100.0 1,216 28.8 7.6 13.3 73.6 5.4 100.0 4,226 Region Eastern 10.2 89.8 100.0 458 39.2 6.5 13.2 74.5 5.8 100.0 1,170 Northern 14.5 85.5 100.0 528 20.1 6.9 11.8 77.4 3.9 100.0 2,623 Southern 9.9 90.1 100.0 528 44.5 8.8 15.2 67.5 8.5 100.0 1,187 Western 8.5 91.5 100.0 398 47.8 5.3 12.4 78.6 3.8 100.0 831 Mother’s education No education 10.8 89.2 100.0 1,299 29.2 7.1 12.4 74.9 5.7 100.0 4,443 Primary 9.5 90.5 100.0 276 38.8 7.8 15.6 73.1 3.4 100.0 713 Secondary or higher 12.7 87.3 100.0 336 51.3 5.2 13.3 77.5 4.0 100.0 655 Wealth quintile Lowest 13.2 86.8 100.0 347 26.2 9.1 15.8 68.9 6.2 100.0 1,327 Second 9.6 90.4 100.0 367 30.1 7.4 11.9 75.2 5.4 100.0 1,220 Middle 13.4 86.6 100.0 383 29.7 6.9 11.8 76.2 5.1 100.0 1,288 Fourth 9.4 90.6 100.0 386 35.0 5.6 12.4 77.5 4.5 100.0 1,102 Highest 9.5 90.5 100.0 429 49.1 4.8 11.9 78.7 4.5 100.0 873 Total 11.0 89.0 100.0 1,911 32.9 7.0 12.9 75.0 5.2 100.0 5,811 Note: Total for reported birth weight includes 12 births with information missing on mother’s smoking status. Total for size of child at birth includes 30 births with information missing on mother’s smoking status. 1 Based on either a written record or the mother’s recall 10.2 VACCINATION COVERAGE Universal immunization of children against the six vaccine-preventable diseases—namely, tuberculosis, diphtheria, whooping cough (pertussis), tetanus, polio, and measles—is crucial to reducing infant and child mortality. Differences in vaccination coverage among sub-groups of the population are useful for programme planning and targeting resources to areas most in need. The 2008 Sierra Leone Demographic and Health Survey (SLDHS) collected information on vaccination coverage for all living children born in the five years preceding the survey. According to the guidelines developed by the World Health Organization, children are considered fully vaccinated when they have received a vaccination against tuberculosis (BCG); three doses each of diphtheria, Child Health | 131 pertussis, and tetanus (DPT) and polio vaccines; and a measles vaccination by the age of 12 months. BCG should be given at birth or at first clinical contact; DPT and polio require three vaccinations at approximately 6, 10, and 14 weeks of age; and measles should be given at or soon after reaching 9 months of age. Information on vaccination coverage was collected in two ways in the SLDHS: from vaccination cards shown to the interviewer and from mothers’ verbal reports. If the cards were available, the interviewer copied the vaccination dates directly onto the questionnaire. When there was no vaccination card for the child or if a vaccine had not been recorded on the card as being given, the respondent was asked to recall the vaccinations given to her child. Vaccination cards were seen by interviewers for less than two-thirds (60 percent) of the children. Table 10.2 shows the percentage of children age 12-23 months who received the various vaccinations by source of information, that is, from the vaccination card or mother’s report. This is the youngest cohort of children who have reached the age by which they should be fully vaccinated. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother’s report), and percentage vaccinated by 12 months of age, Sierra Leone 2008 Source of information BCG DPT Polio1 Measles All basic vaccina- tions2 No vaccina- tions Number of children 1 2 3 0 1 2 3 Vaccinated at any time before survey Vaccination card 58.9 55.4 52.5 45.5 53.0 53.4 50.6 43.5 40.2 34.5 0.2 636 Mother’s report 23.2 21.4 18.3 14.8 18.8 22.2 18.3 6.2 19.6 5.3 15.4 424 Either source 82.0 76.8 70.8 60.3 71.8 75.6 68.9 49.6 59.7 39.8 15.6 1,060 Vaccinated by 12 months of age3 80.4 75.4 67.1 54.6 70.1 74.1 65.3 44.8 45.8 30.5 17.1 1,060 Note: DPT is given as part of the pentavalent (five-component) DTP-HepB+Hib formulation: diphtheria, pertussis, and tetanus (DPT), hepatitis B and Haemophilus influenzae type b conjugate vaccines. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother’s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. According to information from both the vaccination card and the mothers’ reports, overall only 40 percent of children age 12-23 months are fully vaccinated (BCG, measles, and three doses each of DPT and polio). Looking at coverage for specific vaccines, 82 percent of children have received the BCG vaccination, 77 percent the first DPT dose, and 76 percent the first polio dose (Polio 1). Coverage declines for subsequent doses, with only 60 percent of children receiving the recommended three doses of DPT and 50 percent receiving all three doses of polio (Figure 10.1). These figures reflect dropout rates of 21 percent for DPT and 34 percent for polio; the dropout rate represents the proportion of children who received the first dose of a vaccine but did not receive the third dose. The proportion of children vaccinated against measles is 60 percent. Sixteen percent of children have received no vaccinations at all. 132 | Child Health Figure 10.1 Vaccination Coverage among Children Age 12-23 Months Sierra Leone, 2008 82 77 71 60 72 76 69 50 60 40 16 BCG 1 2 3 0 1 2 3 Measles All None 0 20 40 60 80 100 Percent DPT Polio 1 Includes BCG, measles, and three doses each of DPT and polio vaccine (excluding polio 0) Vaccinations are most effective when given at the proper age; thus, it is recommended that children complete the schedule of immunizations during their first year of life, i.e. by 12 months of age. Overall, only 31 percent of children age 12-23 months had all the recommended vaccinations before their first birthday (Figure 10.2). Figure 10.2 Vaccination Coverage during the First Year of Life among Children Age 12-23 Months Sierra Leone, 2008 80 75 67 55 70 74 65 45 46 31 17 BCG 1 2 3 0 1 2 3 Measles All None 0 20 40 60 80 100 Percent DPT Polio Table 10.3 shows vaccination coverage among children age 12-23 months by background characteristics. A slightly higher proportion of girls than boys received all the basic vaccinations (41 percent for females, compared with 39 percent for males). The data also show that, in general, the proportion of children fully immunized tends to increase somewhat as birth order increases, ranging 1 1 1 Includes BCG, measles, and three doses each of DPT and polio vaccine (excluding polio 0) Child Health | 133 from 41 percent of first births to a high of 46 percent among births of order four or higher. However, the lowest proportion of children fully immunized is among births of order two or three (33 percent). There is no difference by urban-rural residence: 40 percent of both urban and rural children receive all the basic childhood vaccinations. Vaccination coverage varies by region, ranging from 33 percent of children fully immunized in the Northern Region to 47 percent of children in the Eastern Region. Children whose mothers have no education (38 percent) are less likely to be fully vaccinated than children whose mothers have reached primary or secondary school (46 and 48 percent, respectively). Differences in the proportion of children fully immunized by wealth quintiles are small. Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report), and percentage with a vaccination card, by background characteristics, Sierra Leone 2008 Background characteristic BCG DPT Polio1 Measles All basic vaccina- tions2 No vaccina- tions Percentage with a vaccination card seen Number of children 1 2 3 0 1 2 3 Sex Male 84.8 78.5 71.0 60.6 73.0 77.5 69.2 49.2 58.8 39.0 13.8 60.9 526 Female 79.3 75.2 70.6 59.9 70.5 73.8 68.6 50.1 60.7 40.7 17.3 59.1 535 Birth order 1 82.3 77.6 72.6 61.9 69.9 74.6 66.4 49.9 61.2 40.5 16.0 56.7 197 2-3 81.6 74.8 67.4 54.9 74.5 74.6 67.9 43.2 55.2 33.1 16.7 57.3 418 4-5 81.1 76.7 71.3 62.7 69.1 77.4 70.1 51.5 61.9 45.8 15.7 62.5 261 6+ 84.1 80.6 75.6 67.5 71.2 76.5 72.2 61.3 65.3 45.8 12.4 66.0 185 Residence Urban 89.0 83.3 78.7 69.8 81.8 84.7 78.7 53.4 64.5 40.4 10.4 58.3 269 Rural 79.7 74.6 68.0 57.0 68.4 72.5 65.5 48.4 58.1 39.6 17.3 60.6 791 Region Eastern 88.7 85.1 75.9 66.5 81.4 84.3 74.5 56.7 63.2 47.4 10.1 66.9 225 Northern 75.2 69.1 62.5 49.1 62.0 64.4 57.8 42.1 51.7 33.1 21.4 56.9 473 Southern 82.6 77.6 74.7 67.7 74.1 81.4 76.0 58.2 66.3 45.2 15.2 63.1 227 Western 93.8 88.7 84.5 76.7 85.8 90.9 86.3 49.9 71.1 41.6 5.0 54.1 135 Mother’s education No education 78.9 72.6 66.4 56.3 67.2 72.0 64.7 47.1 56.3 37.6 18.3 59.6 803 Primary 91.1 87.7 81.4 70.5 83.3 87.0 80.3 57.9 67.1 46.0 8.4 62.7 146 Secondary or higher 93.0 93.0 88.6 75.9 89.6 86.8 84.2 56.9 75.0 48.0 5.7 59.5 111 Wealth quintile Lowest 78.2 74.3 66.5 55.0 64.1 71.9 63.2 45.2 55.7 39.0 19.3 58.2 253 Second 80.3 72.8 67.0 58.6 69.7 68.8 63.4 51.0 61.8 40.5 16.2 64.2 222 Middle 84.2 78.1 69.4 62.2 73.4 76.9 67.5 51.4 58.5 39.3 13.5 61.1 210 Fourth 82.3 76.4 73.0 57.8 75.6 80.1 74.7 52.2 57.4 41.0 15.9 58.4 217 Highest 87.4 85.1 81.7 72.0 79.4 83.4 79.6 48.9 68.2 39.5 11.1 57.7 158 Total 82.0 76.8 70.8 60.3 71.8 75.6 68.9 49.6 59.7 39.8 15.6 60.0 1,060 Note: DPT is given as part of the pentavalent (five-component) DTP-HepB+Hib formulation: diphtheria, pertussis, and tetanus (DPT), hepatitis B and Haemophilus influenzae type b conjugate vaccines. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 10.3 TRENDS IN VACCINATION COVERAGE Table 10.4 is based on children age 12-59 months, and shows the percentage of children who received specific vaccines or doses during the first year of life (according to a vaccination card or the mother’s report) and the percentage of children with a vaccination card. This table illustrates changes in the vaccination programme over time. The survey data show that there has been a marked improvement in vaccination coverage in the five years preceding the survey. For example, only 17 percent of children age 12-23 months have received no vaccinations, compared with 32 percent of children age 48-59 months. The table also shows that 31 percent of children age 12-23 months were fully immunized by 12 months of age, compared with only 19 percent of children age 48-59 months. Similarly, vaccination cards were seen by interviewers for 60 percent of children age 12-23 months, compared with 30 percent of children age 48-59 months. 134 | Child Health Table 10.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Sierra Leone 2008 Age in months BCG DPT Polio1 Measles All basic vaccina- tions2 No vaccina- tions Percentage with a vaccination card seen Number of children 1 2 3 0 1 2 3 12-23 80.4 75.4 67.1 54.6 70.1 74.1 65.3 44.8 45.8 30.5 17.1 60.0 1,060 24-35 75.6 69.7 61.6 47.6 62.8 69.8 60.1 39.1 35.7 22.6 21.8 46.2 939 36-47 67.2 60.8 52.8 38.3 56.6 61.9 51.8 27.8 34.6 17.5 30.4 30.6 984 48-59 66.8 59.9 51.0 38.5 56.1 63.0 50.3 28.1 34.0 19.0 32.0 29.6 904 12-59 73.2 67.4 59.4 46.0 62.0 68.1 57.9 35.7 39.0 23.0 24.5 42.1 3,887 Note: DPT is given as part of the pentavalent (five-component) DTP-HepB+Hib formulation: diphtheria, pertussis, and tetanus (DPT), hepatitis B and Haemophilus influenzae type b conjugate vaccines. Information was obtained from the vaccination card or if there was no written record, from the mother. For children whose information was based on the mother’s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 10.4 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths caused by ARI. In the 2008 Sierra Leone DHS survey, the prevalence of ARI was estimated by asking mothers whether their children under age five had been ill in the two weeks preceding the survey with a cough accompanied by short, rapid breathing that the mother considered to be chest-related. These symptoms are compatible with ARI. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Table 10.5 shows that 7 percent of children under age five years were reported to have had a cough with short rapid breathing (that was not just due to a blocked or runny nose) in the two weeks preceding the survey. Prevalence of ARI peaks among children age 12-23 months (8 percent). Children in rural areas (7 percent) are more likely than children in urban areas (4 percent) to have symptoms of ARI. Children in the Northern and Southern regions (8 and 7 percent, respectively) are more likely to have symptoms of ARI than children in the Eastern (5 percent) and Western (3 percent) regions. More than four in ten children (46 percent) with symptoms of ARI were taken to a health facility or provider for treatment. Less likely to be taken for treatment were children age 24-35 months, girls, children in rural areas, children whose mothers have less education, and children in households in the lowest wealth quintile. Only 23 percent of children living in the Eastern Region were taken to a provider, compared with 71 percent of children in the Southern Region. Treatment with antibiotics can often ameliorate the symptoms of ARI and can save lives. In the SLDHS, only 27 percent of children under five with symptoms of ARI were treated with antibiotics. Children in urban areas were substantially more likely than those in rural areas to be given antibiotics for symptoms of ARI (41 and 25 percent, respectively). The proportion treated with antibiotics was also higher among children living in the Western Region, children whose mothers have secondary or higher education, and children in households in the highest wealth quintile. Child Health | 135 Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey and among children with symptoms of ARI, the percentage for whom advice or treatment was sought from a health facility or provider and percentage who received antibiotics as treatment, according to background characteristics, Sierra Leone 2008 Background characteristic Children under five Children under five with symptoms of ARI Percentage with symptoms of ARI1 Number of children Percentage for whom advice or treatment was sought from a health facility or provider2 Percentage who received antibiotics Number of children Age in months <6 5.7 692 (45.3) (54.7) 40 6-11 6.6 635 (55.8) (28.6) 42 12-23 8.0 1,060 44.5 22.5 85 24-35 6.7 939 37.9 31.9 63 36-47 6.4 984 44.3 21.9 63 48-59 4.9 904 (52.9) (11.7) 44 Sex Male 6.5 2,590 48.5 29.3 169 Female 6.4 2,623 43.1 25.2 167 Mother’s smoking status Smokes cigarettes/tobacco 7.7 508 (51.3) (26.2) 39 Does not smoke 6.4 4,679 45.1 27.4 297 Cooking fuel Electricity or gas * 1 na na 0 Kerosene * 4 na na 0 Coal/lignite (0.0) 23 na na 0 Charcoal 2.5 506 * * 13 Wood/straw3 6.9 4,666 44.9 26.2 324 Residence Urban 4.0 1,397 49.8 40.8 56 Rural 7.4 3,817 45.0 24.6 281 Region Eastern 4.5 1,067 23.4 18.4 48 Northern 8.1 2,354 41.4 24.9 190 Southern 7.1 1,058 71.2 32.7 75 Western 3.2 735 (45.5) (46.7) 24 Mother’s education No education 6.4 3,990 42.2 24.5 256 Primary 7.3 633 (54.0) (31.4) 46 Secondary or higher 5.9 590 (61.9) (42.5) 35 Wealth quintile Lowest 6.6 1,159 39.2 26.4 76 Second 6.6 1,123 46.4 19.9 74 Middle 8.4 1,157 49.2 26.8 98 Fourth 5.8 996 48.0 23.5 58 Highest 4.0 778 (45.7) (55.7) 31 Total 6.5 5,213 45.8 27.3 337 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. Total for symptoms with ARI includes 26 children with information missing on mother’s smoking status and 15 children with information missing on cooking fuel. na = not applicable 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest related) is considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 3 Includes grass, shrubs, crop residues 10.5 FEVER Fever is a symptom of malaria and other acute infections in children. Malaria and other illnesses that cause fever contribute to high levels of malnutrition and mortality. While fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Because malaria is a major contributing cause of death in infancy and early childhood in many developing countries, the presumptive treatment of fever with antimalarial medication is 136 | Child Health advocated in many countries where malaria is endemic. Malaria is discussed in greater detail in Chapter 12. Table 10.6 shows the percentage of children under five with fever during the two weeks preceding the survey and the percentage receiving various treatments, by background characteristics. Overall, one in four children under five years was reported to have had a fever in the past two weeks. Fever is most common among children age 6-35 months (26-34 percent). The prevalence of fever is similar for boys and girls and similar in urban and rural areas. Regional differentials are small but show that the proportion of children with fever is highest in the Western Region (29 percent) and lowest in the Eastern Region (23 percent). The prevalence of fever increases slightly with mother’s level of education and household wealth quintile. Table 10.6 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who received antimalarial drugs, and the percentage who received antibiotic drugs, by background characteristics, Sierra Leone 2008 Background characteristic Children under five Children under five with fever Percentage for whom advice or treatment was sought from health facility or provider1 Percentage who received antimalarial drugs Percentage who received antibiotic drugs Number of children Percentage with fever Number of children Age in months <6 21.0 692 41.6 22.1 32.2 145 6-11 33.8 635 53.3 32.4 30.1 215 12-23 29.1 1,060 42.0 28.7 21.1 308 24-35 25.8 939 43.7 32.3 27.9 242 36-47 20.4 984 40.0 29.6 21.4 201 48-59 19.0 904 39.7 33.8 16.7 172 Sex Male 25.2 2,590 44.0 30.1 26.9 652 Female 24.1 2,623 43.0 30.1 22.2 631 Residence Urban 25.2 1,397 48.5 35.1 36.8 352 Rural 24.4 3,817 41.7 28.2 20.0 931 Region Eastern 23.0 1,067 27.1 22.5 10.5 246 Northern 24.2 2,354 41.4 26.4 18.0 569 Southern 24.1 1,058 57.9 43.9 34.6 254 Western 29.1 735 51.0 32.2 46.6 214 Mother’s education No education 23.5 3,990 39.8 28.5 19.8 936 Primary 27.8 633 50.6 32.4 29.2 176 Secondary or higher 29.0 590 56.7 36.5 46.1 171 Wealth quintile Lowest 23.5 1,159 39.1 27.1 19.0 272 Second 24.2 1,123 46.6 29.1 23.3 272 Middle 23.5 1,157 42.0 29.4 17.8 272 Fourth 24.8 996 39.9 28.8 21.8 248 Highest 28.3 778 51.2 37.2 44.8 220 Total 24.6 5,213 43.5 30.1 24.6 1,283 1 Excludes pharmacy, shop, and traditional practitioner Less than half (44 percent) of children with fever were taken to a health facility or provider for treatment; 30 percent received antimalarial drugs and 25 percent received antibiotics. Compared with children in other regions, children with fever in the Southern Region (44 percent) were more likely to receive antimalarial drugs, while children in the Western Region (47 percent) were more likely to receive antibiotics. The proportion of children who received these treatments is higher in urban areas and among children whose mothers are better educated and from the highest wealth quintile. Child Health | 137 10.6 DIARRHOEAL DISEASE Dehydration resulting from severe diarrhoea is a major cause of morbidity and mortality among young children, although the condition can easily be treated with oral rehy- dration therapy (ORT). Exposure to diar- rhoea-causing agents is frequently related to the use of contaminated water and to unhy- gienic practices in food preparation and dis- posal of excreta. When interpreting the findings of the 2008 SLDHS, it should be noted that the prevalence of diarrhoea varies seasonally. Table 10.7 shows the percentage of children under five with diarrhoea in the two weeks preceding the survey according to se- lected background characteristics. The table shows that 13 percent of children had diar- rhoea in the two weeks before the survey and 3 percent had diarrhoea with blood, a symp- tom of dysentery. Diarrhoea prevalence increases with age to peak at 6-11 months (18 percent). This is the age when children start to be weaned and other liquids and foods are introduced that can facilitate the spread of disease-caus- ing microbes. Diarrhoea prevalence remains at 16-17 percent at age 12-35 months, and then falls in older age groups. Diarrhoea prevalence is slightly higher among children in rural areas (14 percent) than children in urban areas (11 percent), and slightly higher in households with a non-improved source of drinking water or type of toilet facility. Children living in the Southern Region (10 percent), and those in the highest wealth quintile (9 percent) are the least likely to have had diarrhoea in the two weeks preceding the survey. Diarrhoea prevalence is higher than average among children living in the Northern Region (16 percent), among children whose mothers have primary education (15 percent), and children living in households in the second wealth quintile (15 percent). In the 2008 SLDHS, mothers of children who had diarrhoea were asked what was done to treat the illness. Table 10.8 shows the percentage of children with diarrhoea who received specific treatments by background characteristics. Less than half of the children who had diarrhoea in the past two weeks were taken to a health facility or provider (47 percent) for treatment. Children in the Southern Region, children whose mothers had primary or secondary education, and children in households in the higher wealth quintiles were more likely to be taken to a health provider for treatment than other children. Children in the Eastern Region (34 percent) were least likely to be taken for treatment to a health facility or provider. Table 10.7 Prevalence of diarrhoea Percentage of children under age five who had diarrhoea in the two weeks preceding the survey, by background characteristics, Sierra Leone 2008 Background characteristic Diarrhoea in the two weeks preceding the survey Number of children All diarrhoea Diarrhoea with blood Age in months <6 7.8 1.1 692 6-11 18.1 3.7 635 12-23 16.5 3.3 1,060 24-35 15.8 3.8 939 36-47 11.7 2.6 984 48-59 7.6 2.2 904 Sex Male 13.5 2.9 2,590 Female 12.4 2.8 2,623 Source of drinking water1 Improved 11.8 2.7 2,440 Not improved 14.1 2.9 2,762 Toilet facility2 Improved, not shared 10.3 2.1 570 Not improved or shared 13.3 3.0 4,578 Residence Urban 10.9 1.6 1,397 Rural 13.7 3.3 3,817 Region Eastern 11.4 2.5 1,067 Northern 15.8 4.1 2,354 Southern 9.9 1.2 1,058 Western 10.7 1.5 735 Mother’s education No education 12.9 3.1 3,990 Primary 15.0 2.1 633 Secondary or higher 11.5 2.1 590 Wealth quintile Lowest 12.8 3.0 1,159 Second 14.5 3.5 1,123 Middle 13.9 3.7 1,157 Fourth 13.1 1.9 996 Highest 9.4 1.4 778 Total 13.0 2.8 5,213 Note: Total includes 11 children with information missing on source of drinking water and 65 children with information missing on type of toilet facility. 1 See Table 2.7 for definition of categories. 2 See Table 2.8 for definition of categories. 138 | Child Health Oral rehydration therapy (ORT) involves giving the child with diarrhoea a solution prepared from oral rehydration salts (ORS packets) or a home-made, sugar-salt-water solution. The treatments are simple and effective responses to diarrhoeal illness. Almost nine in ten children (86 percent) with diarrhoea were treated with some form of ORT or increased fluids, and over two-thirds (68 percent) were given a solution prepared using a packet of oral rehydration salts (ORS). The use of ORT to treat diarrhoea is most common among children age 36-47 months, children in the Western Region, children whose mothers have attained the primary level of education, and children in households in the middle wealth quintile. Antibiotics are generally not recommended for use in treating non-bloody diarrhoea in young children. However, about four in ten children with diarrhoea (41 percent) were treated with antibiotics, with little difference between the treatment of bloody and non-bloody diarrhoea (45 percent, compared with 40 percent). Treatment of diarrhoea with antibiotics was more likely among urban children, children in the Western Region, children whose mothers have secondary or higher education, and children in the highest wealth quintile. Home remedies were given to one-third of children with diarrhoea; 2 percent were given zinc supplements; and 1 percent were given antimotility drugs or intravenous solutions to treat the diarrhoea. Mothers are encouraged to continue normal feeding practices for children with diarrhoea but to increase the amount of fluids. These practices help to reduce dehydration, and minimize the adverse effects of diarrhoea on the children’s nutritional status. Mothers interviewed in the 2008 SLDHS were asked whether they gave their child with diarrhoea less, the same amount, or more fluids and food than usual. Table 10.9 shows the percent distribution of children under five who had diarrhoea in the two weeks preceding the survey by feeding practices, according to background characteristics. More than half (55 percent) of children with diarrhoea were given more to drink than usual, 19 percent are given the same as usual, and 25 percent are given less to drink than usual or nothing at all. It is particularly disconcerting to note that 16 percent of children with diarrhoea are given much less or nothing to drink. Food intake is curtailed even more than fluid intake during episodes of diarrhoea. Only 15 percent of children with diarrhoea were offered more food than usual, 25 percent were offered the same amount of food, and 55 percent were given less food than usual. These results indicate a gap in practical knowledge of the nutritional requirements of children during episodes of diarrhoea. Further health education efforts are needed to reduce the number of children who become dehydrated or malnourished as a result of diarrhoea. Overall, 38 percent of children with diarrhoea were given increased fluids and continued feeding, and 57 percent were given increased fluids, continued feeding, and ORT. Differentials in these indicators by background characteristics are not large. Children age 36-47 months, children in the Northern Region, children whose mothers have primary education, and children in households in the fourth wealth quintile, are more likely than other children with diarrhoea to be given increased fluids, continued feeding, and ORT during their last episode of diarrhoea. C hi ld H ea lth | 1 39 T ab le 1 0. 8 D ia rr ho ea tr ea tm en t A m on g ch ild re n un de r ag e fiv e w ho h ad d ia rr ho ea in t he t w o w ee ks p re ce di ng t he s ur ve y, t he p er ce nt ag e fo r w ho m a dv ic e or t re at m en t w as s ou gh t fro m a h ea lth f ac ili ty o r pr ov id er , th e pe rc en ta ge g iv en o ra l r eh yd ra tio n th er ap y (O RT ), th e pe rc en ta ge g iv en in cr ea se d flu id s, th e pe rc en ta ge g iv en O RT o r i nc re as ed fl ui ds , a nd th e pe rc en ta ge w ho w er e gi ve n ot he r t re at m en ts , b y ba ck gr ou nd c ha ra ct er ist ic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Pe rc en ta ge o f ch ild re n w ith di ar rh oe a fo r w ho m ad vi ce o r t re at m en t w as s ou gh t f ro m a he al th fa ci lit y or pr ov id er 1 O ra l r eh yd ra tio n th er ap y (O RT ) In cr ea se d flu id s O RT o r in cr ea se d flu id s O th er tr ea tm en ts M iss in g N o tre at m en t N um be r o f ch ild re n w ith di ar rh oe a O RS pa ck et s Re co m m en de d ho m e flu id s (R H F) Ei th er O RS o r RH F An ti- bi ot ic dr ug s An ti- m ot ili ty dr ug s Zi nc su pp le - m en ts In tra - ve no us so lu tio n H om e re m ed y/ ot he r A ge in m on th s < 6 33 .4 67 .5 5. 9 69 .0 62 .3 84 .9 42 .1 0. 0 0. 0 0. 0 36 .4 0. 0 8. 5 54 6- 11 42 .5 68 .2 10 .1 71 .4 47 .0 84 .8 43 .1 1. 0 2. 1 0. 0 23 .3 0. 0 4. 2 11 5 12 -2 3 52 .5 67 .8 11 .1 72 .2 53 .2 84 .4 42 .3 0. 0 3. 9 2. 0 30 .3 0. 3 6. 7 17 5 24 -3 5 47 .4 61 .2 19 .3 69 .2 61 .7 82 .5 40 .9 0. 7 2. 9 0. 6 38 .1 0. 6 8. 4 14 8 36 -4 7 52 .8 78 .7 19 .4 85 .2 58 .5 93 .4 35 .0 1. 7 0. 2 0. 0 36 .8 1. 3 3. 7 11 5 48 -5 9 40 .9 65 .3 14 .5 72 .3 47 .5 83 .5 43 .2 0. 0 0. 0 0. 0 30 .9 11 .4 3. 0 69 S ex M al e 47 .2 66 .0 14 .9 73 .8 52 .2 85 .4 40 .9 1. 2 1. 7 0. 3 31 .4 1. 4 5. 2 34 9 Fe m al e 46 .8 70 .1 13 .2 72 .9 58 .1 85 .8 41 .0 0. 0 2. 4 1. 0 33 .6 1. 9 6. 6 32 6 T yp e of d ia rr ho ea N on b lo od y 47 .0 69 .3 11 .3 73 .4 54 .9 85 .8 39 .8 0. 4 1. 5 0. 7 31 .7 1. 4 5. 8 51 2 Bl oo dy 45 .7 63 .9 23 .5 74 .0 55 .1 86 .2 45 .4 1. 3 4. 2 0. 0 35 .2 0. 0 7. 1 14 7 R es id en ce U rb an 48 .2 78 .4 7. 7 79 .1 45 .3 86 .8 54 .7 2. 0 2. 8 0. 0 24 .0 0. 0 7. 5 15 3 Ru ra l 46 .7 65 .0 15 .9 71 .7 57 .9 85 .2 37 .0 0. 2 1. 8 0. 8 34 .9 2. 1 5. 4 52 3 R e g io n Ea st er n 33 .5 62 .5 12 .5 68 .0 49 .1 85 .8 46 .6 0. 0 1. 2 0. 8 21 .7 2. 6 2. 7 12 1 N or th er n 47 .9 67 .0 17 .1 74 .0 60 .5 86 .3 35 .0 0. 0 2. 2 0. 9 39 .5 0. 5 7. 2 37 1 So ut he rn 58 .4 68 .8 8. 7 71 .9 44 .7 80 .3 44 .5 0. 9 3. 6 0. 0 20 .3 5. 7 5. 6 10 5 W es te rn 48 .6 79 .8 9. 5 80 .8 52 .5 88 .4 55 .8 4. 0 0. 6 0. 0 31 .9 0. 0 4. 8 79 M ot he r’ s ed uc at io n N o ed uc at io n 44 .1 65 .3 15 .5 72 .1 55 .6 85 .3 37 .1 0. 2 2. 2 0. 8 32 .4 1. 3 7. 0 51 3 Pr im ar y 56 .5 82 .9 9. 4 84 .6 60 .0 92 .4 49 .4 1. 0 2. 2 0. 0 31 .9 1. 0 2. 7 95 Se co nd ar y or h ig he r 55 .7 67 .5 9. 8 67 .5 43 .7 77 .7 58 .4 3. 1 0. 9 0. 0 33 .8 4. 5 2. 3 68 W ea lth q ui nt ile Lo w es t 44 .5 53 .3 14 .6 61 .0 48 .3 74 .0 34 .1 0. 0 0. 6 0. 0 33 .5 4. 7 9. 1 14 8 Se co nd 45 .9 71 .7 14 .4 74 .4 56 .1 86 .9 37 .8 0. 6 1. 8 2. 1 42 .3 0. 8 4. 1 16 3 M id dl e 44 .9 67 .7 13 .6 75 .3 63 .7 91 .7 42 .5 0. 0 2. 9 0. 6 26 .0 1. 0 5. 4 16 1 Fo ur th 50 .2 73 .8 17 .5 80 .2 57 .5 89 .3 39 .8 1. 6 3. 1 0. 0 29 .5 0. 7 6. 3 13 0 H ig he st 53 .7 79 .9 7. 4 79 .9 42 .9 86 .1 60 .6 1. 4 1. 8 0. 0 28 .1 0. 0 3. 8 73 To ta l 47 .0 68 .0 14 .1 73 .4 55 .1 85 .6 41 .0 0. 6 2. 0 0. 6 32 .5 1. 6 5. 9 67 6 N ot e: O RT in cl ud es s ol ut io n pr ep ar ed fr om o ra l r eh yd ra tio n sa l ts (O RS ) a nd re co m m en de d ho m e flu id s (R H F) . T ot al in cl ud es 1 0 ch ild re n w ith in fo rm at io n m iss in g on ty pe o f d ia rr ho ea 1 E xc lu de s ph ar m ac y, s ho p, a nd tr ad iti on al p ra ct iti on er | 139Child Health 14 0 | C hi ld H ea lth T ab le 1 0. 9 F ee di ng p ra ct ic es d ur in g di ar rh oe a P er ce nt d ist rib ut io n of c hi ld re n un de r ag e fiv e w ho h ad d ia rr ho ea in th e tw o w ee ks p re ce di ng th e su rv ey b y am ou nt o f l iq ui ds a nd fo od o ffe re d co m pa re d w ith n or m al p ra ct ic e, th e pe rc en ta ge o f c hi ld re n gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g du rin g th e di ar rh oe a ep iso de , a nd th e pe rc en ta ge o f c hi ld re n w ho c on tin ue d fe ed in g an d w er e gi ve n O RT a nd /o r i nc re as ed fl ui ds d ur in g th e ep iso de o f d ia rr ho ea , b y ba ck gr ou nd c ha ra ct er ist ic s, Si er ra L eo ne 2 00 8 B ac kg ro un d ch ar ac te ris tic Am ou nt o f l iq ui ds g iv en To ta l Am ou nt o f f oo d gi ve n To ta l Pe rc en ta ge g iv en in cr ea se d flu id s an d co nt in ue d fe ed in g1 ,2 Pe rc en ta ge w ho c on tin ue d fe ed in g an d w er e gi ve n O RT an d/ or in cr ea se d flu id s3 N um be r o f ch ild re n w ith di ar rh oe a M or e Sa m e as u su al So m e- w ha t le ss M uc h le ss N on e D on ’t kn ow / m iss in g M or e Sa m e as u su al So m e- w ha t le ss M uc h le ss N on e N ev er ga ve fo od D on ’t kn ow / m iss in g A ge in m on th s < 6 62 .3 6. 2 13 .1 18 .3 0. 0 0. 0 10 0. 0 6. 6 8. 5 33 .4 18 .7 8. 5 24 .3 0. 0 10 0. 0 30 .3 43 .1 54 6- 11 47 .0 17 .0 8. 6 26 .4 0. 6 0. 3 10 0. 0 17 .9 16 .4 24 .6 28 .7 2. 2 7. 0 3. 2 10 0. 0 31 .7 48 .4 11 5 12 -2 3 53 .2 20 .6 8. 9 15 .9 0. 0 1. 3 10 0. 0 11 .9 28 .0 26 .1 24 .2 5. 6 3. 9 0. 3 10 0. 0 35 .9 56 .1 17 5 24 -3 5 61 .7 19 .3 4. 3 14 .0 0. 0 0. 6 10 0. 0 18 .0 27 .7 23 .4 25 .0 5. 2 0. 0 0. 6 10 0. 0 45 .8 61 .9 14 8 36 -4 7 58 .5 21 .6 8. 6 8. 7 1. 6 1. 0 10 0. 0 16 .3 35 .0 23 .2 21 .9 3. 3 0. 0 0. 2 10 0. 0 45 .3 69 .1 11 5 48 -5 9 47 .5 19 .9 13 .4 9. 4 0. 0 9. 7 10 0. 0 11 .7 21 .1 23 .5 23 .3 10 .7 0. 0 9. 7 10 0. 0 29 .8 49 .0 69 S ex M al e 52 .2 20 .0 7. 6 18 .7 0. 4 1. 1 10 0. 0 14 .5 25 .7 23 .6 23 .2 5. 1 6. 8 1. 1 10 0. 0 34 .8 55 .1 34 9 Fe m al e 58 .1 17 .2 9. 7 12 .3 0. 4 2. 3 10 0. 0 14 .6 24 .1 26 .6 25 .4 5. 5 1. 2 2. 5 10 0. 0 41 .2 58 .0 32 6 T yp e of d ia rr ho ea N on -b lo od y 54 .9 18 .8 8. 1 16 .4 0. 5 1. 3 10 0. 0 14 .0 24 .4 27 .1 23 .7 4. 8 4. 6 1. 5 10 0. 0 38 .3 57 .5 51 2 Bl oo dy 55 .1 19 .3 9. 9 14 .4 0. 0 1. 2 10 0. 0 17 .8 27 .7 17 .6 27 .6 4. 9 2. 9 1. 4 10 0. 0 37 .9 55 .1 14 7 R es id en ce U rb an 45 .3 23 .3 7. 2 22 .7 0. 8 0. 7 10 0. 0 13 .3 26 .1 29 .2 27 .2 1. 2 2. 3 0. 7 10 0. 0 31 .9 59 .4 15 3 Ru ra l 57 .9 17 .3 9. 0 13 .5 0. 2 2. 0 10 0. 0 14 .9 24 .6 23 .9 23 .3 6. 5 4. 7 2. 1 10 0. 0 39 .6 55 .7 52 3 R eg io n Ea st er n 49 .1 13 .3 13 .5 19 .8 0. 5 3. 8 10 0. 0 6. 0 25 .2 18 .4 40 .8 3. 6 3. 1 2. 8 10 0. 0 25 .8 42 .4 12 1 N or th er n 60 .5 18 .5 7. 7 12 .3 0. 0 1. 1 10 0. 0 21 .1 26 .4 23 .4 15 .1 7. 0 5. 5 1. 6 10 0. 0 46 .8 64 .0 37 1 So ut he rn 44 .7 24 .1 7. 3 19 .3 1. 8 2. 8 10 0. 0 5. 3 16 .2 33 .6 36 .4 3. 5 2. 2 2. 8 10 0. 0 25 .2 44 .7 10 5 W es te rn 52 .5 20 .7 6. 9 19 .9 0. 0 0. 0 10 0. 0 9. 2 29 .1 32 .1 25 .7 2. 0 1. 8 0. 0 10 0. 0 31 .0 58 .9 79 M ot he r’ s ed uc at io n N o ed uc at io n 55 .6 18 .2 8. 3 15 .7 0. 5 1. 8 10 0. 0 16 .6 21 .8 24 .0 25 .2 6. 2 4. 0 2. 1 10 0. 0 37 .8 55 .5 51 3 Pr im ar y 60 .0 25 .3 4. 5 7. 9 0. 0 2. 3 10 0. 0 9. 8 40 .7 22 .3 19 .4 2. 6 4. 2 1. 0 10 0. 0 42 .8 67 .2 95 Se co nd ar y or h ig he r 43 .7 13 .1 17 .0 25 .8 0. 0 0. 4 10 0. 0 5. 7 26 .5 37 .4 23 .2 2. 1 4. 7 0. 4 10 0. 0 31 .3 49 .5 68 W ea lth q ui nt ile Lo w es t 48 .3 22 .7 13 .4 12 .0 0. 0 3. 7 10 0. 0 10 .4 25 .2 24 .4 25 .4 8. 3 1. 3 4. 9 10 0. 0 30 .0 46 .7 14 8 Se co nd 56 .1 12 .8 11 .5 17 .3 0. 8 1. 5 10 0. 0 14 .7 20 .5 30 .7 27 .4 3. 7 2. 2 0. 8 10 0. 0 40 .8 57 .6 16 3 M id dl e 63 .7 20 .1 4. 1 9. 9 0. 8 1. 5 10 0. 0 19 .1 27 .9 16 .8 19 .1 8. 6 7. 0 1. 5 10 0. 0 40 .6 57 .9 16 1 Fo ur th 57 .5 13 .4 5. 6 22 .7 0. 0 0. 7 10 0. 0 16 .6 21 .1 26 .6 24 .2 2. 3 8. 5 0. 7 10 0. 0 45 .7 62 .5 13 0 H ig he st 42 .9 29 .7 8. 0 19 .0 0. 0 0. 4 10 0. 0 9. 1 34 .5 29 .4 25 .9 0. 7 0. 0 0. 4 10 0. 0 27 .4 60 .2 73 To ta l 55 .1 18 .7 8. 6 15 .6 0. 4 1. 7 10 0. 0 14 .6 24 .9 25 .1 24 .2 5. 3 4. 1 1. 8 10 0. 0 37 .9 56 .5 67 6 N ot e: T ot al in cl ud es 1 0 ch ild re n w ith in fo rm at io n m iss in g on ty pe o f d ia rr ho ea . 1 E qu iv al en t t o th e U N IC EF /W H O in di ca to r ‘ H om e m an ag em en t o f d ia rr ho ea . M IC S’ In di ca to r 3 4 2 C on tin ue d fe ed in g pr ac tic es in cl ud es c hi ld re n w ho w er e gi ve n m or e, s am e as u su al , o r s om ew ha t l es s fo od d ur in g th e di ar rh oe a ep iso de . 3 E qu iv al en t t o U N IC EF M IC S In di ca to r 3 5. 140 | Child Health Child Health | 141 10.7 KNOWLEDGE OF ORS PACKETS As mentioned earlier, a simple and effective re- sponse to dehydration caused by diarrhoea is a prompt in- crease in the child’s fluid intake through some form of ORT, which may include the use of a solution prepared from packets of ORS. To ascertain how widespread knowl- edge of ORS is in Sierra Leone, mothers were asked whether they know about ORS packets. Table 10.10 shows that knowledge of ORS is widespread in Sierra Leone, with 91 percent of mothers having heard about it. Knowledge of ORS is slightly higher among urban women, and increases with mother’s level of education and wealth quintile. Mothers in the Northern Region (86 percent) are less likely to have heard of ORS than mothers in other regions (94-97 percent) 10.8 STOOL DISPOSAL If human faeces are left uncontained, disease may spread by direct contact or by animal contact with the fae- ces. Hence, the proper disposal of children’s stools is ex- tremely important in preventing the spread of disease. Ta- ble 10.11 presents information on the disposal of the stools of children under five, by background characteristics. The first three columns are considered safe ways to dispose of children’s faecal material. The most commonly used method of disposal of young children’s stools is rinsing the stools into a toilet or latrine (55 percent). Other methods of stool disposal include throwing them into the garbage (18 percent), putting or rinsing them into a drain or ditch (12 percent), and burying them (less than 1 percent). Three percent of children use a toilet or latrine; only 1 percent of children’s stools are left in the open. Overall, the stools of 58 percent of children are disposed of safely. There are substantial differentials in the manner of disposal of children’s stools. For example, older children are more likely than younger children to have their stools disposed of safely. As expected, urban children and children in households with an improved toilet facility are more likely to have safe disposal of faecal matter than rural children and children in households without such facilities. The proportion of children whose stools are disposed of safely ranges from 43 percent in the Southern Region to 75 percent in the Western Region. By level of education, uneducated mothers are less likely to dispose of their children’s stools safely than mothers with secondary or higher education (54 and 77 percent, respectively). Safe disposal of faecal matter increases with household wealth status, from 38 percent in the lowest quintile to 83 percent in the highest wealth quintile. Table 10.10 Knowledge of ORS packets Among mothers age 15-49 who gave birth in the five years preceding the survey, percentage who know about ORS packets for treatment of diarrhoea, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who know about ORS packets Number of women Age 15-19 84.6 330 20-24 92.1 804 25-34 91.1 1,917 35-49 91.6 1,051 Residence Urban 95.6 1,183 Rural 89.0 2,920 Region Eastern 93.6 809 Northern 85.9 1,869 Southern 95.1 783 Western 96.9 642 Education No education 89.5 3,051 Primary 93.9 515 Secondary or higher 95.9 537 Wealth quintile Lowest 85.0 885 Second 90.8 849 Middle 90.5 893 Fourth 93.3 793 Highest 96.2 683 Total 90.9 4,103 ORS = Oral rehydration salts 142 | Child Health Table 10.11 Disposal of children’s stools Percent distribution of youngest children under age five living with the mother by the manner of disposal of child’s last faecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Sierra Leone 2008 Background characteristic Manner of disposal of children’s stools Total Percentage of children whose stools are disposed of safely Number of mothers Child used toilet or latrine Put/ rinsed into toilet or latrine Buried Put/ rinsed into drain or ditch Thrown into garbage Left in the open Other Missing Age in months <6 1.3 41.5 0.0 27.3 18.8 1.5 6.3 3.3 100.0 42.8 642 6-11 1.8 50.1 0.2 17.3 20.0 1.2 6.6 2.8 100.0 52.1 599 12-23 1.5 57.3 1.0 9.0 18.9 1.4 5.2 5.7 100.0 59.7 968 24-35 2.5 61.2 0.8 7.5 19.2 0.9 4.5 3.5 100.0 64.5 673 36-47 5.6 62.7 1.5 4.5 15.3 1.3 6.1 3.0 100.0 69.8 425 48-59 5.8 62.2 0.3 4.6 15.7 1.8 2.9 6.7 100.0 68.3 323 Toilet facility Improved, not shared1 3.0 78.3 0.0 8.0 5.1 0.7 3.4 1.6 100.0 81.3 380 Not improved or shared 2.5 52.4 0.7 12.9 20.1 1.4 5.6 4.5 100.0 55.6 3,205 Residence Urban 4.0 72.9 0.0 10.2 5.4 0.5 2.9 4.0 100.0 77.0 1,009 Rural 2.0 48.2 0.9 13.3 23.4 1.6 6.3 4.2 100.0 51.1 2,621 Region Eastern 3.0 52.9 0.6 19.4 16.5 0.3 2.9 4.4 100.0 56.5 729 Northern 1.9 57.6 0.7 10.2 20.3 1.5 3.8 4.1 100.0 60.1 1,657 Southern 1.3 40.3 0.9 11.5 25.8 2.7 13.0 4.4 100.0 42.5 692 Western 5.6 68.9 0.3 10.9 6.0 0.3 4.0 3.9 100.0 74.9 552 Education No education 2.2 51.1 0.8 12.7 21.0 1.6 6.1 4.4 100.0 54.1 2,732 Primary 2.7 61.4 0.3 13.0 14.5 0.2 4.7 3.2 100.0 64.5 444 Secondary or higher 4.6 72.7 0.0 10.2 6.5 0.7 1.8 3.6 100.0 77.3 454 Wealth quintile Lowest 1.4 35.2 1.4 16.8 30.9 2.2 7.7 4.5 100.0 37.9 795 Second 1.4 48.7 0.3 13.3 23.5 1.2 7.2 4.4 100.0 50.4 766 Middle 2.4 56.8 1.0 11.0 17.5 1.8 5.5 4.0 100.0 60.1 786 Fourth 2.9 64.1 0.3 11.3 12.6 1.0 3.4 4.4 100.0 67.3 701 Highest 5.6 77.6 0.0 8.5 2.9 0.0 2.1 3.3 100.0 83.2 582 Total 2.6 55.1 0.6 12.4 18.4 1.3 5.4 4.2 100.0 58.3 3,630 Note: Total includes 44 mothers with information missing on type of toilet facility 1 Non-shared facilities that are of the types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated improved pit (VIP) latrine; pit latrine with a slab; and a composting toilet. Nutrition of Children and Adults | 143 NUTRITION OF CHILDREN AND ADULTS 11 This chapter covers nutritional concerns regarding young children and women age 15-49 in Sierra Leone. Infant and young child feeding practices, including breastfeeding and feeding with solid/semisolid foods, are presented for children. Anthropometric assessment of nutritional status, diversity of foods consumed, micronutrient intake, and vitamin A deficiency are presented for women and children under age five. The chapter also covers anaemia in women and children, and in men age 15-59. Adequate nutrition is critical to child development. The period from birth to two years of age is important for optimal growth, health, and development. Unfortunately, this period is often marked by growth faltering, micronutrient deficiencies, and common childhood illnesses such as diarrhoea and acute respiratory infections (ARI). Optimal feeding practices reported in this chapter include early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding for up to two years of age and beyond, timely introduction of complementary feeding at 6 months of age, frequency of feeding solid/semisolid foods, and the diversity of food groups fed to children age 6 to 23 months. A summary indicator that describes the quality of infant and young child (age 6-23 months) feeding practices (IYCF) is included. A woman’s nutritional status has important implications for her health as well as the health of her children. Malnutrition in women results in reduced productivity, increased susceptibility to infections, slow recovery from illness, and heightened risks of adverse pregnancy outcomes. For example, a woman who has poor nutritional status—as indicated by a low body mass index (BMI), short stature, or other micronutrient deficiencies—has a greater risk of obstructed labour, having a baby with low birth weight, dying from postpartum haemorrhage, and sickness for both herself and her baby. 11.1 NUTRITIONAL STATUS OF CHILDREN Anthropometric data on height and weight collected in the 2008 Sierra Leone Demographic and Health Survey (SLDHS) permit the measurement and evaluation of the nutritional status of young children in Sierra Leone. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. 11.1.1 Measurement of Nutritional Status among Young Children The 2008 SLDHS collected data on the nutritional status of children by measuring the height and weight of all children under six years of age. Data were collected with the aim of calculating three indices—weight-for-age, height-for-age, and weight-for-height—all of which take age and sex into consideration. Weight measurements were obtained using lightweight, electronic Seca scales with a digital screen designed and manufactured under the guidance of the United Nations Children’s Fund (UNICEF). Height measurements were carried out using a measuring board produced by Shorr Productions. Children younger than 24 months were measured lying down (recumbent length) on the board, while standing height was measured for older children. For the 2008 SLDHS, the nutritional status of children is calculated using new growth standards published by the World Health Organization (WHO) in 2006. These new growth standards were generated using data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). Each of the three nutritional status indicators described below is expressed in standard deviation units from the WHO Child Growth Standards population median. It should be noted that the indices are not comparable to those based on the NCHS/CDC/WHO standards. However, for the purposes of comparison with earlier surveys, Appendix Table C.7 includes indices expressed in standard deviation 144 | Nutrition of Children and Adults units (SD) from the median of the NCHS/CDC/WHO international reference population, which was in use prior to the new WHO Child Growth Standards. Each of the indices considered in this analysis—height-for-age, weight-for-height, and weight-for-age—provides different information about growth and body composition that is used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children whose Z-scores are below -2 SD are considered thin (wasted) and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight- for-height is below -3 SD are considered severely wasted. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below -2 SD are classified as underweight. Children whose weight-for-age is below -3 SD are considered severely underweight. 11.1.2 Results of Data Collection Measurement of height and weight were obtained for all children under age six living in half of the households selected for the SLDHS sample. The results include children who were not biological offspring of the women interviewed in the survey. Although data were collected for all children under age six, for purposes of comparability, the analysis is limited to children under age five. Valid height and weight measurements were obtained for 82 percent of the 3,378 children under age five in the SLDHS households. Measurements were missing for 8 percent of the children, presumably because the child was not present, the parents refused, or the child was ill. Another 9 percent of children were considered to have implausibly high or low values for the height or weight measures, and an additional 2 percent lacked data on age in months. The following analysis focuses on the children for whom complete and plausible anthropometric and age data were collected. Table 11.1 and Figure 11.1 indicate the percentage of children under age five classified as malnourished according to height-for-age, weight-for-height, and weight-for age indices, by the child’s age and other demographic characteristics. Nutrition of Children and Adults | 145 Table 11.1 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Sierra Leone 2008 Background characteristic Height-for-age Weight-for-height Weight-for-age Number of children Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Age in months <6 6.5 13.6 0.0 4.8 15.3 12.0 -0.1 4.5 14.2 10.0 -0.2 240 6-8 11.2 20.5 -0.6 4.6 10.8 11.0 -0.1 6.2 13.8 4.3 -0.6 146 9-11 8.6 18.4 -0.5 9.6 14.9 8.2 -0.5 6.3 17.3 3.0 -0.7 140 12-17 19.8 32.7 -1.2 5.3 11.9 5.9 -0.4 7.7 20.9 3.9 -0.9 341 18-23 20.7 37.6 -1.3 2.4 8.3 4.8 -0.3 4.6 18.5 3.3 -0.8 196 24-35 26.0 47.5 -1.6 3.1 8.8 9.8 0.0 5.5 20.7 5.1 -0.9 486 36-47 24.7 39.6 -1.5 5.0 10.2 9.7 -0.1 9.1 23.6 2.1 -1.0 626 48-59 23.1 43.0 -1.7 2.9 7.6 6.6 -0.1 8.1 25.5 0.7 -1.1 589 Sex Male 22.5 38.6 -1.4 4.6 9.9 8.4 -0.2 7.9 23.6 3.4 -0.9 1,341 Female 18.7 34.3 -1.2 3.9 10.5 8.4 -0.1 6.3 18.8 3.5 -0.8 1,423 Birth interval in months2 First birth3 18.2 32.0 -1.2 4.4 11.1 6.4 -0.2 5.6 18.5 3.6 -0.8 409 <24 23.5 38.1 -1.5 7.2 13.4 12.0 -0.2 12.3 28.1 3.2 -1.0 276 24-47 22.0 38.9 -1.4 3.9 9.0 7.2 -0.1 6.1 22.7 3.3 -0.9 917 48+ 17.6 31.4 -1.1 3.9 10.7 11.7 -0.1 6.3 16.4 4.5 -0.7 547 Size at birth2 Very small 17.9 36.7 -1.2 6.4 14.9 4.8 -0.5 6.2 27.9 3.5 -1.0 147 Small 23.7 40.5 -1.6 3.9 12.4 8.5 -0.2 11.6 30.3 5.5 -1.1 273 Average or larger 20.1 35.0 -1.3 4.3 9.7 9.1 -0.1 6.1 19.0 3.2 -0.8 1,641 Missing 18.5 29.2 -1.2 5.5 11.0 11.3 0.0 6.3 17.6 5.8 -0.7 88 Mother’s interview status Interviewed 20.3 35.6 -1.3 4.4 10.4 8.8 -0.1 6.8 21.0 3.6 -0.9 2,149 Not interviewed, but in household 17.6 37.4 -1.3 3.1 10.3 5.0 -0.1 6.8 19.8 3.4 -0.8 137 Not interviewed, and not in the household4 22.5 39.5 -1.3 3.7 9.1 7.6 -0.2 8.3 22.0 2.9 -0.9 476 Mother’s nutritional status5 Thin (BMI <18.5) 22.5 37.7 -1.4 8.4 18.0 4.0 -0.7 11.3 29.7 3.2 -1.3 235 Normal (BMI 18.5-24.9) 20.4 36.7 -1.3 3.8 9.2 7.7 -0.2 6.7 21.9 3.1 -0.9 1,309 Overweight/obese (BMI ≥25) 19.7 32.6 -1.3 3.7 9.4 12.3 0.2 5.0 15.5 5.0 -0.6 557 Missing 16.1 32.5 -1.1 7.1 14.1 12.3 -0.2 7.0 17.8 2.4 -0.8 140 Residence Urban 13.9 29.7 -0.9 5.4 11.3 10.3 -0.1 6.7 15.7 4.4 -0.6 750 Rural 23.0 38.9 -1.4 3.8 9.8 7.7 -0.2 7.2 23.1 3.2 -0.9 2,014 Region Eastern 16.4 33.6 -1.2 4.1 9.9 11.6 0.1 6.3 17.7 5.7 -0.6 507 Northern 22.6 39.5 -1.4 3.3 8.6 5.8 -0.2 7.5 23.5 2.7 -1.0 1,328 Southern 24.0 38.1 -1.4 6.5 14.5 11.7 -0.2 8.7 23.6 3.4 -1.0 546 Western 14.0 26.9 -0.9 4.4 9.9 8.6 -0.2 4.5 13.9 3.4 -0.7 383 Mother’s education6 No education 21.2 37.9 -1.4 4.6 10.8 8.0 -0.2 8.1 23.2 3.7 -0.9 1,799 Primary 21.4 31.1 -1.2 6.3 10.1 12.3 0.0 3.0 14.2 2.4 -0.7 253 Secondary or higher 11.2 22.4 -0.8 0.7 7.8 9.0 -0.1 1.2 10.8 4.3 -0.5 226 Wealth quintile Lowest 22.6 36.5 -1.3 4.1 11.6 9.5 -0.1 7.0 21.8 3.6 -0.8 605 Second 26.2 43.6 -1.6 3.7 9.0 7.3 -0.2 7.7 25.7 1.4 -1.1 581 Middle 20.7 37.7 -1.3 4.3 9.4 7.8 -0.2 8.0 23.4 3.6 -0.9 616 Fourth 18.9 36.5 -1.3 4.5 9.1 8.8 -0.1 7.1 19.5 4.5 -0.8 590 Highest 11.2 22.7 -0.6 4.8 12.6 8.8 -0.2 4.6 11.8 4.7 -0.5 373 Total 20.6 36.4 -1.3 4.2 10.2 8.4 -0.2 7.1 21.1 3.5 -0.9 2,764 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO standards. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 2 children with information missing on mother’s interview status and 8 children with information missing on mother’s education 1 Includes children who are below -3 standard deviations (SD) from the WHO Child Growth Standards population median 2 Excludes children whose mothers were not interviewed 3 First born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 4 Includes children whose mothers are deceased 5 Excludes children whose mothers were not weighed and measured. Mother’s nutritional status in terms of BMI (Body Mass Index) is presented in Table 11.10. 6 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire 146 | Nutrition of Children and Adults Figure 11.1 Nutritional Status of Children by Age Sierra Leone, 2008 # # # ### #### #### #### ## ## # #### # #### ## ##### ############ ###### ##) )) ))))))) )))))))))))))))) ))))))))) )))) )))) ))))))))) ))))))) 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Age (months) 0 10 20 30 40 50 60 Percent Stunted Wasted Underweight) # Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. 11.1.3 Levels of Malnutrition The data in Table 11.1 show that 36 percent of children under five are stunted (below -2 SD), with 21 percent being severely stunted (-3 SD). Children age 24-35 months (48 percent) and age 48- 59 months (43 percent) are most likely to be stunted, while those under 6 month are the least likely to be stunted (14 percent). Male children are slightly more likely to be stunted than female children (39 percent, compared with 34 percent). The spacing of births has some impact on stunting; children born 24 to 47 months after a prior sibling (39 percent) are more likely to be stunted than children born after a longer birth interval (31 percent). The pattern of stunting by the reported size of the child at birth is not uniform, children reported as being ‘small’ at birth are more likely to be stunted (41 percent) than those described as ‘very small’ at birth (37 percent) or ‘average or larger’ at birth (35 percent). The extent of stunting decreases as mother’s nutritional status increases. The level of stunting is high in the rural areas (39 percent) and lower in the urban areas (30 percent). Stunting varies by region; it is highest in the Northern and Southern regions (40 and 38 percent, respectively) and lowest in the Western Region (27 percent). The percentage of stunted children generally declines with increasing level of mother’s education and wealth quintile. For example, 38 percent of children born to mothers with no education are stunted, compared with 22 percent of children born to mothers with secondary or higher education. Similarly, children in households in the second wealth quintile (44 percent) are almost twice as likely to be stunted as children in households in the highest wealth quintile (23 percent). The weight-for-height index (wasting) provides information about children’s recent experience with food intake. Wasting represents failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of recent illness or of seasonal variations in food supplies. Overall, 10 percent of children under five are wasted, with 4 percent severely wasted. Wasting is highest among children under 6 months and children age 9-11 months (15 percent each); wasting is lowest among children age 18-23 months and age 48-59 months (8 percent each). The level of wasting varies slightly with birth interval, size at birth, and residence. Wasting is more common in the Southern Region than elsewhere. The extent of wasting decreases as mother’s nutritional status improves. Nutrition of Children and Adults | 147 Table 11.1 highlights another problem among some young children in Sierra Leone: 8 percent are overweight (i.e., more than two standard deviations (+2 SD) above the median for the reference population. By age, the highest proportion of overweight children is among those age under 9 months (11 to 12 percent). Birth interval is also relevant, children born 24 to 47 months after a prior sibling are the least likely to be overweight (7 percent), while those born less than 24 months (short birth interval) or 48 months or more (long birth interval) after a prior sibling are more likely to be overweight (12 percent each). The percentage of overweight children increases as size at birth and mother’s nutritional status increase. There is a small difference by urban-rural residence (10 and 7 percent, respectively), and by region, the prevalence of overweight children ranges from 6 percent in the Northern Region to 12 percent each in the Eastern and Southern Regions. Although variation by mother’s level of education is not uniform, the highest proportion of overweight children is found among those whose mothers have primary education (12 percent). Children whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are considered underweight. The measure reflects the effects of both acute and chronic malnutrition. Overall, 21 percent of Sierra Leonean children are underweight, with 7 percent classified as severely underweight. Peak levels of low weight-for-age are found among children age 48-59 months (26 percent). Male children are more likely to be underweight than female children. The percentage of children who are underweight decreases as birth interval, size at birth and mother’s nutritional status increase. Children living in rural areas are more likely to be underweight than urban children (23 and 16 percent, respectively). The proportion of underweight children ranges from 14 percent in the Western Region to 24 percent each in the Northern and Southern regions. Children whose mothers have secondary or higher education (11 percent) are substantially less likely to be underweight than children whose mothers have no education (23 percent). Similarly, children in the wealthiest households (12 percent) are much less likely to be underweight than children in poorer households (20-26 percent). The nutritional status of children in the 2005 MICS survey (SSL and UNICEF, 2007) was calculated using NCHS/CDC/WHO standards. For the 2008 SLDHS, the nutritional status of children is calculated using new growth standards published by the World Health Organization (WHO) in 2006. In order to compare the nutritional status of children under age five between the two surveys, each of the three nutritional status indicators was re-run using the NCHS/CDC/WHO international reference population (see Appendix Table C.7). There has been a modest improvement over the past five years in the nutritional status of children under age five in Sierra Leone. Compared with the MICS 2005 results, the proportion of children whose height-for-age is below minus two standard deviations (stunted) decreased from 40 percent in 2005 to 34 percent in 2008, and the proportion of children whose weight-for-age is below minus two standard deviations (underweight) decreased from 30 percent in 2005 to 25 percent in 2008. Regarding wasting, the proportion of children whose weight-for-height is below -2 SD has not changed in the past five years, with 9 percent in the 2005 MICS and in the 2008 SLDHS. The improvements in nutritional status are fairly small and should be interpreted with caution; when sampling errors are taken into consideration, it is likely that the nutritional status of children under five years in Sierra Leone has remained the same over the past five years. 11.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the contraction of the uterus and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. 148 | Nutrition of Children and Adults Table 11.2 shows the percentage of all children born in the five years before the survey by breastfeeding status and the timing of initial breastfeeding and by background characteristics. Overall, 95 percent of children born in the past five years were breastfed at some time and 51 percent of children were breastfed within one hour of birth. Data from the 2008 SLDHS show that there is no difference in early initiation of breastfeeding by sex of the child. Urban children (49 percent) are slightly less likely to receive breast milk during the first hour after birth than rural children (51 percent). The proportion of children who receive early breastfeeding varies by type of assistance at delivery and region. Children whose mothers received no assistance at delivery were the least likely to start breastfeeding within the first hour after the birth. The proportion of women who began breastfeeding within an hour of birth is highest in the Northern Region (61 percent) and lowest in the Eastern Region, where only 38 percent of newborns received the same attention. Eighty-six percent of babies were breastfed within the first 24 hours after delivery. Table 11.2 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed; for last-born children in the five years preceding the survey who were ever breastfed, the percentage who started breastfeeding within one hour and within one day of birth, and the percentage who received a prelacteal feed, by background characteristics, Sierra Leone 2008 Background characteristic Breastfeeding among children born in past five years Among last-born children ever breastfed: Number of last-born children ever breastfed Percentage ever breastfed Number of children born in past five years Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a prelacteal feed2 Sex Male 94.8 2,880 50.7 85.4 60.0 1,937 Female 94.3 2,931 50.3 86.0 58.4 1,974 Assistance at delivery Health professional3 95.2 2,466 49.0 90.0 54.2 1,738 Traditional birth attendant 93.8 2,605 50.4 83.8 64.5 1,734 Other 93.6 548 63.3 84.5 63.9 362 No one 96.9 57 (46.1) (71.2) (52.8) 33 Missing 99.2 136 (9.7) (11.0) (11.9) 44 Place of delivery Health facility 95.6 1,430 50.7 90.3 54.1 1,015 At home 94.1 4,172 51.3 85.3 61.8 2,815 Other (92.0) 49 (39.3) (90.6) (70.3) 33 Missing 98.0 160 (5.3) (7.0) (6.1) 48 Residence Urban 94.2 1,585 48.5 86.4 68.1 1,118 Rural 94.7 4,226 51.3 85.4 55.6 2,794 Region Eastern 96.7 1,170 38.2 89.8 41.2 782 Northern 93.2 2,623 60.7 82.4 62.2 1,767 Southern 96.1 1,187 46.1 90.0 47.4 758 Western 93.5 831 42.0 84.4 88.2 605 Mother’s education No education 94.5 4,443 51.9 86.1 57.1 2,912 Primary 95.2 713 47.6 83.3 62.7 496 Secondary or higher 94.0 655 45.2 85.7 67.4 504 Wealth quintile Lowest 93.9 1,327 50.4 86.7 50.3 836 Second 96.6 1,220 52.6 86.3 55.2 828 Middle 94.2 1,288 53.4 83.6 55.1 858 Fourth 94.1 1,102 50.7 86.9 61.7 750 Highest 93.8 873 43.7 85.0 78.4 640 Total 94.6 5,811 50.5 85.7 59.2 3,911 Note: Table is based on children born in the five years preceding the survey regardless of whether the children was living or dead at the time of interview. Figures in parentheses are based on 25 to 49 unweighted cases. 1 Includes children who started breastfeeding within one hour of birth 2 Anything other than breast milk given to child during the first three days of life. 3 Doctor, nurse, midwife, or MCH aid Nutrition of Children and Adults | 149 Survey results show that over half of babies (59 percent) received a prelacteal feed, i.e., anything other than breast milk given to a child during the first three days of life. Children whose births were assisted by a traditional birth attendant and those born at home were more likely to receive a prelacteal feed than those born at a health facility or with the assistance of a health provider. A prelacteal feed is more common in urban areas (68 percent) than rural areas (56 percent). It is practiced most commonly in the Western Region (88 percent) and in households in the highest wealth quintile (78 percent). Figure 11.2 shows the percentage of newborns who received various types of prelacteal liquids among last-born children in the five years preceding the survey who received a prelacteal feed. The vast majority of children received plain water (90 percent), 20 percent received sugar water, gripe water (commercial preparation for colicky babies), or sugar and salt water. Another 5 percent received milk other than breast milk. Other liquids such as infant formula, tea, honey, fruit juice, and other were given to 1 percent of children who received a prelacteal feed. Figure 11.2 Types of Prelacteal Liquids Received by Last-born Children in the Five Years Preceding the Survey Sierra Leone, 2008 5 90 13 5 2 1 Milk other than breast milk Plain water Sugar or glucose water Gripe water Sugar and salt water Other Prelacteal liquid received 0 20 40 60 80 100 Percent 2 1 Note: Percentages do not add to 100.0 because some children received more than one type of prelacteal feed. 1 Commercial preparation for soothing colicky babies 2 ’Other’ includes fruit juice, infant formula, tea/infusions, and honey. 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first 6 months of life and that children be given solid or semisolid complementary foods, in addition to continued breastfeeding, from age 6 months to 24 months or more, when the child is fully weaned. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for several reasons. First, it exposes infants to pathogens and increases their risk of infection, especially disease. Second, it decreases infants’ intake of breast milk and therefore suckling, which reduces breast milk pro- duction. Third, in low-resource settings, supplementary food is often nutritionally inferior. Information on complementary feeding was obtained by asking mothers about the current breastfeeding status of their children under five years of age and—for the youngest child born in the three years preceding the survey and living with the mother—the foods and liquids given to the child the day and night preceding the survey. 150 | Nutrition of Children and Adults Table 11.3 shows the percent distribution of youngest children under three years of age living with the mother by breastfeeding status, and percentage of children under three years using a bottle with a nipple, according to age in months. The results presented in Table 11.3 and Figure 11.3 show that the duration of breastfeeding in Sierra Leone is long. Almost all children (95 percent) under age 6 months are breastfed and, at age 12-15 months, the majority of children (82 percent) are still breastfeeding. By age 20-23 months, 50 percent of children have been weaned. Compared with any breastfeeding, exclusive breastfeeding in Sierra Leone is less common and much shorter in duration. Only 22 percent of children under 2 months of age are exclusively breastfed, and this level declines to 3 percent among children age 4-5 months. Overall, only 11 percent of children under 6 months are exclusively breastfed, considerably less than the recommended 100 percent. In addition to breast milk, 5 percent of children are given other (non-breast) milk, 17 percent are given water, 29 percent are given other liquids, and 33 percent are given complementary foods in the form of solid or mushy foods. At age 6-9 months, more than nine in ten Sierra Leonean children are still breastfeeding, but most are also receiving other liquids and solid or mushy foods; 73 percent of breastfeeding children in this age group receive complementary foods. Among children age 9-11 months, more than 90 percent are still breastfeeding and 77 percent are also receiving complementary foods. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under three years who are living with their mother by breastfeeding status; the percentage currently breastfeeding; and the percentage of all children under three years using a bottle with a nipple, according to age in months, Sierra Leone 2008 Age in months Not breast- feeding Exclusively breastfed Breastfeeding and consuming: Total Percentage currently breast- feeding Number of youngest children under three years Percentage using a bottle with a nipple1 Number of children under three years Plain water only Non-milk liquids/ juice Other milk Comple- mentary foods 0-1 4.9 22.3 22.1 29.2 6.2 15.3 100.0 95.1 162 15.8 173 2-3 4.2 11.5 20.4 35.5 5.5 23.0 100.0 95.8 244 18.4 269 4-5 6.6 3.4 9.4 21.0 4.8 54.9 100.0 93.4 236 14.4 250 6-8 5.3 0.0 9.5 10.5 2.4 72.4 100.0 94.7 317 18.8 340 9-11 9.3 1.0 4.4 7.9 0.6 76.7 100.0 90.7 281 11.1 295 12-17 20.3 0.9 2.3 2.4 0.5 73.5 100.0 79.7 616 7.2 658 18-23 46.2 0.7 1.1 1.3 0.0 50.7 100.0 53.8 352 5.4 402 24-35 80.0 0.5 0.0 0.4 0.0 19.1 100.0 20.0 673 3.9 939 0-3 4.5 15.8 21.1 33.0 5.8 19.9 100.0 95.5 407 17.4 442 0-5 5.2 11.2 16.8 28.6 5.4 32.8 100.0 94.8 642 16.3 692 6-9 5.4 0.0 8.7 10.9 2.1 72.9 100.0 94.6 402 17.1 430 12-15 18.1 1.0 2.4 2.6 0.6 75.3 100.0 81.9 437 8.4 468 12-23 29.7 0.8 1.9 2.0 0.3 65.2 100.0 70.3 968 6.5 1,060 20-23 49.8 0.5 0.8 0.9 0.0 48.0 100.0 50.2 225 4.6 259 Note: Breastfeeding status refers to a 24-hour period (yesterday and the past night). Children classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, so the percentages add to 100 percent. Thus, children who receive breast milk and non-milk liquids and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Children who receive complementary foods are classified in that category as long as they are also breastfeeding. 1Based on all children under three years Use of bottles with nipples is not widespread, which is encouraging because contamination can occur with this method of feeding: only 16 percent of the youngest infants (0 to 1 month) are fed with a bottle with a nipple. This proportion increases to 19 percent for children age 6 to 8 months before declining. Nutrition of Children and Adults | 151 Figure 11.3 Infant Feeding Practices by Age Sierra Leone, 2008 <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months 0% 20% 40% 60% 80% 100% Pe rc en t Exclusively breastfed Plain water only Breastmilk & non-milk liquids Breastmilk & other milk/formula Breastmilk & complementary foods Not breastfed 0 40 60 80 100 20 11.4 DURATION AND FREQUENCY OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding by background characteristics. The estimates of median and mean durations of breastfeeding are based on current status data, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The median duration of any breastfeeding in Sierra Leone is 20 months, although the median duration of exclusive breastfeeding is very short—less than one month. The differentials in these two variables by background characteristics are small; however, rural children are breastfed somewhat longer than urban children, and the median duration of any breastfeeding decreases as mother’s level of education and wealth quintile increases. Almost all children under six months (96 percent) are breastfed at least six times a day. On average, children are fed more frequently during the day (mean number of feeds: 7.5) than during the night (mean number of feeds: 5.0). The frequency of breastfeeding varies only slightly by background characteristics. 152 | Nutrition of Children and Adults Table 11.4 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey; and percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of day and night feeds, by background characteristics, Sierra Leone 2008 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Frequency of breastfeeding among children under six months of age2 Any breast- feeding Exclusive breast- feeding Predomi- nant breast- feeding3 Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 18.9 0.5 2.9 98.0 7.8 5.1 309 Female 20.7 0.5 1.9 93.6 7.2 4.9 321 Residence Urban 18.0 0.4 1.4 96.4 7.9 5.2 160 Rural 20.5 0.5 2.5 95.6 7.3 4.9 469 Region Eastern 19.8 0.6 3.3 99.5 8.1 5.3 131 Northern 21.4 0.5 2.1 94.2 7.0 4.6 308 Southern 17.7 0.5 3.1 95.0 7.6 5.4 114 Western 17.9 0.4 0.7 97.3 8.1 5.3 76 Mother’s education No education 20.5 0.5 2.7 95.2 7.4 5.0 473 Primary 19.0 0.4 1.9 98.5 7.2 4.8 79 Secondary or higher 16.2 0.4 1.4 96.9 8.4 5.2 77 Wealth quintile Lowest 20.3 0.5 3.0 97.4 7.3 5.0 168 Second 20.9 0.5 2.3 97.0 7.9 5.2 131 Middle 20.7 0.4 2.6 91.7 6.5 4.3 131 Fourth 18.6 0.5 2.3 96.2 8.2 5.4 119 Highest 17.1 0.4 1.4 96.7 7.6 5.1 81 Total 19.7 0.5 2.3 95.8 7.5 5.0 629 Mean for all children 19.0 1.5 4.9 na na na na Note: Median and mean durations are based on the distribution at the time of the survey of the proportion of births, by months since birth. Includes both children living and dead at the time of the survey. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding 2 Excludes children without a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only Nutrition of Children and Adults | 153 11.5 TYPES OF COMPLEMENTARY FOODS UNICEF and WHO recommend the introduction of solid food to infants around the age of 6 months because by that age breast milk alone is no longer sufficient to maintain a child’s optimal growth. In the transition to eating the family diet, children from the age of 6 months should be fed small quantities of solid and semisolid foods throughout the day. During this transition period (age 6-23 months), the prevalence of malnutrition increases substantially in many countries because of increased infections and poor feeding practices. Table 11.5 provides information on the types of foods and liquids given to youngest children under three years of age living with their mother on the day and night preceding the survey, according to their breastfeeding status. Among breastfeeding children age 6-23 months, 87 percent received solid or semi-solid foods. The most common supplementary foods given to breastfeeding children age 6-23 months are the following: foods made from grains (76 percent), other liquids (73 percent), fruits and vegetables rich in vitamin A (56 percent), and meat, fish, poultry, and eggs (47 percent). Consumption of anything cooked with butter, fat, or oil generally begins at age 4-5 months (7 percent) and increases steadily to 47 percent by age 18-23 months and then declines to 43 percent at age 24-35 months. As expected, as children get older, the proportion given each type of food generally increases. Table 11.5 shows that the proportion of non-breastfeeding children age 6-23 months who consume various foods is generally higher than the proportion of breastfeeding children. Eighty-four percent of children received foods made from grain, 78 percent ate fruits and vegetables rich in vitamin A, 76 percent consumed liquids other than water, and more than two-thirds ate meat, fish, poultry, or eggs. Approximately four in ten (44 percent) non-breastfeeding children age 6-23 months consumed foods made with oil, fat, or butter. 15 4 | N ut rit io n of C hi ld re n an d Ad ul ts Ta bl e 11 .5 F oo ds a nd li qu id s co ns um ed b y ch ild re n in th e da y an d ni gh t p re ce di ng th e in te rv ie w Am on g yo un ge st c hi ld re n un de r th re e ye ar s of a ge li vi ng w ith t he m ot he r, pe rc en ta ge w ho c on su m ed s pe ci fic li qu id s an d so lid o r se m i-s ol id fo od s in t he d ay a nd n ig ht p re ce di ng t he in te rv ie w , b y br ea st fe ed in g st at us a nd a ge , S ie rr a Le on e 20 08 Ag e in m on th s Li qu id s So lid o r s em i-s ol id fo od s An y so lid or s em i- so lid fo od Fo od s m ad e w ith o il, fa t, or bu tte r Su ga ry fo od s N um be r o f ch ild re n In fa nt fo rm ul a O th er m ilk 1 O th er liq ui ds 2 Fo rti fie d ba by fo od s Fo od m ad e fro m gr ai ns 3 Fr ui ts a nd ve ge ta bl es ric h in vi ta m in A 4 O th er fru its a nd ve ge ta bl es Fo od s m ad e fro m ro ot s an d tu be rs Fo od s m ad e fro m le gu m es an d nu ts M ea t, fis h, po ul try , an d eg gs C he es e, yo gu rt, ot he r m ilk pr od uc t BR EA ST FE ED IN G C H IL D RE N 0- 1 5. 8 4. 5 46 .5 2. 2 11 .7 4. 9 2. 1 1. 7 0. 9 2. 3 3. 0 16 .1 2. 4 1. 4 15 4 2- 3 8. 5 6. 5 58 .9 3. 7 16 .6 5. 0 2. 4 2. 8 3. 8 5. 3 3. 9 22 .9 3. 0 3. 0 23 4 4- 5 12 .3 14 .8 70 .9 11 .7 49 .1 19 .6 9. 9 7. 8 7. 7 11 .8 8. 7 57 .6 6. 6 7. 2 22 0 6- 8 16 .7 17 .1 68 .7 25 .7 67 .9 27 .2 10 .9 12 .2 14 .6 23 .8 7. 1 76 .3 15 .4 16 .1 30 0 9- 11 10 .0 13 .9 70 .5 15 .5 75 .6 49 .1 12 .4 13 .0 18 .7 35 .8 2. 7 84 .6 20 .4 16 .9 25 5 12 -1 7 10 .1 9. 1 75 .6 11 .4 78 .6 68 .6 25 .4 24 .4 28 .7 56 .1 7. 3 92 .3 40 .3 22 .0 49 1 18 -2 3 5. 3 6. 9 74 .0 4. 3 83 .7 77 .0 23 .0 24 .3 34 .9 71 .8 3. 1 94 .3 46 .6 14 .8 19 0 24 -3 5 3. 7 3. 3 77 .2 4. 5 83 .8 82 .6 37 .4 39 .5 38 .2 68 .7 13 .0 95 .5 42 .7 14 .6 13 5 6- 23 10 .9 11 .7 72 .6 14 .6 76 .2 55 .8 18 .8 19 .1 24 .1 46 .5 5. 7 87 .1 31 .1 18 .4 1, 23 6 To ta l 9. 9 10 .3 69 .1 11 .4 61 .6 43 .6 15 .8 15 .9 19 .1 35 .8 6. 1 71 .3 23 .6 13 .8 1, 97 9 N O N -B RE AS TF EE D IN G C H IL D RE N 0- 5 (1 3. 4) (1 2. 2) (4 9. 9) (1 3. 4) (4 0. 2) (1 7. 4) (2 0. 1) (9 .1 ) (9 .6 ) (1 7. 1) (9 .6 ) (4 3. 3) (9 .6 ) (6 .4 ) 34 6- 11 (1 5. 8) (1 9. 3) (8 0. 4) (1 6. 5) (6 8. 8) (5 9. 9) (3 0. 2) (2 9. 1) (3 0. 3) (5 0. 7) (1 5. 4) (8 8. 0) (2 1. 4) (1 3. 8) 43 12 -1 7 10 .9 22 .0 70 .8 13 .9 83 .2 73 .5 28 .3 23 .1 30 .4 58 .6 11 .5 90 .2 34 .9 30 .3 12 5 18 -2 3 7. 9 16 .9 77 .8 3. 6 87 .6 86 .0 34 .6 36 .5 39 .5 79 .9 12 .4 97 .7 56 .0 32 .2 16 3 24 -3 5 7. 8 12 .9 76 .9 5. 8 87 .7 89 .9 36 .7 37 .7 39 .7 78 .5 8. 0 98 .5 52 .2 27 .7 53 8 6- 23 10 .1 19 .1 75 .5 9. 2 83 .5 77 .9 31 .7 30 .5 34 .9 68 .0 12 .5 93 .6 43 .5 29 .1 33 1 To ta l 8. 8 15 .2 75 .4 7. 3 84 .4 82 .8 34 .2 34 .0 36 .8 72 .4 9. 7 94 .6 47 .4 27 .4 90 3 N ot e: B re as tfe ed in g st at us a nd fo od c on su m ed re fe r t o a 24 -h ou r p er io d (y es te rd ay a nd th e pa st n ig ht ). Fi gu re s in p ar en th es es a re b as ed o n 25 to 4 9 un w ei gh te d ca se s. 1 O th er m ilk in cl ud es fr es h, ti nn ed a nd p ow de re d an im al m ilk . 2 D oe s no t i nc lu de p la in w at er 3 I nc lu de s fo rt ifi ed b ab y fo od 4 I nc lu de s fru its a nd v eg et ab le s su ch a s pu m pk in , r ed o r y el lo w y am s or s qu as h, c ar ro ts , r ed s w ee t p ot at oe s, d ar k gr ee n le af y ve ge ta bl es , m an go es , p ap ay as , a nd o th er lo ca lly g ro w n fru its an d ve ge ta bl es th at a re ri ch in v ita m in A 154 | Nutrition of Children and Adults Nutrition of Children and Adults | 155 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Infant and young child feeding (IYCF) practices include timely initiation of feeding solid/semi-solid foods from age 6 months, and increasing the amount and variety of foods and the frequency of feedings as children grow older, while maintaining frequent breastfeeding. Guidelines have been established with respect to IYCF practices for children age 6-23 months (PAHO/WHO, 2003; WHO, 2005). Table 11.6 presents the results of the 2008 SLDHS according to IYCF practices. The indicators focus on the percentage of children for whom feeding practices meet minimum standards with respect to— • Food diversity (i.e., the number of food groups consumed), • Feeding frequency (i.e., the number of times child is fed), and • Consumption of breast milk or other milks or milk products. Breastfed children are considered fed in accordance with minimum IYCF practices if they consume foods from at least three food groups1 and receive foods other than breast milk at least twice per day in the case of children age 6-8 months and at least three times per day in the case of children age 9-23 months. Non-breastfed children are considered fed in accordance with minimum IYCF practices if they consume milk or milk products, are fed from at least four food groups (including milk products), and are fed at least four times per day. The results of the 2008 SLDHS show that in Sierra Leone, more than half (52 percent) of breastfed children age 6-23 months received foods from three or more food groups in the 24 hours preceding the survey; 42 percent were fed the minimum number of times in the past 24 hours; and the percentage of children who fall into both categories was 28 percent (Figure 11.4). The combined proportion of breastfed children age 6-23 months fed in accordance with IYCF practices generally increases with mother’s level of education and wealth quintile; however, it is particular low among children in the Northern Region (22 percent). Among non-breastfed children age 6-23 months, 30 percent received milk or milk products, 60 percent received food from at least four food groups, and 15 percent were fed four or more times per day. However, only 5 percent of non-breastfed children were fed in accordance with all three IYCF practices. The results in Table 11.6 indicate that the majority of young children in Sierra Leone are not being fed appropriately. Overall, feeding practices meet the minimum standards for only 23 percent of children age 6-23 months. The most common problem with feeding practices in Sierra Leone is an inadequate number of feedings. Eighty-five percent of children age 6-23 months received breast milk or milk products and 54 percent received foods from the recommended number of food groups for their age; however, only 36 percent were fed the minimum number of times per day. Appropriate feeding practices are more common for breastfed children than for non-breastfed children (28 and 5 percent, respectively). There is little difference in feeding practices by age, sex of child, or urban-rural residence. Overall, the children most likely to be fed appropriately are those in the Western Region (32 percent), those whose mothers have primary education (27 percent), and those in the highest wealth quintile (28 percent), although differences are not large. 1 Food groups used in the assessment of minimum standard of feeding practices include: infant formula, milk other than breast milk, cheese or yogurt or other milk products; foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; fruits and vegetables rich in vitamin A; other fruits and vegetables; eggs; meat, poultry, fish, and shellfish (and organ meats); beans, peas, and nuts; and foods made with oil, fat, or butter. 15 6 | N ut rit io n of C hi ld re n an d Ad ul ts T ab le 1 1. 6 In fa nt a nd y ou ng c hi ld fe ed in g (IY C F) p ra ct ic es P er ce nt ag e of y ou ng es t c hi ld re n ag e 6- 23 m on th s liv in g w ith th ei r m ot he r w ho a re fe d ac co rd in g to th re e IY C F fe ed in g pr ac tic es b as ed o n br ea st fe ed in g st at us , n um be r of fo od g ro up s co ns um ed , a nd n um be r of ti m es c hi ld w as fe d du rin g th e da y an d ni gh t p re ce di ng th e su rv ey , b y ba ck gr ou nd c ha ra ct er ist ic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Am on g br ea st fe d ch ild re n 6- 23 m on th s, pe rc en ta ge fe d: N um be r o f br ea st fe d ch ild re n 6- 23 m on th s Am on g no n- br ea st fe d ch ild re n 6- 23 m on th s, pe rc en ta ge fe d: N um be r o f no n- br ea st fe d ch ild re n 6- 23 m on th s Am on g al l c hi ld re n 6- 23 m on th s, pe rc en ta ge fe d: N um be r o f al l c hi ld re n 6- 23 m on th s 3+ fo od gr ou ps 1 M in im um tim es o r m or e2 Bo th 3 + fo od gr ou ps a nd m in im um ti m es or m or e M ilk o r m ilk pr od uc ts 3 4+ fo od gr ou ps 4+ ti m es W ith 3 IY C F pr ac tic es 4 Br ea st m ilk or m ilk pr od uc ts 3 3+ o r 4 + fo od g ro up s5 M in im um tim es o r m or e6 W ith a ll 3 IY C F pr ac tic es A ge in m on th s 6- 8 29 .5 56 .1 23 .3 30 0 * * * * 17 95 .6 29 .7 53 .4 22 .2 31 7 9- 11 39 .5 37 .3 22 .8 25 5 (4 2. 4) (6 0. 5) (1 2. 9) (7 .3 ) 26 94 .6 41 .5 35 .0 21 .3 28 1 12 -1 7 64 .6 37 .2 30 .2 49 1 32 .5 48 .8 10 .1 1. 8 12 5 86 .3 61 .4 31 .7 24 .4 61 6 18 -2 3 72 .7 38 .7 33 .2 19 0 27 .7 71 .3 20 .2 7. 7 16 3 66 .6 72 .0 30 .2 21 .4 35 2 S ex M al e 50 .3 41 .3 26 .9 60 1 34 .8 60 .5 17 .0 7. 2 16 7 85 .8 52 .5 36 .0 22 .6 76 8 Fe m al e 53 .9 42 .7 27 .9 63 5 25 .4 59 .5 13 .0 3. 0 16 4 84 .7 55 .1 36 .6 22 .8 79 9 R es id en ce U rb an 48 .4 47 .1 28 .5 31 0 52 .6 77 .8 20 .6 11 .8 12 1 86 .7 56 .7 39 .7 23 .8 43 1 Ru ra l 53 .4 40 .3 27 .1 92 6 17 .1 49 .7 11 .8 1. 3 21 0 84 .7 52 .7 35 .1 22 .3 1, 13 6 R eg io n Ea st er n 56 .8 46 .9 30 .6 25 8 9. 4 49 .8 8. 7 0. 0 61 82 .6 55 .5 39 .6 24 .7 31 9 N or th er n 47 .8 28 .8 21 .8 55 2 26 .4 50 .8 13 .1 3. 5 13 5 85 .5 48 .4 25 .7 18 .2 68 7 So ut he rn 53 .2 55 .6 30 .5 25 9 20 .5 64 .0 14 .6 1. 2 73 82 .5 55 .5 46 .6 24 .1 33 2 W es te rn 57 .6 57 .5 36 .7 16 7 70 .6 85 .4 26 .1 18 .4 62 92 .1 65 .1 49 .0 31 .8 22 8 M ot he r’ s ed uc at io n N o ed uc at io n 51 .6 39 .7 26 .5 92 9 19 .0 54 .8 14 .3 1. 6 22 7 84 .1 52 .2 34 .7 21 .6 1, 15 7 Pr im ar y 50 .8 48 .7 31 .2 16 8 (4 6. 0) (6 9. 0) (1 6. 5) (1 2. 2) 47 88 .2 54 .8 41 .7 27 .0 21 5 Se co nd ar y or h ig he r 57 .6 49 .6 29 .4 13 9 61 .6 73 .2 16 .8 13 .2 57 88 .9 62 .1 40 .1 24 .7 19 5 W ea lth q ui nt ile Lo w es t 56 .9 37 .1 25 .6 27 1 15 .2 39 .1 2. 3 0. 0 65 83 .5 53 .4 30 .4 20 .6 33 6 Se co nd 52 .5 39 .3 24 .7 28 2 18 .5 54 .9 16 .6 4. 4 60 85 .8 52 .9 35 .4 21 .2 34 1 M id dl e 47 .7 42 .2 25 .7 27 3 19 .1 51 .1 9. 4 2. 5 55 86 .4 48 .3 36 .7 21 .8 32 8 Fo ur th 50 .0 42 .5 31 .0 24 2 18 .5 69 .1 24 .5 0. 7 75 80 .8 54 .5 38 .3 23 .8 31 7 H ig he st 54 .2 53 .6 32 .8 16 8 71 .4 79 .3 19 .6 16 .2 76 91 .1 62 .0 43 .0 27 .6 24 5 To ta l 52 .1 42 .0 27 .5 1, 23 6 30 .2 60 .0 15 .0 5. 1 33 1 85 .2 53 .8 36 .3 22 .7 1, 56 7 N ot e: A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. F ig ur es in p ar en th es es a re b as ed o n 25 to 4 9 un w ei gh te d ca se s. 1 Fo od g ro up s: a . i nf an t fo rm ul a, m ilk o th er th an b re as t m ilk , c he es e or y og ur t o r ot he r m ilk p ro du ct s; b . f oo ds m ad e fro m g ra in s, r oo ts , a nd tu be rs , i nc lu di ng p or rid ge a nd fo rti fie d ba by fo od fr om g ra in s; c . v ita m in A -r ic h fru its a nd v eg et ab le s (a nd re d pa lm o il) ; d . o th er fr ui ts a nd v eg et ab le s; e . e gg s; f. m ea t, po ul tr y, fi sh , a nd s he llf ish (a nd o rg an m ea ts ); g. le gu m es a nd n ut s; h . f oo ds m ad e w ith o il, fa t, or b ut te r. 2 A t l ea st tw ic e a da y fo r b re as tfe d in fa nt s 6- 8 m on th s an d at le as t t hr ee ti m es a d ay fo r b re as tfe d ch ild re n 9- 23 m on th s 3 I nc lu de s co m m er ci al in fa nt fo rm ul a, fr es h, ti nn ed , a nd p ow de re d an im al m ilk , a nd c he es e, y og ur t, an d ot he r m ilk p ro du ct s 4 N on -b re as tfe d ch ild re n ag e 6- 23 m on th s ar e co ns id er ed to b e fe d w ith a m in im um s ta nd ar d of th re e In fa nt a nd Y ou ng C hi ld F ee di ng p ra ct ic es if th ey r ec ei ve o th er m ilk o r m ilk p ro du ct s an d ar e fe d at le as t t he m in im um nu m be r o f t im es p er d ay w ith a t l ea st th e m in im um n um be r o f f oo d gr ou ps 5 3 + fo od g ro up s fo r b re as tfe d ch ild re n an d 4+ fo od g ro up s fo r n on -b re as tfe d ch ild re n 6 F ed s ol id o r s em i-s ol id fo od a t l ea st tw ic e a da y fo r i nf an ts 6 -8 m on th s, 3 + ti m es fo r o th er b re as tfe d ch ild re n, a nd 4 + ti m es fo r n on -b re as tfe d ch ild re n Nutrition of Children and Adults156 | Nutrition of Children and Adults | 157 Figure 11.4 Infant and Young Child Feeding (IYCF) Practices Sierra Leone, 2008 28 5 23 72 95 77 Breastfed children Non-breastfed children All children age 6-23 months 0% 20% 40% 60% 80% 100% Fed with all 3 IYCF practices Not fed with all 3 IYCF practices 11.7 ANAEMIA IN CHILDREN Anaemia is a condition characterized by a reduction in the volume of red blood cells and a decrease in the concentration of haemoglobin in the blood. Haemoglobin is necessary for transporting oxygen to tissues and organs in the body. About half of the global burden of anaemia is the result of iron deficiency. Iron deficiency, in turn, is caused by inadequate dietary intake of bioavailable iron, increased iron requirements during rapid growth periods (such as pregnancy and infancy), and increased blood loss due to hookworm or schistosome infestation. Nutritional anaemia includes the anaemic burden from iron deficiency, plus deficiencies in folate, vitamins B and B12, and certain trace elements involved with red blood cell production. Anaemia in children is associated with impaired mental and physical development and with increased morbidity and mortality. Anaemia can be a particularly serious problem for pregnant women, leading to premature delivery and low birth weight. The most common causes of anaemia in Sierra Leone are inadequate dietary intake of iron, malaria, and intestinal worm infestation. Iron and folic acid supplementation and anti-malarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bed nets (ITNs) by pregnant women and children under five, and six-month de-worming for children age two to five years are some of the important measures to reduce the anaemia burden in vulnerable groups. The 2008 SLDHS included anaemia testing of children age 6-59 months and women age 15- 49 in every second household selected for the 2008 SLDHS sample. Anaemia levels were determined by measuring the level of haemoglobin in the blood, with a decreased concentration characterizing anaemia. For haemoglobin measurements, a drop of capillary blood was taken with a finger prick (using sterile, disposable instruments). Haemoglobin concentration was measured using the HemoCue photometer system. As described in Chapter 1, trained personnel with each interviewing team performed the testing procedures on eligible, consenting respondents. 158 | Nutrition of Children and Adults Table 11.7 presents anaemia prevalence for children age 6-59 months by background characteristics. The results are based on tests of 2,653 (de facto) children who were present in the household at the time of the testing, whose parents consented to their being tested, and whose haemoglobin results represented plausible data. In Table 11.7, children with anaemia were classified into three groups according to the level of haemoglobin in their blood:2 • Mild anaemia: haemoglobin concentration 10.0-10.9 g/dl • Moderate anaemia: haemoglobin concentration 7.0-9.9 g/dl • Severe anaemia: haemoglobin concentration less than 7.0 g/dl The 2008 SLDHS results show that 76 percent of children age 6-59 months have some level of anaemia, including 28 percent of children who are mildly anaemic, 44 percent who are moderately anaemic, and 4 percent who are severe anaemia. The prevalence of any anaemia declines with age, from 87 percent among children age 12-17 months to 68 percent among children age 48-59 months. Anaemia is equally common in boys and girls. Children in rural areas (77 percent) are more likely than those in urban areas (73 percent) to be anaemic. Looking at the regional patterns, children in the Northern Region (79 percent) are the most likely to be anaemic. The prevalence of anaemia is also high among children whose mothers have little or no education, and children in households in the three lowest (poorest) wealth quintiles. The World Health Organization considers the level of anaemia observed among young children in Sierra Leone to be a major-level public health concern.3 Compared with estimates from recent Demographic and Health Surveys conducted in the region, the prevalence of any anaemia among children in Sierra Leone (76 percent) is similar to that in Guinea (76 percent in 2005) and Ghana (76 percent in 2003), but lower than the prevalence in Mali (81 percent in 2006) or Senegal (83 percent in 2005) (CPS/MS, DNSI/MEIC [Mali] and Macro International Inc., 2007; DNS [Guinée] and ORC Macro, 2006; Ndiaye et al., 2006; CRDH [Sénégal] and ORC Macro, 2005; GSS, NMIMR [Ghana], and ORC Macro, 2004). 2 The classification is based on criteria developed by the World Health Organization (DeMaeyer et al., 1989). Because haemoglobin levels vary by altitude, each child’s result was adjusted based on altitude measurements taken in the sample cluster in which they were measured. 3 WHO considers anaemia prevalence over 40 percent in a population as a major public health problem; prevalence of 20-40 percent is considered a medium-level public health problem; and prevalence of 5-19.9 percent is considered a mild public health problem (World Health Organization, 2001). Nutrition of Children and Adults | 159 Table 11.7 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteristics, Sierra Leone 2008 Background characteristic Anaemia status by haemoglobin level Number of children Mild (10.0-10.9 g/dl) Moderate (7.0-9.9 g/dl) Severe (below 7.0 g/dl) Any anaemia Age in months 6-8 28.0 49.4 5.6 83.0 149 9-11 26.7 43.4 9.9 80.0 146 12-17 24.4 57.4 5.0 86.8 360 18-23 25.9 46.3 3.9 76.1 203 24-35 26.2 49.4 2.7 78.2 520 36-47 31.0 38.9 3.1 73.0 658 48-59 31.3 34.5 2.0 67.7 618 Sex Male 27.4 44.7 4.2 76.3 1,300 Female 29.4 43.0 3.0 75.5 1,353 Mother’s interview status Interviewed 28.8 44.9 3.6 77.2 1,988 Not interviewed but in household 27.9 33.9 5.6 67.4 136 Not interviewed, and not in the household1 27.3 42.2 3.2 72.8 527 Residence Urban 30.0 40.6 2.0 72.7 734 Rural 27.8 45.0 4.2 77.1 1,919 Region Eastern 30.1 38.7 5.7 74.4 478 Northern 26.8 48.5 4.1 79.3 1,217 Southern 27.2 42.7 2.2 72.1 562 Western 33.2 37.4 1.7 72.2 396 Mother’s education2 No education 28.1 45.4 3.9 77.4 1,674 Primary 30.7 41.3 4.5 76.6 231 Secondary or higher 32.8 36.5 1.4 70.7 211 Wealth quintile Lowest 26.8 46.6 5.2 78.7 578 Second 27.4 44.7 4.6 76.7 562 Middle 29.8 45.7 3.6 79.1 574 Fourth 26.3 44.3 3.0 73.6 552 Highest 33.2 34.8 0.7 68.7 387 Total 28.4 43.8 3.6 75.9 2,653 Note: Table is based on children who slept in the household the night before the interview. Prevalence of anaemia, based on haemoglobin levels, is adjusted for altitude using CDC formulas (CDC, 1998). Haemoglobin measured in grams per decilitre (g/dl). Total includes 2 children with information missing on mother’s interview status and 8 children with information missing on mother’s education. 1 Includes children whose mothers are deceased 2 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers were not listed in the Household Questionnaire. 11.8 IODIZATION OF HOUSEHOLD SALT Dietary deficiency of iodine is a major global public health concern. A lack of sufficient iodine is known to cause goiter, cretinism (a severe form of neurological defect), spontaneous abortion, premature birth, infertility, stillbirth, and increased child mortality. Iodine deficiency disorder (IDD) is the single most common cause of preventable mental retardation and brain damage. Since iodine cannot be stored for long periods by the body, tiny amounts are needed regularly. Where soil and therefore crops and grazing animals do not provide sufficient dietary iodine to the population, and where seafood is not regularly consumed, food fortification has proven to be a highly successful and sustainable intervention. The fortification of salt with iodine is the most common method of preventing IDD. 160 | Nutrition of Children and Adults In the 2008 SLDHS, cooking salt in households was tested for the presence of iodine.4 Fortified salt that contains 15 parts per million (ppm) of iodine is considered adequate for the prevention of IDD. Table 11.8 shows that, among households with salt tested, more than half (58 percent) have adequately iodized salt (15+ ppm); 21 percent have salt that is not adequately iodized (<15 ppm); and 20 percent have salt with no iodine content (0 ppm). A larger proportion of urban households have adequately iodized salt than rural households (70 percent, compared with 52 percent). The Northern Region has the lowest percentage of households with adequately iodized salt (42 percent); in the other regions, the proportions range from 59 percent in the Southern Region to 77 percent in the Eastern Region. The percentage of households using adequately iodized salt increases with wealth status, to 76 percent in households in the highest wealth quintile. Aside from the price of iodized salt, other factors such as uncontrolled humidity, packaging materials, and storage (longer than 6 months) may have an effect on the iodine content of the salt (WHO, 2001). Table 11.8 Presence of iodized salt in household Among all households, percentage with household salt tested for iodine content and percentage with no salt; and among households with salt tested, percent distribution by level of iodine in the salt (parts per million [ppm]), according to background characteristics, Sierra Leone 2008 Background characteristic Percentage of all households with: Number of households Among households with salt tested, percent distribution by iodine content of salt Number of households Salt tested for iodine No salt None (0 ppm) Inadequate (<15 ppm) Adequate (15+ ppm) Total Residence Urban 90.0 10.0 2,469 12.6 17.1 70.3 100.0 2,223 Rural 92.3 7.7 4,815 24.1 23.8 52.1 100.0 4,442 Region Eastern 89.0 11.0 1,494 1.6 21.0 77.4 100.0 1,330 Northern 94.6 5.4 2,757 34.3 23.6 42.1 100.0 2,607 Southern 91.0 9.0 1,583 16.8 24.2 58.9 100.0 1,440 Western 88.8 11.2 1,449 15.0 15.1 69.9 100.0 1,288 Wealth quintile Lowest 92.8 7.2 1,607 22.0 25.3 52.7 100.0 1,491 Second 92.0 8.0 1,440 24.0 23.9 52.1 100.0 1,326 Middle 92.5 7.5 1,344 26.8 21.9 51.3 100.0 1,244 Fourth 90.9 9.1 1,368 21.4 20.2 58.4 100.0 1,243 Highest 89.2 10.8 1,526 7.8 16.1 76.1 100.0 1,361 Total 91.5 8.5 7,284 20.3 21.6 58.2 100.0 6,665 11.9 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is a serious contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, food fortification, and direct supplementation. Table 11.9 presents information on children’s intake of several key micronutrients. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the body’s epithelial tissue. Severe vitamin A deficiency can cause eye damage. Vitamin A deficiency can also increase the severity of infections such as measles and diarrhoeal diseases in children, and slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, yellow-orange sweet potatoes, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for 4-6 months. Periodic dosing (usually every 6 months) with vitamin A supplements is one method of ensuring that children at risk do not develop vitamin A deficiency. 4 Salt testing kits supplied by UNICEF were used to measure iodine levels. Nutrition of Children and Adults | 161 Iron is essential for cognitive development. Low iron intake can also contribute to anaemia. Iron requirements are greatest between the ages of 6 and 12 months, when growth is extremely rapid. The 2008 SLDHS collected information on the consumption of foods rich in vitamin A and foods rich in iron. Table 11.9 shows that 75 percent of children age 6-35 months living with their mother consumed foods rich in vitamin A in the 24 hours preceding the survey, and 59 percent consumed foods rich in iron. There is a steady increase with age in the proportion of children consuming foods rich in vitamin A (from 35 percent among children age 6-8 months to 93 percent among those age 24- 35 months) and iron (from 25 percent among children age 6-8 months to 77 percent among those age 24-35). Children who are not breastfeeding are more likely to consume foods rich in vitamin A and iron than children who are breastfeeding; presumably this is because they are older on average than breastfeeding children. Differences in consumption of vitamin A-rich foods by other background characteristics are not large. However, children born to the youngest women (age 15-20) are markedly less likely to consume iron-rich foods (45 percent) than children born to older women (59-61 percent). Similarly, children in the Northern Region (51 percent) are considerably less likely to consume iron- rich foods than children in other regions (62-68 percent). Consumption of foods rich in iron is generally higher among urban children, children whose mothers are more educated, and children who live in households in the highest wealth quintile. The 2008 SLDHS also collected information on vitamin A supplementation and iron supplementation. As shown in Table 11.9, only 26 percent of children age 6-59 months received a vitamin A supplement in the 6 months preceding the survey. Supplementation is higher among younger children: about one-third of children age 6-17 months received vitamin A supplements, compared with only one-fifth of those age 36-59 months. Children who are breastfeeding are more likely than non-breastfeeding children to have received a vitamin A supplement in the past 6 months. The data show that children in urban areas (30 percent) are slightly more likely to receive a vitamin A supplement than children in rural areas (25 percent). The proportion of children receiving vitamin A supplements is highest in the Southern and Western regions (34 and 32 percent, respectively) and lowest in the Eastern region (21 percent). The proportion of children receiving vitamin A supplements generally increases with mother’s level of education and wealth quintile; however the pattern by wealth quintile is less uniform. Regarding iron supplements, only 20 percent of children age 6-59 months received an iron supplement in the seven days preceding the survey. As with vitamin A supplementation, iron supplementation is higher among breastfeeding children, urban children, children whose mothers have secondary or higher education, and children in the higher wealth quintiles. Children in the Southern and Western regions (29-31 percent) are twice as likely to receive iron supplements as those in the Eastern and Northern regions (14-15 percent). In addition to obtaining information on vitamin A and iron supplementation, the 2008 SLDHS collected data on whether children under age 6-59 months had received de-worming medication in the past six months, because intestinal worms can contribute to both anaemia and vitamin A deficiency. Table 11.9 shows that 37 percent of children age 6-59 months received de-worming medication in the six months preceding the survey. Older children, non-breastfeeding children, children in urban areas and in the Southern and Western regions, and children whose mothers have secondary or higher education, and children in households in the highest wealth quintile are more likely to receive de- worming medication than other children. 16 2 | N ut rit io n of C hi ld re n an d Ad ul ts T ab le 1 1. 9 M ic ro nu tri en t i nt ak e am on g ch ild re n A m on g yo un ge st c hi ld re n ag e 6- 35 m on th s w ho a re li vi ng w ith th ei r m ot he r, th e pe rc en ta ge s w ho c on su m ed v ita m in A -r ic h an d iro n- ric h fo od s in th e da y or n ig ht p re ce di ng th e su rv ey , a nd a m on g al l ch ild re n 6- 59 m on th s, th e pe rc en ta ge s w ho w er e gi ve n vi ta m in A s up pl em en ts in th e six m on th s pr ec ed in g th e su rv ey , w ho w er e gi ve n iro n su pp le m en ts in th e la st s ev en d ay s, a nd w ho w er e gi ve n de - w or m in g m ed ic at io n in th e six m on th s pr ec ed in g th e su rv ey , a nd a m on g al l c hi ld re n ag e 6- 59 m on th s w ho li ve in h ou se ho ld s th at w er e te st ed fo r i od iz ed s al t, th e pe rc en ta ge w ho li ve in h ou se ho ld s w ith ad eq ua te ly io di ze d sa lt, b y ba ck gr ou nd c ha ra ct er ist ic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Yo un ge st c hi ld re n ag e 6- 35 m on th s liv in g w ith th e m ot he r Al l c hi ld re n ag e 6- 59 m on th s C hi ld re n ag e 6- 59 m on th s in h ou se ho ld s w ith s al t te st ed fo r i od in e Pe rc en ta ge w ho co ns um ed fo od s ric h in v ita m in A in p as t 2 4 ho ur s1 Pe rc en ta ge w ho co ns um ed fo od s ric h in ir on in p as t 2 4 ho ur s2 N um be r o f ch ild re n Pe rc en ta ge w ho re ce iv ed v ita m in A su pp le m en t in p as t 6 m on th s Pe rc en ta ge w ho re ce iv ed ir on su pp le m en t in p as t 7 d ay s Pe rc en ta ge w ho re ce iv ed de -w or m in g m ed ic at io n in p as t 6 m on th s3 N um be r o f ch ild re n Pe rc en ta ge li vi ng in h ou se ho ld s w ith a de qu at el y io di ze d sa lt4 N um be r o f ch ild re n A ge in m on th s 6- 8 35 .3 24 .8 31 7 32 .4 23 .7 12 .6 34 0 59 .1 31 7 9- 11 56 .8 37 .7 28 1 34 .7 24 .3 22 .6 29 5 54 .0 27 1 12 -1 7 76 .8 56 .6 61 6 33 .0 25 .0 28 .7 65 8 58 .1 61 6 18 -2 3 87 .4 75 .5 35 2 27 .9 23 .4 42 .5 40 2 59 .8 36 9 24 -3 5 93 .4 76 .5 67 3 27 .0 21 .1 43 .0 93 9 55 .1 87 8 36 -4 7 na na 0 19 .7 15 .2 42 .9 98 4 57 .0 92 3 48 -5 9 na na 0 20 .1 15 .8 41 .8 90 4 58 .0 83 2 S ex M al e 74 .6 59 .6 1, 12 1 26 .0 19 .6 38 .2 2, 25 1 56 .5 2, 10 5 Fe m al e 75 .5 57 .8 1, 11 9 25 .8 20 .3 35 .8 2, 27 0 57 .9 2, 10 1 B re as tf ee di ng s ta tu s Br ea st fe ed in g 65 .1 48 .6 1, 37 1 32 .1 23 .5 25 .2 1, 46 8 55 .4 1, 37 0 N ot b re as tfe ed in g 92 .5 76 .9 78 6 23 .6 18 .8 44 .3 2, 66 1 58 .6 2, 47 0 M iss in g 74 .3 52 .5 83 18 .4 13 .9 31 .8 39 2 54 .5 36 6 M ot he r’ s ag e at b ir th 15 -1 9 71 .8 45 .1 17 3 28 .4 18 .4 31 .4 26 3 58 .3 23 2 20 -2 9 75 .9 60 .0 1, 15 5 24 .2 20 .7 37 .1 2, 26 9 60 .2 2, 11 2 30 -3 9 73 .5 59 .3 74 3 27 .7 19 .0 37 .8 1, 57 5 55 .5 1, 48 2 40 -4 9 79 .6 61 .2 16 9 26 .7 20 .2 36 .9 41 4 46 .4 38 0 R es id en ce U rb an 73 .7 63 .5 60 5 29 .5 27 .5 46 .6 1, 22 0 68 .4 1, 12 4 Ru ra l 75 .6 56 .9 1, 63 5 24 .6 17 .1 33 .4 3, 30 1 53 .1 3, 08 1 R eg io n Ea st er n 74 .0 61 .7 45 6 20 .5 14 .3 31 .4 92 3 80 .2 82 7 N or th er n 75 .9 51 .2 1, 00 5 22 .7 14 .7 30 .8 2, 01 5 41 .0 1, 93 5 So ut he rn 75 .3 65 .4 46 1 33 .9 29 .1 46 .6 93 9 63 .1 86 3 W es te rn 73 .5 68 .3 31 7 32 .1 30 .8 50 .3 64 4 69 .6 58 1 M ot he r’ s ed uc at io n N o ed uc at io n 75 .9 57 .3 1, 69 0 24 .0 16 .4 33 .6 3, 47 4 53 .7 3, 23 2 Pr im ar y 71 .5 61 .5 28 8 29 .8 27 .6 44 .3 54 7 65 .0 50 3 Se co nd ar y or h ig he r 73 .6 64 .3 26 2 35 .1 35 .8 52 .2 50 1 72 .9 47 1 W ea lth q ui nt ile Lo w es t 75 .6 58 .5 47 4 23 .5 15 .4 31 .3 97 7 57 .0 91 5 Se co nd 76 .0 52 .6 48 5 22 .7 14 .3 32 .1 97 8 53 .2 91 0 M id dl e 75 .0 57 .2 49 4 28 .2 19 .2 34 .4 1, 01 4 48 .8 94 3 Fo ur th 74 .3 61 .6 44 5 24 .7 24 .2 40 .9 86 6 56 .8 81 6 H ig he st 74 .1 66 .0 34 2 32 .0 30 .1 50 .9 68 6 76 .6 62 2 To ta l 75 .1 58 .7 2, 23 9 25 .9 19 .9 37 .0 4, 52 1 57 .2 4, 20 6 N ot e: In fo rm at io n on v ita m in A , i ro n su pp le m en ts ,a nd d e- w or m in g m ed ic at io n is ba se d on th e m ot he r’s re ca ll. na = N ot a pp lic ab le 1 In cl ud es m ea t ( an d or ga n m ea t), fi sh , p ou ltr y, e gg s, p um pk in , r ed o r ye llo w y am s or s qu as h, c ar ro ts , r ed s w ee t p ot at oe s, d ar k gr ee n le af y ve ge ta bl es , m an go , p ap ay a, a nd o th er lo ca lly g ro w n fru its a nd ve ge ta bl es ri ch in v ita m in A 2 I nc lu de s m ea t, (in cl ud in g or ga n m ea t), fi sh , p ou ltr y, a nd e gg s 3 D e- w or m in g fo r i nt es tin al p ar as ite s is co m m on ly d on e fo r h el m in th es a nd fo r s ch ist os om ia sis . 4 Sa lt co nt ai ni ng 1 5 pa rts p er m ill io n (p pm ) o f i od in e or m or e. E xc lu de s ch ild re n in h ou se ho ld s in w hi ch s al t w as n ot te st ed . 162 | Nutrition of Children and Adults Nutrition of Children and Adults | 163 As discussed earlier, insufficient iodine in the diet can lead to mental retardation and other negative health outcomes in children. Table 11.9 shows that 57 percent of children age 6-59 months are in households that use adequately iodized salt, and children in urban areas are more likely than those in rural areas to have adequately iodized salt (68 percent, compared with 53 percent). There are substantial differences by region, ranging from 41 percent of children in households with adequately iodized salt in the Northern Region to 80 percent in the Eastern Region. 11.10 NUTRITIONAL STATUS OF WOMEN Anthropometric data on height and weight were collected for women age 15-49 interviewed in half of the households selected for the survey. In this report, two indicators of nutritional status based on these data are presented: the percentage of women with very short stature (less than 145 cm) and body mass index (BMI). BMI, or the Quetelet index, is used to measure thinness or obesity. BMI is defined as weight in kilograms divided by height squared in meters (kg/m2). A cutoff point of 18.5 is used to define thinness, or acute undernutrition, and a BMI of 25.0 or above usually indicates overweight or obesity. The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. Low pre-pregnancy BMI and short stature are risk factors for poor birth outcomes and obstetric complications. In developing countries, maternal underweight is a leading risk factor for preventable death and diseases. Table 11.10 presents the mean values of the two indicators of nutritional status and the proportion of women falling into various high-risk categories, by background characteristics. Respondents for whom there was no information on height and/or weight and for whom a BMI could not be estimated are excluded from this analysis. The analysis of height is based on 3,425 women, and the analysis of BMI is based on 3,105 women. Table 11.10 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean Body Mass Index (BMI), and the percentage with specific BMI levels, by background characteristics, Sierra Leone 2008 Background characteristic Height Body Mass Index1 Mean Body Mass Index (BMI) Normal Thin Overweight/obese Number of women 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17.0 (Moder- ately and severely thin) ≥25.0 (Total over- weight/ obese) 25.0-29.9 (Over- weight) ≥30.0 (Obese) Percentage below 145 cm Number of women Age 15-19 16.8 531 22.4 62.2 16.0 10.4 5.6 21.8 17.8 4.1 472 20-29 12.8 1,332 23.2 62.1 11.3 6.3 5.0 26.6 18.8 7.8 1,138 30-39 13.3 1,017 24.2 57.7 8.8 5.9 3.0 33.5 22.1 11.3 948 40-49 9.9 545 24.3 52.5 11.1 7.5 3.6 36.4 23.2 13.1 546 Residence Urban 12.2 1,209 24.7 50.4 8.1 4.3 3.8 41.5 28.0 13.6 1,102 Rural 13.6 2,216 22.9 63.9 13.0 8.5 4.4 23.2 16.3 6.9 2,003 Region Eastern 18.5 610 23.8 60.4 8.2 4.6 3.6 31.4 22.0 9.3 538 Northern 14.6 1,379 23.5 63.9 9.1 7.3 1.7 27.0 18.9 8.1 1,270 Southern 13.7 752 22.9 55.7 18.3 10.3 8.0 26.0 18.5 7.5 664 Western 4.7 685 24.3 51.9 10.6 4.9 5.7 37.5 24.3 13.2 633 Education No education 12.6 2,311 23.3 61.8 11.7 7.5 4.2 26.5 18.4 8.1 2,078 Primary 19.1 425 24.2 54.5 10.0 6.7 3.3 35.5 23.9 11.5 383 Secondary or higher 11.0 690 24.2 53.2 10.4 5.8 4.6 36.5 25.0 11.5 644 Wealth quintile Lowest 16.8 608 23.2 60.6 13.8 7.6 6.2 25.7 16.3 9.3 571 Second 12.1 690 22.5 65.2 14.4 8.7 5.7 20.4 14.5 5.9 600 Middle 13.7 662 23.2 62.7 10.9 8.8 2.1 26.4 20.1 6.3 581 Fourth 15.0 718 23.9 59.1 8.9 6.1 2.8 32.0 21.9 10.1 658 Highest 8.8 748 24.8 49.6 8.9 4.5 4.3 41.5 27.9 13.7 695 Total 13.1 3,425 23.6 59.1 11.2 7.0 4.2 29.7 20.4 9.3 3,105 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in metres (kg/m2). 1 Excludes pregnant women and women with a birth in the past two months 164 | Nutrition of Children and Adults The data show that only 13 percent of women age 15-49 are less than 145 cm in height. The Eastern Region has the highest proportion of women who are short in stature (19 percent), while the Western Region (5 percent) has the lowest proportion. Women with primary education (19 percent) and those in the lowest wealth quintile (17 percent) are more likely to be short than other women. The mean BMI is in the normal range (18.5-24.9) for all background characteristics. At the national level, 11 percent of women are considered to be thin (BMI < 18.5); however, only 4 percent of women are considered to be severely thin (BMI < 17). The mean BMI for women age 15-49 is 23.6. Thirty percent of women are in the overweight or obese categories, with 9 percent of women considered to be obese (BMI ≥ 30.0). The proportion of overweight or obese women is positively correlated with age. Thus, age group 15-19 has the lowest proportion of overweight or obese women (22 percent) and age group 40-49 has the highest proportion (36 percent). The data show that urban women (42 percent) are substantially more likely to be overweight or obese than rural women (23 percent). A regional comparison shows that the Southern Region has the lowest proportion of overweight or obese women (26 percent) and the Western Region has the highest proportion (38 percent). Overweight and obesity are higher among women with more education, and household wealth status has a positive relationship with overweight/obesity levels; women in the highest wealth quintile are more likely to be overweight or obese (42 percent) than other women. 11.11 FOODS CONSUMED BY MOTHERS The quality and quantity of foods consumed by women influences their health and that of their children, especially the health of breastfeeding children. The 2008 SLDHS included questions on the types of foods consumed by mothers of children under age three, during the day and night preceding the interview. Table 11.11 shows that the foods most commonly consumed by mothers living with a child under three years include vitamin A-rich fruits and vegetables (91 percent); foods made from grains (82 percent); meat, fish, shellfish, poultry, and eggs (79 percent); other solid or semi-solid foods (58 percent); and foods cooked with palm oil, fat, or butter (51 percent). About four in ten women consume foods made from roots and tubers, foods made from legumes, and other fruits and vegetables. Differences in consumption of these food groups by background characteristics are not large, although there is a tendency for consumption to be higher among urban mothers, those with more education, and those in the higher wealth quintiles. Consumption of meat, fish, shellfish, poultry, and eggs is particularly high among women in the Western Region (92 percent). The data show that only 8 percent of mothers drank milk in the 24 hours preceding the interview. Women in urban areas (19 percent) are more likely to drink milk than those in rural areas (4 percent). At the regional level, the percentage of women drinking milk is highest in the Western Region (29 percent), compared with 4-5 percent in other regions. Twelve percent of women drank tea or coffee, and 71 percent drank other liquids in the past 24 hours. N ut rit io n of C hi ld re n an d Ad ul ts | 1 65 Ta bl e 11 .1 1 F oo ds c on su m ed b y m ot he rs in th e da y an d ni gh t p re ce di ng th e in te rv ie w Am on g w om en a ge 1 5- 49 w ith a c hi ld u nd er a ge th re e ye ar s liv in g w ith th em , t he p er ce nt ag e w ho c on su m ed s pe ci fic ty pe s of fo od s in th e da y an d ni gh t p re ce di ng th e in te rv ie w , by b ac kg ro un d ch ar ac te ris tic s, S ie rr a Le on e 20 08 Ba ck gr ou nd ch ar ac te ris tic Li qu id s So lid o r s em i-s ol id fo od s Fo od s m ad e w ith oi l/f at / bu tte r Su ga ry fo od s N um be r of w om en M ilk Te a/ co ffe e O th er liq ui ds Fo od s m ad e fro m gr ai ns Fo od s m ad e fro m ro ot s/ tu be rs Fo od s m ad e fro m le gu m es M ea t/f ish / sh el lfi sh / po ul try / eg gs C he es e/ yo gu rt Vi ta m in A- ric h fru its / ve ge - ta bl es 1 O th er fru its / ve ge - ta bl es O th er so lid o r se m i-s ol id fo od s Ag e 15 -1 9 5. 4 11 .4 67 .4 78 .9 43 .8 40 .4 76 .0 11 .2 89 .3 39 .6 61 .2 47 .6 17 .7 25 0 20 -2 9 8. 2 12 .1 70 .0 82 .9 42 .6 41 .1 79 .9 10 .9 91 .1 38 .9 58 .4 51 .6 20 .1 1, 47 1 30 -3 9 8. 2 12 .2 72 .8 82 .7 46 .3 40 .6 79 .4 7. 6 90 .2 40 .8 54 .7 50 .7 16 .6 96 0 40 -4 9 6. 1 10 .1 78 .0 81 .8 47 .8 44 .8 77 .1 6. 2 92 .0 47 .9 65 .4 56 .5 20 .6 20 1 Re si de nc e U rb an 19 .0 27 .8 71 .4 86 .7 33 .8 46 .7 86 .4 16 .7 93 .7 40 .4 54 .2 61 .7 28 .7 77 1 Ru ra l 3. 7 6. 2 71 .2 80 .9 48 .2 39 .1 76 .6 6. 9 89 .6 40 .2 59 .2 47 .5 15 .1 2, 11 1 Re gi on Ea st er n 3. 6 8. 7 65 .2 79 .2 46 .0 44 .5 83 .1 5. 0 86 .5 44 .1 49 .3 50 .9 10 .0 59 2 N or th er n 4. 4 5. 9 74 .2 84 .1 42 .1 39 .0 70 .6 7. 7 93 .4 39 .3 60 .5 43 .8 18 .7 1, 31 3 So ut he rn 5. 2 10 .8 70 .0 77 .9 62 .6 36 .5 86 .1 8. 6 88 .1 41 .5 68 .1 53 .1 15 .5 57 6 W es te rn 29 .1 38 .1 72 .2 88 .2 22 .7 49 .7 91 .8 23 .4 91 .9 35 .7 47 .6 73 .9 36 .3 40 1 Ed uc at io n N o ed uc at io n 4. 7 7. 9 71 .0 81 .5 47 .9 40 .8 77 .7 7. 6 90 .6 40 .2 59 .3 49 .5 15 .9 2, 16 9 Pr im ar y 10 .0 15 .6 73 .1 83 .1 36 .1 37 .9 80 .3 9. 5 92 .0 40 .2 57 .5 50 .1 22 .2 36 6 Se co nd ar y or h ig he r 25 .1 33 .6 70 .9 87 .2 30 .8 46 .6 87 .3 21 .5 90 .3 40 .4 49 .8 63 .7 32 .8 34 7 W ea lth q ui nt ile Lo w es t 3. 4 6. 2 64 .5 78 .8 47 .9 37 .6 76 .1 7. 4 89 .0 38 .8 52 .0 47 .5 10 .3 64 8 Se co nd 3. 7 5. 3 73 .6 82 .4 50 .8 35 .9 76 .8 5. 8 88 .9 42 .3 64 .2 49 .0 17 .3 62 2 M id dl e 4. 2 7. 1 78 .6 81 .4 49 .6 42 .4 76 .8 6. 6 93 .1 44 .4 62 .5 48 .9 17 .0 62 6 Fo ur th 5. 8 10 .1 66 .1 84 .5 39 .7 44 .6 80 .3 9. 2 91 .1 34 .9 58 .5 48 .8 19 .9 55 7 H ig he st 28 .4 39 .7 74 .2 86 .7 28 .0 47 .4 89 .5 22 .8 92 .1 40 .2 50 .1 67 .3 34 .5 42 9 To ta l 7. 8 11 .9 71 .3 82 .4 44 .3 41 .1 79 .2 9. 5 90 .7 40 .2 57 .9 51 .3 18 .7 2, 88 2 N ot e: F oo ds c on su m ed in th e pa st 2 4 ho ur s (y es te rd ay a nd th e pa st n ig ht ). 1 I nc lu de s fru its a nd v eg et ab le s su ch a s pu m pk in , r ed o r y el lo w y am s or s qu as h, c ar ro ts , r ed s w ee t p ot at oe s, g re en le af y ve ge ta bl es , m an go es , p ap ay as , a nd o th er lo ca lly g ro w n fru its an d ve ge ta bl es th at a re ri ch in v ita m in A ` | 165Nutrition of Children and Adults 166 | Nutrition of Children and Adults 11.12 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects mother and infant against anaemia. It is estimated that one-fifth of perinatal mortality and one-tenth of maternal mortality are attributable to iron deficiency anaemia. Anaemia also results in an increased risk of premature delivery and low birth weight. Finally, iodine deficiency is also related to a number of adverse pregnancy outcomes. Table 11.12 presents a number of measures that are useful in assessing the extent to which women are receiving adequate vitamin A and iron; it also shows the proportion who took de-worming medication during their last pregnancy in the past five years. The first indicators focus on the percentage of women with children under age three who reported consuming foods rich in vitamin A and iron during the 24 hours preceding the interview. The results indicate that 95 percent of mothers with young children consumed vitamin A-rich foods and 79 percent consumed iron-rich foods in the 24 hours preceding the interview. Table 11.12 shows the proportion of women who receive vitamin A supplements after giving birth. Slightly more than half (55 percent) of mothers with young children reported that they had received a postpartum dose of vitamin A within two months of delivering, but this varies with residence, region, educational attainment, and wealth status. Women in urban areas (63 percent) are more likely to receive vitamin A supplements than those in rural areas (52 percent). At the regional level, the percentage of women who reported receiving a postpartum dose of vitamin A is highest in the Western and Southern regions (62 and 64 percent, respectively) and lowest in the Northern Region (50 percent). The likelihood that a woman will receive a postpartum dose of vitamin A increases with mother’s level of education and wealth quintile. Regarding iron supplementation during pregnancy, Table 11.12 shows that among women with a birth in the past five years, about half reported taking iron tables during the pregnancy for their last birth. However, more than half of these women (28 percent) took the iron supplements for less than 60 days. Seventeen percent of women did not take any iron tablets or syrup during pregnancy, however, a relatively large proportion of women (30 percent) said they did not know if they had received iron tables or syrup during pregnancy. Intake varies considerably by region; more than half of women in the Western Region took iron tablets for 60 or more days, compared with 17 percent of women in the Northern Region. Forty-four percent of mothers said they took de-worming medication during their most recent pregnancy. Use of de-worming medication during pregnancy is higher among urban women, women in the Southern Region, better educated women, and women in the higher wealth quintiles. Table 11.12 shows that 57 percent of mothers with young children live in households with adequately iodized salt (15+ ppm) N ut rit io n of C hi ld re n an d Ad ul ts | 1 67 T ab le 1 1. 12 M ic ro nu tri en t i nt ak e am on g m ot he rs A m on g w om en a ge 1 5- 49 w ith a c hi ld u nd er a ge th re e ye ar s liv in g w ith th em , t he p er ce nt ag es w ho c on su m ed v ita m in A -r ic h an d iro n- ric h fo od s in th e 24 h ou rs p re ce di ng th e su rv ey ; an d am on g w om en ag e 15 -4 9 w ith a c hi ld u nd er fi ve y ea rs , t he p er ce nt ag e w ho r ec ei ve d a vi ta m in A d os e po st pa rtu m (w ith in t w o m on th s of t he la st b irt h) , t he p er ce nt ag e w ith n ig ht b lin dn es s du rin g pr eg na nc y fo r th e la st bi rth , t he d ist rib ut io n of w om en b y nu m be r of d ay s th ey to ok ir on ta bl et s or s yr up d ur in g pr eg na nc y fo r th e la st b irt h, a nd p er ce nt ag e w ho to ok d e- w or m in g m ed ic at io n du rin g pr eg na nc y fo r th e la st b irt h; an d am on g w om en w ith a c hi ld u nd er fi ve y ea rs li vi ng in h ou se ho ld s w ith s al t t es te d fo r i od in e, th e pe rc en ta ge in h ou se ho ld s w ith a de qu at el y io di ze d sa lt, b y ba ck gr ou nd c ha ra ct er ist ic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic W om en w ith a c hi ld u nd er th re e ye ar s liv in g w ith th em W om en w ith a c hi ld u nd er fi ve y ea rs N um be r of w om en W om en w ith a c hi ld un de r f iv e ye ar s in ho us eh ol ds w ith s al t te st ed fo r i od in e Pe rc en ta ge w ho re ce iv ed vi ta m in A do se po st pa rtu m 3 Pe rc en ta ge w ith ni gh t b lin dn es s du rin g pr eg na nc y fo r l as t b irt h N um be r o f d ay s w om en to ok ir on ta bl et s or s yr up du rin g pr eg na nc y fo r l as t b irt h Pe rc en ta ge of w om en w ho to ok de -w or m in g m ed ic at io n du rin g pr eg na nc y fo r l as t b irt h Pe rc en ta ge in ho us eh ol ds w ith ad eq ua te ly io di ze d sa lt5 N um be r of w om en Pe rc en ta ge co ns um ed vi ta m in A - ric h fo od s1 Pe rc en ta ge co ns um ed iro n- ric h fo od s2 N um be r of w om en Re po rte d Ad ju st ed 4 N on e < 60 60 -8 9 90 + D on ’t kn ow / m iss in g A ge 15 -1 9 95 .1 76 .0 25 0 52 .6 9. 2 0. 6 16 .2 31 .6 7. 2 14 .3 30 .7 43 .8 33 0 57 .7 30 0 20 -2 9 94 .3 79 .9 1, 47 1 54 .2 7. 5 0. 7 15 .5 27 .6 6. 1 18 .3 32 .6 44 .4 2, 01 7 59 .1 1, 88 3 30 -3 9 95 .8 79 .4 96 0 55 .5 8. 8 0. 6 18 .7 28 .2 8. 2 17 .8 27 .1 43 .7 1, 37 7 56 .1 1, 29 4 40 -4 9 94 .0 77 .1 20 1 58 .3 11 .8 1. 1 16 .4 29 .4 10 .9 13 .5 29 .8 41 .6 37 9 46 .6 34 7 R es id en ce U rb an 97 .0 86 .4 77 1 63 .2 5. 3 0. 4 8. 2 18 .9 8. 6 29 .3 34 .9 45 .7 1, 18 3 69 .7 1, 09 8 Ru ra l 94 .1 76 .6 2, 11 1 51 .5 9. 8 0. 8 20 .1 32 .1 6. 8 12 .5 28 .5 43 .1 2, 92 0 51 .7 2, 72 6 R eg io n Ea st er n 94 .3 83 .1 59 2 52 .4 5. 9 0. 4 9. 6 37 .4 5. 4 15 .8 31 .8 33 .3 80 9 80 .0 73 4 N or th er n 94 .9 70 .6 1, 31 3 49 .7 11 .6 1. 0 26 .0 32 .4 8. 3 8. 3 25 .0 39 .0 1, 86 9 40 .2 1, 78 5 So ut he rn 93 .8 86 .1 57 6 63 .9 9. 0 0. 6 13 .0 21 .5 6. 0 17 .9 41 .6 62 .8 78 3 63 .7 72 0 W es te rn 97 .2 91 .8 40 1 62 .0 2. 0 0. 2 3. 3 13 .2 8. 5 44 .6 30 .4 48 .3 64 2 70 .3 58 6 E du ca tio n N o ed uc at io n 94 .7 77 .7 2, 16 9 52 .9 9. 0 0. 8 19 .6 30 .0 7. 4 14 .5 28 .4 41 .5 3, 05 1 52 .7 2, 84 3 Pr im ar y 94 .8 80 .3 36 6 56 .4 9. 1 0. 0 10 .7 28 .8 5. 8 20 .9 33 .8 49 .3 51 5 64 .0 47 6 Se co nd ar y or h ig he r 96 .2 87 .3 34 7 64 .4 5. 2 0. 7 5. 8 17 .9 8. 2 30 .0 38 .0 52 .0 53 7 73 .7 50 5 W ea lth q ui nt ile Lo w es t 93 .2 76 .1 64 8 46 .8 9. 6 0. 3 22 .7 31 .5 6. 5 9. 9 29 .4 40 .3 88 5 54 .2 82 7 Se co nd 94 .0 76 .8 62 2 52 .5 9. 8 1. 0 22 .2 34 .4 4. 6 10 .7 28 .1 42 .4 84 9 53 .0 78 8 M id dl e 95 .9 76 .8 62 6 52 .6 9. 1 0. 9 17 .7 33 .4 8. 1 12 .1 28 .8 43 .3 89 3 47 .8 83 8 Fo ur th 94 .6 80 .3 55 7 61 .3 8. 1 0. 9 14 .9 23 .8 10 .4 19 .9 30 .9 45 .7 79 3 56 .7 74 6 H ig he st 97 .6 89 .5 42 9 63 .8 5. 0 0. 2 3. 0 14 .9 7. 2 38 .9 36 .0 48 .8 68 3 77 .7 62 5 To ta l 94 .9 79 .2 2, 88 2 54 .9 8. 5 0. 7 16 .7 28 .3 7. 3 17 .3 30 .4 43 .8 4, 10 3 56 .9 3, 82 4 1 In cl ud es m ea t ( an d or ga n m ea t), fi sh , p ou ltr y, e gg s, p um pk in , r ed o r y el lo w y am s or s qu as h, c ar ro ts , r ed s w ee t p ot at oe s, m an go , p ap ay a, a nd o th er lo ca lly g ro w n fru its a nd v eg et ab le s ric h in v ita m in A 2 I nc lu de s m ea t ( an d or ga n m ea t), fi sh , p ou ltr y, a nd e gg s 3 W ith in tw o m on th s fo llo w in g th e la st b irt h 4 W om en w ho re po rte d ni gh t b lin dn es s bu t d id n ot re po rt di ffi cu lty w ith v isi on d ur in g th e da y 5 S al t c on ta in in g 15 p pm o f i od in e or m or e. E xc lu de s w om en in h ou se ho ld s w he re s al t w as no t t es te d. | 167Nutrition of Children and Adults 168 | Nutrition of Children and Adults 11.13 ANAEMIA IN ADULTS The same equipment and procedures used to measure anaemia in children were employed to measure anaemia in women and men, except for persons whose blood was also being collected for HIV testing. For those persons, the first 3-5 drops of blood were collected on filter paper cards for HIV testing and the next drop was collected in a microcuvette for anaemia testing. Three levels of anaemia are distinguished: • Mild anaemia: 10.0-10.9 grams/decilitre for pregnant women, 10.0-11.9 g/dl for non-pregnant women, and 12.0-12.9 g/dl for men, • Moderate anaemia: 7.0-9.9 g/dl for women and 9.0-11.9 g/dl for men, and • Severe anaemia: less than 7.0 g/dl for women and less than 9.0 g/dl for men. Appropriate adjustments to these cutoff points were made for respondents living at altitudes above 1,000 metres and respondents who smoke, because both of these groups require more haemoglobin in their blood (Centers for Disease Control and Prevention, 1998). Table 11.13.1 shows the prevalence of anaemia in women age 15-49. Anaemia is less prevalent among women than children: 45 percent of women in Sierra Leone have some level of anaemia, compared with 76 percent of children. The large majority of women are mildly anaemic Table 11.13.1 Prevalence of anaemia in women Percentage of women age 15-49 with anaemia, by background characteristics, Sierra Leone 2008 Background characteristic Anaemia status by haemoglobin level Any anaemia Number of women Mild Moderate Severe Not pregnant 10.0-11.9 g/dl 7.0-9.9 g/dl <7.0 g/dl <12.0 g/dl Pregnant 10.0-10.9 g/dl 7.0-9.9 g/dl <7.0 g/dl <11.0 g/dl Age 15-19 36.4 12.3 1.8 50.6 516 20-29 33.7 11.8 0.3 45.8 1,298 30-39 33.1 10.8 0.6 44.6 1,008 40-49 31.1 8.1 0.6 39.8 542 Number of children ever born 0 35.3 13.2 1.2 49.7 578 1 35.9 8.7 0.8 45.4 506 2-3 33.0 13.1 0.6 46.7 985 4-5 31.3 9.9 0.4 41.6 693 6+ 33.2 8.7 0.5 42.5 602 Maternity status Pregnant 36.9 24.0 1.4 62.3 281 Breastfeeding 35.4 8.8 0.7 44.9 993 Neither 32.1 10.3 0.6 43.1 2,092 Smoking status Smokes cigarettes/tobacco 29.8 8.3 0.8 38.9 345 Does not smoke 34.0 11.3 0.7 46.1 3,003 Residence Urban 34.5 11.6 0.6 46.7 1,138 Rural 33.0 10.7 0.7 44.5 2,227 Region Eastern 32.2 9.9 0.8 43.0 530 Northern 34.6 9.8 0.8 45.2 1,397 Southern 29.7 12.5 0.6 42.8 774 Western 36.7 12.8 0.4 49.9 664 Education No education 33.3 11.4 0.5 45.1 2,299 Primary 31.1 10.7 1.6 43.5 416 Secondary or higher 35.9 9.7 0.9 46.5 650 Wealth quintile Lowest 31.4 10.8 1.2 43.4 629 Second 35.6 11.1 0.7 47.4 666 Middle 34.3 10.9 0.6 45.8 663 Fourth 30.9 12.2 0.7 43.8 714 Highest 35.4 10.0 0.3 45.7 693 Total 33.5 11.0 0.7 45.2 3,365 Note: Table is based on women who stayed in the household the night before the interview. Prevalence is adjusted for altitude and for smoking status, if known, using CDC formulas (CDC, 1998). Total includes 17 women with information missing on smoking status. Haemoglobin measured in grams per decilitre (g/dl). Nutrition of Children and Adults | 169 (34 percent), while 11 percent are moderately anaemic, and less than 1 percent are severely anaemic. As expected, the prevalence of anaemia is higher among pregnant women (62 percent) and breastfeeding women (45 percent) than among other women. The prevalence of any anaemia in women is the highest in the Western Region (50 percent). In all other regions the level of any anaemia is between 43 and 45 percent. Compared with estimates from recent Demographic and Health Surveys, the prevalence of any anaemia among women age 15-49 in Sierra Leone (45 percent) is similar to the prevalence in Ghana (45 percent in 2003), but lower than the prevalence in Guinea (53 percent in 2005), Senegal (59 percent in 2005), and Mali (69 percent in 2006) (CPS/MS, DNSI/MEIC [Mali] and Macro International Inc., 2007; DNS [Guinée] and ORC Macro, 2006; Ndiaye et al., 2006; CRDH [Sénégal] and ORC Macro, 2005; GSS, NMIMR [Ghana], and ORC Macro, 2004). The results of anaemia testing in men indicate that in Sierra Leone anaemia is less prevalent among men than women (Table 11.13.2). Only 21 percent of men age 15-49 have some level of anaemia, compared with 45 percent of women. As with women, the majority of men are mildly anaemic (17 percent), while 4 percent are moderately anaemic, and less than 1 percent are severely anaemic. Younger men (below age 20) and older men (age 50-59) are more likely to be anaemic (27 and 26 percent, respectively) than men in other age groups. Table 11.13.2 Prevalence of anaemia in men Percentage of men age 15-49 with anaemia, by background characteristics, Sierra Leone 2008 Background characteristic Anaemia status by haemoglobin level Any anaemia (<13.0 g/dl) Number of men Mild (12.0-12.9 g/dl) Moderate (9.0-11.9 g/dl) Severe (<9.0 g/dl) Age 15-19 21.3 5.4 0.0 26.8 468 20-29 14.9 3.5 0.3 18.8 744 30-39 14.1 3.6 0.2 17.9 824 40-49 18.1 4.6 0.9 23.7 603 Smoking status Smokes cigarettes/tobacco 14.4 4.7 0.9 20.0 987 Does not smoke 17.8 3.8 0.1 21.7 1,651 Residence Urban 15.6 3.2 0.5 19.4 969 Rural 17.0 4.7 0.3 22.0 1,669 Region Eastern 15.6 3.4 0.5 19.5 458 Northern 17.1 3.6 0.1 20.8 1,029 Southern 14.8 5.6 0.5 20.8 597 Western 18.0 4.4 0.7 23.0 555 Education No education 16.2 4.5 0.3 21.0 1,291 Primary 18.2 5.7 0.4 24.3 373 Secondary or higher 16.3 3.0 0.5 19.9 974 Wealth quintile Lowest 17.6 5.9 0.1 23.7 517 Second 16.1 4.1 0.0 20.2 482 Middle 21.9 4.2 0.8 26.9 472 Fourth 12.2 3.3 0.1 15.6 535 Highest 15.6 3.3 0.8 19.7 633 Total 15-49 16.5 4.1 0.4 21.0 2,638 50-59 18.7 6.1 1.2 26.1 289 Total 15-59 16.7 4.3 0.5 21.5 2,927 Note: Table is based on men who stayed in the household the night before the interview. Prevalence is adjusted for altitude and for smoking status, if known, using CDC formulas (CDC, 1998). Haemoglobin measured in grams per decilitre (g/dl). Malaria | 171 MALARIA 12 Malaria is one of the most serious public health problems in Sierra Leone, accounting for over 40 percent of outpatient morbidity. The most vulnerable groups include children under five years, pregnant women, refugees, and returnees. The malaria health problem was exacerbated by 10 years of civil conflict that resulted in substantial population displacement and damage to the health system. In an effort to reduce the malaria burden in Sierra Leone, the Government of Sierra Leone launched the Roll Back Malaria (RBM) initiative in 2002 and formed a Task Force to provide technical support to the programme. Toward this effort, the Government of Sierra Leone developed a strategy document outlining several intervention measures for malaria control and prevention for 2004-2008 (MOHS, 2006). The inter- vention areas outlined in the National Malaria Strategy (NMS) document are: 1) Management of malarial illness; 2) Multiple disease prevention, which includes vector control by use of insecticide-treated mosquito nets (ITNs) and control of malaria in pregnancy; 3) Advocacy, Information, Education Communication and Social Mobilization; 4) Partnership strengthening and programme management; 5) Capacity building; 6) Operational Research; and 7) Monitoring and Evaluation to assess the extent of implementation of several of these malaria control strategies. This plan is in line with the Abuja Declaration, which the Government of Sierra Leone signed in April 2000. The objectives of the National Malaria Strategy were to ensure that by the year 2005 at least 60 percent of those at risk of malaria, particularly pregnant women and children under five, have access to the most suitable and affordable combination of personal and community protective measures such as insecticide-treated mosquito nets (ITNs) and prompt, effective treatment for malaria. Another objective was to ensure that at least 60 percent of all pregnant women have access to intermittent preventive treatment (IPT). As part of this plan, the Ministry of Health and Sanitation (MHS) has endorsed the use of more effective drugs for treatment in Sierra Leone—Artesunate plus Amodiaquine combination therapy (ACT). Data from the 2008 Sierra Leone Demographic and Health Survey (SLDHS) can be used to assess the extent of implementation of several of these malaria control strategies. 12.1 MOSQUITO NETS 12.1.1 Ownership of Mosquito Nets The ownership and use of mosquito nets, both treated and untreated, is the primary health intervention for reducing malaria transmission and morbidity in communities prone to the vector—the Anopheles mosquito. In Sierra Leone, there are various types of insecticide-treated mosquito nets (ITNs) available on the market. They include long-lasting nets that require re-treatment after about five years and other nets that need to be re-treated every six months or after three washes. During SLDHS data collection, interviewers had with them examples of the various types of bed nets used in 172 | Malaria Sierra Leone. These were shown to respondents to enable them to determine the brand of bed nets used in the household. In an effort to make mosquito nets more affordable, the Government of Sierra Leone has waived taxes on the importation of nets into the country. Developmental partners have also contributed by supplying some ITNs for distribution at subsidized costs to pregnant women and children under five in deprived areas of the country. These nets are distributed through routine public health services. Since 2002, over 400,000 ITNs have been distributed nationwide, linking malaria prevention with immunization and antenatal care visits. In addition, 30,000 nets from the European Union and 234,000 nets from UNICEF are being distributed (MOHS, 2006). Table 12.1 shows the percentage of households with at least one and with more than one mosquito net (treated or untreated), the percentage of households with at least one and more than one ever-treated mosquito net, and the percentage of households with at least one and with more than one insecticide-treated net (ITN), by background characteristics. The data show that 40 percent of households in Sierra Leone own a mosquito net (treated or untreated), and 16 percent of households own more than one net. There is almost no difference by urban-rural residence in mosquito net ownership, although rural households are more likely to own more than one net. Mosquito net ownership is highest in the Southern Region (48 percent) and lowest in the Eastern Region (35 percent). The percentage of households with at least one net increases with household wealth status, from 33 percent among the poorest households to 44 percent among households in the middle and fourth wealth quintiles. The average number of mosquito nets per household is 0.6. More than one-third (37 percent) of households own at least one insecticide-treated net (ITN). Households in the Southern Region reported the highest ownership of ITNs (45 percent), with lower ownership reported in other regions (34-35 percent). Wealthier households are more likely to own at least one ITN than poorer households. The average numbers of ITNs per household is 0.6. Table 12.1 Ownership of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), ever-treated mosquito nets and insecticide- treated net1 (ITN), and the average number of nets per household, by background characteristics, Sierra Leone 2008 Background characteristic Any type of mosquito net Ever-treated mosquito net1 Insecticide-treated mosquito net (ITN)2 Number of households Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ever- treated nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Residence Urban 38.5 14.6 0.6 37.7 13.3 0.6 36.5 12.8 0.5 2,469 Rural 40.0 17.0 0.6 38.9 15.7 0.6 36.7 14.6 0.6 4,815 Region Eastern 35.4 11.5 0.5 34.4 10.6 0.5 33.5 10.4 0.5 1,494 Northern 39.1 16.4 0.6 38.3 15.0 0.6 35.2 13.6 0.6 2,757 Southern 47.5 23.4 0.8 46.5 22.1 0.8 44.9 20.8 0.7 1,583 Western 35.5 12.8 0.5 34.5 11.0 0.5 33.5 10.9 0.5 1,449 Wealth quintile Lowest 32.7 12.2 0.5 31.7 10.7 0.5 30.4 10.1 0.4 1,607 Second 39.0 16.3 0.6 37.9 15.1 0.6 33.9 13.2 0.5 1,440 Middle 43.5 19.6 0.7 42.2 18.0 0.7 39.9 16.5 0.6 1,344 Fourth 43.7 17.7 0.7 43.2 16.8 0.7 41.8 16.4 0.7 1,368 Highest 39.8 16.1 0.6 38.7 14.5 0.6 38.2 14.3 0.6 1,526 Total 39.5 16.2 0.6 38.5 14.8 0.6 36.6 14.0 0.6 7,284 1 An ever-treated net is 1) a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. Malaria | 173 12.1.2 Use of Mosquito Nets by Children Age is an important factor in determining levels of acquired immunity against malaria. For the first six months of life, antibodies acquired from the mother during pregnancy protect children from malaria. This immunity is gradually lost, as children start developing their own immunity over a period of time. The level of immunity developed depends on the level of exposure to malaria infection, but it is believed that in malaria endemic areas like Sierra Leone, children acquire some immunity by the fifth birthday. Such children no longer suffer from severe life-threatening malaria, although malaria illness affects all members of the community, regardless of age. The Government of Sierra Leone recognizes that children under five years are a high risk group, and it recommends that children under five years be protected from by sleeping under ITNs. In the 2008 SLDHS, respondents to the Household Questionnaire were asked about the use of mosquito nets by all members of the household the night before the interview. Table 12.2 presents information on use of mosquito nets by children under five years in all households and in households with an ITNs, by background characteristics. The data show that 28 percent of children under five years in all households slept under a mosquito net (treated or untreated) the night before the survey; 27 percent of children in all households slept under an ever-treated net; and 26 percent slept under an ITN the night before the survey. In households that own at least one insecticide-treated net, however, substantially more children under age five slept under an ITN the night before the survey (61 percent). Table 12.2 Use of mosquito nets by children Among children under five years in all households, the percentage who, on the night preceding the interview, slept under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN), and among children under five years in households with at least one ITN, the percentage who slept under an ITN the past night, by background characteristics, Sierra Leone 2008 Background characteristic Among children under five in all households, percentage who, the past night: Among children under five in households with an ITN2 Slept under any net Slept under an ever-treated net1 Slept under an ITN2 Number of children Percentage who slept under an ITN the past night2 Number of children Age in years <1 34.8 34.0 31.9 1,447 68.9 669 1 30.5 29.1 27.3 1,220 63.6 524 2 28.4 27.8 26.7 1,140 60.8 500 3 24.3 24.0 22.8 1,413 58.6 549 4 21.6 21.0 20.1 1,350 49.4 549 Sex Male 27.5 26.8 25.5 3,274 61.1 1,366 Female 28.3 27.5 26.0 3,297 60.2 1,426 Residence Urban 30.9 30.6 29.9 1,772 66.0 802 Rural 26.9 25.9 24.2 4,799 58.5 1,990 Region Eastern 26.6 25.6 25.0 1,325 65.0 509 Northern 24.9 24.0 21.8 2,964 57.6 1,124 Southern 36.6 36.0 34.9 1,316 61.6 746 Western 27.3 27.1 26.3 967 61.6 413 Wealth quintile Lowest 24.9 24.0 22.8 1,497 64.7 528 Second 25.9 24.9 22.2 1,382 59.0 521 Middle 28.2 27.4 25.7 1,427 54.5 672 Fourth 33.3 32.8 32.0 1,255 64.9 618 Highest 28.3 27.8 27.3 1,009 60.7 453 Total 27.9 27.2 25.8 6,571 60.6 2,792 1 An ever-treated net is 1) a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment, or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 174 | Malaria Children’s age is inversely related to the likelihood of sleeping under a mosquito net: the youngest children are most likely to have slept under any net (35 percent), an ever-treated net (34 percent), and an ITN (32 percent) the night before the survey, and the oldest children are least likely to have slept under any of the three types of bed nets (22, 21, and 20 percent, respectively). Children in rural areas are less likely to sleep under any net (27 percent) than their urban counterparts (31 percent). The proportion of children who slept under any type of mosquito net was highest in the Southern Region (37 percent) and lowest in the Northern Region (25 percent). The proportion of children who slept under a mosquito net generally increases with household wealth status, peaking at 33 percent among children in the fourth wealth quintile. In households that own at least one ITN, there are small differences in the proportion of children who slept under a mosquito net the past night, by background characteristics. Children age four years (49 percent), children in households in the middle wealth quintile (55 percent), and children in rural areas (59 percent) were less likely than other children to sleep under an ITN the night before the interview. The percentage of children in households with ITNs who slept under an ITN is highest in the Eastern Region (65 percent) and lowest in the Northern Region (58 percent). 12.1.3 Use of Mosquito Nets by Women Malaria is especially dangerous during pregnancy and this has prompted many advocacy campaigns to educate not only pregnant women, but also the general public on the importance of preventing malaria during pregnancy. Tables 12.3.1 and 12.3.2 show, for all households and for households with at least one ITN, the percentage of the de facto population of women and the percentage of the de facto population of pregnant women who slept under a mosquito net (treated or untreated) the past night and who slept under an ITN the past night, by background characteristics. The data show negligible differences between all women and pregnant women in the use of nets; 29 percent of all women and 29 percent of pregnant women slept under a net the past night; 27-28 percent slept under an ever-treated net; and 27 percent slept under an ITN. Similar to the results observed for children, in households that own at least one ITN, substantially more women slept under an ITN the night before the survey (65 percent of all women and 70 percent of pregnant women). Women in rural areas are more likely to sleep under a mosquito net than women in urban areas, and the rural-urban differential is slightly larger for pregnant women. As seen for children, use of mosquito nets by women is highest in the Southern Region: 36 percent of all women and 33 percent of pregnant women slept under an ITN the past night. The use of a net is lowest in the Western Region (about 20 percent among all women and 13 percent among pregnant women). Surprisingly, better educated women are the least likely to sleep under a net (23 percent, compared with 28 percent for women with no education). This pattern is more pronounced among all women than among pregnant women. Similarly, women in the highest wealth quintile are less likely than other women to sleep under any net (treated or untreated). These results may in part be because women in wealthier households, better educated women, and women in urban areas are more likely to live in houses with mosquito screening on the windows and doors, hence the redundancy of using mosquito nets. Malaria | 175 Table 12.3.1 Use of mosquito nets by women Among all women age 15-49 in all households, the percentage who slept the past night under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN); and among all women age 15-49 in households with at least one ITN, the percentage who slept the past night under an ITN, by background characteristics, Sierra Leone 2008 Background characteristic Among women age 15-49 in all households, percentage who, the past night: Women age 15-49 in households with an ITN2 Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of women Percentage who slept under an ITN2 the past night Number of women Residence Urban 24.8 24.2 23.6 2,858 58.4 1,153 Rural 31.1 30.1 28.1 5,067 69.2 2,059 Region Eastern 28.5 27.6 27.0 1,431 69.6 554 Northern 28.2 27.3 24.9 3,212 64.6 1,240 Southern 38.0 37.2 35.6 1,662 70.9 833 Western 20.9 20.2 19.8 1,620 55.0 583 Education No education 30.5 29.5 27.6 5,205 71.1 2,018 Primary 28.2 27.7 27.1 1,040 63.5 444 Secondary or higher 23.9 23.3 22.7 1,645 50.5 738 Wealth quintile Lowest 27.7 26.8 25.5 1,477 77.6 485 Second 30.0 29.0 25.5 1,456 68.5 541 Middle 32.7 31.8 29.6 1,538 66.9 680 Fourth 31.3 30.6 30.0 1,596 64.5 742 Highest 23.5 22.6 22.5 1,859 54.8 762 Total 28.8 28.0 26.5 7,925 65.4 3,211 1 An ever-treated net is 1) a pretreated net or a non-pretreated that has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment, or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 176 | Malaria Table 12.3.2 Use of mosquito nets by pregnant women Among pregnant women age 15-49 in all households, the percentage who slept the past night under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN); and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept the past night under an ITN, by background characteristics, Sierra Leone 2008 Background characteristic Among pregnant women age 15-49 in all households, percentage who, the past night: Pregnant women age 15-49 in households with an ITN2 Percentage who slept under an ITN2 the past night Number of women Slept under any net Slept under an ever- treated net1 Slept under an ITN2 Number of women Residence Urban 22.1 22.1 21.8 173 64.1 59 Rural 31.2 29.5 29.3 442 72.1 179 Region Eastern 27.1 25.8 25.3 109 67.5 41 Northern 30.2 28.6 28.1 260 71.6 102 Southern 34.2 33.2 33.2 168 74.6 75 Western 13.3 13.3 13.3 77 (51.0) 20 Education No education 29.8 28.1 27.7 445 74.1 167 Primary 25.3 25.3 25.3 84 (59.3) 36 Secondary or higher 26.0 26.0 26.0 86 (62.3) 36 Wealth quintile Lowest 21.7 20.6 20.6 130 (73.2) 37 Second 37.4 35.1 34.3 143 78.3 63 Middle 28.4 26.5 26.1 138 62.7 57 Fourth 34.0 34.0 34.0 114 73.5 53 Highest 18.2 18.2 18.2 89 (56.8 ) 28 Total 28.6 27.4 27.2 615 70.1 238 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 1 An ever-treated net is 1) a pretreated net or a non-pretreated that has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment, or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 12.2 INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY 12.2.1 Malaria Prophylaxis during Pregnancy In malaria endemic areas, adults acquire some immunity that protects them from repeated malaria infection. However, pregnant women—especially those pregnant for the first time—are more susceptible to malaria infection. In some cases, malaria infections remain asymptomatic but may lead to the development of anaemia. Malaria infection during pregnancy can also interfere with the maternal-foetus exchange, leading to low birth weight. One of the strategies the Sierra Leone National Malaria Strategy has adopted for malaria control is Intermittent Preventive Treatment (IPT) of pregnant women with sulphadoxine- pyrimethamine (SP), also known as Fansidar. Government strategy calls for pregnant women to receive two doses of IPT in the second and third trimesters, to reduce the risk of malaria infection. In the 2008 SLDHS, women who had a live birth in the two years preceding the survey were asked whether they had received any drugs to prevent getting malaria during the pregnancy for their most recent birth and, if yes, which drug. If they had received SP, they were further asked how many times they received it and whether they received it during an antenatal care visit. Table 12.4 shows the percentage of women age 15-49 with a live birth in the two years preceding the survey who during the pregnancy received an anti-malarial drug for prevention, received SP/Fansidar, received any other anti-malarial drugs, and who received Intermittent Preventive Treatment (IPT). Malaria | 177 Table 12.4 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy Among women age 15-49 with a live birth in the two years preceding the survey, percentage who during the pregnancy received any anti-malarial drug for prevention; percentage who received any SP/Fansidar and two or more doses of SP/Fansidar; and percentage who received Intermittent Preventive Treatment (IPT), by background characteristics, Sierra Leone 2008 Background characteristic Percentage who received any anti- malarial drug SP/Fansidar Intermittent Preventive Treatment1 Number of women with a live birth in the two years preceding the survey Percentage who received any SP/Fansidar Percentage who received 2+ doses Percentage who received any SP/Fansidar during an ANC visit Percentage who received 2+ doses, at least one during an ANC visit Residence Urban 41.3 25.4 14.3 21.2 11.9 681 Rural 31.4 17.3 11.1 15.1 9.8 1,797 Region Eastern 33.1 21.6 15.5 18.9 13.6 500 Northern 28.0 11.9 7.2 9.5 5.4 1,114 Southern 43.7 29.7 19.3 26.5 17.2 507 Western 40.9 25.6 11.9 22.9 11.4 357 Education No education 30.2 17.3 10.8 14.8 9.3 1,819 Primary 44.7 24.7 16.1 20.1 12.8 339 Secondary or higher 45.0 26.6 14.3 24.7 13.7 319 Wealth quintile Lowest 30.5 17.1 10.9 14.7 9.6 570 Second 33.5 18.5 11.5 15.6 9.6 535 Middle 28.2 17.8 11.8 15.3 10.3 517 Fourth 35.7 18.8 13.2 15.9 10.8 476 Highest 46.5 27.7 13.1 24.7 11.9 379 Total 34.1 19.5 12.0 16.8 10.3 2,478 1 Intermittent Preventive Treatment (IPT) during pregnancy is preventive treatment with sulfadoxine- pyrimethamine (SP/Fansidar) during an antenatal care visit. The survey results show that more than one-third (34 percent) of women age 15-49 with a live birth in the two years preceding the survey received some kind of anti-malarial medicine for prevention of malaria during the last pregnancy. However, only 20 percent of women said they received SP/Fansidar—the recommended drug for prevention of malaria during pregnancy in Sierra Leone—at least once during the pregnancy, and just 12 percent of women said they received SP/Fansidar twice during their pregnancy. Urban women (41 percent) are more likely to take anti-malarial drugs during pregnancy than rural women (31 percent). The Southern Region (44 percent) has the highest percentage of women taking any anti-malarial drug, while the Northern Region (28 percent) has the lowest. The use of anti- malarial drugs during pregnancy increases with mother’s level of education and wealth quintile. Differences in the proportion of women treated with one dose of SP/Fansidar and two or more doses of SP/Fansidar by background characteristics are not large, and are similar to those observed for women receiving any anti-malarial drugs during pregnancy. Use of SP/Fansidar for IPT was introduced in Sierra Leone in 2005 as a replacement for chloroquine prophylaxis because of high levels of chloroquine resistance. Some pregnant women may have received chloroquine prophylaxis because the drug was still in stock for some time after the change in the anti-malarial drug policy. The use of IPT by pregnant women for the last birth in the two years preceding the survey can serve as a baseline for the newly instituted IPT programme. Only 17 percent of women with a birth in the two years preceding the survey who used IPT received SP/Fansidar during an antenatal visit. Most of them were from the Southern and Western Regions (27 and 23 percent, respectively). The National Malaria Strategy recommends that pregnant women take at least two doses of SP/Fansidar during pregnancy as IPT against malaria (MOHS, 2006). Only 178 | Malaria 10 percent of women said they received two or more doses, at least one of which was during an ANC visit. There is a small increase in IPT coverage with increasing level of mother’s education, from 9 percent among those with no education to 14 percent among those with secondary or higher education. Similarly, ITP coverage increases slightly with household wealth status, from 10 percent among women in the lowest wealth quintile to 12 percent among those in the highest wealth quintile. 12.2.2 Prevalence and Management of Childhood Malaria The Government of Sierra Leone recognizes that most malarial fevers occur at home, and it has accepted that prompt and effective malaria treatment is important to prevent the disease from becoming severe and complicated. Mothers are also educated to give correct doses of anti-malarial drugs and to recognize danger signs requiring referral. Because the major manifestation of malaria is fever, in the 2008 SLDHS mothers were asked whether their children under age five had a fever in the two weeks preceding the survey. Although fever can occur all year round, malaria is more prevalent during the rainy season, and such temporal factors must be taken into account when interpreting the occurrence of fever as an indicator of malaria prevalence. If a fever was reported for the child, the mother was asked whether treatment was sought at a health facility and whether the child was given any medication and, if so, how soon the medication was given after the episode of illness began. Table 12.5 presents information on children under age five with fever in the two weeks preceding the survey including the percentage who received anti-malarial drugs and the percentage who received anti-malarial drugs the same or next day, by background characteristics. One in four children under five years (25 percent) had a fever in the two weeks preceding the survey. Of these, 30 percent received an anti-malarial drug, but only 15 percent of children received the anti-malarial drug the same or next day as the onset of the fever. Fever is most common among younger children, then decreases with age. The proportion of children with fever differs little by urban-rural residence. The Western Region has the highest percentage of children with fever (29 percent), compared with 23-24 percent in other regions. The prevalence of fever is highest among children of more educated women and women in the higher wealth quintiles. It may be that these women are more likely to recognize and report fever in their young children than women with less education and women in lower wealth quintiles. Malaria | 179 Table 12.5 Prevalence and prompt treatment of fever Percentage of children under five with fever in the two weeks preceding the survey; and among children with fever, the percentage who received anti-malarial drugs and the percentage who received the drugs the same or next day following onset of fever, by background characteristics, Sierra Leone 2008 Background characteristic Children under five Children under five with fever Percentage with fever in the two weeks preceding the survey Number of children Percentage who received anti-malarial drugs Percentage who received anti-malarial drugs same or next day Number of children Age (in months) <12 27.1 1,326 28.3 14.6 360 12-23 29.1 1,060 28.7 13.4 308 24-35 25.8 939 32.3 14.1 242 36-47 20.4 984 29.6 16.7 201 48-59 19.0 904 33.8 19.1 172 Residence Urban 25.2 1,397 35.1 18.0 352 Rural 24.4 3,817 28.2 14.0 931 Region Eastern 23.0 1,067 22.5 8.3 246 Northern 24.2 2,354 26.4 11.1 569 Southern 24.1 1,058 43.9 29.8 254 Western 29.1 735 32.2 16.3 214 Mother’s education No education 23.5 3,990 28.5 13.7 936 Primary 27.8 633 32.4 15.8 176 Secondary or higher 28.6 531 34.0 19.5 152 Wealth quintile Lowest 23.5 1,159 27.1 14.2 272 Second 24.2 1,123 29.1 15.0 272 Middle 23.5 1,157 29.4 13.5 272 Fourth 24.8 996 28.8 14.6 248 Highest 28.3 778 37.2 19.2 220 Total 24.6 5,213 30.1 15.1 1,283 Older children are slightly more likely to be given anti-malarial drugs for treatment of fever and to receive the drugs the same or the next day, compared with younger children. Children living in the urban areas are slightly more likely than children in the rural areas to be given anti-malarial drugs and to receive them within a day or two of the onset of fever. Children living in the Southern Region are the most likely to have been given an anti-malarial drug (44 percent) and the most likely to have received the drug the same or the next day (30 percent). Children of more educated women and women in the highest wealth quintile are also more likely than other children to be given anti-malarial drugs and to receive these drugs the same or the next day. Table 12.6 presents information on the type and timing of anti-malarial drugs received by children under five with fever in the two weeks preceding the survey. The percentage who received specific anti-malarial drugs and the percentage who received each type of drug the same or next day after developing the fever are shown by background characteristics. 18 0 | M al ar ia T ab le 1 2. 6 T yp e an d tim in g of a nt i-m al ar ia l d ru gs A m on g ch ild re n un de r fiv e w ith fe ve r in th e tw o w ee ks p re ce di ng th e su rv ey , t he p er ce nt ag e w ho r ec ei ve d sp ec ifi c an ti- m al ar ia l d ru gs a nd th e pe rc en ta ge w ho r ec ei ve d ea ch ty pe o f d ru g th e sa m e or n ex t d ay a fte r d ev el op in g fe ve r, by b ac kg ro un d ch ar ac te ris tic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Pe rc en ta ge o f c hi ld re n w ho re ce iv ed s pe ci fic a nt i-m al ar ia l d ru gs : Pe rc en ta ge o f c hi ld re n w ho re ce iv ed an ti- m al ar ia l d ru gs th e sa m e or n ex t d ay N um be r of ch ild re n w ith fe ve r SP / Fa ns id ar C hl or o- qu in e Am od ia - qu in e Q ui ni ne AC T1 G ba ng ba ro ot / Sh ek u Tu re le av es O th er an ti- m al ar ia l SP / Fa ns id ar C hl or o- qu in e Am od ia - qu in e Q ui ni ne AC T1 G ba ng ba ro ot / Sh ek u Tu re le av es O th er an ti- m al ar ia l A ge (i n m on th s) < 12 0. 5 14 .5 2. 1 1. 3 7. 4 3. 9 2. 9 0. 5 7. 7 1. 6 0. 0 1. 7 1. 9 1. 1 36 0 12 -2 3 3. 5 10 .4 5. 1 0. 3 4. 8 3. 6 2. 7 1. 8 5. 5 1. 7 0. 0 0. 7 2. 0 1. 7 30 8 24 -3 5 0. 8 17 .4 4. 7 0. 3 11 .0 1. 8 0. 9 0. 8 7. 2 2. 8 0. 0 2. 5 0. 7 0. 9 24 2 36 -4 7 2. 0 17 .6 5. 1 0. 8 3. 7 2. 0 1. 7 1. 5 10 .4 2. 1 0. 0 2. 1 0. 9 1. 7 20 1 48 -5 9 4. 8 13 .6 4. 7 1. 6 4. 1 5. 6 3. 3 3. 3 8. 4 2. 4 0. 9 2. 3 2. 5 1. 0 17 2 R es id en ce U rb an 3. 2 19 .3 4. 4 1. 3 5. 5 1. 8 2. 8 2. 7 10 .7 2. 1 0. 4 1. 3 1. 1 0. 8 35 2 Ru ra l 1. 7 12 .6 4. 0 0. 6 6. 8 3. 9 2. 2 0. 9 6. 4 2. 0 0. 0 1. 9 1. 8 1. 5 93 1 R eg io n Ea st er n 0. 6 14 .6 2. 5 0. 9 3. 5 0. 9 1. 0 0. 6 5. 9 1. 1 0. 0 0. 9 0. 0 0. 3 24 6 N or th er n 2. 1 12 .1 1. 1 0. 9 7. 0 5. 1 3. 3 1. 3 4. 8 0. 5 0. 3 0. 9 2. 3 2. 0 56 9 So ut he rn 2. 8 15 .6 12 .0 1. 2 9. 8 2. 9 1. 9 2. 0 12 .7 6. 9 0. 0 4. 5 2. 2 1. 5 25 4 W es te rn 2. 8 19 .2 4. 6 0. 0 4. 1 2. 2 1. 9 2. 0 11 .1 1. 6 0. 0 1. 5 1. 0 0. 2 21 4 M ot he r’ s ed uc at io n N o ed uc at io n 1. 7 13 .4 3. 3 0. 8 6. 3 4. 1 2. 2 1. 1 6. 7 1. 3 0. 0 1. 8 1. 8 1. 5 93 6 Pr im ar y 3. 4 16 .0 4. 1 0. 7 5. 8 1. 1 4. 8 2. 2 8. 1 2. 8 0. 0 0. 7 1. 1 1. 5 17 6 Se co nd ar y or hi gh er 2. 6 17 .1 7. 7 1. 4 6. 8 1. 4 0. 8 1. 9 10 .2 4. 2 1. 0 1. 9 1. 4 0. 3 15 2 W ea lth q ui nt ile Lo w es t 2. 0 12 .3 5. 2 1. 0 3. 0 2. 6 3. 8 1. 3 6. 7 1. 0 0. 0 0. 5 1. 2 3. 8 27 2 Se co nd 0. 9 13 .8 4. 9 0. 7 6. 7 5. 2 1. 4 0. 0 6. 4 3. 8 0. 0 1. 8 2. 6 0. 4 27 2 M id dl e 2. 6 13 .0 2. 2 0. 5 10 .5 3. 0 0. 7 1. 8 7. 5 0. 7 0. 0 2. 9 1. 2 0. 0 27 2 Fo ur th 1. 2 12 .0 4. 1 1. 0 6. 9 4. 2 2. 9 0. 7 5. 8 2. 6 0. 0 2. 1 2. 9 1. 6 24 8 H ig he st 4. 1 22 .4 4. 1 0. 9 4. 7 1. 3 3. 1 3. 7 12 .3 2. 2 0. 7 1. 5 0. 0 0. 6 22 0 T ot al 2. 1 14 .4 4. 1 0. 8 6. 4 3. 3 2. 4 1. 4 7. 6 2. 0 0. 1 1. 7 1. 6 1. 3 1, 28 3 1 A rt em isi ni n C om bi na tio n Th er ap y (A C T) 180 | Malaria Malaria | 181 Chloroquine, which was withdrawn from the Sierra Leone market in 2006 because of the high level of resistance to the drug, is by far the most common anti-malarial drug administered for fever (14 percent), followed by Artemisinin Combination Therapy (ACT) (6 percent), Amodiaquine (4 percent) and Fansidar (2 percent). Quinine, reserved for treatment of severe and complicated malaria cases in health facilities, is taken by less than 1 percent of children with fever. It is noteworthy that 3 percent of children were treated with traditional herbal medicines (Gbangba root/Sheku Ture leaves) that are believed by some in Sierra Leone to cure malaria. Two percent of children received other anti- malarial drugs. Differences in the types of anti-malarial drugs used to manage fever are small. Children living in the Southern Region are more likely to have received all types of anti-malarial drugs and more likely to have taken the drugs the same or the next day, compared with other children. Children age 24-35 months (11 percent), those living in the Southern Region (10 percent), and those in the middle wealth quintile (11 percent) are more likely than other children to be given ACT to treat fever. However, in the majority of cases, the fever was not managed appropriately, with ACT not being given as recommended in the national policy. Because of the need to treat malaria quickly, it can be useful for parents to have anti-malarial drugs at home. The SLDHS data show that anti-malarial drugs were at home when the child became ill with fever in only 31 percent of the cases (Table 12.7). However, mothers of 56 percent of the children treated with local herbal medicines reported having the anti-malarial herbs (Gbangba root/Sheku Ture leaves) at home when their children became ill with fever. The proportion having the anti-malarial drugs at home was higher for mothers whose children were treated with chloroquine and SP/Fansidar (29 percent each). Mothers of 22 percent of children treated with ACT and 20 percent of children treated with Amidiaquine reported having the drugs in the household when the child became ill with fever. In conclusion, the results provided in this report highlight the large gap between the national targets set for 2005 by the National Malaria Strategy and the present coverage of malaria interventions. Advocacy programmes need to be implemented that will increase the use of insecticide- treated mosquito nets, provide for re-treatment of mosquito nets, manage paediatric fevers, and facilitate the uptake of IPT. Table 12.7 Availability at home of anti-malarial drugs received by children with fever Among children under five with fever in the two weeks preceding the survey and who received specific anti-malarial drugs, the percentage for whom the drug was at home when the child became ill with fever, Sierra Leone 2008 Drug Children under five with fever who received anti-malarial drug Percentage for whom the drug was at home when child became ill with fever Number of children SP/Fansidar (29.3) 27 Chloroquine 29.4 185 Amodiaquine (19.5) 53 Quinine * 11 ACT1 21.6 82 Gbangba root/Sheku Ture leaves (55.8) 43 Other anti-malarials (16.1) 30 Any anti-malarial drug 30.6 386 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. 1 Artemisinin Combination Therapy (ACT) HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 183 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 Acquired immune deficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV), which weakens the immune system and makes the body susceptible to and unable to recover from other opportunistic diseases and eventually leads to death through these secondary infections. The predominant mode of HIV transmission is through heterosexual contact, followed in magnitude by perinatal transmission in which the mother passes the virus to the child during pregnancy, delivery, or breastfeeding. Other modes of transmission are through infected blood and unsafe injections. The future course of Sierra Leone’s AIDS epidemic depends on a number of variables including level of HIV/AIDS-related knowledge in the general population, social stigmatization, risk behaviour modification, access to quality services for sexually transmitted infections (STI), provision and uptake of HIV counselling and testing, and access to care including prevention and treatment of opportunistic infections and antiretroviral therapy (ART). The principal objective of this chapter is to establish the prevalence of relevant knowledge, perceptions, and behaviours at the national level and in the various geographic and socio-economic subgroups of the population. In this way, prevention programmes can target those groups most in need of information and most at risk of HIV infection. This chapter presents the results on HIV/AIDS knowledge, attitudes, and related behaviours for the general adult population age 15-49. The chapter also includes information HIV/AIDS knowledge and sexual activity among young people, because young adults are the main target of many HIV prevention efforts. 13.1 HIV/AIDS KNOWLEDGE, TRANSMISSION, AND PREVENTION METHODS 13.1.1 Awareness of HIV/AIDS In the 2008 SLDHS, respondents were asked whether they had heard of AIDS. Those who reported having heard of AIDS were asked a number of questions about whether and how HIV/AIDS could be avoided. Table 13.1 shows that knowledge of AIDS in Sierra Leone is higher among men (83 percent) than among women (69 percent). Generally, awareness is somewhat higher among younger women age 15-24. Among men, there is no clear relationship between age and the proportion who have heard about AIDS. Awareness of AIDS is highest among never-married women who have ever had sex (89 percent) and is lowest among women who are currently married or living with a man as if married (65 percent). Among men, knowledge of AIDS is highest among divorced, separated, or widowed men (94 percent), followed by never-married men who have had sex (88 percent), and it is lowest among never-married men who have never had sex (67 percent). By residence, women and men in urban areas (87 and 95 percent, respectively) are more likely to have heard about AIDS than their counterparts in rural areas (59 and 76 percent, respectively). There are regional variations in the level of knowledge of AIDS. Table 13.1 shows that women and men in the Western Region are the most knowledgeable about AIDS (95 and 98 percent, respectively), while women in the Northern Region (59 percent) and men in the Southern Region (71 percent) are the least knowledgeable. 184 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Sierra Leone 2008 Background characteristic Women Men Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-24 72.7 2,384 81.2 929 15-19 70.7 1,198 77.8 526 20-24 74.7 1,186 85.7 403 25-29 68.9 1,643 85.0 446 30-39 67.2 2,175 81.2 899 40-49 67.5 1,172 86.3 671 Marital status Never married 82.2 1,399 80.5 1,085 Ever had sex 88.6 924 87.6 702 Never had sex 69.9 475 67.3 383 Married/living together 65.3 5,525 83.9 1,767 Divorced/separated/widowed 79.6 450 94.0 92 Residence Urban 87.4 2,655 94.5 1,123 Rural 59.3 4,719 75.8 1,822 Region Eastern 69.6 1,325 88.1 557 Northern 58.6 3,001 78.7 1,131 Southern 65.3 1,542 70.9 617 Western 94.9 1,506 97.6 639 Education No education 59.7 4,860 73.9 1,426 Primary 79.3 960 79.0 414 Secondary or higher 93.7 1,554 96.0 1,104 Wealth quintile Lowest 56.1 1,382 66.2 558 Second 56.7 1,368 75.8 520 Middle 58.3 1,428 81.2 530 Fourth 77.2 1,472 88.4 597 Highest 92.7 1,723 97.5 739 Total 15-49 69.4 7,374 82.9 2,944 50-59 na 0 75.7 336 Total 15-59 na 0 82.2 3,280 na = Not applicable Knowledge about HIV/AIDS increases steadily with the level of education. Table 13.1 shows that for women, knowledge of AIDS increases from 60 percent among women with no education to 79 percent among those with primary education to 94 percent among women with secondary or higher education. Similarly, for men, knowledge of AIDS increases from 74 percent among men with no education to 79 percent among those with primary education to 96 percent among men with secondary or higher education. For both male and female respondents, knowledge of AIDS increases with increasing wealth quintile. For example, awareness about AIDS increases steadily from 56 percent among women in the lowest wealth quintile to 93 percent among those in the highest wealth quintile. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 185 13.1.2 Knowledge of HIV/AIDS Transmission and Prevention Methods HIV among adults is mainly transmitted through heterosexual contact between a person who is HIV positive and a person who is HIV negative. Consequently, AIDS prevention programmes focus their messages and efforts on three important aspects of sexual behaviour: delaying sexual debut in young persons (abstinence), limiting the number of sexual partners or staying faithful to one partner, and using condoms (the ABC message). To ascertain whether programmes have effectively communicated these messages, the 2008 SLDHS asked respondents if people can reduce their chances of getting the AIDS virus by using a condom every time they have sex, by having just one HIV-negative sexual partner who has no other sex partners, and by not having sexual intercourse at all. As shown in Table 13.2, 43 percent of women and 62 percent of men know that consistent use of condoms is a means of preventing the spread of HIV. About half of women and two-thirds of men know that limiting sexual intercourse to one faithful, HIV-negative partner can reduce the chances of contracting HIV. Just 40 percent of women and 58 percent of men age 15-49 know that abstinence is a way of reducing the chances of getting HIV. Approximately the same proportions of respondents (38 percent of women and 56 percent of men) said that people can reduce the chances of getting the AIDS virus by using condoms and limiting sex to one HIV-negative partner. Thus, knowledge of HIV/AIDS is higher among men than women for each of the three specified prevention methods. Surprisingly, older women, currently married women, and women who have never had sex are less likely than other women to know of ways to avoid getting HIV. Urban women and women living in the Western Region are more likely to be aware of safe sexual practices than other women. There is a strong, positive relationship between respondent’s level of education and knowledge of ways to prevent HIV. For example, only 28 percent of women with no education say that the risk of getting HIV can be reduced by using condoms and limiting sex to one HIV-negative partner, compared with 66 percent of women with secondary or higher education. As with women, level of education among men is an important factor associated with knowledge of HIV/AIDS; men with the least education and those who have never had sex are less likely than other men to know of ways to avoid the AIDS virus. Men in their thirties are less knowledgeable about safe sex, compared with younger and older men. There are noticeable variations in knowledge of HIV/AIDS by residence. As with women, urban men and men in the Western Region are more likely to be aware of safe sexual practices than rural men and men in other regions. Only 45 percent of men in the Southern Region cited using condoms and limiting sex to one HIV-negative partner as a way to avoid HIV/AIDS, compared with 70 percent of men in the Western Region. As expected, respondents’ wealth status has a positive correlation with knowledge of HIV prevention methods. Women and men in higher wealth quintiles are more likely than those in lower quintiles to be aware of HIV prevention methods. 186 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, said that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is HIV negative and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who say HIV can be prevented by: Percentage of men who say HIV can be prevented by: Using condoms1 Limiting sexual intercourse to one HIV- negative partner2 Using condoms and limiting sexual intercourse to one HIV- negative partner1,2 Abstaining from sexual intercourse Number of women Using condoms1 Limiting sexual intercourse to one HIV- negative partner2 Using condoms and limiting sexual intercourse to one HIV- negative partner1,2 Abstaining from sexual intercourse Number of men Age 15-24 47.4 51.0 41.3 43.4 2,384 64.2 65.8 57.2 59.9 929 15-19 44.4 48.6 38.5 41.2 1,198 60.5 62.2 54.0 57.7 526 20-24 50.4 53.4 44.3 45.6 1,186 69.0 70.4 61.4 62.7 403 25-29 42.0 48.7 37.1 38.6 1,643 61.8 69.2 56.0 57.3 446 30-39 42.3 45.7 37.1 38.8 2,175 58.3 63.9 52.9 54.0 899 40-49 38.3 45.8 33.7 39.0 1,172 65.1 69.4 59.2 59.5 671 Marital status Never married 59.2 61.5 52.7 52.9 1,399 63.1 65.6 56.6 58.9 1,085 Ever had sex 66.9 67.8 59.2 57.8 924 69.7 73.0 63.3 64.0 702 Never had sex 44.3 49.3 40.1 43.4 475 51.1 52.1 44.3 49.7 383 Married/living together 38.9 44.0 33.7 36.9 5,525 61.1 66.5 55.3 56.8 1,767 Divorced/separated/ widowed 47.0 56.3 43.5 41.8 450 73.6 76.9 66.8 57.7 92 Residence Urban 61.7 65.8 54.6 52.6 2,655 75.3 79.2 68.3 69.2 1,123 Rural 32.8 38.2 28.6 33.3 4,719 54.2 58.8 48.7 50.4 1,822 Region Eastern 36.9 38.8 28.4 34.5 1,325 62.7 66.4 55.0 57.0 557 Northern 37.7 41.5 33.1 35.6 3,001 60.9 64.6 55.1 54.6 1,131 Southern 34.4 40.7 31.1 35.6 1,542 50.3 53.0 44.7 49.4 617 Western 68.8 77.0 62.9 59.4 1,506 75.7 83.3 70.1 71.4 639 Education No education 31.8 37.2 27.6 31.7 4,860 50.6 55.1 44.4 47.5 1,426 Primary 52.2 58.4 44.5 49.2 960 54.9 60.0 48.4 49.9 414 Secondary or higher 73.5 75.9 66.3 61.5 1,554 80.0 83.8 74.3 73.6 1,104 Wealth quintile Lowest 29.3 34.4 24.9 30.1 1,382 41.9 44.6 35.0 38.8 558 Second 30.8 34.8 26.3 30.2 1,368 55.3 59.1 48.6 51.5 520 Middle 32.3 38.3 28.4 32.2 1,428 58.5 63.7 52.8 53.5 530 Fourth 50.2 54.9 44.0 47.2 1,472 70.4 74.6 64.7 63.2 597 Highest 67.4 72.0 60.3 57.1 1,723 78.6 83.8 73.0 74.5 739 Total 15-49 43.2 48.1 37.9 40.3 7,374 62.2 66.5 56.2 57.6 2,944 50-59 na na na na 0 50.9 57.0 45.0 51.8 336 Total 15-59 na na na na 0 61.1 65.6 55.0 57.0 3,280 na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 187 13.1.3 Rejection of Misconceptions about HIV/AIDS In addition to knowing about effective ways to avoid contracting HIV, it is useful to be able to identify incorrect beliefs about AIDS, to eliminate misconceptions. Common misconceptions about HIV/AIDS include, the idea that all people who are HIV positive look sick, and the belief that the virus can be transmitted through mosquito or other insect bites, by sharing food with someone who is HIV positive, or by witchcraft and other supernatural means. Respondents were asked about these four misconceptions and the results are presented in Tables 13.3.1 and 13.3.2 for women and men, respectively. Table 13.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about HIV/AIDS transmission and prevention; and the percentage with comprehensive knowledge about AIDS, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who say that: Percentage who say that a healthy- looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of women A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot contract HIV by sharing food with a person who has AIDS Age 15-24 41.2 39.5 46.6 41.8 23.7 17.2 2,384 15-19 39.0 41.1 46.1 41.0 23.2 16.4 1,198 20-24 43.5 38.0 47.1 42.5 24.2 18.0 1,186 25-29 35.8 30.2 38.3 33.5 17.1 11.8 1,643 30-39 35.4 31.5 38.5 34.7 18.5 13.3 2,175 40-49 35.5 26.6 36.7 32.1 17.1 12.0 1,172 Marital status Never married 56.0 52.3 60.6 57.1 35.2 27.2 1,399 Ever had sex 62.7 56.5 67.1 63.3 38.7 30.8 924 Never had sex 43.0 44.2 47.9 45.1 28.4 20.1 475 Married/living together 32.6 27.8 35.3 30.5 15.8 10.7 5,525 Divorced/separated/ widowed 38.8 37.4 47.1 43.5 18.7 13.1 450 Residence Urban 60.0 50.6 62.3 57.1 34.3 25.5 2,655 Rural 24.6 23.2 28.7 24.6 11.4 7.5 4,719 Region Eastern 28.1 34.8 44.2 38.1 19.8 12.7 1,325 Northern 26.4 27.2 28.4 26.5 13.2 9.4 3,001 Southern 31.7 23.3 35.4 30.0 14.7 9.5 1,542 Western 73.3 53.1 67.9 60.8 37.5 29.0 1,506 Education No education 24.9 22.2 28.3 23.9 10.8 6.8 4,860 Primary 42.4 39.4 48.2 39.9 18.2 12.0 960 Secondary or higher 73.3 63.1 75.2 72.9 48.2 37.7 1,554 Wealth quintile Lowest 20.9 20.0 26.1 20.0 8.9 6.0 1,382 Second 21.9 21.5 28.2 22.6 9.9 6.2 1,368 Middle 25.0 23.0 28.6 24.7 11.3 7.7 1,428 Fourth 41.8 39.1 44.6 42.7 23.6 16.1 1,472 Highest 69.3 55.7 69.4 64.4 39.5 30.1 1,723 Total 15-49 37.4 33.0 40.8 36.3 19.7 14.0 7,374 1 Two most common local misconceptions about HIV transmission: mosquito bites and sharing food with a person who has AIDS 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV-negative, faithful partner can reduce the chances of getting the AIDS virus; knowing that a healthy-looking person can have the AIDS virus; and rejecting the two most common local misconceptions about HIV/AIDS transmission and prevention. The results in Tables 13.3.1 and 13.3.2 indicate that not many Sierra Leonean adults have accurate knowledge about the ways in which the AIDS virus is transmitted. Only 37 percent of women and 57 percent of men know that a healthy-looking person can have HIV, the virus that causes AIDS. Furthermore, just 33 percent of women and 46 percent of men know that AIDS cannot be transmitted by mosquito bites, and 41 percent of women and 59 percent of men believe that AIDS cannot be transmitted by supernatural means. Finally, 36 percent of women and 49 percent of men know that the AIDS virus cannot be transmitted by sharing food with a person who has AIDS. Likewise, only 20 percent of women and 31 percent of men correctly reported that a healthy-looking 188 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour person can have the AIDS virus and rejected two of the most common misconceptions about the transmission of AIDS in Sierra Leone—namely, that AIDS can be transmitted by mosquito bites or by sharing food and utensils with someone who has AIDS. Tables 13.3.1 and 13.3.2 provide an assessment of the level of comprehensive knowledge of HIV/AIDS prevention and transmission. Comprehensive knowledge is defined as: 1) knowing that both condom use and limiting sexual intercourse to one HIV-negative person are HIV/AIDS prevention methods, 2) being aware that a healthy-looking person can have HIV, and 3) rejecting the two most common local misconceptions about the transmission of HIV, namely, that the AIDS virus can be transmitted by mosquito bites and by sharing food and utensils with someone who has HIV/AIDS. The 2008 SLDHS results indicate that only 14 percent of women and 25 percent of men age 15-49 in Sierra Leone have comprehensive knowledge of HIV/AIDS prevention and transmission. Table 13.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention; and the percentage with comprehensive knowledge about AIDS, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of men who say that: Percentage of men who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of men A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot contract HIV by sharing food with a person who has AIDS Age 15-24 56.7 51.0 61.3 52.8 32.9 27.6 929 15-19 52.4 46.6 57.6 50.5 30.1 26.1 526 20-24 62.3 56.8 66.1 55.9 36.6 29.6 403 25-29 58.8 48.0 57.8 48.8 31.4 24.2 446 30-39 53.3 42.1 53.3 44.5 29.0 22.0 899 40-49 60.5 44.1 62.2 47.6 31.4 25.3 671 Marital status Never married 57.6 51.1 60.6 53.9 35.2 29.0 1,085 Ever had sex 64.3 56.6 66.8 58.7 39.9 32.8 702 Never had sex 45.4 41.0 49.3 45.2 26.4 22.1 383 Married/living together 56.2 43.2 56.9 45.1 29.0 22.7 1,767 Divorced/separated/ widowed 59.0 48.1 65.4 48.6 26.2 16.6 92 Residence Urban 74.6 63.1 73.9 66.3 47.9 38.8 1,123 Rural 45.8 35.9 49.0 37.5 20.8 16.3 1,822 Region Eastern 55.9 35.2 50.1 41.5 20.7 14.2 557 Northern 53.5 48.3 56.3 44.1 30.4 24.3 1,131 Southern 42.6 33.1 48.5 43.3 23.0 19.9 617 Western 77.4 65.0 79.5 67.2 49.3 39.9 639 Education No education 43.3 32.8 45.0 32.3 17.5 12.8 1,426 Primary 46.4 30.7 46.3 38.4 18.3 13.6 414 Secondary or higher 78.2 69.5 80.5 73.2 53.6 44.6 1,104 Wealth quintile Lowest 33.2 25.7 38.0 27.1 13.8 8.9 558 Second 47.6 38.2 50.5 36.3 22.0 17.2 520 Middle 52.5 40.0 54.3 45.5 25.4 20.4 530 Fourth 62.3 49.2 62.7 53.0 33.2 27.0 597 Highest 79.9 69.6 79.3 71.7 53.2 43.8 739 Total 15-49 56.8 46.3 58.5 48.5 31.2 24.9 2,944 50-59 48.3 39.9 50.6 42.3 25.1 20.3 336 Total men 15-59 56.0 45.6 57.7 47.8 30.5 24.4 3,280 1 Two most common local misconceptions: mosquito bites and sharing a food with a person who has AIDS 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV-negative, faithful partner can reduce the chances of getting the AIDS virus; knowing that a healthy-looking person can have the AIDS virus; and rejecting the two most common local misconceptions about AIDS transmission or prevention. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 189 Tables 13.3.1 and 13.3.2 show substantial variation in knowledge of AIDS by background characteristics. The proportions of women and men who reject the most common misconceptions and know that a healthy-looking person can have the AIDS virus, or who have comprehensive knowledge about AIDS, are highest in age group 20-24 and among never-married respondents who have ever had sex. For all indicators, the proportion of women and men with correct knowledge about HIV/AIDS prevention and transmission is higher in urban areas than in rural areas. Variations in knowledge of AIDS are also seen by region. Women in the Northern Region (9 percent) have the lowest level of comprehensive knowledge about AIDS, while women in the Western Region (29 percent) have the highest level. Among men, comprehensive knowledge ranges from 14 percent in the Eastern Region to 40 percent in the Western Region. Education and wealth status are directly related to correct knowledge about common misconceptions about AIDS and comprehensive knowledge of HIV/AIDS prevention and transmission. Among women, for example, 38 percent of those with secondary or higher education have comprehensive knowledge about prevention and transmission of AIDS, compared with 7 percent of women with no education. Similarly, among men, the level of comprehensive knowledge is 45 percent among those with secondary or higher education, compared with 14 and 13 percent, respectively, among men with primary education or no education. Looking at wealth status, 6 percent of women in the lowest quintile have comprehensive knowledge about AIDS, compared with 30 percent of women in the highest wealth quintile. Similarly, 9 percent of men in the lowest quintile have comprehensive knowledge about AIDS, compared with 44 percent of men in the highest wealth quintile. 13.2 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing the general level of knowledge about the transmission of HIV from mother to child, and about the use of antiretroviral drugs to reduce the risk of mother-to-child transmission (MTCT), is critical to preventing the spread of HIV from mother to child. To assess MTCT knowledge, respondents in the 2008 SLDHS were asked if the virus that causes AIDS can be transmitted from a mother to her baby during pregnancy, delivery, or breastfeeding and whether they know of any special drugs a mother with HIV can take to reduce the risk of transmission to the baby. Table 13.4 shows that women are slightly less likely than men to know of the risk of mother- to-child transmission of HIV through breastfeeding (45 and 50 percent, respectively). Among women, those who are pregnant are more likely to have this knowledge than those who are not pregnant (52 and 44 percent, respectively). Smaller proportions of respondents (14 percent of women and 24 percent of men) are aware that a mother can reduce the risk of transmitting HIV to her child by taking special drugs during pregnancy. Overall, about one in ten women (13 percent) and one in five men (20 percent) know that HIV can be transmitted through breastfeeding and that the risk of MTCT can be reduced by the mother taking special drugs during pregnancy. Looking at marital status, knowledge is lowest among respondents who have never had sex and currently married women. A larger proportion of respondents in urban areas than in rural areas know about MTCT and the use of special drugs to reduce the risk of MTCT. Women and men living in the Western Region are markedly more likely to have MTCT knowledge than women and men living in other regions. As seen earlier, respondents’ socio-economic status, as measured by level of education and wealth quintile, have a positive correlation with knowledge of MTCT. 190 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child through breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who know that: Percentage of men who know that: HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding, and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding, and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 46.6 15.2 13.2 2,384 49.1 21.7 17.7 929 15-19 41.5 13.3 10.8 1,198 45.5 19.9 16.0 526 20-24 51.8 17.1 15.6 1,186 53.8 24.1 20.1 403 25-29 43.7 12.9 11.2 1,643 49.0 22.1 16.9 446 30-39 43.9 15.0 13.7 2,175 46.6 24.8 20.2 899 40-49 42.8 12.4 11.5 1,172 57.1 27.3 24.2 671 Marital status Never married 53.3 19.5 16.1 1,399 47.8 21.7 17.1 1,085 Ever had sex 60.1 22.2 18.5 924 54.5 24.4 20.3 702 Never had sex 40.1 14.2 11.5 475 35.5 16.6 11.3 383 Married/living together 41.6 12.6 11.6 5,525 50.8 25.0 21.1 1,767 Divorced/separated/ widowed 53.9 16.0 14.6 450 64.7 31.3 27.0 92 Currently pregnant Pregnant 51.9 13.9 12.8 598 na na na 0 Not pregnant or not sure 43.9 14.2 12.6 6,776 na na na 0 Residence Urban 59.7 23.4 20.3 2,655 60.1 33.6 27.0 1,123 Rural 36.1 8.9 8.3 4,719 44.0 18.0 15.4 1,822 Region Eastern 39.6 12.1 10.9 1,325 38.8 12.0 9.6 557 Northern 35.9 10.6 8.6 3,001 47.9 24.0 19.6 1,131 Southern 39.9 10.0 9.6 1,542 49.9 17.8 16.4 617 Western 70.9 27.3 25.2 1,506 64.3 40.4 32.4 639 Education No education 35.1 8.3 7.7 4,860 40.7 15.9 13.3 1,426 Primary 52.8 14.4 13.4 960 42.4 15.0 12.6 414 Secondary or higher 69.1 32.3 27.7 1,554 65.3 37.8 30.9 1,104 Wealth quintile Lowest 32.0 7.1 6.6 1,382 35.3 9.1 8.5 558 Second 34.8 8.8 8.5 1,368 47.0 21.8 18.7 520 Middle 34.3 9.0 8.1 1,428 43.1 21.1 15.5 530 Fourth 50.0 15.1 12.7 1,472 57.1 28.0 25.1 597 Highest 66.2 27.6 24.6 1,723 62.9 35.6 28.0 739 Total 15-49 44.6 14.2 12.6 7,374 50.2 24.0 19.8 2,944 50-59 na na na 0 44.0 23.6 20.6 336 Total 15-59 na na na 0 49.5 24.0 19.9 3,280 na = Not applicable 13.3 STIGMA ASSOCIATED WITH AIDS AND ATTITUDES RELATED TO HIV/AIDS Widespread stigma and discrimination in a population can adversely affect people’s willingness to be tested as well as their adherence to antiretroviral therapy. Reduction of stigma and discrimination in a population is, thus, an important impetus to the success of programmes targeting HIV/AIDS prevention and control. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 191 To assess the level of stigma, SLDHS respondents who had heard of AIDS were asked if they would be willing to care for a relative sick with AIDS in their own households, if they would be willing to buy fresh vegetables from a shopkeeper who has the AIDS virus, if they thought a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching, and if they would want to keep a family member’s HIV status secret. Tables 13.5.1 and 13.5.2 show the results for women and men, respectively. Both women and men tend to express more positive attitudes to the question on care for a family member sick with AIDS than to the questions about the HIV-positive shopkeeper selling vegetables or the HIV-positive female teacher. About half of women (49 percent) and three-fourths of men (73 percent) said they would be willing to care for a family member sick with AIDS in their home. About 60 percent of women and men said they would not want to keep secret that a family member is infected with HIV. These results indicate that individuals are generally supportive of providing a caring environment for family members who were sick with AIDS. Women and men age 20-24, those who never-married who ever had sex, urban respondents, and those with secondary or higher education are somewhat more likely to say that they would be willing to care for a family member with AIDS in their home, compared with other respondents. There are marked regional variations, especially among women. Women in the Northern Region (37 percent) are the least likely to say they would take care of a relative sick with AIDS in their home, compared with 63 percent of women in the Western Region, and 47-53 percent of women in the other regions. Similarly, men in the Northern Region (62 percent) are the least likely to agree to take care of a family member with AIDS in their home, compared with men in the other regions (79-80 percent). Empowering persons living with AIDS is a critical programme area. Survey data show that only 20 percent of women and 40 percent of men would buy fresh food from a shopkeeper with the AIDS virus, while 31 percent of women and 53 percent of men said that an HIV-positive female teacher should be allowed to continue teaching. The percentage expressing accepting attitudes on all four measures is just 5 percent for women and 15 percent for men age 15-49. Higher education and urban residence are generally associated with more accepting attitudes towards non-relatives who are HIV positive and to greater willingness to care for relatives sick with AIDS in their own home. For example, the percentage of women expressing accepting attitudes towards a female teacher who is HIV positive but not sick is 44 percent among urban women, compared with 20 percent among rural women; it is 19 percent among women with no education, compared with 54 percent among those with higher education. On the other hand, respondents in rural areas, those in households in the lower wealth quintiles, and respondents with no education are generally more likely to say that they would not want to keep secret that a family member was HIV positive. Wealth also correlates with positive attitudes towards those who are HIV positive, the higher the wealth quintile, the more likely respondents are to show acceptance on all four indicators. These results indicate that individuals are generally supportive of providing a caring environment for family members if they are HIV positive. This support can ensure early diagnosis and treatment, an approach that is encouraged by the national programme in Sierra Leone. 192 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes towards people with AIDS, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who: Percentage of women expressing accepting attitudes on all four indicators Number of women who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 51.8 23.1 35.4 53.9 5.2 1,734 15-19 49.3 23.4 34.5 55.3 5.4 847 20-24 54.2 22.7 36.2 52.5 5.0 887 25-29 45.4 17.9 28.8 66.1 4.9 1,132 30-39 49.2 20.0 29.5 63.1 5.6 1,462 40-49 48.5 16.8 25.3 67.3 4.6 791 Marital status Never married 56.9 30.1 44.9 46.6 6.4 1,150 Ever had sex 59.4 31.1 45.6 46.0 6.9 818 Never had sex 50.8 27.7 43.2 48.1 5.2 332 Married/living together 46.3 17.1 26.2 66.1 4.8 3,610 Divorced/separated/ widowed 52.8 17.6 30.8 60.3 4.5 358 Residence Urban 57.0 27.5 43.7 47.5 6.2 2,321 Rural 42.6 13.9 19.9 72.7 4.3 2,798 Region Eastern 47.4 23.0 28.3 69.5 7.6 922 Northern 37.1 12.2 20.4 74.0 3.6 1,760 Southern 52.7 18.7 25.6 68.0 6.6 1,007 Western 62.5 28.9 48.5 35.7 4.4 1,430 Education No education 42.7 11.4 19.1 70.4 3.6 2,901 Primary 44.1 20.0 30.2 58.4 4.3 762 Secondary or higher 64.7 37.5 54.1 44.6 8.7 1,456 Wealth quintile Lowest 43.5 11.5 17.3 73.8 3.4 775 Second 42.5 14.5 19.6 71.0 3.8 776 Middle 38.2 12.9 20.4 72.4 3.4 833 Fourth 47.7 20.3 28.9 63.7 6.0 1,136 Highest 61.9 30.5 49.2 43.0 6.9 1,597 Total 15-49 49.1 20.1 30.7 61.3 5.1 5,118 HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 193 Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes towards people with HIV/AIDS, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of men who: Percentage of men expressing accepting attitudes on all four indicators Number of men who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 71.3 41.1 59.5 54.1 13.6 754 15-19 65.4 37.0 53.1 53.9 12.1 409 20-24 78.4 46.0 67.0 54.5 15.4 345 25-29 68.6 38.2 47.3 56.7 12.6 379 30-39 76.0 40.5 51.0 61.9 15.8 730 40-49 73.4 40.3 50.9 63.8 15.9 579 Marital status Never married 70.3 42.1 58.5 53.1 14.0 873 Ever had sex 75.8 44.2 60.0 53.4 14.3 615 Never had sex 57.2 37.1 55.0 52.5 13.5 258 Married/living together 74.5 39.7 50.2 62.2 15.3 1,482 Divorced/separated/ widowed 68.8 30.6 45.0 68.1 10.7 87 Residence Urban 75.0 48.2 63.5 53.9 18.9 1,062 Rural 71.1 34.2 44.9 63.2 11.4 1,381 Region Eastern 79.6 43.0 49.2 69.8 17.2 490 Northern 61.5 34.4 47.9 61.2 13.6 890 Southern 78.6 36.5 46.1 52.0 12.3 438 Western 79.4 49.1 68.1 52.9 15.7 624 Education No education 69.0 29.7 40.0 67.5 11.7 1,054 Primary 70.4 32.4 46.0 62.1 14.0 327 Secondary or higher 77.3 53.2 68.1 50.0 17.8 1,061 Wealth quintile Lowest 64.9 27.8 35.2 63.5 10.2 369 Second 69.7 34.2 47.1 63.8 12.2 395 Middle 76.7 40.9 48.9 66.8 15.0 430 Fourth 75.6 41.7 56.5 58.7 16.9 528 Highest 74.1 48.6 65.2 50.2 16.5 720 Total 15-49 72.8 40.3 53.0 59.2 14.7 2,442 50-59 75.4 34.2 51.9 59.8 14.4 254 Total 15-59 73.0 39.7 52.9 59.2 14.6 2,696 13.4 ATTITUDES TOWARDS NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent it are of little use if people feel powerless to negotiate safer sex practices with their partners. In an effort to assess the ability of women to negotiate safer sex with a spouse who has an STI, women and men were asked if they thought that a wife is justified in refusing to have sexual intercourse with her husband or asking that he use a condom if she knows that he has an STI. Table 13.6 shows that nearly two-thirds of women and three-fourths of men agree that a woman is justified in refusing to have sex with her husband if she knows he has an STI (62 percent of women and 76 percent of men). Over half of women (56 percent) and three-fourths of men (75 percent) believe that a woman is justified in asking her husband to use a condom if he has an STI. Over two-thirds of women (69 percent) and 80 percent of men agree with one or both statements. There are some differences in these attitudes by background characteristics. Rural respondents, women and men age 15-19, and those who never married and never had sex are generally less supportive of women negotiating safer sex practices with their husbands, compared with urban respondents and those of other age groups and marital status. In terms of regional 194 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour variation, women and men in the Western Region are most supportive of a woman refusing to have sexual intercourse or asking that they use a condom, if she knows her husband has an STI (81 and 92 percent, respectively), while women and men in the Northern Region are the least supportive (62 and 71 percent, respectively). Respondents with higher education are more supportive of women negotiating safer sex with their husbands than those with less education. Table 13.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who think that, if a husband has a sexually transmitted disease, his wife is justified in refusing to have sexual intercourse with him or asking that they use a condom, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who think that a woman is justified in: Percentage of men who think that a woman is justified in: Refusing to have sexual intercourse Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Number of women Refusing to have sexual intercourse Asking that they use a condom Refusing sexual intercourse or asking that they use a condom Number of men Age 15-24 58.9 56.9 67.2 2,384 68.8 70.9 73.7 929 15-19 54.4 52.6 61.7 1,198 63.8 66.4 68.7 526 20-24 63.4 61.2 72.7 1,186 75.4 76.9 80.2 403 25-29 63.7 56.6 69.2 1,643 74.0 72.1 78.0 446 30-39 62.7 55.5 69.3 2,175 80.2 77.8 84.1 899 40-49 65.0 51.1 69.8 1,172 79.7 78.1 85.9 671 Marital status Never married 61.6 63.5 70.5 1,399 68.6 70.7 73.2 1,085 Ever had sex 70.0 71.2 79.0 924 76.4 78.1 80.6 702 Never had sex 45.4 48.3 53.8 475 54.3 57.2 59.8 383 Married/living together 61.5 53.1 67.6 5,525 79.3 77.0 84.2 1,767 Divorced/separated/ widowed 69.4 60.1 76.3 450 85.2 81.7 88.7 92 Residence Urban 66.2 66.1 76.6 2,655 80.6 82.4 85.1 1,123 Rural 59.7 49.5 64.2 4,719 72.5 70.2 77.4 1,822 Region Eastern 63.6 51.8 69.1 1,325 86.4 80.9 90.3 557 Northern 55.7 50.3 61.5 3,001 68.1 64.9 70.7 1,131 Southern 66.0 56.0 70.1 1,542 67.4 72.4 76.7 617 Western 69.3 68.5 81.0 1,506 87.2 89.4 92.0 639 Education No education 59.4 49.5 64.8 4,860 73.6 69.7 78.1 1,426 Primary 62.8 59.0 70.3 960 65.5 66.8 71.7 414 Secondary or higher 69.6 71.9 79.7 1,554 81.9 84.5 86.4 1,104 Total 15-49 62.0 55.5 68.7 7,374 75.6 74.8 80.3 2,944 50-59 na na na 0 80.2 75.2 85.9 336 Total 15-59 na na na 0 76.0 74.9 80.9 3,280 na = Not applicable 13.5 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH Condom use is one of the main strategies for combating the spread of HIV. Social acceptance of condom use among young people is a key factor in the use of condoms to prevent the sexual transmission of HIV and other STIs, as well as preventing early pregnancy. However, educating youth about condoms is sometimes controversial, with some people saying it promotes early sexual experimentation. Other people favour teaching youth to abstain from sexual intercourse until they are married. To gauge attitudes towards education about condoms, SLDHS respondents were asked if they thought that children age 12-14 should be taught about using a condom to avoid AIDS. The results are shown in Table 13.7. Because the table focuses on adult opinions, the results are tabulated only for respondents age 18-49. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 195 Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 years should be taught about using a condom to avoid AIDS, by background characteristics, Sierra Leone 2008 Background characteristic Agree that children age 12-14 should be taught about using a condom to avoid AIDS Women Men Percentage who agree Number of women Percentage who agree Number of men Age 18-24 35.9 1,756 59.9 653 18-19 34.7 570 56.6 250 20-24 36.4 1,186 61.9 403 25-29 27.4 1,643 56.8 446 30-39 30.1 2,175 49.3 899 40-49 25.9 1,172 53.5 671 Marital status Never married 51.7 875 58.0 809 Married or living together 26.4 5,425 52.7 1,767 Divorced/separated/ widowed 34.2 446 50.3 92 Residence Urban 46.8 2,347 62.8 997 Rural 21.4 4,399 49.0 1,671 Region Eastern 30.7 1,211 48.3 515 Northern 21.2 2,785 56.7 1,017 Southern 25.8 1,399 40.5 564 Western 52.8 1,350 68.5 572 Education No education 22.8 4,703 43.8 1,372 Primary 35.8 750 53.3 321 Secondary or higher 54.0 1,293 69.1 976 Wealth quintile Lowest 18.8 1,295 36.5 511 Second 22.2 1,280 50.3 477 Middle 21.4 1,323 56.9 490 Fourth 34.6 1,330 59.1 541 Highest 50.6 1,518 64.8 650 Total 18-49 30.2 6,746 54.2 2,669 50-59 na 0 40.1 336 Total 18-59 na 0 52.6 3,004 na = Not applicable More men than women agree that children age 12-14 years should be taught about the use of condoms to avoid AIDS (54 percent of men and 30 percent of women age 15-49). Never married women and men and those under age 25 are somewhat more likely than other respondents to agree on safe sex education for children age 12-14. Urban women and men are more likely than their rural counterparts to agree on teaching children age 12-14 about condom use to avoid AIDS. By region, agreement on teaching children age 12-14 about the use of condoms ranges from high of 69 percent of men and 53 percent of women in the Western Region to 41 percent of men in the Southern Region and 21 percent of women in the Northern Region. The proportion of respondents who support teaching children age 12-14 about condoms increases with level of education and wealth quintile. For example, 51 percent of women with secondary or higher education, compared with 23 percent of women with no education, agree on instructing children 12-14 years about condoms. The figures for men are 69 and 44 percent, respectively. 196 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour 13.6 HIGHER-RISK SEX Given that most HIV infections in Sierra Leone are contracted through heterosexual contact, information on sexual behaviour is important in designing and monitoring intervention programmes to control the spread of HIV. The 2008 SLDHS included questions on respondents’ sexual partners during their lifetime and in the 12 months preceding the survey. For male respondents, an additional question was asked on whether they paid anyone in exchange for sex during the 12 months preceding the interview. Information on the use of condoms at the last sexual encounter with each type of partner was collected for women and men. These questions are sensitive, and it is recognized that some respondents may have been reluctant to provide information on recent sexual behaviour. 13.6.1 Multiple Partners and Condom Use Tables 13.8.1 and 13.8.2 show the percentage of women and men, respectively, age 15-49 years who had more than one sexual partner and the percentage who engaged in higher-risk sexual intercourse1 in the past 12 months among all women and all men, and among those who had sex in the past 12 months. The data show that women are far less likely than men to report having had two or more sexual partners in the past 12 months (4 percent of all women and 16 percent for all men). Furthermore, only 15 percent of all women reported having higher-risk sexual intercourse in the year before the survey, compared with 34 percent of all men. Among respondents who had sex in the 12 months before the survey, only 5 percent of women reported having more than one sexual partner, compared with 21 percent of men. Similarly, 21 percent of women had higher-risk sex in the past 12 months, compared with 45 percent of men. The 2008 SLDHS also assessed condom use among women and men with multiple partners or who had higher-risk sex in the 12 months preceding the survey. Although truly effective protection would require condom use at every sexual encounter, the sexual encounters covered here are those considered to pose the greatest risk of HIV transmission. 1 Sexual intercourse with a non-marital, non-cohabiting partner H IV /A ID S- Re la te d Kn ow le dg e, A tt itu de s, a nd B eh av io ur | 1 97 T ab le 1 3. 8. 1 M ul tip le s ex ua l p ar tn er s an d hi gh er -r isk s ex ua l i nt er co ur se in th e pa st 1 2 m on th s: W om en A m on g al l w om en a ge 1 5- 49 , t he p er ce nt ag e w ho h ad s ex ua l i nt er co ur se w ith m or e th an o ne p ar tn er a nd th e pe rc en ta ge w ho h ad h ig he r- ris k se xu al in te rc ou rs e in th e pa st 1 2 m on th s; a m on g w om en ag e 15 -4 9 w ho h ad s ex ua l i nt er co ur se in th e pa st 1 2 m on th s, th e pe rc en ta ge w ho h ad s ex ua l i nt er co ur se w ith m or e th an o ne p ar tn er a nd th e pe rc en ta ge w ho h ad h ig he r- ris k se xu al in te rc ou rs e; a m on g w om en w ho h ad m or e th an o ne p ar tn er in t he p as t 12 m on th s, t he p er ce nt ag e w ho u se d a co nd om a t la st s ex ua l i nt er co ur se ; am on g w om en w ho h ad h ig he r- ris k se xu al in te rc ou rs e in t he p as t 12 m on th s, t he p er ce nt ag e w ho u se d a co nd om a t la st s ex ua l i nt er co ur se w ith t ha t pe rs on ; an d am on g w om en w ho e ve r ha d se xu al in te rc ou rs e, t he m ea n nu m be r of s ex ua l p ar tn er s du rin g lif et im e, b y ba ck gr ou nd c ha ra ct er ist ic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Al l w om en (p as t 1 2 m on th s) W om en w ho h ad se xu al in te rc ou rs e (p as t 1 2 m on th s) W om en w ho h ad 2+ p ar tn er s (p as t 1 2 m on th s) W om en w ho h ad h ig he r- ris k se xu al in te rc ou rs e1 (p as t 1 2 m on th s) W om en w ho e ve r h ad se xu al in te rc ou rs e Pe rc en ta ge w ho h ad 2+ p ar tn er s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 N um be r o f w om en Pe rc en ta ge w ho h ad 2+ p ar tn er s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 N um be r o f w om en Pe rc en ta ge w ho u se d a co nd om a t l as t se xu al in te rc ou rs e N um be r o f w om en Pe rc en ta ge w ho us ed a c on do m at la st s ex ua l in te rc ou rs e w ith th at p ar tn er N um be r o f w om en M ea n nu m be r o f se xu al pa rtn er s in lif et im e N um be r o f w om en A ge 15 -2 4 4. 0 26 .6 2, 38 4 6. 4 42 .6 1, 48 6 12 .2 95 9. 5 63 4 1. 9 1, 83 8 15 -1 9 3. 7 29 .5 1, 19 8 7. 0 56 .1 63 1 10 .6 44 7. 6 35 4 1. 6 76 4 20 -2 4 4. 3 23 .6 1, 18 6 5. 9 32 .7 85 6 13 .6 50 12 .0 28 1 2. 1 1, 07 4 25 -2 9 3. 5 11 .2 1, 64 3 4. 8 15 .1 1, 21 8 6. 3 58 6. 1 18 4 2. 1 1, 51 7 30 -3 9 3. 2 8. 9 2, 17 5 4. 2 11 .8 1, 63 2 3. 0 69 3. 6 19 3 2. 4 1, 95 7 40 -4 9 2. 9 6. 5 1, 17 2 4. 0 8. 9 86 0 (0 .0 ) 34 2. 7 76 2. 5 1, 04 4 M ar ita l s ta tu s N ev er m ar rie d 6. 0 53 .4 1, 39 9 10 .8 95 .9 77 8 14 .8 84 8. 5 74 7 2. 2 87 1 M ar rie d or li vi ng to ge th er 2. 9 3. 1 5, 52 5 3. 8 4. 1 4, 18 5 2. 8 15 9 7. 2 17 2 2. 2 5, 08 7 D iv or ce d/ se pa ra te d/ w id ow ed 2. 8 37 .7 45 0 5. 5 72 .5 23 4 * 13 3. 1 16 9 2. 9 39 8 R es id en ce U rb an 4. 4 26 .9 2, 65 5 6. 1 36 .9 1, 93 4 9. 2 11 7 8. 5 71 4 2. 5 2, 19 5 Ru ra l 2. 9 7. 9 4, 71 9 4. 3 11 .4 3, 26 2 4. 7 13 9 5. 3 37 3 2. 1 4, 16 0 R eg io n Ea st er n 4. 4 13 .8 1, 32 5 5. 9 18 .3 99 1 7. 6 59 7. 1 18 3 2. 4 1, 19 2 N or th er n 1. 7 9. 0 3, 00 1 2. 6 13 .8 1, 95 3 (1 0. 6) 51 5. 5 27 0 1. 9 2, 67 2 So ut he rn 6. 3 14 .1 1, 54 2 8. 6 19 .2 1, 13 4 3. 0 98 7. 3 21 7 2. 4 1, 27 8 W es te rn 3. 2 27 .8 1, 50 6 4. 4 37 .4 1, 11 9 9. 3 49 8. 9 41 8 2. 6 1, 21 3 E du ca tio n N o ed uc at io n 2. 8 6. 7 4, 86 0 3. 9 9. 4 3, 45 8 4. 4 13 5 3. 3 32 3 2. 2 4, 38 4 Pr im ar y 4. 3 18 .8 96 0 6. 5 28 .9 62 6 2. 5 41 6. 3 18 1 2. 3 76 6 Se co nd ar y or h ig he r 5. 2 37 .6 1, 55 4 7. 2 52 .4 1, 11 3 13 .0 80 10 .1 58 4 2. 4 1, 20 6 W ea lth q ui nt ile Lo w es t 2. 3 6. 2 1, 38 2 3. 4 9. 0 94 7 0. 0 32 2. 2 86 2. 1 1, 17 9 Se co nd 2. 5 7. 4 1, 36 8 3. 7 10 .9 92 9 2. 7 35 4. 0 10 1 2. 0 1, 22 4 M id dl e 3. 8 10 .1 1, 42 8 5. 5 14 .6 99 2 5. 2 55 4. 3 14 5 2. 1 1, 27 9 Fo ur th 4. 5 17 .7 1, 47 2 6. 4 25 .1 1, 03 9 11 .9 67 7. 5 26 1 2. 4 1, 28 7 H ig he st 4. 0 28 .7 1, 72 3 5. 3 38 .4 1, 29 0 8. 2 68 9. 9 49 5 2. 4 1, 38 7 T ot al 3. 5 14 .8 7, 37 4 4. 9 20 .9 5, 19 7 6. 8 25 6 7. 4 1, 08 8 2. 2 6, 35 6 N ot e: A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. F ig ur es in p ar en th es es a re b as ed o n 25 to 4 9 un w ei gh te d ca se s. 1 S ex ua l i nt er co ur se w ith a n on -m ar ita l, no n- co ha bi tin g pa rtn er HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 197 198 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Among women who had more than one partner in the 12 months before the survey, only 7 percent said they used a condom during the most recent sexual intercourse, far lower than the 15 percent reported by men. Among women who reported having had higher-risk intercourse in the past 12 months, only 7 percent used a condom at the last higher-risk sex (Table 13.8.1). For men, the comparable figure is again higher—22 percent, indicating that men are three times as likely to practice safe sex as women (Table 13.8.2). The lower levels of multiple partnership, higher-risk sexual intercourse, and condom use reported by women, compared with men, may be accurate or may be due to reluctance on the part of women to report behaviour that is not be generally accepted. Lack of condom negotiation skills among women may account for some aspects of the pattern. Among both women and men who had sexual intercourse in the 12 months preceding the survey, the prevalence of higher-risk sex generally decreases as age increases. By definition, higher- risk sex is most common among women and men who have never married and those who are currently divorced, separated, or widowed. This is because those who are not married but are sexually active are by definition having sex with someone who is not a marital partner. For this reason, almost all (96 percent) never-married women and about nine in ten (89 percent) never-married men had higher-risk sexual intercourse in the 12 months preceding the survey. One in four (25 percent) currently married men had higher-risk sexual intercourse. Respondents in urban areas and those in the Western Region are more likely than other respondents to have had higher-risk sexual intercourse in the past 12 months. Likewise, the prevalence of higher-risk sex generally increases with increasing level of education and wealth quintile. Condom use among respondents who had higher-risk sexual intercourse in the past 12 months is more likely among urban residents, those in age group 20-24, and those living in the Western Region. Among females, condom use with higher-risk sexual intercourse is higher among never- married women than those of another marital status. Condom use at last higher-risk sexual intercourse is higher among respondents with secondary or higher education and those in the highest wealth quintile. The differences in condom use are more pronounced among men than women. The 2008 SLDHS results indicate that while the proportion of young women engaging in higher-risk sexual intercourse has not changed (43 percent in both the 2008 SLDHS and the 2005 MICS), the proportion using condoms at last higher-risk sexual intercourse has declined from 20 percent in the 2005 MICS to 10 percent in the 2008 SLDHS (SSL and UNICEF, 2005). Women have an average of 2 partners in their lifetime. There are no significant variations in the number of lifetime partners by background characteristics. The mean number of lifetime sexual partners reported by men is 7, but this figure varies substantially across sub-groups. As expected, the number is larger for older men (3 for men age 15-19, compared with 10 for men age 40-49). Rural men have more partners than urban men (8 and 6 sexual partners, respectively). There are also notable differences by region, from 5 sexual partners in the Northern Region to 13 in the Southern Region. The mean number of lifetime sexual partners tends to decrease with increasing wealth quintile, i.e., men in the lower wealth quintiles have more partners (7-8 partners) than men in the highest wealth quintiles (5 partners). Based on these figures, one could suggest that Sierra Leonean women are more committed in their sexual relationships than their male counterparts; however, other factors may be involved such as the practice of polygynous marriage in Sierra Leone. H IV /A ID S- Re la te d Kn ow le dg e, A tt itu de s, a nd B eh av io ur | 1 99 T ab le 1 3. 8. 2 M ul tip le s ex ua l p ar tn er s an d hi gh er -r isk s ex ua l i nt er co ur se in th e pa st 1 2 m on th s: M en A m on g al l m en a ge 1 5- 49 , t he p er ce nt ag e w ho h ad s ex ua l i nt er co ur se w ith m or e th an o ne p ar tn er a nd th e pe rc en ta ge w ho h ad h ig he r- ris k se xu al in te rc ou rs e in th e pa st 1 2 m on th s; a m on g m en a ge 15 -4 9 w ho h ad s ex ua l i nt er co ur se in t he p as t 12 m on th s, t he p er ce nt ag e w ho h ad s ex ua l i nt er co ur se w ith m or e th an o ne p ar tn er a nd t he p er ce nt ag e w ho h ad h ig he r- ris k se xu al in te rc ou rs e; a m on g m en w ho h ad m or e th an o ne p ar tn er in th e pa st 1 2 m on th s, th e pe rc en ta ge w ho u se d a co nd om a t l as t s ex ua l i nt er co ur se ; a m on g m en w ho h ad h ig he r- ris k se xu al in te rc ou rs e in th e pa st 1 2 m on th s, th e pe rc en ta ge w ho u se d a co nd om a t la st s ex ua l i nt er co ur se w ith t ha t pa rtn er ; an d am on g m en w ho e ve r ha d se xu al i nt er co ur se , th e m ea n nu m be r of s ex ua l p ar tn er s du rin g lif et im e, b y ba ck gr ou nd ch ar ac te ris tic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Al l m en (p as t 1 2 m on th s) M en w ho h ad se xu al in te rc ou rs e (p as t 1 2 m on th s) M en w ho h ad 2+ p ar tn er s (p as t 1 2 m on th s) M en w ho h ad h ig he r- ris k se xu al in te rc ou rs e1 (p as t 1 2 m on th s) M en w ho e ve r h ad se xu al in te rc ou rs e Pe rc en ta ge w ho h ad 2+ p ar tn er s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 N um be r o f m en Pe rc en ta ge w ho h ad 2+ p ar tn er s Pe rc en ta ge w ho h ad hi gh er -r isk se xu al in te rc ou rs e1 N um be r o f m en Pe rc en ta ge w ho u se d a co nd om a t l as t se xu al in te rc ou rs e N um be r o f m en Pe rc en ta ge w ho us ed a c on do m at la st s ex ua l in te rc ou rs e w ith th at p ar tn er N um be r o f m en M ea n nu m be r o f se xu al pa rtn er s in lif et im e N um be r o f m en A ge 15 -2 4 10 .1 43 .4 92 9 18 .9 81 .8 49 3 29 .2 93 22 .4 40 3 3. 7 45 6 15 -1 9 4. 4 32 .4 52 6 12 .0 89 .0 19 2 (1 3. 6) 23 15 .1 17 1 2. 6 19 9 20 -2 4 17 .5 57 .8 40 3 23 .4 77 .2 30 1 34 .3 70 27 .7 23 3 4. 5 25 7 25 -2 9 18 .3 44 .5 44 6 22 .1 53 .5 37 1 21 .6 82 23 .5 19 8 6. 5 23 9 30 -3 9 18 .8 28 .2 89 9 21 .5 32 .3 78 6 10 .1 16 9 21 .1 25 4 8. 8 52 1 40 -4 9 17 .5 20 .8 67 1 20 .5 24 .5 57 0 7. 0 11 7 20 .8 14 0 9. 7 33 8 M ar ita l s ta tu s N ev er m ar rie d 10 .5 50 .2 1, 08 5 18 .7 89 .1 61 2 32 .8 11 4 23 .6 54 5 4. 2 51 7 M ar rie d or li vi ng to ge th er 18 .9 21 .9 1, 76 7 21 .8 25 .3 1, 53 0 9. 0 33 4 19 .7 38 7 8. 4 98 4 D iv or ce d/ se pa ra te d/ w id ow ed 13 .9 67 .7 92 16 .4 79 .6 79 * 13 23 .2 63 12 .2 53 R es id en ce U rb an 16 .0 43 .2 1, 12 3 21 .3 57 .5 84 4 27 .8 18 0 34 .4 48 6 6. 2 54 0 Ru ra l 15 .4 28 .0 1, 82 2 20 .4 37 .0 1, 37 7 7. 2 28 1 10 .3 51 0 7. 6 1, 01 4 R eg io n Ea st er n 21 .3 33 .9 55 7 27 .7 44 .2 42 7 7. 4 11 8 13 .5 18 9 6. 6 37 3 N or th er n 11 .3 25 .6 1, 13 1 15 .9 35 .9 80 8 7. 5 12 8 11 .8 29 0 5. 0 53 9 So ut he rn 15 .0 35 .5 61 7 19 .2 45 .6 48 1 14 .8 92 18 .1 21 9 12 .5 34 8 W es te rn 19 .1 46 .4 63 9 24 .1 58 .8 50 5 31 .3 12 2 40 .5 29 7 5. 5 29 4 E du ca tio n N o ed uc at io n 15 .2 26 .4 1, 42 6 19 .1 33 .0 1, 13 8 7. 4 21 7 9. 8 37 6 7. 2 79 3 Pr im ar y 14 .7 31 .6 41 4 22 .7 48 .9 26 7 10 .8 61 15 .7 13 1 7. 6 19 8 Se co nd ar y or h ig he r 16 .6 44 .2 1, 10 4 22 .5 59 .9 81 5 25 .9 18 4 33 .2 48 8 6. 8 56 3 W ea lth q ui nt ile Lo w es t 12 .4 25 .7 55 8 16 .4 33 .9 42 2 1. 2 69 3. 5 14 3 7. 1 33 0 Se co nd 15 .7 26 .2 52 0 20 .7 34 .7 39 4 4. 9 81 12 .7 13 7 7. 9 29 9 M id dl e 16 .8 29 .5 53 0 21 .9 38 .5 40 5 12 .0 89 14 .1 15 6 8. 3 29 9 Fo ur th 15 .3 35 .3 59 7 20 .5 47 .2 44 6 12 .8 91 20 .2 21 1 7. 2 27 8 H ig he st 17 .6 47 .2 73 9 23 .5 63 .0 55 3 33 .1 13 0 38 .0 34 8 5. 4 34 8 T ot al 1 5- 49 15 .7 33 .8 2, 94 4 20 .8 44 .8 2, 22 1 15 .2 46 1 22 .1 99 5 7. 1 1, 55 4 5 0- 59 21 .4 12 .0 33 6 25 .5 14 .3 28 1 4. 6 72 6. 6 40 9. 5 16 3 T ot al 1 5- 59 16 .2 31 .6 3, 28 0 21 .3 41 .4 2, 50 2 13 .8 53 3 21 .5 1, 03 5 7. 4 1, 71 7 N ot e: A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. F ig ur es in p ar en th es es a re b as ed o n 25 to 4 9 un w ei gh te d ca se s. 1 S ex ua l i nt er co ur se w ith a n on -m ar ita l, no n- co ha bi tin g pa rtn er HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 199 200 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour 13.6.2 Transactional Sex Transactional sex involves the exchange of sex for money, favours, or gifts. Transactional sex is associated with high risk of contracting HIV and other sexually transmitted infections because of compromised power relations and the tendency towards multiple partnerships as a result. In the 2008 SLDHS, men who had had sexual intercourse in the past 12 months were asked if they had paid anyone for sex during this period. The results in Table 13.9 indicate that only 2 percent of men paid for sex in the 12 months preceding the survey. Data show that younger men age 15-19 are the less likely to pay for sex than older men. Divorced, widowed, and separated men are somewhat more likely to pay for sex than never-married men or those currently married or living with a woman. Looking at regions, men in the Southern Region are more likely to pay for sex (5 percent) than men in other regions (1-2 percent). Table 13.9 Payment for sexual intercourse: Men Percentage of men age 15-49 reporting payment for sexual intercourse in the past 12 months, by background characteristics, Sierra Leone 2008 Background characteristic Payment for sexual intercourse in the past 12 months Percentage who paid for sexual intercourse Number of men Age 15-24 1.5 929 15-19 0.7 526 20-24 2.5 403 25-29 3.8 446 30-39 2.4 899 40-49 1.2 671 Marital status Never married 2.3 1,085 Married or living together 1.8 1,767 Divorced/separated/ widowed 4.4 92 Residence Urban 1.9 1,123 Rural 2.2 1,822 Region Eastern 0.6 557 Northern 1.6 1,131 Southern 4.7 617 Western 1.5 639 Education No education 1.9 1,426 Primary 2.0 414 Secondary or higher 2.3 1,104 Wealth quintile Lowest 1.1 558 Second 2.2 520 Middle 3.7 530 Fourth 1.5 597 Highest 1.8 739 Total 15-49 2.0 2,944 50-59 0.8 336 Total 15-59 1.9 3,280 13.7 COVERAGE OF HIV COUNSELLING AND TESTING Knowledge of their HIV status helps people who are HIV negative make decisions that will reduce risk and increase the use of safe sex practices to remain disease free. For those who are HIV positive, knowledge of their status allows them to take action to protect their sexual partners, to access HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 201 treatment, and to plan for the future. In the 2008 SLDHS, respondents were asked whether they had ever been tested for HIV. If they said that they had been tested, respondents were asked when they were most recently tested, whether they had received the results of their last test, and where they had been tested. If they had never been tested, they were asked if they knew a place where they could go to be tested. Tables 13.10.1 and 13.10.2 present the results of these questions for women and men, respectively. Tables 13.10.1 and 13.10.2 show that only 27 percent of women and 33 percent of men know where to get an HIV test. Even fewer have ever been tested; 13 percent of women and 8 percent of men age 15-49 have ever had an HIV test and, in the past 12 months, only 4 percent of women and 3 percent of men have been tested and received their test results. Table 13.10.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Sierra Leone 2008 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and whether they received the results of the last HIV test Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of women Ever tested, received results Ever tested, did not receive results Never tested1 Age 15-24 29.7 9.0 3.3 87.6 100.0 12.4 4.4 2,384 15-19 25.5 5.6 1.8 92.6 100.0 7.4 3.3 1,198 20-24 34.0 12.5 4.9 82.7 100.0 17.3 5.6 1,186 25-29 28.0 10.8 4.2 85.0 100.0 15.0 4.7 1,643 30-39 27.8 10.8 3.2 86.0 100.0 14.0 4.4 2,175 40-49 20.5 5.8 1.9 92.3 100.0 7.7 2.2 1,172 Marital status Never married 40.3 12.9 1.9 85.2 100.0 14.8 6.3 1,399 Ever had sex 48.7 18.0 2.9 79.2 100.0 20.8 8.5 924 Never had sex 24.0 3.0 0.0 97.0 100.0 3.0 1.9 475 Married/living together 23.7 8.7 3.5 87.8 100.0 12.2 3.7 5,525 Divorced/separated/ widowed 31.2 8.1 4.9 87.0 100.0 13.0 2.2 450 Residence Urban 46.0 18.8 3.8 77.4 100.0 22.6 8.2 2,655 Rural 16.8 4.2 3.0 92.9 100.0 7.1 1.8 4,719 Region Eastern 21.5 5.6 2.8 91.6 100.0 8.4 2.5 1,325 Northern 17.2 4.1 2.8 93.1 100.0 6.9 1.5 3,001 Southern 26.5 7.6 3.2 89.2 100.0 10.8 4.2 1,542 Western 53.5 25.5 4.6 70.0 100.0 30.0 10.6 1,506 Education No education 16.8 4.7 2.8 92.5 100.0 7.5 1.9 4,860 Primary 32.0 10.2 5.2 84.7 100.0 15.3 4.4 960 Secondary or higher 57.5 23.7 3.6 72.7 100.0 27.3 10.8 1,554 Wealth quintile Lowest 12.9 2.3 2.0 95.8 100.0 4.2 0.9 1,382 Second 16.3 5.3 2.2 92.5 100.0 7.5 2.5 1,368 Middle 18.4 3.8 3.7 92.5 100.0 7.5 1.8 1,428 Fourth 30.7 8.9 5.0 86.1 100.0 13.9 4.3 1,472 Highest 52.2 23.6 3.3 73.1 100.0 26.9 9.6 1,723 Total 27.3 9.4 3.3 87.3 100.0 12.7 4.1 7,374 1 Includes ‘don’t know/missing’ 202 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Knowledge about where to get an HIV test is much more common among women and men in urban areas than those in rural areas and it is highest among respondents living in the Western Region, which may reflect the urban bias in the distribution of HIV testing services in Sierra Leone. Knowledge of the various sites for HIV testing services is also higher among educated women and men and among those in the higher wealth quintiles. Table 13.10.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Sierra Leone 2008 Background characteristic Percentage who know where to get an HIV test Percent distribution of men by testing status and whether they received the results of the last HIV test Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of men Ever tested, received results Ever tested, did not receive results Never tested1 Age 15-24 31.4 3.2 0.9 95.9 100.0 4.1 1.2 929 15-19 26.2 1.4 0.5 98.1 100.0 1.9 0.4 526 20-24 38.3 5.6 1.4 93.0 100.0 7.0 2.2 403 25-29 33.5 7.7 1.5 90.9 100.0 9.1 4.0 446 30-39 32.3 9.1 1.8 89.1 100.0 10.9 4.8 899 40-49 34.4 9.0 1.2 89.7 100.0 10.3 4.5 671 Marital status Never married 32.7 4.3 1.2 94.5 100.0 5.5 1.6 1,085 Ever had sex 39.0 6.0 1.4 92.6 100.0 7.4 2.4 702 Never had sex 21.1 1.3 0.8 97.8 100.0 2.2 0.2 383 Married/living together 32.1 8.7 1.5 89.8 100.0 10.2 4.6 1,767 Divorced/separated/ widowed 45.2 6.4 0.0 93.6 100.0 6.4 2.4 92 Residence Urban 54.9 13.2 1.6 85.2 100.0 14.8 6.5 1,123 Rural 19.0 3.2 1.1 95.6 100.0 4.4 1.6 1,822 Region Eastern 26.2 3.5 1.7 94.9 100.0 5.1 1.3 557 Northern 21.7 3.8 1.2 95.0 100.0 5.0 2.3 1,131 Southern 28.2 5.3 1.2 93.5 100.0 6.5 3.3 617 Western 62.2 17.5 1.3 81.2 100.0 18.8 7.5 639 Education No education 14.4 1.9 0.5 97.6 100.0 2.4 1.4 1,426 Primary 26.5 3.6 2.9 93.5 100.0 6.5 1.7 414 Secondary or higher 58.7 14.9 1.8 83.3 100.0 16.7 6.7 1,104 Wealth quintile Lowest 12.4 1.2 0.6 98.2 100.0 1.8 0.6 558 Second 17.9 2.6 1.5 95.8 100.0 4.2 2.2 520 Middle 22.8 4.5 1.0 94.5 100.0 5.5 2.2 530 Fourth 36.8 6.1 2.0 91.9 100.0 8.1 2.8 597 Highest 62.2 17.0 1.4 81.6 100.0 18.4 7.9 739 Total 15-49 32.7 7.0 1.3 91.7 100.0 8.3 3.4 2,944 50-59 27.5 3.4 1.0 95.6 100.0 4.4 1.9 336 Total 15-59 32.2 6.7 1.3 92.1 100.0 7.9 3.3 3,280 1 Includes ‘don’t know/missing’ HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 203 13.7.1 HIV Testing during Antenatal Care One of the tragic consequences of HIV infection in women is the transmission of the virus to their children. This can occur during pregnancy, at the time of delivery, or through breastfeeding. Worldwide, the effects of mother-to-child transmission (MTCT) of HIV are staggering. As part of the strategy for the prevention of mother-to-child transmission of HIV, all women should be counselled about HIV/AIDS during antenatal care and offered an HIV test. In the 2008 SLDHS, women age 15- 49 who gave birth in the two years preceding the survey were asked whether they received counselling during antenatal care for their most recent birth, whether they were offered and accepted a test for the AIDS virus as part of their antenatal care, and if tested, whether they received the test results. Table 13.11 shows that among women who gave birth in the two years preceding the survey, 23 percent received HIV counselling during antenatal care for their most recent birth, and about one in ten of these women (10 percent) were offered and accepted an HIV test and received the results of the test. Overall, only 8 percent of women who gave birth in the two years preceding the survey were counselled about HIV, were offered and voluntarily accepted an HIV test, and received the test results. Women age 20-24, those living in urban areas, women in the Western Region, and those with secondary or higher education, are more likely than other women to have received all three services. Table 13.11 Pregnant women counselled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received HIV counselling during antenatal care for their most recent birth, and percentage who accepted an offer of HIV testing by whether they received their test results, according to background characteristics, Sierra Leone 2008 Background characteristic Percentage who received HIV counselling during antenatal care Percentage who were offered and accepted an HIV test during antenatal care and who2: Percentage who were counselled about HIV, were offered and accepted an HIV test, and who received results2 Number of women who gave birth in the past two years3 Received results Did not receive results Age 15-24 25.9 12.9 3.1 10.6 759 15-19 22.9 10.3 3.0 7.6 260 20-24 27.5 14.2 3.1 12.2 498 25-29 20.3 10.6 2.9 7.9 759 30-39 22.8 8.7 4.3 7.2 801 40-49 16.4 5.7 3.1 3.3 160 Residence Urban 40.8 26.8 5.0 20.7 681 Rural 15.7 4.1 2.8 3.5 1,797 Region Eastern 15.1 4.8 2.8 4.0 500 Northern 14.6 4.7 2.7 4.3 1,114 Southern 27.0 6.3 4.0 5.2 507 Western 51.5 41.4 5.7 30.7 357 Education No education 16.1 4.9 2.9 4.2 1,819 Primary 31.2 13.5 5.4 10.9 339 Secondary or higher 50.2 37.9 4.3 28.3 319 Total 15-49 22.6 10.4 3.4 8.2 2,478 1 In this context, ‘counselled’ means that someone talked with the respondent about all three of the following topics: 1) babies getting the AIDS virus from their mother, 2) preventing the virus, and 3) getting tested for the virus. 2. Only women who were offered the test are included here. Women who were either required or asked for the test are excluded from the numerator of this measure. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. 204 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour 13.8 MALE CIRCUMCISION Male circumcision is widely practiced in Sierra Leone and often serves as a rite of passage to adulthood. Recently, male circumcision has been shown to be associated with lower transmission of STIs, including HIV (WHO and UNAIDS, 2007). To examine this relationship, men interviewed in the 2008 SLDHS were asked if they were circumcised. Table 13.12 shows that male circumcision is indeed widespread in Sierra Leone, with almost all men being circumcised (96 percent). This is seen for all ages, residential groups, and levels of education. 13.9 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS Sexually transmitted infections are closely associ- ated with HIV because they increase the likelihood of contracting HIV and share similar risk factors. In the 2008 SLDHS, all respondents who ever had sex were asked if they had had a sexually transmitted infection (STI) or symptoms of an STI (including bad-smelling/ abnormal genital discharge and genital sore or ulcer) in the 12 months preceding the survey. Table 13.13 shows the self-reported prevalence of STIs and STI symptoms among women and men who have ever had sex. The data indicate that 9 percent of women and 7 percent of men who have ever had sex reported having had an STI in the 12 months before the survey. A higher percentage of women (15 percent) than men (8 percent) reported having had an abnormal genital discharge. Furthermore, 12 percent of women and 4 percent of men reported having had a genital sore or ulcer in the 12 months before the survey. Overall, 19 percent of women and 11 percent of men age 15-49 have either had an STI or symptoms of an STI in the 12 months preceding the survey. According to Table 13.13, respondents under age 30 are more likely to report having had an STI or symptoms of an STI than those who are age 30 and older. Currently married men and women are less likely than those who have never married or are divorced, separated, or widowed, to report having had an STI or symptoms of an STI in the past 12 months. Urban respondents are more affected by STIs than their rural counterparts, the difference being more pronounced among women (25 percent of urban women, compared with 16 percent of rural women). Women and men in the Western Region (32 and 14 percent, respectively) are more likely to report STI symptoms than respondents in other regions. There is a positive association between the reported prevalence of an STI or symptoms of an STI and level of education. For example, 24 percent of women with secondary or higher education reported having had an STI or symptoms of an STI in the past 12 months, compared with 18 percent of women with no education. Table 13.13 also shows that among men, those who are not circumcised are somewhat more likely to report STI symptoms than those who are circumcised (15 and 11 percent, respectively). Table 13.12 Male circumcision Percentage of men age 15-49 who report having been circumcised, by background characteristics, Sierra Leone 2008 Background characteristic Percentage circumcised Number of men Age 15-24 95.8 929 15-19 95.2 526 20-24 96.7 403 25-29 95.4 446 30-39 97.4 899 40-49 94.6 671 Residence Urban 97.0 1,123 Rural 95.3 1,822 Region Eastern 97.9 557 Northern 94.4 1,131 Southern 95.6 617 Western 97.4 639 Education No education 95.2 1,426 Primary 96.9 414 Secondary or higher 96.6 1,104 Total 15-49 96.0 2,944 50-59 96.8 336 Total 15-59 96.1 3,280 HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 205 Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STIs symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage who reported having an STI or symptoms of an STI in the past 12 months, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of women who reported having in the past 12 months: Number of women who ever had sexual intercourse Percentage of men who reported having in the past 12 months: Number of men who ever had sexual intercourse STI Bad smelling/ abnormal genital discharge Genital sore/ ulcer STI/genital discharge/ sore or ulcer STI Bad smelling/ abnormal genital discharge Genital sore/ ulcer STI/genital discharge/ sore or ulcer Age 15-24 8.7 16.0 13.0 20.2 1,916 6.8 8.2 4.0 12.5 568 15-19 9.4 14.7 12.9 19.5 783 4.1 4.3 3.5 8.1 226 20-24 8.2 16.9 13.1 20.8 1,133 8.6 10.8 4.3 15.5 343 25-29 8.6 17.0 13.8 21.7 1,636 9.3 11.9 4.8 15.1 428 30-39 8.9 14.9 9.8 18.6 2,175 6.8 8.4 3.9 10.6 899 40-49 7.2 12.6 9.7 15.8 1,172 5.4 6.0 3.3 8.9 666 Marital status Never married 9.4 18.1 12.6 23.5 924 8.5 10.6 4.1 14.8 702 Married or living together 8.2 14.5 11.5 18.3 5,525 5.8 7.0 3.6 9.5 1,767 Divorced/separated/ widowed 9.6 19.4 11.3 22.8 450 15.7 16.7 7.5 20.9 92 Male circumcision Circumcised na na na na 0 6.9 8.3 3.8 11.3 2,455 Not circumcised na na na na 0 5.2 10.5 5.6 15.2 54 Residence Urban 9.8 20.3 12.8 25.0 2,383 7.6 8.8 3.9 12.7 959 Rural 7.8 12.7 11.0 16.3 4,515 6.5 8.0 3.9 10.6 1,602 Region Eastern 13.3 16.1 14.3 19.7 1,248 5.5 5.4 1.7 7.4 496 Northern 6.7 12.5 10.1 16.2 2,853 6.4 8.3 4.0 11.0 944 Southern 6.5 11.6 6.8 13.6 1,457 8.0 10.0 4.4 12.4 544 Western 10.0 24.5 17.6 31.8 1,341 7.7 9.2 5.3 14.4 578 Education No education 7.8 13.8 11.4 17.5 4,757 6.2 7.6 3.8 10.2 1,331 Primary 10.8 16.1 13.1 22.2 829 6.2 7.3 3.8 11.3 301 Secondary or higher 9.5 20.4 11.8 24.3 1,313 8.0 9.6 4.2 13.0 929 Total 15-49 8.5 15.3 11.6 19.3 6,899 6.9 8.3 3.9 11.4 2,561 50-59 na na na na 0 3.2 3.7 1.8 5.4 335 Total 15-59 na na na na 0 6.4 7.8 3.7 10.7 2,896 Note: Total includes 53 men with information missing on male circumcision na = Not applicable Figure 13.1 shows the proportion of women and men reporting an STI or symptoms of an STI who sought advice or treatment from various sources. Most women and men seek treatment from a health facility or health professional (41 percent of women and 54 percent of men). However, more than two in five women (43 percent) and about one in five men (19 percent) do not get any advice or treatment. 206 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Figure 13.1 Women and Men Age 15-49 Who Sought Advice or Treatment for STIs Sierra Leone, 2008 41 6 6 43 54 21 6 19 Clinic/hospital/ private doctor/ other health Advice or medicine from shop/pharmacy Advice or treatment from other source No advice or treatment 0 10 20 30 40 50 60 Percent Women Men professional 13.10 PREVALENCE OF MEDICAL INJECTIONS Injection overuse in a health care setting can contribute to the transmission of blood-borne pathogens because it amplifies the effect of unsafe practices such as reuse of injection equipment. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2008 SLDHS were asked if they had received an injection in the past 12 months, and if so, they were asked if their last injection was given with a syringe from a new, unopened package. It should be noted that medical injections can be self-administered (e.g., insulin for diabetes). These injections were not included in the calculation. Table 13.14 shows that 36 percent of women and 39 percent of men received a medical injection in the past 12 months. The average number of injections was 1.6 among women and 2.2 among men. The potential risk of transmission of HIV associated with such injections is very low because a large majority of respondents—96 percent of women and 93 percent of men—who received medical injections reported that the syringe and needle were taken from a new, unopened package. These figures are encouraging for Sierra Leoneans, especially for the Ministry of Health and Sanitation, because contaminated needles can be a medium for transmitting HIV. Both the likelihood of receiving an injection in the past 12 months and the likelihood that the injection was safe generally increase with level of education and wealth quintile. Injections are particularly common among urban residents and respondents in the Western and Southern Regions. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 207 Table 13.14 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Sierra Leone 2008 Background characteristic Women Men Percentage who received a medical injection in past 12 months Average number of medical injections per person in past 12 months Number of women For last injection, syringe and needle taken from new, unopened package Number of women receiving medical injections in past 12 months Percentage who received a medical injection in past 12 months Average number of medical injections per person in past 12 months Number of men For last injection, syringe and needle taken from new, unopened package Number of men receiving medical injections in past 12 months Age 15-24 35.6 1.5 2,384 96.3 849 31.9 1.5 929 90.7 296 15-19 31.8 1.1 1,198 95.7 381 28.2 1.2 526 86.4 148 20-24 39.5 1.8 1,186 96.7 468 36.7 1.8 403 94.9 148 25-29 36.9 1.5 1,643 96.3 606 35.9 1.5 446 93.2 160 30-39 36.7 1.8 2,175 94.2 799 42.5 2.7 899 93.7 382 40-49 33.7 1.8 1,172 97.4 395 44.2 2.8 671 94.8 297 Residence Urban 42.8 2.1 2,655 97.9 1,137 49.3 2.9 1,123 93.8 553 Rural 32.0 1.3 4,719 94.2 1,512 31.9 1.7 1,822 92.5 582 Region Eastern 39.9 1.8 1,325 93.1 528 50.2 2.7 557 91.5 279 Northern 29.7 1.2 3,001 94.3 890 29.2 1.7 1,131 85.8 331 Southern 35.0 1.5 1,542 95.9 539 28.2 1.5 617 98.7 174 Western 45.9 2.5 1,506 99.8 691 54.9 3.2 639 98.6 351 Education No education 31.6 1.4 4,860 94.4 1,536 32.7 1.7 1,426 93.1 466 Primary 40.3 2.0 960 97.2 387 36.1 2.1 414 94.3 149 Secondary or higher 46.7 2.2 1,554 98.0 726 47.1 2.7 1,104 92.8 520 Wealth quintile Lowest 28.5 1.1 1,382 92.3 394 27.4 1.4 558 90.8 153 Second 32.4 1.5 1,368 94.5 443 34.1 1.9 520 92.1 178 Middle 31.8 1.3 1,428 94.6 455 34.4 1.5 530 93.5 183 Fourth 37.7 1.7 1,472 95.9 555 37.5 2.5 597 92.6 224 Highest 46.5 2.3 1,723 98.9 801 53.9 3.1 739 94.7 398 Total 15-49 35.9 1.6 7,374 95.8 2,649 38.5 2.2 2,944 93.1 1,135 Total 15-59 na na 0 na 0 38.6 2.2 3,280 92.6 1,267 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist or other health worker. na = Not applicable Respondents who had had an injection in the past 12 months were asked where they obtained their last injection. The information is summarized in Figure 13.2. Nearly two-thirds of women (65 percent) and more than half of men age 15-49 (53 percent) received their last medical injection from a public sector facility. Furthermore, about one in five women (22 percent) and two in five men (41 percent) received their last injection from a private medical facility. 208 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Figure 13.2 Facility Where Last Medical Injection Was Received Sierra Leone, 2008 65 21 44 0 22 10 0 5 7 1 11 1 53 23 30 0 41 15 0 15 10 1 5 0 TO TA L P UB LIC M ED IC AL Go vt. ho sp ita l Go vt. he alt h c en tre Ot he r p ub lic m ed ica l TO TA L P RIV AT E M ED IC AL Pri va te ho sp ita l, c lin ic Pr iva te de nta l c lin ic Ph arm ac y Pr iva te he alt h w ork er Ot he r p riv ate m ed ica l Ho me Ot he r lo ca tio n 0 10 20 30 40 50 60 70 Percent Women Men 13.11 HIV/AIDS-RELATED KNOWLEDGE AND SEXUAL BEHAVIOUR AMONG YOUTH This section addresses knowledge of HIV/AIDS issues and related sexual behaviour among youth age 15-24. Special attention is paid to this group because it accounts for half of all new HIV cases worldwide (Ross et al., 2006). In addition to knowledge of HIV transmission, data are presented on age at first sex, condom use, age differences between sexual partners, sex related to alcohol use, and voluntary counselling and testing for HIV. 13.11.1 HIV/AIDS-related Knowledge among Young Adults Young respondents were asked the same set of questions on beliefs about HIV transmission as other respondents. Information on the overall level of knowledge of the major ways to avoid HIV and rejection of the major misconceptions about the transmission of HIV are shown in Tables 13.2, 13.3.1, and 13.3.2. In general, the results indicate the level of awareness of prevention methods to combat AIDS. Table 13.15 shows the level of the composite indicator, ‘comprehensive knowledge,’ among young people by background characteristics. The results show that 17 percent of young women and 28 percent of young men have comprehensive knowledge of AIDS. Comprehensive knowledge is highest among never-married young women and men who have ever had sex (28 and 33 percent among women and men, respectively), young people who live in urban areas (28 percent among women and 40 percent among men), youth living in the Western Region (31 percent among women and 39 percent among men), those with secondary and higher education (35 percent among women and 41 percent among men), and youth in the highest wealth quintile (31 percent among women and 42 percent among men). HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 209 Table 13.15 Comprehensive knowledge about AIDS and knowledge of a source for condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source for condoms, by background characteristics, Sierra Leone 2008 Background characteristic Women age 15-24 Men age 15-24 Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of women Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of men Age 15-19 16.4 24.3 1,198 26.1 35.2 526 15-17 16.1 21.4 628 20.5 28.9 276 18-19 16.7 27.5 570 32.3 42.1 250 20-24 18.0 29.0 1,186 29.6 52.1 403 20-22 17.8 28.6 836 29.2 49.9 283 23-24 18.3 30.0 350 30.4 57.1 120 Marital status Never married 24.5 37.0 1,166 28.6 42.2 838 Ever had sex 27.6 48.9 698 33.2 58.0 477 Never had sex 19.7 19.2 468 22.4 21.3 360 Ever married 10.2 16.7 1,219 18.4 45.0 91 Residence Urban 27.6 40.0 1,061 39.5 63.2 470 Rural 8.8 15.9 1,323 15.3 21.2 458 Region Eastern 15.5 27.4 403 18.4 32.0 130 Northern 12.3 19.9 913 26.7 27.1 383 Southern 11.0 23.5 487 20.5 31.6 168 Western 31.2 39.3 581 38.5 79.1 248 Education No education 6.5 11.8 1,099 13.5 20.3 232 Primary 12.1 21.7 479 6.5 23.4 182 Secondary or higher 34.8 49.8 806 41.4 59.2 515 Wealth quintile Lowest 5.8 12.8 391 10.2 12.5 128 Second 8.4 13.5 360 16.9 19.4 131 Middle 11.1 21.7 416 22.3 27.1 144 Fourth 18.7 29.0 513 24.3 43.4 188 Highest 30.5 42.2 704 42.4 68.8 338 Total 15-24 17.2 26.6 2,384 27.6 42.5 929 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one HIV-negative, faithful partner can reduce the chances of getting the AIDS virus; knowing that a healthy-looking person can have the AIDS virus; and rejecting the two most common local misconceptions about AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 2 Friends, family members, and home are not considered sources for condoms. 13.11.2 Knowledge of Condom Sources among Young Adults Condom use plays an important role in preventing the transmission of STIs and HIV, as well as preventing unwanted pregnancies. Younger people are often at a higher risk of contracting STIs because they are more likely to be experimenting with sex before marriage. Knowledge of a source for condoms helps young adults to obtain and use them appropriately. As shown in Table 13.15, there is a large difference in knowledge of a source for condoms between men and women age 15-24; more men than women know at least one source for condoms (43 and 27 percent, respectively). Knowledge of a condom source generally increases with respondent’s age and is higher among never-married young women and men who have ever had sex. For both young men and women, knowledge of a condom source is higher among urban residents, those in the Western Region, those with higher levels of education, and those in the higher wealth quintiles, compared with their counterparts. 13.11.3 Trends in Age at First Sex Because HIV transmission in Sierra Leone occurs primarily through heterosexual intercourse, age at first intercourse marks the time at which most people become exposed to the risk of HIV. 210 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Table 13.16 shows the percentage of young women and men who had sexual intercourse by exact age 15 and 18, by background characteristics. More women than men have had sex by age 15 and 18. Twenty-five percent of young women and 11 percent of young men had their first sex before the age of 15. About seven in ten (69 percent) young women and half (48 percent) of young men had sex by age 18. Table 13.16 Age at first sexual intercourse among youth Percentage of young women and young men age 15-24 who had sexual intercourse before age 15, and percentage of young women and of young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Sierra Leone 2008 Background characteristic Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 22.3 1,198 na na 11.4 526 na na 15-17 22.7 628 na na 13.1 276 na na 18-19 22.0 570 74.6 570 9.6 250 53.3 250 20-24 26.8 1,186 66.8 1,186 10.5 403 44.8 403 20-22 26.9 836 68.0 836 12.3 283 46.6 283 23-24 26.5 350 63.9 350 6.3 120 40.4 120 Marital status Never married 12.9 1,166 52.2 642 10.6 838 46.2 562 Ever married 35.7 1,219 79.2 1,115 14.9 91 59.4 91 Knows condom source1 Yes 19.2 635 64.1 501 11.8 395 56.9 315 No 26.5 1,749 71.4 1,256 10.4 534 39.9 338 Residence Urban 16.5 1,061 60.8 753 10.5 470 50.7 345 Rural 31.0 1,323 75.8 1,003 11.6 458 45.1 308 Region Eastern 22.9 403 77.0 290 5.6 130 38.3 88 Northern 29.3 913 74.0 697 7.1 383 42.9 269 Southern 30.4 487 71.2 345 20.5 168 51.6 115 Western 13.4 581 54.9 424 13.5 248 58.2 181 Education No education 32.5 1,099 76.4 942 12.2 232 47.6 178 Primary 29.6 479 77.7 269 10.2 182 43.7 89 Secondary or higher 10.8 806 52.9 545 10.8 515 49.3 386 Wealth quintile Lowest 27.5 391 72.8 304 14.7 128 55.2 81 Second 30.6 360 76.1 271 11.9 131 34.9 88 Middle 35.1 416 77.9 312 10.6 144 48.9 103 Fourth 25.4 513 71.4 370 12.9 188 47.4 131 Highest 13.0 704 56.7 499 8.4 338 50.4 249 Total 24.6 2,384 69.3 1,756 11.0 929 48.1 653 na = Not applicable 1 Friends, family members, and home are not considered sources for condoms. Variations by background characteristics are greater among women than men. Ever-married young women and men are substantially more likely to initiate sexual activity by age 15 or by age 18 than those who have never married. Urban women are less likely to have sex by age 15 (17 percent) or by age 18 (61 percent) than their rural counterparts (31 and 76 percent, respectively). The opposite is seen for young men; by age 18, urban young men are more likely to have had sex than rural men; however, there is almost no urban-rural differential by age 15. Across regions, young women and men in the Southern Region are the most likely to have had first sex by age 15 (30 and 21 percent, respectively). Young women living in the Western Region and young men in the Eastern Region are the least likely to have sex by age 15 or by age 18. For young women, higher educational attainment is associated with a lower likelihood of initiating sex at early ages. For example, whereas 33 percent of women age 15-24 with no education HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 211 had sex by age 15, only 11 percent of women with secondary or higher education had sex by the same age. The proportion of young women initiating sex by age 15 and 18 is lowest among women in the highest wealth quintile. The differentials by level of education and wealth quintile for young men are less clear. 13.11.4 Condom Use at First Sex Consistent condom use is advocated by HIV control programmes to reduce the risk of sexual transmission of HIV among sexually active young adults. Young adults who use condoms at first sex are more likely to sustain condom use later in life. Condom use at first sex serves as an indicator of reduced risk of exposure at the beginning of sexual activity. Table 13.17 shows that condom use at first sex is rare in Sierra Leone. Among young adults age 15-24 who have ever had sexual intercourse, only 3 percent of young women and 7 percent of young men used a condom the first time they had sex. Never-married women and men are more likely to use a condom at first sex than those who have been married. Condom use at first sex is also higher among respondents who know where to obtain a condom; the difference in condom use at first sex by knowledge of a condom source is larger for men than women. Young adults who live in urban areas, in the Western Region, those with secondary or higher education, and young people in the highest wealth quintiles are more likely to use a condom at first sex than other groups. Table 13.17 Condom use at first sexual intercourse among youth Among young women and young men age 15-24 who have ever had sexual intercourse, percentage who used a condom the first time they had sexual intercourse, by background characteristics, Sierra Leone 2008 Background characteristic Women age 15-24 Men age 15-24 Percentage who used a condom at first sexual intercourse Number of women who have ever had sexual intercourse Percentage who used a condom at first sexual intercourse Number of men who have ever had sexual intercourse Age 15-19 3.4 783 7.2 226 15-17 4.0 297 7.2 74 18-19 3.0 486 7.2 152 20-24 2.6 1,133 7.3 343 20-22 3.1 788 7.1 230 23-24 1.4 345 7.8 113 Marital status Never married 4.8 698 8.1 477 Ever married 1.8 1,219 3.0 91 Knows condom source1 Yes 4.9 545 12.1 318 No 2.1 1,372 1.1 251 Residence Urban 4.5 793 10.6 315 Rural 1.8 1,124 3.1 253 Region Eastern 3.4 327 0.2 71 Northern 2.4 767 3.7 206 Southern 1.6 403 4.6 100 Western 4.8 419 15.2 191 Education No education 0.7 1,000 0.0 152 Primary 3.5 348 3.3 72 Secondary or higher 6.5 568 11.3 344 Wealth quintile Lowest 1.9 332 0.0 76 Second 1.2 307 6.9 73 Middle 2.3 353 2.4 79 Fourth 3.8 424 1.4 109 Highest 4.4 500 14.2 232 Total 15-24 2.9 1,916 7.3 568 1 Friends, family members, and home are not considered sources for condoms. 212 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour 13.11.5 Abstinence and Premarital Sex The period between age at first sex and age at marriage is often a time of sexual experimentation. Premarital sex and the interval between sexual initiation and marriage are among the factors contributing to the spread of HIV. Table 13.18 shows, for never-married women and men age 15-24, the percentage who have never had sex, the percentage who had sex in the past 12 months, and among those who had sexual intercourse in the past 12 months, the percentage who used a condom at last sexual intercourse. Never-married young adults age 15-24 show a relatively high level of abstinence: 40 percent of women and 43 percent of men have never had sexual intercourse. Half of all never-married women and men age 15-24 had sexual intercourse in the 12 months preceding the survey. Only 9 percent of never-married women reported using a condom at last sexual intercourse in the past 12 months, compared with 20 percent of young men. Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Sierra Leone 2008 Background characteristic Never-married women age 15-24 Never-married men age 15-24 Percentage who have never had sexual intercourse Percentage who had sexual intercourse in past 12 months Number of never- married women Among women who had sexual intercourse in the past 12 months: Percentage who have never had sexual intercourse Percentage who had sexual intercourse in past 12 months Number of never- married men Among men who had sexual intercourse in the past 12 months: Percentage who used condom at last sexual intercourse Number of women Percentage who used condom at last sexual intercourse Number of men Age 15-19 50.1 42.6 827 7.7 352 57.6 35.9 521 13.1 187 15-17 63.1 32.3 524 5.0 169 73.1 22.3 276 10.5 61 18-19 27.6 60.4 303 10.3 183 40.2 51.2 245 14.3 126 20-24 15.8 72.2 338 11.2 244 19.0 72.4 317 24.9 229 20-22 18.0 70.2 269 13.1 189 22.7 67.5 232 24.8 157 23-24 7.4 80.1 69 4.8 56 8.7 85.9 85 24.9 73 Knows condom source1 Yes 20.9 72.1 431 13.7 311 21.7 69.2 354 32.7 245 No 51.4 38.9 735 4.2 286 58.6 35.5 484 0.9 172 Residence Urban 36.7 56.3 731 10.9 412 35.3 57.1 439 29.8 250 Rural 45.9 42.6 435 5.4 185 51.5 41.6 399 4.1 166 Region Eastern 37.7 52.5 203 7.2 107 49.5 44.3 118 8.8 52 Northern 40.7 49.9 357 4.0 178 51.3 42.3 345 7.0 146 Southern 40.8 46.3 207 11.9 96 45.3 50.6 149 13.5 75 Western 40.6 54.2 399 13.2 216 25.4 63.2 226 39.6 143 Education No education 47.1 42.6 210 2.4 90 44.4 46.6 181 5.3 85 Primary 47.4 42.1 275 7.9 116 63.5 33.5 173 5.4 58 Secondary or higher 35.0 57.5 680 11.1 391 35.2 56.6 484 27.0 274 Wealth quintile Lowest 55.6 34.6 107 (2.4) 37 48.7 43.7 108 (0.0) 47 Second 43.7 44.5 120 (3.7) 53 50.7 42.6 115 (2.0) 49 Middle 42.3 46.9 150 4.7 70 51.2 40.4 127 5.5 51 Fourth 33.8 52.8 261 9.1 138 47.3 48.1 166 18.1 80 Highest 38.7 56.5 528 12.1 298 33.0 58.6 323 33.3 189 Total 40.1 51.2 1,166 9.2 597 43.0 49.7 838 19.6 416 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 1 Friends, family members, and home are not considered sources for condoms. Condom use at last sexual intercourse increases with age, especially among men. It is also higher among respondents who know where to obtain a condom; the differential in condom use at last sex by knowledge of a condom source is also larger for men than women. It is notable that never- married youth in urban areas are more likely to have used a condom at last sexual intercourse than youth in rural areas. The percentage of young adults who used condoms at last sexual intercourse is highest in the Western Region and lowest in the Northern Region. Furthermore, youth report greater use of condoms if they have secondary or higher education or live in households in the highest wealth quintile. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 213 13.11.6 Higher-risk Sex and Condom Use among Young Adults In Sierra Leone, HIV is most commonly transmitted through unprotected sex with a person who is HIV positive. To prevent the transmission of HIV among young people, the use of safe sex practices is important. The safe sex methods most commonly advocated for preventing HIV transmission are the ABC methods (abstinence, being faithful to one HIV-negative partner, and condom use). Tables 13.19.1 and 13.19.2 show the proportion of young women and men age 15-24 who had higher-risk sexual intercourse2 in the 12 months preceding the survey, and among those who had higher-risk sexual intercourse, the proportion who used a condom at last higher-risk sex. The data show that higher-risk sex is more common among young men (82 percent) than among young women (43 percent). Further, condom use at last higher-risk sexual intercourse was reported by 22 percent of young men, compared with 10 percent of young women. Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Women Among young women age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse, and among those who had higher-risk sexual intercourse in the past 12 months, the percentage who used a condom at last higher-risk sexual intercourse, by background characteristics, Sierra Leone 2008 Background characteristic Women age 15-24 who had sexual intercourse in past 12 months Women age 15-24 who had higher-risk sexual intercourse in past 12 months Percentage who had higher-risk sexual intercourse1 Number of women Percentage who used a condom at last higher- risk sexual intercourse1 Number of women Age 15-19 56.1 631 7.6 354 15-17 67.7 251 5.0 169 18-19 48.4 380 10.0 184 20-24 32.7 856 12.0 280 20-22 35.2 603 13.4 212 23-24 26.7 253 7.7 67 Marital status Never married 96.1 597 9.5 573 Ever married 6.7 890 10.4 60 Knows condom source2 Yes 68.1 478 13.8 326 No 30.5 1,008 5.0 307 Residence Urban 64.0 675 10.9 432 Rural 24.8 812 6.6 201 Region Eastern 41.3 265 7.8 109 Northern 34.4 544 5.4 187 Southern 35.4 313 11.6 111 Western 62.0 365 12.9 226 Education No education 15.1 728 6.3 110 Primary 48.8 262 7.6 128 Secondary or higher 79.7 497 11.1 396 Wealth quintile Lowest 16.2 241 (2.2) 39 Second 23.8 230 3.6 55 Middle 33.1 245 6.1 81 Fourth 46.6 331 9.9 154 Highest 69.1 440 12.3 304 Total 15-24 42.6 1,486 9.6 633 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. 2 Sexual intercourse with a non-marital, non-cohabiting partner. 214 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Higher-risk sexual intercourse is more prevalent among younger respondents and those who never married. This is expected because older respondents are more likely to be married. Urban women age 15-24 are more likely to have higher-risk sexual intercourse than their rural counterparts (64 and 25 percent, respectively). The same pattern is seen among men, but the difference is less pronounced (89 percent among urban men and 73 percent among rural men). By region, women and men in the Western Region are most likely to have higher-risk sexual intercourse and most likely to use a condom at last higher-risk sex. For example, 90 percent of young men in the Western Region reported that they had had higher-risk sexual intercourse in the past 12 months, and 40 percent of men reported using a condom at last higher-risk sex. Condom use at last higher-risk sex is substantially lower among young respondents in other regions. For example, 85 percent of young men in the Eastern Region had higher-risk sex in the past year, but only 11 percent of these reported use of a condom at last higher-risk sex. Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Men Among young men age 15-24 who had sexual intercourse in the past 12 months, the percentage who had higher-risk sexual intercourse, and among those who had higher-risk sexual intercourse in the past 12 months, the percentage who reported that a condom was used at last higher-risk sexual intercourse, by background characteristics, Sierra Leone 2008 Background characteristic Men age 15-24 who had sexual intercourse in past 12 months Men age 15-24 who had higher-risk sexual intercourse in past 12 months Percentage who had higher-risk sexual intercourse1 Number of men Percentage who used a condom at last higher- risk sexual intercourse1 Number of men Age 15-19 89.0 192 15.1 171 15-17 87.0 61 12.1 53 18-19 89.9 130 16.5 117 20-24 77.2 301 27.7 233 20-22 75.5 198 26.0 150 23-24 80.4 103 30.8 83 Marital status Never married 90.2 416 22.4 375 Ever married 36.4 77 21.7 28 Knows condom source2 Yes 89.9 278 35.0 250 No 71.3 216 1.9 154 Residence Urban 88.5 276 32.0 244 Rural 73.3 217 7.8 159 Region Eastern 85.0 64 10.9 55 Northern 76.7 178 10.9 137 Southern 74.6 91 18.0 68 Western 90.2 160 39.7 144 Education No education 71.5 125 7.3 89 Primary 77.1 66 6.1 51 Secondary or higher 87.0 302 30.7 263 Wealth quintile Lowest 68.1 66 (0.0) 45 Second 82.6 62 (8.8) 51 Middle 65.8 68 (11.0) 45 Fourth 84.0 97 20.9 82 Highest 90.4 199 35.4 180 Total 15-24 81.8 493 22.4 403 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. The proportion of young people age 15-24 who reported higher-risk sexual intercourse in the 12 months preceding the survey increases with level of education and wealth quintile. However, condom use at the last higher-risk sexual intercourse is generally higher for these same groups. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 215 Figure 13.3 presents data on the extent of risky and safe sex practices among young people in Sierra Leone by broad age groups. Twenty percent of women and 39 percent of men age 15-24 have never had sex, and an additional 18 percent of women and 8 percent of men have had sex but not in the 12 months preceding the survey. Although 2 percent of women and 7 percent of men age 15-24 say they had sex with only one partner in the past 12 months and that they used a condom the last time, the largest proportion of young people fall in the category of those who say they had only one partner in the past year but did not use a condom the last time (56 percent of women and 36 percent of men). The proportion of young people who had multiple sexual partners in the past 12 months is not large (4 percent of women and 10 percent of men); however, the proportion who did not use a condom the last time they had sex far exceeds the proportion who did. Figure 13.3 Abstinence, Being Faithful, and Condom Use (ABC) among Young Women and Men Sierra Leone, 2008 15-19 20-24 15-24 15-19 20-24 15-24 0% 20% 40% 60% 80% 100% Percent Never had sexual intercourse 0 partners past year 1 partner & used condom 1 partner & no condom 2+ partner & used condom 2+ partners & no condom Women Men 13.11.7 Cross-generational Sexual Partners In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the spread of HIV and other STIs because if a younger, HIV-negative partner has sex with an older, HIV-positive partner, the virus can be transmitted to the younger, HIV-negative cohort. To examine age differences between sexual partners, women age 15-19 who had sexual intercourse with a higher-risk partner (non-marital, non-cohabiting partner) in the 12 months preceding the survey were asked the age of their partner. If the young woman did not know the exact age of the partner, she was asked if the partner was older or younger than herself and, if older, whether the partner was 10 or more years older. The results are shown in Table 13.20. Only 11 percent of women age 15-19 reported having higher-risk sexual intercourse with an older male partner. There are few meaningful differences by background characteristics because the small sample sizes hamper analysis. Nevertheless, it is interesting that there is little difference by urban-rural residence, and no strong pattern by wealth quintile. Age-mixing is lower among women age 18-19 (7 percent), those living in the Northern Region (6 percent), and among women with secondary or higher education (9 percent). 216 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Table 13.20 Age-mixing in sexual relationships among women age 15-19 Percentage of women age 15-19 who had higher-risk sexual intercourse in the past 12 months with men who were 10 or more years older than themselves, by background characteristics; and percentage of women age 15-24 who had higher-risk sexual intercourse in the past 12 months with men who were 10 or more years older than themselves, Sierra Leone 2008 Background characteristic Percentage of women who had higher-risk intercourse with a man 10+ years older1 Number of women who had higher-risk intercourse in the past 12 months1 Age 15-17 15.3 169 18-19 7.1 184 Marital status Never married 10.3 340 Ever married * 14 Knows condom source2 Yes 9.9 160 No 12.0 193 Residence Urban 10.6 222 Rural 11.8 131 Region Eastern 14.3 71 Northern 5.5 130 Southern 16.1 62 Western 12.9 91 Education No education 11.3 44 Primary 14.8 99 Secondary or higher 9.2 210 Wealth quintile Lowest * 24 Second (7.9) 33 Middle 14.2 64 Fourth 11.3 91 Highest 11.4 142 Total 15-19 11.0 354 Total 15-24 12.3 634 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 Friends, family members, and home are not considered sources for condoms. 13.11.8 Drunkenness during Sexual Intercourse among Young Adults Engaging in sex intercourse while under the influence of alcohol can impair judgment, compromise power relations, and increase risky sexual behaviour. Respondents age 15-24 who reported having sexual intercourse in the past 12 months were asked for each partner if they or their partner drank alcohol the last time they had sex and whether they or their partner were drunk. As shown in Table 13.21, very few young people (less than 1 percent) reported being drunk during their last sexual intercourse. Only 2 percent of young women and 1 percent of young men who had sexual intercourse in the past 12 months said they or their partner were drunk. There is little variation by background characteristics. HIV/AIDS-related Knowledge, Attitudes, and Behaviour | 217 Table 13.21 Drunkenness during sexual intercourse among youth Among all young women and young men age 15-24, the percentage who had sexual intercourse in the past 12 months while being drunk and percentage who had sexual intercourse in the past 12 months when drunk or with a partner who was drunk, by background characteristics, Sierra Leone 2008 Background characteristic Women age 15-24 Men age 15-24 Percentage who had sexual intercourse in past 12 months when drunk Percentage who had sexual intercourse in past 12 months when drunk or with a partner who was drunk Number of women Percentage who had sexual intercourse in past 12 months when drunk Percentage who had sexual intercourse in past 12 months when drunk or with a partner who was drunk Number of men Age 15-19 0.1 1.1 1,198 0.2 0.2 526 15-17 0.0 0.2 628 0.0 0.0 276 18-19 0.1 2.2 570 0.5 0.5 250 20-24 0.2 2.0 1,186 1.2 1.2 403 20-22 0.2 2.3 836 0.7 0.7 283 23-24 0.1 1.3 350 2.5 2.5 120 Marital status Never married 0.0 1.1 1,166 0.7 0.7 838 Ever married 0.2 2.0 1,219 0.1 0.1 91 Knows condom source1 Yes 0.1 2.2 635 0.7 0.7 395 No 0.1 1.3 1,749 0.6 0.6 534 Residence Urban 0.2 1.8 1,061 1.3 1.3 470 Rural 0.1 1.4 1,323 0.0 0.0 458 Region Eastern 0.5 1.8 403 0.9 0.9 130 Northern 0.0 1.3 913 0.5 0.5 383 Southern 0.1 1.8 487 1.2 1.2 168 Western 0.0 1.6 581 0.5 0.5 248 Education No education 0.2 1.9 1,099 0.9 0.9 232 Primary 0.0 1.2 479 0.0 0.0 182 Secondary or higher 0.0 1.3 806 0.8 0.8 515 Wealth quintile Lowest 0.3 1.6 391 0.0 0.0 128 Second 0.0 0.8 360 0.0 0.0 131 Middle 0.1 2.0 416 0.8 0.8 144 Fourth 0.0 2.2 513 1.1 1.1 188 Highest 0.1 1.1 704 0.9 0.9 338 Total 15-24 0.1 1.6 2,384 0.7 0.7 929 1 Friends, family members, and home are not considered sources for condoms. 13.11.9 Voluntary HIV Counselling and Testing among Young Adults A person’s knowledge of their own HIV status can provide motivation to practice safer sexual behaviour. People who learn that they are HIV negative may decide to take precautions so as not to become HIV positive, and those who learn that they are carrying the virus may be more likely to take precautions to avoid transmitting HIV to others. Table 13.22 shows that women age 15-24 are about three times as likely as young men to have been tested for HIV in the 12 months preceding the survey and to have received the results (6 and 2 percent, respectively). Recent HIV testing is more common among the never-married young people, those who say that they know of a place to get a condom, young people in urban areas, and those living in the Western Region. The prevalence of recent HIV testing increases with level of education and wealth quintile. 218 | HIV/AIDS-related Knowledge, Attitudes, and Behaviour Table 13.22 Recent HIV tests among youth Among young women and young men age 15-24 who had sexual intercourse in the 12 months preceding the survey, the percentage who were tested for HIV in the past 12 months and received the results, by background characteristics, Sierra Leone 2008 Background characteristic Women age 15-24 who had sexual intercourse in past 12 months Men age 15-24 who had sexual intercourse in past 12 months Percentage who were tested for HIV in past 12 months and received results Number of women Percentage who were tested for HIV in past 12 months and received results Number of men Age 15-19 4.4 631 0.7 192 15-17 3.5 251 0.0 61 18-19 5.0 380 1.0 130 20-24 7.0 856 2.9 301 20-22 6.6 603 3.1 198 23-24 7.7 253 2.6 103 Marital status Never married 7.6 597 2.3 416 Ever married 4.7 890 0.7 77 Knows condom source1 Yes 11.4 478 3.2 278 No 3.3 1,008 0.5 216 Residence Urban 9.9 675 3.4 276 Rural 2.5 812 0.3 217 Region Eastern 2.9 265 1.7 64 Northern 2.6 544 0.0 178 Southern 5.7 313 1.4 91 Western 13.1 365 4.9 160 Education No education 2.1 728 0.0 125 Primary 5.1 262 0.0 66 Secondary or higher 11.8 497 3.4 302 Wealth quintile Lowest 0.7 241 0.0 66 Second 5.4 230 1.1 62 Middle 4.7 245 0.0 68 Fourth 4.1 331 0.0 97 Highest 11.0 440 4.8 199 Total 15-24 5.9 1,486 2.1 493 1 Friends, family members, and home are not considered sources for condoms. HIV Prevalence and Associated Factors | 219 HIV PREVALENCE AND ASSOCIATED FACTORS 14 The first case of HIV/AIDS in Sierra Leone was diagnosed in 1987. Since then, nearly 6,000 individuals have tested positive for HIV, more than one-third developed AIDS, and over 500 have died (UNGASS, 2007). Consequently, the Government has made a strong political commitment to combat the HIV/AIDS epidemic. These efforts led to the establishment of the National HIV/AIDS Council (NAC) in 2002, with the Head of State as the Chairman. The council is comprised of public and private sector representatives in roughly equal numbers, as well as people living with HIV/AIDS (PLWHA). In 2002, the National AIDS Secretariat (NAS) was established by an act of Parliament within the Office of the President. The NAS mandate is to coordinate the multi-sectoral effort to reduce the spread of HIV and to mitigate the impact of the disease both on persons who are HIV positive and on those around them who are affected. Furthermore, a National HIV/AIDS Policy was adopted by the Cabinet and endorsed by the President in 2002. In 2005, a strategic plan of action for implementation of the National Policy was developed with support from the UN Thematic Group on HIV/AIDS. In Sierra Leone, national HIV prevalence estimates have been derived primarily from sentinel surveillance of pregnant women and from two national sero-prevalence surveys conducted in 2002 and 2005. In April 2002, the first national sero-prevalence survey conducted jointly by the Centres for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA) and Statistics Sierra Leone (SSL), reported a national HIV prevalence of 1 percent, 2 percent in Freetown and around 1 percent outside of Freetown. Subsequent to the CDC-funded survey, in April 2004 the first antenatal care sentinel surveillance based on eight sentinel sites was conducted by the Health Sector Response Group (ARG) within the National AIDS Secretariat (NAS). This survey reported a national HIV prevalence rate among pregnant women of 3 percent; the level among pregnant women in the capital, Freetown, was 4 percent. In 2005, a second national sero-prevalence survey was commissioned by the National AIDS Secretariat and conducted jointly by the Nimba Research Institute in Ghana and Statistics Sierra Leone. This survey reported a national HIV prevalence rate of about 2 percent, with similar rates of 2 percent for both women and men age 15-49. The second ANC sentinel surveillance, which was conducted in 2006, reported a national prevalence of 4 percent among pregnant women attending ANC services at 13 sentinel sites. While the ANC sentinel surveillance data are useful for monitoring trends in the epidemic, there are limitations to estimating HIV prevalence in the general adult population from data derived exclusively from pregnant women attending these selected antenatal clinics. The ANC data do not capture any information on HIV prevalence in men, in non-pregnant women, nor in women who do not attend a clinic for pregnancy care. Pregnant women are more at risk for contracting HIV than those who may be avoiding both HIV and pregnancy through the use of condoms, or women who are less sexually active, and are, therefore, less likely to become pregnant or to expose themselves to HIV. In addition, there are biases in surveillance of pregnant women because HIV reduces fertility, and a woman’s knowledge of her HIV status may influence fertility choices. To observe the overall trend in the HIV/AIDS prevalence rates in Sierra Leone since the 2002 and 2005 national sero-prevalence surveys were carried out, and to obtain more representative measures of HIV prevalence than were available from the 2006 ANC sentinel surveillance, an HIV testing component was included in the 2008 Sierra Leone Demographic and Health Survey (SLDHS). This represents the first time that HIV testing has been conducted within a nationally representative sample of the Sierra Leone population. Additionally, this is the first time that HIV results have been (anonymously) linked with broader behavioural, social, and demographic factors. Understanding the distribution of HIV in the population and analyzing the social, biological and behavioural factors 220 | HIV Prevalence and Associated Factors associated with HIV infection provide new insights and knowledge about the HIV epidemic in Sierra Leone that may lead to more precise targeting of messages and interventions. The HIV prevalence rates obtained by the SLDHS are comparable with the HIV rates from other countries that have conducted DHS surveys using the same standardized methodology. The 2008 SLDHS data can be used as baseline data to monitor survey-based HIV prevalence dynamics because HIV testing can be repeated in future DHS surveys in Sierra Leone, using the same standardized methodology and questionnaires that (anonymously) link HIV results with key behavioural and socio-economic factors. This chapter presents information on SLDHS coverage of HIV testing among women age 15- 49 and men age 15-59, the prevalence of HIV, and factors associated with the transmission of HIV in the population. The chapter first presents information on the coverage of testing by gender, urban- rural residence, region, socio-demographic factors, and behavioural indicators. Then HIV prevalence rates are presented by socio-demographic, behavioural, and other risk factors. 14.1 COVERAGE OF HIV TESTING 14.1.1 Coverage by Sex, Residence, and Region In the 2008 SLDHS, all women age 15-49 and men age 15-59 (who were eligible for the interview in households selected for the male survey, i.e., every second household selected for the SLDHS) were asked if they would consent to give a few drops of blood from a finger prick for HIV testing. Table 14.1 presents coverage rates for HIV testing and the reasons given for not being tested, by gender, urban-rural residence, and region. Overall, HIV tests were conducted on 88 percent of the 3,954 eligible women age 15-49 and 85 percent of the 3,541 eligible men age 15-59. For both sexes combined, coverage was 86 percent, with rural residents more likely to be tested than their urban counterparts (89 and 83 percent, respectively). Table 14.1 also shows that, contrary to instructions given to field staff, a very small number of respondents were tested for HIV despite not being interviewed (less than 2 percent). Refusal to give blood is the most common reason for non-response on the HIV testing component, for both women and men; 5 percent of women and 6 percent of men were interviewed but refused to provide a blood sample. Refusal rates are higher in urban than rural areas, especially for men. For both sexes, the Western and Northern regions had the highest refusal rates (7 percent each), while the Southern Region had the lowest (1 percent). There are strong differences in coverage rates for HIV testing by region. Among both sexes, the Southern Region had the highest rate of HIV testing (95 percent), followed by the Eastern Region (89 percent). The Western Region (80 percent) and the Northern Region (82 percent) had the lowest testing rates. In every region, HIV testing coverage was higher for women than men. HIV Prevalence and Associated Factors | 221 Table 14.1 Coverage of HIV testing by residence and region Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to residence and region unweighted), Sierra Leone 2008 Background characteristic Testing status Total Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Inter- viewed Not interviewed Inter- viewed Not interviewed Inter- viewed Not interviewed Inter- viewed Not interviewed WOMEN 15-49 Residence Urban 85.8 1.8 5.7 2.0 0.2 0.6 2.2 1.7 100.0 1,663 Rural 89.0 1.9 4.1 1.2 0.2 0.7 1.2 1.7 100.0 2,291 Region Eastern 89.7 1.1 4.8 0.7 0.1 0.1 1.1 2.4 100.0 902 Northern 82.9 3.3 6.4 3.0 0.2 1.1 1.2 1.8 100.0 1,228 Southern 95.5 0.9 1.1 0.0 0.1 0.1 1.1 1.0 100.0 964 Western 83.5 1.6 6.3 2.2 0.2 1.3 3.3 1.6 100.0 860 Total 87.7 1.8 4.7 1.6 0.2 0.7 1.6 1.7 100.0 3,954 MEN 15-59 Residence Urban 80.0 2.4 7.5 3.1 0.1 1.2 2.4 3.3 100.0 1,559 Rural 88.9 1.2 3.8 1.1 0.2 0.8 1.8 2.2 100.0 1,982 Region Eastern 88.1 0.8 5.3 0.8 0.0 0.7 2.1 2.2 100.0 857 Northern 80.8 2.9 7.0 3.6 0.1 0.8 1.3 3.6 100.0 1,014 Southern 94.1 0.8 1.6 0.5 0.1 0.2 1.6 1.1 100.0 880 Western 76.8 2.3 8.0 2.9 0.4 2.4 3.5 3.7 100.0 790 Total 85.0 1.7 5.5 2.0 0.1 1.0 2.1 2.7 100.0 3,541 TOTAL (WOMEN 15-49 and MEN 15-59) Residence Urban 83.0 2.1 6.5 2.5 0.2 0.9 2.3 2.5 100.0 3,222 Rural 89.0 1.5 4.0 1.2 0.2 0.8 1.5 2.0 100.0 4,273 Region Eastern 88.9 1.0 5.0 0.7 0.1 0.4 1.6 2.3 100.0 1,759 Northern 81.9 3.1 6.7 3.3 0.2 1.0 1.2 2.6 100.0 2,242 Southern 94.8 0.9 1.4 0.2 0.1 0.2 1.4 1.1 100.0 1,844 Western 80.3 1.9 7.1 2.5 0.3 1.8 3.4 2.6 100.0 1,650 Total 86.4 1.8 5.1 1.8 0.2 0.8 1.8 2.2 100.0 7,495 1 Includes all Dried Blood Spot (DBS) samples tested at the lab and for which there is a result, i.e. positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes: 1) other results of blood collection (e.g. technical problem in the field), 2) lost specimens, 3) non-corresponding bar codes, and 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 14.1.2 Coverage by Socio-demographic Characteristics Table 14.2 shows the coverage rates for HIV testing among women age 15-49 and men age 15-59 by interview status and reason for not being tested, according to background characteristics. Coverage rates for women are generally stable across age groups (86 to 90 percent). For men, the highest coverage for HIV testing is in age group 30-39 (89 percent), while the lowest rate is in age group 20-24 (80 percent). 222 | HIV Prevalence and Associated Factors Table 14.2 Coverage of HIV testing by selected background characteristics Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to selected background characteristics (unweighted), Sierra Leone 2008 Background characteristic Testing status Total Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Inter- viewed Not interviewed Inter- viewed Not interviewed Inter- viewed Not interviewed Inter- viewed Not interviewed WOMEN 15-49 Age 15-19 85.8 2.6 5.4 1.7 0.5 0.3 2.1 1.7 100.0 664 20-24 86.7 1.4 5.2 1.7 0.3 1.2 1.4 2.1 100.0 655 25-29 87.9 1.8 4.5 1.4 0.1 0.6 1.7 2.0 100.0 845 30-34 88.5 1.1 3.3 1.6 0.2 0.9 2.9 1.5 100.0 549 35-39 89.5 2.8 3.8 1.0 0.0 0.7 1.0 1.2 100.0 601 40-44 87.8 1.7 6.1 1.4 0.0 0.0 0.6 2.5 100.0 362 45-49 87.4 1.1 5.8 2.9 0.0 1.1 1.1 0.7 100.0 278 Education No education 88.3 1.9 4.6 1.5 0.2 0.6 1.4 1.5 100.0 2,529 Primary 86.8 2.5 5.0 1.0 0.2 0.8 1.3 2.5 100.0 522 Secondary or higher 86.4 1.4 5.0 2.1 0.1 0.8 2.4 1.8 100.0 903 Wealth quintile Lowest 91.1 1.6 3.3 1.0 0.0 0.1 1.4 1.4 100.0 695 Second 90.0 1.5 3.4 1.0 0.1 0.9 0.7 2.3 100.0 681 Middle 87.5 2.2 5.3 1.8 0.4 0.6 0.8 1.4 100.0 719 Fourth 87.4 2.0 5.3 1.4 0.2 0.8 1.3 1.5 100.0 860 Highest 84.0 1.9 5.7 2.3 0.1 0.9 3.2 1.9 100.0 999 Total 87.7 1.8 4.7 1.6 0.2 0.7 1.6 1.7 100.0 3,954 MEN 15-59 Age 15-19 83.3 2.2 5.1 2.2 0.0 0.8 2.7 3.8 100.0 603 20-24 80.4 1.7 6.8 2.4 0.0 2.2 3.1 3.5 100.0 459 25-29 83.0 2.9 5.6 2.3 0.6 1.0 2.3 2.3 100.0 481 30-34 89.1 0.3 5.1 2.3 0.3 0.3 1.5 1.3 100.0 396 35-39 89.2 1.3 3.3 1.8 0.2 0.9 1.3 2.0 100.0 545 40-44 86.2 1.4 6.5 1.7 0.0 0.6 2.0 1.7 100.0 356 45-49 85.8 1.7 5.7 1.7 0.0 1.4 1.7 2.0 100.0 353 50-54 81.3 2.0 7.6 1.5 0.0 0.0 2.5 5.1 100.0 198 55-59 86.0 2.0 5.3 0.7 0.0 1.3 0.7 4.0 100.0 150 Education No education 87.7 1.2 4.7 1.5 0.0 0.6 1.8 2.5 100.0 1,629 Primary 87.1 1.4 4.5 1.2 0.2 1.0 1.4 3.3 100.0 511 Secondary or higher 81.0 2.4 6.7 2.9 0.3 1.4 2.6 2.7 100.0 1,401 Wealth quintile Lowest 91.6 1.1 2.0 0.9 0.0 0.5 2.0 1.9 100.0 644 Second 89.0 0.9 4.4 0.9 0.4 0.9 1.1 2.5 100.0 562 Middle 86.7 1.2 5.7 1.7 0.0 0.7 1.7 2.4 100.0 592 Fourth 84.0 2.4 5.4 2.1 0.1 0.8 2.1 3.0 100.0 757 Highest 78.1 2.4 8.1 3.3 0.2 1.7 2.8 3.2 100.0 986 Total 85.0 1.7 5.5 2.0 0.1 1.0 2.1 2.7 100.0 3,541 1 Includes all Dried Blood Spot (DBS) samples tested at the lab and for which there is a result, i.e. positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes: 1) other results of blood collection (e.g. technical problem in the field), 2) lost specimens, 3) non-corresponding bar codes, and 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. HIV testing coverage among women is fairly similar across education levels, while men with secondary or higher education were least likely to be tested and most likely to refuse testing. Similarly, those in the highest (richest) wealth quintile were the least likely to be tested and had the highest levels of refusal (6 percent of women and 8 percent of men). Among both women and men and across all sub-groups, the main reason for not being tested for HIV is refusal to provide a blood sample. Table 14.2 shows the coverage rates for HIV testing among women age 15-49 and men age 15-59 by interview status and reason for not being tested, according to background characteristics. HIV Prevalence and Associated Factors | 223 Appendix Tables C.8-C.11 show coverage rates for HIV testing among women and men who were interviewed by socio-demographic characteristics. The proportion of respondents who were tested is generally uniform across groups, varying little by marital status, frequency of travel away from home, and various sexual behavioural indicators. This provides assurance that the HIV prevalence rates are not likely to be biased by disproportionate non-response. 14.2 HIV PREVALENCE 14.2.1 HIV Prevalence by Age Results from the 2008 SLDHS indicate that 1.5 percent of Sierra Leonean adults age 15-49 have HIV (Table 14.3). HIV prevalence in women age 15-49 is 1.7 percent, while for men age 15-49, it is 1.2 percent. Prevalence peaks among women and men in age group 30-34 (2.4 percent for women and 1.8 percent for men). The higher level of HIV among women than men is common in most population-based estimates of HIV prevalence. There are no consistent patterns of HIV prevalence by age among either women or men; rather the levels fluctuate by age group. Table 14.3 HIV prevalence by age Among the de facto women and men age 15-49 who were interviewed and tested, the percentage HIV positive, by age, Sierra Leone 2008 Age Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 1.3 529 0.0 487 0.7 1,016 20-24 1.5 559 1.3 365 1.4 924 25-29 2.2 772 1.5 407 2.0 1,179 30-34 2.4 471 1.8 352 2.1 823 35-39 1.2 568 1.4 499 1.3 1,067 40-44 2.1 308 0.9 309 1.5 617 45-49 1.0 241 2.1 306 1.6 547 Total 15-49 1.7 3,448 1.2 2,726 1.5 6,174 50-59 na na 0.6 301 na na Total 15-59 na na 1.2 3,027 na na na = Not applicable 14.2.2 HIV Prevalence by Socio-economic Characteristics Table 14.4 shows data on HIV prevalence by various socio-economic characteristics. Differences among ethnic groups are small. For example, HIV prevalence among the Temne and Mende groups is about 1 percent, compared with 2.1 percent among respondents in other ethnic groups combined. Differences by religion and employment status are also small. Urban residents have a slightly higher risk of contracting HIV (2.5 percent) than rural residents (1 percent). The HIV epidemic exhibits some degree of regional heterogeneity, with the prevalence rate ranging from less than 1 percent in the Southern Region to 2.9 percent in the Western Region where the capital, Freetown, is located. A similar pattern is observed for both women and men. Table 14.4 shows that the proportion of respondents who are HIV positive does not vary much by education, although it is slightly higher among those with secondary or higher education. Finally, data in Table 14.4 show that HIV prevalence is lowest among respondents in the lowest (poorest) wealth quintile (less than 1 percent) and highest among those in the highest (richest) wealth quintile (2.3 percent). This relationship is true for both women and men, but it appears to be somewhat more pronounced for men. 224 | HIV Prevalence and Associated Factors Table 14.4 HIV prevalence by socio-economic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by socio-economic characteristics, Sierra Leone 2008 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Residence Urban 2.7 1,205 2.2 1,040 2.5 2,245 Rural 1.2 2,243 0.6 1,686 1.0 3,929 Region Eastern 1.6 601 1.1 510 1.4 1,111 Northern 1.4 1,433 0.9 1,055 1.2 2,488 Southern 1.1 733 0.5 569 0.8 1,302 Western 3.1 682 2.6 592 2.9 1,274 Education No education 1.6 2,341 1.1 1,316 1.4 3,657 Primary 2.0 423 0.8 386 1.4 810 Secondary or higher 2.1 684 1.5 1,023 1.8 1,707 Employment (past 12 months) Not employed 1.8 759 1.2 403 1.6 1,162 Employed 1.7 2,673 1.2 2,321 1.5 4,994 Ethnicity Temne 1.6 1,189 0.9 995 1.3 2,184 Mende 1.3 1,087 0.9 834 1.1 1,921 Other 2.3 1,173 1.9 896 2.1 2,069 Religion Christian 1.8 783 1.0 586 1.5 1,369 Muslim 1.7 2,625 1.3 2,128 1.5 4,753 Other (2.1) 41 * 11 (2.7) 52 Wealth quintile Lowest 0.8 627 0.2 522 0.6 1,149 Second 1.9 679 0.5 483 1.3 1,162 Middle 1.0 674 1.0 487 1.0 1,161 Fourth 2.3 732 1.9 556 2.1 1,288 Highest 2.4 736 2.1 678 2.3 1,414 Total 15-49 1.7 3,448 1.2 2,726 1.5 6,174 50-59 na na 0.6 301 na na Total 15-59 na na 1.2 3,027 na na Note: Total includes 16 women and 2 men with information missing on employment. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. na = Not applicable 14.2.3 HIV Prevalence by Demographic Characteristics Marital status is related to HIV prevalence, and the pattern is similar for both women and men (Table 14.5). As expected, never-married respondents who have never had sex have the lowest prevalence of HIV (0.2 percent). Respondents who are widowed have higher rates of HIV (5.0 percent) than those in other marital categories. A few women who reported that they had never been in a union and had never had sex are HIV positive, suggesting either reporting errors on sexual behaviour or non-sexual transmission of HIV. HIV Prevalence and Associated Factors | 225 Table 14.5 HIV prevalence by demographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by demographic characteristics, Sierra Leone 2008 Demographic characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Never married 2.2 587 1.0 993 1.5 1,580 Ever had sexual intercourse 2.9 406 1.6 642 2.1 1,048 Never had sexual intercourse 0.7 181 0.0 350 0.2 532 Married/living together 1.4 2,644 1.3 1,650 1.4 4,293 Divorced or separated 2.7 121 3.4 72 3.0 193 Widowed 5.6 97 * 11 5.0 108 Type of union In polygynous union 0.9 996 1.1 292 1.0 1,288 Not in polygynous union 1.8 1,594 1.3 1,358 1.6 2,952 Not currently in union 2.7 805 1.2 1,076 1.8 1,881 Don’t know/missing 0.0 53 na 0 0.0 53 Times slept away from home in past 12 months None 1.9 1,881 1.2 1,152 1.6 3,032 1-2 2.0 874 1.7 519 1.8 1,393 3-4 1.2 363 0.2 434 0.6 797 5+ 0.9 299 1.7 601 1.4 900 Missing (0.0) 33 * 19 (0.0) 52 Time away in past 12 months Away for more than 1 month 1.4 515 1.7 520 1.5 1,034 Away only for less than 1 month 1.7 977 1.0 994 1.4 1,970 Not away 1.9 1,886 1.2 1,152 1.6 3,038 Missing 1.3 71 0.8 61 1.0 131 Currently pregnant Pregnant 0.8 288 na na na na Not pregnant or not sure 1.8 3,160 na na na na ANC for last birth in the past 3 years ANC provided by the public sector 1.3 1,282 na na na na ANC provided by other than the public sector 2.9 208 na na na na No ANC/no birth in last 3 years 1.9 1,936 na na na na Male circumcision Circumcised na na 1.2 2,616 na na Not circumcised na na 2.4 57 na na Don’t know/missing na na (2.3) 53 na na Total 15-49 1.7 3,448 1.2 2,726 1.5 6,174 50-59 na na 0.6 301 na na Total 15-59 na na 1.2 3,027 na na Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. na = Not applicable By type of union, HIV prevalence is slightly lower among respondents who are in a polygynous union (1.0 percent), than those who are not currently in union (1.8 percent); however, the difference is small (0.8 percent). People who travel away from home—particularly if they stay away for long periods—are assumed to be at greater risk of contracting HIV because they engage in higher-risk sexual behaviour. However, no such pattern was observed in the data on women and men in Sierra Leone. For example, the data show that respondents who slept away from home one or two times in the 12 months before the survey, or who never slept away from home (1.8 and 1.6 percent, respectively) have higher HIV prevalence than those who slept away from home three or four times during the same period of time (0.6 percent). Similarly, HIV prevalence does not vary in any meaningful way by duration of time that 226 | HIV Prevalence and Associated Factors women and men spent away from home. However, the survey results on these issues are mixed, possibly because of the overall low prevalence rates. HIV prevalence among pregnant women in the SLDHS is 0.8 percent. This figure provides a useful benchmark for comparison with HIV rates of pregnant women tested during sentinel surveillance. HIV prevalence among women who were not pregnant at the time of the 2008 SLDHS interview is 1.8 percent. Differences in HIV prevalence by type of antenatal care for the most recent birth are not large. Nevertheless, the prevalence rate for women who received ANC from a public sector provider prior to a live birth in the three years preceding the survey is lower (1.3 percent) than that for women who did not receive any ANC (1.9 percent) and women who received ANC somewhere other than the private sector (2.9 percent). Several recent studies have shown evidence of a protective effect of circumcision among men. The 2008 SLDHS data show that men who are circumcised (1.2 percent) are slightly less likely to have HIV than those who are not circumcised (2.4 percent). However, because of the small number of men in the survey who were not circumcised, the results should be viewed with caution. 14.2.4 HIV Prevalence by Sexual Behaviour Indicators Table 14.6 examines the prevalence of HIV by sexual behaviour indicators among respondents who have ever had sexual intercourse. It is important to note that responses about risky sexual behaviours may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk. Generally, the patterns of HIV prevalence are similar for women and men, although the differences are larger among women. Women age 15-49 who had first sexual intercourse at age 16-17 have the highest HIV prevalence (3.2 percent), compared with other women. The same pattern is observed for men age 15-49. Women age 15-49 years who had higher-risk sexual intercourse (sex with a non-marital, non- cohabiting partner) are slightly more likely to have HIV than those who are sexually active but did not have a higher-risk partner (3.1 and 1 percent, respectively). Among men age 15-49, those reporting a higher-risk partner in the past year also have a slightly higher HIV prevalence (1.9 percent) than sexually active men who did not have a higher- risk partner (1.2 percent) or those who did not have any recent sexual intercourse (0.6 percent). Overall, there is a slight tendency for HIV prevalence to be higher among those who had higher-risk sexual intercourse in the past 12 months (2.3 percent) than among those who either did not have sex in the past 12 months (1.6 percent) or who had sexual intercourse, but not higher-risk sexual intercourse (1.4 percent). HIV prevalence increases with the number of higher-risk sexual partners. For example, HIV prevalence rises from 1.6 percent among women and 1 percent among men who did not have any higher-risk partners in the past 12 months, to 6.2 percent among women and 2.9 percent among men who had two higher-risk sexual partners in the past 12 months. Overall, HIV prevalence rises from 1.4 percent among respondents who had no higher-risk sexual partners in the past 12 months to 3.6 percent among those with two higher-risk sexual partners in that period. HIV Prevalence and Associated Factors | 227 Table 14.6 HIV prevalence by sexual behaviour Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by sexual behaviour characteristics, Sierra Leone 2008 Sexual behaviour characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sexual intercourse <16 1.5 1,652 1.2 554 1.4 2,206 16-17 3.2 639 1.9 516 2.6 1,155 18-19 1.5 396 1.6 574 1.5 970 20+ 1.7 195 1.1 683 1.3 878 Missing 1.2 360 (0.0) 36 1.0 396 Higher-risk intercourse in past 12 months1 Had higher-risk intercourse 3.1 484 1.9 899 2.3 1,383 Had sexual intercourse, not higher risk 1.4 1,921 1.2 1,148 1.4 3,069 No sexual intercourse in past 12 months 1.9 837 0.6 315 1.6 1,153 Number of sexual partners in past 12 months 0 1.6 746 0.0 191 1.3 937 1 1.7 2,287 1.4 1,608 1.6 3,895 2 3.2 114 2.3 380 2.5 493 3+ * 4 1.2 48 1.1 52 Missing 4.3 91 1.4 136 2.6 227 Number of higher-risk partners in past 12 months2 0 1.6 2,758 1.1 1,464 1.4 4,222 1 2.8 442 1.8 728 2.2 1,170 2 6.2 39 2.9 147 3.6 186 3+ * 2 (0.0) 25 (0.0) 27 Condom use Ever used a condom 2.4 179 2.5 653 2.5 832 Never used a condom 1.8 3,043 1.0 1,605 1.5 4,648 Missing * 20 0.4 105 0.4 125 Condom use at last sexual intercourse in past 12 months Used condom 0.0 50 1.8 190 1.4 239 Did not use condom 1.8 2,329 1.5 1,834 1.7 4,163 No sexual intercourse in past 12 months 1.9 837 0.6 315 1.6 1,153 Missing (4.4) 26 * 24 (2.3) 50 Condom use at last higher-risk intercourse in past 12 months Used condom (0.0) 31 1.7 193 1.5 224 Did not use condom 3.3 453 1.9 706 2.5 1,159 No higher-risk intercourse/ no intercourse past 12 months 1.6 2,758 1.1 1,464 1.4 4,222 Number of lifetime partners 1 1.2 1,212 0.0 218 1.0 1,430 2 2.3 843 0.4 217 1.9 1,060 3-4 2.5 741 2.2 373 2.4 1,114 5-9 1.7 193 1.5 332 1.6 524 10+ * 19 0.5 308 0.9 327 Missing 0.8 235 2.0 915 1.7 1,149 Paid for sexual intercourse in past 12 months3 Yes na na 0.0 55 na na Used condom na na * 15 na na Did not use condom na na (0.0) 40 na na No sexual intercourse in past 12 months na na 1.4 2,308 na na Total 15-49 1.8 3,242 1.4 2,363 1.6 5,605 50-59 na na 0.6 293 na na Total 15-59 na na 1.3 2,656 na na Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. na = Not applicable 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 At least one non-marital, non-cohabiting partner among the last three partners in the past 12 months 3 Includes men who reported having a prostitute for at least one of their last three sexual partners in the past 12 months 228 | HIV Prevalence and Associated Factors Condoms, when used properly, are an effective way of preventing the transmission of HIV and other STIs. Although this would suggest that HIV rates should be lower among condom users, there are a number of factors that may influence the direction of the relationship. For example, condom use rates may be higher among individuals who are HIV positive because they are seeking to protect a partner who is HIV negative. Also, reported condom use cannot be assumed to be ‘correct condom use.’ Thus, it is not surprising that the association between condom use and HIV prevalence is not uniform. Overall, HIV prevalence is highest among respondents who did not use a condom during higher-risk sexual intercourse (2.5 percent) than among those who did use a condom (1.5 percent) or those who did not have any higher-risk sex during the past year (1.4 percent). This pattern holds true for both women and men. Looking at the relationship between HIV infection and the number of lifetime partners, HIV prevalence increases with the number of lifetime sexual partners that a person has had and it reaches a peak among those who have had three or four partners, after which it drops as the number of partners increases. 14.3 HIV PREVALENCE BY OTHER CHARACTERISTICS RELATED TO HIV RISK Some sexually transmitted infections (STIs) have been shown to facilitate transmission of HIV. Consequently, it would be expected that women and men with a history of STIs or STI symptoms would have higher HIV prevalence rates than those with none. As shown in Table 14.7, there is no difference in the prevalence of HIV among women with STIs and those without; however, HIV prevalence is higher among those who did not know whether they had an STI (2.4 percent). Men who reported having an STI or STI symptoms were slightly less likely to be HIV positive than those who did not report having an STI, although the difference is very small (1.1 and 1.5 percent, respectively). Women and men who have ever been tested for HIV are more likely to be HIV positive than those who have never been tested. Among women and men who have ever had sex, the level of HIV is 3.0 percent among those who have ever been tested, compared with 1.6 percent for women and 1.2 percent for men who have never been tested. Table 14.7 HIV prevalence by selected characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by whether they had an STI in the past 12 months and by prior testing for HIV, Sierra Leone 2008 Characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Sexually transmitted infection in past 12 months Had STI or STI symptoms 1.6 639 1.1 266 1.5 906 No STI, no symptoms 1.8 2,387 1.5 1,924 1.7 4,312 Don’t know/missing 2.4 215 0.3 172 1.5 387 Prior HIV testing Ever tested 3.0 429 3.0 210 3.0 640 Received results 3.8 316 3.6 176 3.7 492 Did not receive results 0.7 113 (0.0) 34 0.5 147 Never tested 1.6 2,741 1.2 1,811 1.4 4,552 Missing 3.3 72 1.6 342 1.9 414 Total 15-49 1.8 3,242 1.4 2,363 1.6 5,605 Note: Figures in parentheses are based on 25 to 49 unweighted cases. Women and men who are HIV positive are slightly more likely to have been tested in the past for HIV and to have been given the results, than those who are HIV negative (Table 14.8). Among women who are HIV positive, 20 percent said that they had been tested for HIV at some time and had received the results of their last test; among women who are HIV negative, only 9 percent reported being tested previously and received the result. However, 75 percent of HIV-positive women said HIV Prevalence and Associated Factors | 229 they had never been tested. For men, there is a similar pattern; 19 percent of those who are HIV positive have previously been tested and know the results of their last test, compared with 6 percent of those who are HIV negative. Nevertheless, the survey results imply that the vast majority of people who are HIV positive (75 percent of women and 64 percent of men) are not aware of their HIV status, mainly because they were never tested and are thus less likely to take precautions to prevent transmission. Table 14.8 Prior HIV testing by current HIV status Percent distribution of women and men age 15-49 by HIV testing status prior to the survey, according to whether HIV positive or negative, Sierra Leone 2008 HIV testing prior to the survey Women Men Total HIV positive HIV negative HIV positive HIV negative HIV positive HIV negative Previously tested Received result of last test 20.2 9.0 (19.1) 6.4 19.8 7.8 Did not receive result of last test 1.3 3.5 (0.0) 1.3 0.8 2.6 Not previously tested 74.6 85.5 (64.1) 75.4 70.9 81.0 Missing 3.9 2.0 (16.8) 16.8 8.5 8.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 60 3,389 33 2,692 93 6,081 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 14.4 HIV PREVALENCE AMONG YOUTH HIV prevention programmes often target youth because they are generally more likely than older people to be experimenting with sex. Infection rates among youth provide some insight into the incidence of new cases, because young people living with HIV are more likely to have contracted the virus, compared with adults. As shown in Table 14.9, 1.4 percent of women and 0.5 percent of men age 15-24 are HIV positive. Among young women, HIV prevalence is highest for the 23-24 age group, while among young men it is highest for the 20-22 age group. HIV rates are somewhat higher among the never-married youth who have ever had sex than among other sub-groups. HIV prevalence is slightly higher among young pregnant women than among young non- pregnant women. Although low, HIV prevalence among young people in urban areas is twice that observed among young people in rural areas (1.6 percent, compared with 0.6 percent). Young women living in the Eastern Region (2.6 percent) and young women and men in the Western Region (2.1 and 1.6 percent, respectively) are more likely to have HIV than young people in other regions. The data show no clear patterns for HIV prevalence by level of education or wealth quintile. For example, among young women, HIV prevalence is highest for those who have no education (1.8 percent), while among young men it is highest for those with secondary or higher education (1 percent). Similarly, among young women, HIV prevalence is highest for those in the fourth wealth quintile (2.6 percent), while for young men it is highest for those in the highest wealth quintile (1.2 percent). Few conclusions can be drawn from these data because the HIV prevalence levels are low and the differentials are small. 230 | HIV Prevalence and Associated Factors Table 14.9 HIV prevalence among young people by background characteristics Percentage HIV positive among women and men age 15-24 who were tested for HIV, by background characteristics, Sierra Leone 2008 Background characteristic Women 15-24 Men 15-24 Total 15-24 Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 1.3 529 0.0 487 0.7 1,016 15-17 1.0 270 0.0 248 0.5 518 18-19 1.6 259 0.0 239 0.8 498 20-24 1.5 559 1.3 365 1.4 924 20-22 1.2 379 1.5 259 1.3 638 23-24 2.3 180 0.8 106 1.8 286 Marital status Never married 1.6 487 0.6 771 1.0 1,258 Ever had sex 2.1 310 1.1 437 1.5 748 Never had sex 0.7 177 0.0 334 0.2 511 Married/living together 0.9 575 0.0 75 0.8 650 Divorced/separated/widowed * 26 * 6 (8.5) 32 Currently pregnant Pregnant 1.7 131 na na na na Not pregnant or not sure 1.4 958 na na na na Residence Urban 2.0 464 1.1 441 1.6 905 Rural 1.0 624 0.0 411 0.6 1,035 Region Eastern 2.6 175 0.0 118 1.6 292 Northern 1.2 424 0.0 345 0.7 769 Southern 0.1 232 0.5 156 0.3 388 Western 2.1 257 1.6 234 1.9 490 Education No education 1.8 522 0.0 202 1.3 723 Primary 0.8 199 0.0 170 0.4 369 Secondary or higher 1.2 367 1.0 481 1.1 848 Wealth quintile Lowest 0.8 171 0.0 113 0.5 284 Second 1.6 176 0.0 121 0.9 298 Middle 0.3 196 0.0 129 0.2 324 Fourth 2.6 243 0.5 171 1.7 414 Highest 1.4 302 1.2 318 1.3 620 Total 15-24 1.4 1,088 0.5 852 1.0 1,940 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. na = Not applicable Table 14.10 presents HIV prevalence rates by sexual behaviour indicators for young people age 15-24 who have ever had sexual intercourse. Young women whose first sex was with a man ten or more years older have only marginally higher HIV prevalence, compared with those whose first partner was less than ten years older. Among both young women and young men, the HIV infection rate is higher for those who had higher-risk sexual intercourse than for those who did not. There is a clear HIV prevalence increase among youth as the number of sexual partners in the past 12 months increases, from 0.3 percent among youth with no recent sexual partners to 4 percent among those who had two or more sexual partners. Regarding HIV prevalence and the number of higher-risk sexual partners in the past 12 months, prevalence is higher among those with two or more higher-risk partners than among those with one or no higher-risk partners. HIV Prevalence and Associated Factors | 231 Table 14.10 HIV prevalence among young people by sexual behaviour Percentage HIV positive among women and men age 15-24 who ever had sex and were tested for HIV, by sexual behaviour, Sierra Leone 2008 Sexual behaviour characteristic Women 15-24 Men 15-24 Total 15-24 Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Relative age of first sexual partner 10+ years older 1.6 218 na na na na <10 years older/same age/younger/ don’t know 1.4 554 na na na na Missing 2.2 140 na na na na Higher-risk intercourse in past 12 months1 Had higher-risk intercourse 2.7 278 1.3 365 1.9 643 Had sexual intercourse, not higher-risk 1.0 425 0.0 83 0.8 508 No sexual intercourse in past 12 months 1.2 209 0.0 70 0.9 279 Number of sexual partners in past 12 months 0 0.4 201 0.0 63 0.3 265 1 1.6 663 0.2 358 1.1 1,021 2+ (3.3) 40 4.4 87 4.0 127 Missing * 8 * 9 * 17 Number of higher-risk partners in past 12 months2 0 1.0 634 0.0 153 0.8 786 1 2.5 248 0.7 290 1.5 538 2+ (4.4) 30 3.5 75 3.7 105 Condom use Ever used a condom 1.1 66 1.3 170 1.3 237 Never used a condom 1.6 838 0.7 330 1.4 1,167 Missing * 7 * 18 * 26 Condom use at first sex Used condom (0.0) 24 (0.0) 39 0.0 64 Did not use condom 1.5 842 1.0 461 1.3 1,303 Missing (6.9) 28 * 15 (4.5) 43 Condom use at last sex in past 12 months Used condom at last sex (0.0) 24 1.3 83 1.0 107 Did not use condom 1.8 672 1.0 358 1.5 1,030 No sexual intercourse in past 12 months 1.2 209 0.0 70 0.9 279 Missing * 6 * 8 * 14 Total 15-24 1.6 911 0.9 518 1.3 1,429 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. Na = Not applicable 1 Sexual intercourse with a non-marital, non-cohabiting partner 2 At least one non-marital, non-cohabiting partner among the last three partners in the past 12 months Young women who have ever used a condom are only slightly less likely to be HIV positive (1.1 percent) than those who have never used a condom (1.6 percent), while the opposite is true for young men: 1.3 percent of men who have ever used a condom are HIV positive, compared with 0.7 percent of those who never used a condom. Among both young women and men, HIV prevalence is slightly higher for those who did not use a condom during their first sexual encounter than for those who did use a condom. Finally, young women who did not use a condom during last sexual intercourse in the past year have higher HIV prevalence (1.8 percent) than those who did not (close to 0 percent). The opposite is seen for men, although the differentials among men are very small. With such low levels of HIV, it is difficult to identify any patterns in the differentials. 232 | HIV Prevalence and Associated Factors 14.5 HIV PREVALENCE AMONG COUPLES Both partners were tested in a total of 1,412 cohabiting couples in the 2008 SLDHS. Results shown in Table 14.11 indicate that for 98 percent of cohabiting couples, both partners are HIV negative. In a very small proportion of couples (0.4 percent), both partners are HIV positive; and in 1.9 percent of couples one partner is HIV positive and the other is HIV negative. These discordant couples are at high risk for HIV transmission, especially if they do not mutually know their HIV status or do not use condoms consistently. For 0.7 percent of cohabiting couples, the man is HIV positive and the woman is HIV negative, while for 1.2 percent of couples, the woman is HIV positive and the man is HIV negative. Couple-oriented voluntary counselling and testing (VCT) services, where partners (including those in polygynous marriages) go together and receive the HIV test results together, are available at some locations in the country, but couples attend as clients in only a few VCT centres. Differentials in couple patterns of HIV and discordance by background characteristics are too small to note. 14.6 MEASURING THE HIV BURDEN IN SIERRA LEONE The HIV prevalence rate obtained in the 2005 Sierra Leone sero-prevalence survey was 1.54 percent (SSL and NAS, 2005), which is the same as the rate obtained in the 2008 SLDHS (1.5 percent among respondents age 15-49). The results of the 2008 SLDHS confirm that Sierra Leone has a low-level HIV epidemic, and provide useful information on the distribution of HIV in the population. The inclusion of HIV testing in the 2008 SLDHS is important because the results provide the basis for more precise estimates of the HIV burden in Sierra Leone and permit the calibration of estimates of HIV prevalence based on sentinel surveillance of pregnant women. This linkage of HIV test results with demographic and behavioural data enhances the understanding of the distribution, patterns, and risk factors of HIV in Sierra Leone, with the potential to improve planning and implementation of health programmes. Further analysis of the 2008 SLDHS data will provide additional information on the links between behaviour, knowledge, and HIV prevalence in Sierra Leone. HIV Prevalence and Associated Factors | 233 Table 14.11 HIV prevalence among couples Percent distribution of couples living in the same household, both of whom were tested for HIV, by the HIV status, according to background characteristics, Sierra Leone 2008 Background characteristic Both HIV positive Man HIV positive, woman HIV negative Woman HIV positive, man HIV negative Both HIV negative Total Number Woman’s age 15-19 1.7 0.0 0.5 97.8 100.0 92 20-29 0.4 0.4 1.7 97.5 100.0 641 30-39 0.3 0.7 0.2 98.7 100.0 487 40-49 0.0 2.0 2.1 96.0 100.0 192 Man’s age 15-19 * * * * 100.0 4 20-29 0.7 0.0 1.4 97.9 100.0 225 30-39 0.5 0.8 1.2 97.5 100.0 560 40-49 0.3 0.9 1.5 97.2 100.0 433 50-59 0.0 0.7 0.0 99.3 100.0 190 Age difference between partners Woman older (0.0) (0.0) (0.0) (100.0) 100.0 46 Same age/man older by 0-4 years 0.4 1.7 1.6 96.3 100.0 339 Man older by 5-9 years 0.6 0.3 1.1 97.9 100.0 465 Man older by 10-14 years 0.0 0.3 0.6 99.2 100.0 336 Man older by 15+ years 0.6 0.7 1.7 96.9 100.0 227 Type of union Monogamous 0.4 0.5 1.5 97.6 100.0 1,041 Polygynous 0.3 1.4 0.4 97.9 100.0 338 Don’t know/missing (0.0) (0.0) (0.0) (100.0) 100.0 33 Residence Urban 0.8 1.0 1.9 96.3 100.0 366 Rural 0.3 0.6 0.9 98.2 100.0 1,046 Region Eastern 0.6 0.3 1.3 97.8 100.0 282 Northern 0.5 1.2 1.3 97.0 100.0 581 Southern 0.0 0.0 0.1 99.9 100.0 345 Western 0.7 1.0 2.4 96.0 100.0 204 Woman’s education No education 0.4 0.7 1.1 97.7 100.0 1,113 Primary 0.0 1.1 1.4 97.5 100.0 152 Secondary or higher 0.9 0.0 1.2 97.9 100.0 147 Man’s education No education 0.3 0.7 0.5 98.4 100.0 894 Primary 0.9 0.0 2.4 96.7 100.0 153 Secondary or higher 0.4 0.9 2.2 96.5 100.0 366 Wealth quintile Lowest 0.3 0.0 0.9 98.7 100.0 331 Second 0.5 0.3 1.5 97.7 100.0 319 Middle 0.1 0.8 0.3 98.8 100.0 297 Fourth 0.6 1.7 1.5 96.2 100.0 256 Highest 0.6 1.0 1.7 96.7 100.0 210 Total 0.4 0.7 1.2 97.7 100.0 1,412 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. The table based on couples for which a valid test result (positive or negative) is available for both partners. Women’s Empowerment and Demographic and Health Outcomes | 235 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 This chapter presents information on indicators of women’s empowerment, develops three empowerment indices, and relates these indices to select demographic and health outcomes. The study of women’s status and empowerment is important on its own, but takes on a special significance in conjunction with the study of demographic and health outcomes. As caretakers for children, women are the focus of a number of population, health, and nutrition programmes. The constraints women face in obtaining information about, accessing, and utilizing these programmes are inherently tied to their status in society, but also their status in the home. The 2008 Sierra Leone Demographic and Health Survey (SLDHS) Woman’s and Man’s Questionnaires collected data on the general background characteristics (e.g., age, education, wealth quintile, and employment status) of respondents and also data more specific to women’s empower- ment, such as receipt of cash earnings, the magnitude of a woman’s earnings relative to those of her husband, and control over the use of their own earnings and those of the spouse.1 The SLDHS also collected data from women and men on the woman’s participation in household decision-making, on the circumstances under which the respondent feels that a woman is justified in refusing to have sexual intercourse with her husband, and her/his attitude toward wife beating. For this report, three separate indices of empowerment were developed based on women’s responses. The first index is based on the number of household decisions in which the respondent participates, the second on her opinion on the number of reasons that justify wife beating, and the third on her opinion on the number of circumstances for which a woman is justified in refusing to have sexual intercourse with her husband. The ranking of women on these three indices is then related to selected demographic and health outcomes including contraceptive use and the use of reproductive health care services during pregnancy, childbirth, and the postnatal period. 15.1 EMPLOYMENT AND FORM OF EARNINGS Table 15.1 shows the percentage of currently married women and men age 15-49 who were employed in the 12 months before the survey and the percent distribution of the employed respondents by type of earnings they received (cash, in-kind, both, or neither). Eighty-five percent of currently married women reported being employed in the past 12 months. The percentage of currently married women who were employed increases with age peaking at 89 percent for age group 30-34 and then fluctuates at 87-89 percent in older age groups. Although employment is assumed to go hand in hand with payment for work, not all women receive earnings for the work they do, and even among women who do receive earnings, not all are paid in cash. Seventeen percent of employed women receive payment in cash only, and just 6 percent receive both cash and in-kind payment. Five percent of women who were employed in the past 12 months receive payment only in kind. A large majority of employed women (72 percent) do not receive any form of payment for their work. 1 The questions were phrased in terms of ‘husband/partner’ (for women) and ‘wife/partner’ (for men), referring to marital partners; however in this report, the word ‘partner’ has been dropped to simplify the text and tables. 236 | Women’s Empowerment and Demographic and Health Outcomes Table 15.1 also shows that nearly all men age 15-49 (98 percent) were involved in some type of work in the 12 months preceding the survey. Men in the younger age group with large enough number of cases for analysis (20-24 years) are slightly less likely to be employed than older men. Men are more likely to receive cash for their work than women. About one in four men (26 percent) receive only cash for their work, one in ten (10 percent) receive cash and in-kind payment, and just 1 percent are paid in kind only. More than six in ten men (63 percent) do not receive any payment for their work. Table 15.1 Employment and cash earnings of currently married women Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Sierra Leone 2008 Age Currently married respondents Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Total Number of respondents Percentage employed Number of respondents Cash only Cash and in-kind In-kind only Not paid Missing WOMEN 15-19 76.2 359 13.0 5.5 5.7 75.2 0.5 100.0 273 20-24 74.1 812 15.4 5.2 6.8 72.3 0.3 100.0 602 25-29 85.1 1,429 18.0 4.3 4.8 71.9 0.9 100.0 1,217 30-34 88.5 899 18.2 7.1 4.2 69.9 0.6 100.0 796 35-39 87.8 1,022 16.7 5.1 4.0 73.7 0.5 100.0 898 40-44 87.4 572 17.5 6.9 4.6 70.4 0.5 100.0 500 45-49 88.6 431 16.1 5.9 4.7 72.9 0.4 100.0 382 Total 84.5 5,525 17.0 5.5 4.8 72.1 0.6 100.0 4,668 MEN 15-19 * 5 * * * * * 100.0 5 20-24 95.3 79 27.4 4.8 4.1 63.7 0.0 100.0 75 25-29 96.9 283 20.4 10.6 2.1 66.9 0.0 100.0 274 30-34 97.6 308 28.6 9.3 0.4 61.7 0.0 100.0 301 35-39 97.8 479 24.1 10.2 0.6 64.7 0.4 100.0 468 40-44 97.7 303 34.1 10.0 0.4 55.6 0.0 100.0 296 45-49 98.9 310 23.5 9.1 1.5 65.3 0.6 100.0 307 Total 15-49 97.7 1,767 26.0 9.6 1.1 63.1 0.2 100.0 1,726 50-59 97.3 310 25.6 12.2 0.3 61.6 0.4 100.0 301 Total 15-59 97.6 2,077 25.9 10.0 0.9 62.9 0.2 100.0 2,027 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 15.2 USE OF EARNINGS Besides having access to income, women need to be able to exert control over their earnings to be empowered. To assess this, currently married women who earned cash for their work in the 12 months preceding the survey were asked who the main decision-maker is with regard to the use of their earnings. Women’s perception on the magnitude of their earnings relative to those of their husband is also explored as another measure of their empowerment. Table 15.2.1 presents the results on use of women’s earnings. About one-third (34 percent) of currently married women who receive cash earnings reported that they are the main decision-makers on how their earnings are used; a slightly larger proportion of women (37 percent) reported that they decide jointly with their husband. More than one in four women (27 percent) reported that their husband alone decides how their earnings are used. This proportion is markedly higher (at least 40 percent) among the youngest women, those from the Northern Region, and those from the second and middle wealth quintiles. Women in their 30s and early 40s are more likely than younger or older women to make independent decisions on their earnings, with women age 40-44 being the most likely to do so (44 percent). Women with five or more children are more likely to decide on their own how to use their earnings than women with fewer or no children. Rural women (27 percent) and those living in the Eastern and Northern regions are less empowered in terms of this indicator (24 and 25 percent, respectively) Women’s Empowerment and Demographic and Health Outcomes | 237 The data indicate a positive relationship between level of education and women’s decision- making power regarding how their cash earnings are used. More than four in ten women with secondary or higher education (44 percent) reported that they make independent decisions on how to use the money they earn, compared with about three in ten women (30 percent) with no education. Women in the highest wealth quintile are the most likely to decide independently on how to spend their earnings (45 percent), while those in the second wealth quintile are the least likely (21 percent). Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife’s cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Sierra Leone 2008 Background characteristic Person who decides how the wife’s cash earnings are used: Total Woman’s cash earnings compared with husband’s cash earnings: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing More Less About the same Husband has no earnings Don’t know/ Missing Age 15-19 (29.1) (23.9) (40.6) (3.8) (2.5) 100.0 (15.7) (63.5) (13.7) (0.0) (7.1) 100.0 51 20-24 31.2 38.8 22.3 1.8 6.0 100.0 7.3 70.6 11.7 0.9 9.5 100.0 124 25-29 28.1 37.1 33.1 0.2 1.5 100.0 11.5 69.3 11.7 2.1 5.4 100.0 272 30-34 37.0 35.0 26.4 0.6 1.0 100.0 9.9 73.8 10.0 1.9 4.4 100.0 202 35-39 38.6 39.4 21.5 0.0 0.5 100.0 14.7 61.1 14.5 4.4 5.4 100.0 196 40-44 44.3 36.5 18.8 0.0 0.5 100.0 13.8 69.1 8.1 2.8 6.2 100.0 122 45-49 30.1 43.4 26.5 0.0 0.0 100.0 15.8 65.2 8.7 3.6 6.8 100.0 84 Number of living children 0 34.2 33.3 30.7 0.0 1.8 100.0 9.7 72.9 12.2 0.0 5.2 100.0 110 1-2 31.1 38.1 27.3 1.2 2.3 100.0 11.8 68.4 12.2 1.4 6.2 100.0 400 3-4 33.6 38.7 25.9 0.4 1.4 100.0 13.1 64.4 10.7 4.8 6.9 100.0 344 5+ 41.8 34.4 23.7 0.0 0.0 100.0 12.3 71.6 10.1 1.7 4.2 100.0 196 Residence Urban 43.1 37.5 18.1 0.6 0.8 100.0 12.2 67.8 10.9 3.5 5.5 100.0 482 Rural 26.8 36.8 33.7 0.6 2.2 100.0 12.0 68.4 11.7 1.6 6.3 100.0 567 Region Eastern 23.8 56.2 18.2 0.0 1.8 100.0 10.4 67.0 19.7 0.9 2.0 100.0 133 Northern 25.0 27.5 46.0 0.9 0.6 100.0 12.3 66.5 10.1 4.5 6.7 100.0 305 Southern 40.2 31.0 24.7 0.7 3.4 100.0 11.9 70.3 10.7 1.0 6.1 100.0 279 Western 42.0 43.4 13.4 0.4 0.8 100.0 12.8 68.4 9.6 2.4 6.8 100.0 332 Education No education 30.4 35.3 32.2 0.5 1.6 100.0 12.7 69.9 9.6 2.5 5.3 100.0 658 Primary 35.4 37.7 23.1 1.8 1.9 100.0 12.7 60.4 15.7 2.7 8.5 100.0 146 Secondary or higher 43.7 41.5 13.5 0.0 1.2 100.0 10.2 68.0 13.4 2.2 6.2 100.0 246 Wealth quintile Lowest 30.0 34.5 30.2 0.0 5.3 100.0 7.5 63.2 16.7 2.8 9.8 100.0 125 Second 21.4 35.9 41.9 0.9 0.0 100.0 15.1 68.8 12.0 0.6 3.5 100.0 156 Middle 25.9 31.4 40.0 1.1 1.6 100.0 13.3 67.5 9.9 2.8 6.5 100.0 174 Fourth 36.2 35.9 26.0 0.5 1.4 100.0 12.0 69.7 9.6 2.8 5.8 100.0 250 Highest 44.5 42.4 11.8 0.4 1.0 100.0 11.9 68.8 11.0 2.7 5.6 100.0 344 Total 34.2 37.1 26.5 0.6 1.6 100.0 12.1 68.2 11.3 2.4 6.0 100.0 1,050 Note: Figures in parentheses are based on 25 to 49 unweighted cases. Regarding the relative magnitude of women’s earnings compared with those of their husband, 68 percent of women reported that they earn less than their husband, 12 percent believe that they earn more, and 11 percent said that they earn about the same amount. Thus, nearly one in four employed married women earns at least as much as her husband. Women age 20-24 (7 percent), those with no children (10 percent), women living in the Eastern Region (10 percent), and women in the lowest wealth quintile (8 percent) are less likely than their counterparts to report that they earn more than their husband. Surprisingly, the data show that women with secondary or higher education are somewhat less likely (10 percent) than women with no education or with a primary education (13 percent each) to report that they earn more than their husband. In the 2008 SLDHS, men who earned cash for their work in the 12 months preceding the survey were asked about the main decision-maker on how their earnings are used. Currently married women whose husbands receive cash earnings were also asked about who mainly makes the decision on how their husband’s cash earnings are used. The data are presented in Table 15.2.2. 238 | Women’s Empowerment and Demographic and Health Outcomes Table 15.2.2 Control over men’s cash earnings Percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women 15-49 whose husbands receive cash earnings, by person who decides how husband’s cash earnings are used, according to background characteristics, Sierra Leone 2008 Background characteristic Men Women Person who decides how husband’s cash earnings are used: Total Number of men Person who decides how husband’s cash earnings are used: Total Number of women Mainly wife Husband and wife jointly Mainly husband Other Missing Mainly wife Husband and wife jointly Mainly husband Other Missing Age 15-19 na na na na na 0.0 0 5.3 38.9 51.3 0.8 3.6 100.0 346 20-24 * * * * * 100.0 24 3.2 42.2 52.2 0.6 1.7 100.0 795 25-29 8.2 45.8 45.9 0.0 0.0 100.0 85 4.3 38.7 54.2 0.5 2.2 100.0 1,404 30-34 4.7 37.4 52.2 0.0 5.7 100.0 114 4.6 40.4 53.6 0.1 1.2 100.0 886 35-39 5.6 43.1 48.0 0.0 3.3 100.0 161 5.7 41.1 51.5 0.0 1.7 100.0 1,004 40-44 5.5 45.0 46.8 0.0 2.8 100.0 130 8.4 42.0 48.6 0.0 1.1 100.0 560 45-49 1.9 39.2 56.7 0.0 2.3 100.0 100 8.7 39.9 50.7 0.0 0.7 100.0 426 Number of living children 0 3.9 35.7 53.8 0.0 6.6 100.0 52 4.6 38.7 52.4 1.9 2.5 100.0 505 1-2 5.2 45.4 48.1 0.0 1.2 100.0 204 5.0 38.7 53.8 0.2 2.3 100.0 2,095 3-4 5.0 35.6 56.9 0.0 2.5 100.0 208 5.2 41.0 52.3 0.1 1.3 100.0 1,754 5+ 5.5 46.0 43.2 0.0 5.3 100.0 150 6.2 43.5 49.2 0.1 1.1 100.0 1,066 Residence Urban 3.5 43.7 49.5 0.0 3.3 100.0 356 6.5 42.5 48.3 0.4 2.3 100.0 1,513 Rural 7.3 38.3 51.6 0.0 2.9 100.0 258 4.8 39.6 53.8 0.3 1.5 100.0 3,907 Region Eastern 3.6 57.0 36.7 0.0 2.8 100.0 75 8.2 35.0 55.1 0.0 1.7 100.0 1,005 Northern 7.0 38.3 47.9 0.0 6.9 100.0 113 3.7 45.5 48.5 0.3 1.9 100.0 2,388 Southern 8.2 30.1 60.4 0.0 1.3 100.0 187 5.2 33.8 59.4 0.6 1.0 100.0 1,193 Western 2.2 46.8 48.1 0.0 2.9 100.0 239 6.4 41.5 49.5 0.0 2.5 100.0 834 Education No education 5.9 35.7 54.4 0.0 4.0 100.0 254 5.1 39.2 53.9 0.3 1.5 100.0 4,201 Primary 1.6 47.1 49.4 0.0 1.9 100.0 79 5.7 37.6 53.7 0.7 2.4 100.0 590 Secondary or higher 5.3 44.9 47.1 0.0 2.7 100.0 281 6.3 51.2 40.0 0.0 2.6 100.0 629 Wealth quintile Lowest 10.1 33.8 53.1 0.0 3.1 100.0 82 5.1 35.0 58.1 0.2 1.5 100.0 1,162 Second 10.5 36.5 50.3 0.0 2.7 100.0 63 4.3 36.9 56.6 0.6 1.6 100.0 1,127 Middle 6.6 38.3 55.1 0.0 0.0 100.0 86 4.3 43.3 50.7 0.2 1.5 100.0 1,165 Fourth 2.5 44.9 47.0 0.0 5.5 100.0 150 6.4 42.4 49.1 0.0 2.0 100.0 1,026 Highest 2.9 44.3 49.9 0.0 2.8 100.0 233 6.6 45.3 45.4 0.4 2.3 100.0 940 Total 15-49 5.1 41.4 50.4 0.0 3.1 100.0 614 5.3 40.4 52.3 0.3 1.8 100.0 5,420 50-59 2.1 38.9 57.0 0.9 1.1 100.0 114 na na na na na 0.0 0 Total 15-59 4.6 41.0 51.4 0.1 2.8 100.0 728 na na na na na 0.0 0 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable Overall, half of currently married men who receive cash earnings and currently married women whose husbands receive cash earnings reported that the husband alone mainly decides how his cash earnings are used. About four in ten men and women said that this decision is made jointly by the husband and wife. One in twenty men and women said that the decision about how the husband’s cash earnings are used is made mainly by the wife. Older men age 45-49 are more likely than other men to report that they alone decide on how their cash earnings are used. Among women, the variations in this indicator by age are small. Men and women with five or more children are the least likely to report that the husband alone decides how his cash earnings are used, compared with respondents with fewer or no children. Respondents living in the Southern Region (60 percent of men and 59 percent of women) are more likely than respondents in the other regions to report the husband as the main decision-maker on this indicator. At the opposite end of the scale, women with secondary or higher education (40 percent) and those from the highest wealth quintile (45 percent) are least likely to report that the husband alone makes the decision on how his cash earnings are used. Differences by other background characteristics are small. Finally, it is worth noting that women with secondary or higher education (51 percent) and men from the Eastern Region (57 percent) are most likely to decide jointly with their spouses how to use the husband’s cash earnings. Women’s Empowerment and Demographic and Health Outcomes | 239 Table 15.3 shows, for currently married women who earned cash in the past 12 months, the person who decides how their cash earnings are used and for all currently married women whose husbands earned cash in the past 12 months, the person who decides how their husband’s cash earnings are used, according to the relative magnitude of the earnings of women and their husband or partner. Table 15.3 Women’s control over her own earnings and over those of her husband Percent distributions of currently married women age 15-49 with cash earnings in the past 12 months by person who decides how the wife’s cash earnings are used and of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband’s cash earnings are used, according to the relation between woman’s and husband’s cash earnings, Sierra Leone 2008 Women’s earnings relative to husband’s earnings Person who decides how the wife’s cash earnings are used: Total Number of women Person who decides how husband’s cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing Mainly wife Wife and husband jointly Mainly husband Other Missing More than husband 29.6 46.1 22.7 1.7 0.0 100.0 127 14.7 58.1 27.2 0.0 0.0 100.0 115 Less than husband 37.5 32.7 29.3 0.5 0.0 100.0 715 6.0 38.9 53.0 0.9 1.2 100.0 715 Same as husband 14.4 70.2 15.4 0.0 0.0 100.0 119 2.5 72.3 23.3 0.0 1.8 100.0 119 Husband has no cash earnings or did not work (45.1) (23.3) (29.2) (0.0) (2.3) 100.0 26 na na na na na 0.0 0 Woman worked but has no cash earnings na na na na na 0.0 0 5.4 38.7 54.4 0.2 1.3 100.0 3,582 Woman did not work na na na na na 0.0 0 3.5 43.3 48.9 0.2 4.1 100.0 827 Don’t know/missing 40.2 11.9 22.9 0.0 25.1 100.0 63 3.3 19.1 70.3 1.6 5.7 100.0 62 Total1 34.2 37.1 26.5 0.6 1.6 100.0 1,050 5.3 40.4 52.3 0.3 1.8 100.0 5,420 Note: Figures in parentheses are based on 25 to 49 unweighted cases. na = Not applicable 1 Excludes cases in which a woman or her husband/partner has no earnings, and includes cases in which a woman does not know whether she earned more or less than her husband/partner Women whose husbands did not work or had no cash income are more likely to decide how their own incomes are used (45 percent) compared with women whose incomes are less (38 percent) or the same as their husband’s (15 percent). On the other hand, women who earn more than their husbands are more likely to decide how the husband’s income is used. Women who said they earn about the same amount as their husbands are more likely to make joint decisions with their husbands about how to use their own and their husbands’ incomes. 15.3 WOMAN’S PARTICIPATION IN DECISION-MAKING Women’s participation in the decision-making process is an important indicator of their empowerment. To assess women’s decision-making autonomy, the 2008 SLDHS sought information on women’s participation in four types of household decisions: her own health care; making large household purchases; making household purchases for daily needs; and visits to family or relatives. Table 15.4.1 shows the percent distribution of currently married women according to the person in the household who usually makes decisions concerning these matters. Women are considered to participate in decision-making if they make decisions alone or jointly with their husband or someone else. The strength of women’s role in decision-making varies with the type of decision. One in four currently married women reported that they alone made the final decision about daily household purchases. However, more than one-third (35 percent) said that their husband alone makes the decision about the purchase of daily household needs. Although more than one in ten (12 percent) women make sole decisions on their own health care, nearly half (47 percent) reported that their husband makes such decisions mainly by himself. Decisions on large household purchases are most likely to be made by the husband (49 percent), followed by the respondent and her husband jointly (39 percent). Approximately half of women (48 percent) reported that the decision to visit family or relatives is made jointly with their husband, and around four in ten (37 percent) said that their husbands alone make this decision. 240 | Women’s Empowerment and Demographic and Health Outcomes Table 15.4.1 Women’s participation in decision-making Percent distribution of currently married women age 15-49 by person who usually makes decisions about four kinds of issues, Sierra Leone 2008 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 11.8 39.7 46.7 0.6 0.1 1.0 100.0 5,525 Major household purchases 9.6 39.4 49.4 0.5 0.1 1.0 100.0 5,525 Purchases of daily household needs 25.3 38.0 34.8 0.8 0.2 0.9 100.0 5,525 Visits to her family or relatives 13.1 48.1 37.4 0.3 0.1 0.9 100.0 5,525 In the 2008 SLDHS, men were asked about who they think should have a greater say in making decisions about five specific issues: making large household purchases; making household purchases for daily needs; visits to wife’s family or relatives; what to do with the money a wife earns; and how many children to have. Fifty-two percent of men believe that the decision about how many children to have should be made jointly with their spouse (Table 15.4.2). Most men believe that the decision on major household purchases (58 percent) should be made mostly by the husband alone or jointly with their spouse (34 percent), while only 6 percent of men say the wife alone should have the greater say in making this decision. An almost equal proportion of men believe that the wife alone (34 percent) or the husband alone (36 percent) should make the decision on purchases for daily household needs. It is worth noting that a sizeable percentage of men think that the decision on visits to wife’s family or relatives should be made jointly (47 percent) or by the husband alone (45 percent). Finally, an equal proportion of men, around four in ten, believe that the husband alone or the wife and husband jointly should make the decision on how the wife’s earnings are used. Overall, data show that for four of the five issues, the majority of men think that these decisions should be made by the husband alone or by the wife and husband jointly, except for purchases for daily household needs that could be decided equally by the wife or by the husband alone. Table 15.4.2 Women’s participation in decision-making according to men Percent distribution of currently married men age 15-49 by person who they think should have a greater say in making decisions about five kinds of issues, Sierra Leone 2008 Decision Wife Wife and husband equally Husband Don’t know/ depends Missing Total Number of men Major household purchases 5.6 34.1 58.4 1.3 0.5 100.0 1,767 Purchases for daily household needs 33.5 28.7 36.2 1.0 0.6 100.0 1,767 Visits to wife’s family or relatives 6.3 46.8 45.2 1.1 0.7 100.0 1,767 What to do with the money the wife earns 15.7 41.4 41.3 1.1 0.5 100.0 1,767 How many children to have 4.4 52.1 40.0 2.9 0.5 100.0 1,767 Table 15.5.1 shows the percentage of married women who reported that they alone or jointly with their husband make specific household decisions, according to background characteristics. The results indicate that four in ten of currently married women participate in all of the four specified decisions, while more than one in four (27 percent) reported that they do not participate in any of the decisions. The majority of currently married women participate in making decisions on daily purchases (63 percent) and visits to family or relatives (61 percent), but fewer participate in making decisions about their own health care (52 percent) or about making large household purchases (49 percent). Older women are more likely than younger women to have a say in all the specified decisions. Participation in decision-making is highest among employed women who are paid in cash (48 percent) and those with five or more children (44 percent). Urban women are more likely than rural women to participate in all four decisions (45 and 38 percent, respectively). Looking at regional variations, the proportion of women who participate in all four specified decisions is lowest among Women’s Empowerment and Demographic and Health Outcomes | 241 women living in the Southern Region (31 percent) and highest in the Western Region (46 percent). The proportion of women who participate in all four decisions is highest among women with secondary or higher education and among women in the highest wealth quintile (50 percent each). Women may have a say in some but not other decisions. To assess a woman’s overall decision-making autonomy, the decisions in which she participates—that is, in which she alone has the final say or she and her husband decide jointly—are added together. The total number of decisions in which a woman participates is one simple measure of her empowerment. The number of decisions which a woman makes herself or jointly with her husband is positively related to women’s empowerment and reflects the degree of decision-making control women are able to exercise in areas that affect their lives and environments. Figure 15.1 shows the distribution of currently married women according to the number of decisions in which they participate. As can be seen in the figure, around four in ten women reported that they participate in four household decisions, while around one-fourth do not participate in any decision-making at all. Table 15.5.1 Women’s participation in decision-making Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Sierra Leone 2008 Background characteristic Specific decisions Percentage who participate in all four decisions Percentage who participate in none of the four decisions Number of women Own health care Making major household purchases Making purchases for daily household needs Visits to her family or relatives Age 15-19 42.1 40.5 51.8 51.4 32.9 37.4 359 20-24 47.7 46.8 62.2 60.0 36.2 28.0 812 25-29 50.0 46.8 62.5 60.4 38.7 27.8 1,429 30-34 53.4 51.1 63.9 60.7 40.9 25.9 899 35-39 53.5 49.3 63.5 62.8 40.2 25.3 1,022 40-44 56.9 52.8 67.3 68.7 44.1 22.2 572 45-49 56.1 56.8 70.3 62.7 45.5 23.7 431 Employment (past 12 months) Not employed 51.7 50.7 61.2 60.1 43.7 30.5 835 Employed for cash 59.9 57.4 69.5 67.0 48.2 22.0 1,050 Employed, not for cash 49.3 46.3 62.3 60.1 36.4 27.0 3,591 Number of living children 0 44.7 43.5 56.7 56.4 33.3 33.3 516 1-2 49.2 47.0 61.5 58.7 38.6 29.3 2,136 3-4 52.5 50.6 64.1 62.3 40.4 25.4 1,793 5+ 57.9 52.8 68.7 67.1 43.7 20.8 1,080 Residence Urban 55.3 54.1 67.7 65.5 45.1 23.4 1,561 Rural 50.1 46.9 61.6 59.6 37.5 28.1 3,965 Region Eastern 46.2 47.6 56.2 52.8 38.2 35.8 1,028 Northern 57.1 51.0 69.2 67.6 42.5 20.4 2,434 Southern 41.7 41.8 55.1 50.6 30.7 34.6 1,206 Western 56.1 54.9 66.6 68.6 46.0 23.1 858 Education No education 49.9 46.6 61.6 59.7 37.9 28.4 4,280 Primary 53.1 52.2 64.4 61.6 40.9 24.7 601 Secondary or higher 60.7 61.5 73.9 71.6 50.3 18.2 644 Wealth quintile Lowest 45.2 42.9 61.5 56.8 33.6 28.8 1,178 Second 46.7 40.6 57.5 55.7 33.2 31.3 1,144 Middle 53.5 51.2 62.2 60.4 40.4 27.7 1,186 Fourth 54.7 53.1 65.7 64.4 43.7 25.2 1,051 Highest 59.2 59.0 71.2 71.0 49.5 19.6 967 Total 51.5 49.0 63.3 61.3 39.7 26.8 5,525 Note: Total includes 50 women with information missing on employment in the past 12 months. 242 | Women’s Empowerment and Demographic and Health Outcomes Figure 15.1 Number of Household Decisions in Which Currently Married Women Participate 27 11 13 10 40 0 1 2 3 4 0 10 20 30 40 50 Percent Number of decisions SLDHS 2008Note: See Table 15.5.1 for specific decisions. Men were asked about their attitudes towards wives’ participation in the decision-making process. Table 15.5.2 indicates that around one-fourth (26 percent) of currently married men age 15- 49 believe that a wife should independently or jointly with her husband have a say on all five specified decisions. Men are most likely to agree on women’s participation in deciding on purchases for daily household needs (62 percent), on what to do with the money the wife earn, and on the number of children to have (57 percent each). However, they are somewhat less likely to agree on a wife’s decision-making participation with regard to the purchase of major household items (40 percent) or visits to her family or friends (53 percent). Urban men, those living in the Eastern Region, men age 40-44, unemployed men, and those employed for cash are more likely than other men to think that a wife should have the greater say or an equal say with her husband for all five decisions. The more educated or wealthy a man is, the more likely he is to support a wife’s participation in household decision-making. Women’s Empowerment and Demographic and Health Outcomes | 243 Table 15.5.2 Men’s attitudes towards wives’ participation in decision-making Percentage of currently married men age 15-49 who think a wife should have the greater say alone or equal say with her husband on five specific kinds of decisions, by background characteristics, Sierra Leone 2008 Background characteristic Specific decision All five decisions None of the five decisions Number of men Making major household purchases Making purchases for daily household needs Visits to her family or relatives What to do with the money the wife earns How many children to have Age 15-19 * * * * * * * 5 20-24 30.5 58.4 53.9 49.6 53.1 21.3 28.0 79 25-29 38.9 63.6 52.3 56.1 59.0 21.8 17.1 283 30-34 37.4 60.9 52.4 57.4 52.1 25.4 21.3 308 35-39 38.4 59.9 48.8 53.5 55.4 26.1 24.3 479 40-44 50.5 66.8 57.7 63.6 59.9 32.2 15.1 303 45-49 36.9 62.6 56.5 58.7 58.4 26.4 20.7 310 Employment (past 12 months) Not employed (50.2) (60.9) (51.0) (68.2) (66.4) (35.2) (18.2) 39 Employed for cash 45.5 68.7 52.5 61.2 57.7 30.2 19.9 614 Employed, not for cash 36.4 58.9 53.7 54.6 55.8 23.8 20.9 1,108 Number of living children 0 37.5 60.4 54.6 58.7 56.9 24.3 20.6 126 1-2 40.0 63.7 55.2 57.7 57.2 26.6 20.4 583 3-4 45.0 64.4 51.1 60.8 60.7 30.5 19.9 526 5+ 34.7 58.7 52.4 52.2 51.6 21.9 21.8 532 Residence Urban 44.4 66.9 56.7 66.0 63.0 30.2 15.8 517 Rural 37.8 60.2 51.6 53.3 53.9 24.5 22.7 1,250 Region Eastern 49.8 65.1 69.3 68.3 71.2 40.1 18.1 382 Northern 24.7 53.0 44.8 46.1 48.8 12.6 23.3 689 Southern 50.1 66.6 54.5 58.1 54.1 34.9 25.0 388 Western 47.8 73.5 49.5 66.1 58.8 28.3 12.5 308 Education No education 35.2 57.9 50.8 53.8 52.9 24.2 23.9 1,081 Primary 44.1 61.7 53.1 53.7 55.3 26.4 24.1 203 Secondary or higher 48.0 71.9 58.3 65.6 65.3 30.6 12.1 483 Wealth quintile Lowest 40.7 58.3 55.4 55.2 51.9 30.6 27.8 391 Second 34.5 55.6 48.4 51.1 50.2 19.3 25.5 370 Middle 35.5 61.1 53.0 56.0 59.2 21.5 16.3 350 Fourth 41.7 63.9 51.1 55.3 56.8 28.7 19.8 353 Highest 47.4 74.4 58.1 69.7 66.8 31.3 11.7 303 Total 15-49 39.7 62.2 53.1 57.0 56.5 26.2 20.7 1,767 50-59 37.9 54.1 53.9 49.6 50.1 27.3 27.0 310 Total 15-59 39.5 61.0 53.2 55.9 55.6 26.3 21.6 2,077 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. Total includes 6 men with information missing on employment in the past 12 months 15.4 ATTITUDES TOWARD WIFE BEATING The critical problems that women face are many and diverse. One of these, and essentially the most serious, is the issue of violence against women, and Sierra Leone is no exception in this regard. This is a serious issue because it concerns the personal security of women, and the right to personal security is fundamental to all other rights. The attitudes of women and men towards wife beating can be considered a proxy indicator for their attitudes towards domestic violence. All women and men interviewed in the 2008 SLDHS were asked whether a husband is justified in hitting or beating his wife in each of the following five situations: if she burns the food; if she argues with him; if she goes out without telling him; if she neglects the children; and if she refuses to have sexual intercourse with him. A lower score on the ‘number of reasons wife beating is justified’ indicates a woman’s greater sense of entitlement, self-esteem and status, and reflects positively on her sense of empowerment. 244 | Women’s Empowerment and Demographic and Health Outcomes A woman who believes that a husband is justified in hitting or beating his wife, for any of the five specified reasons, may consider herself to be of low status both absolutely and relative to men. Such a perception could act as a barrier to accessing health care for herself and her children, affect her attitude toward contraceptive use, and impact her general well-being. Table 15.6.1 indicates that nearly two-thirds of women age 15-49 (65 percent) believe that a husband is justified in beating his wife for at least one of the specified reasons. The most widely accepted reason for wife beating among women is arguing with the husband (54 percent). Around half of women believe that a husband is justified in beating his wife if she goes out without telling him (50 percent) or neglects the children (49 percent). About four in ten women (39 percent) believe that a husband is justified in hitting or beating his wife if she refuses to have sexual intercourse with him, while one in four feels that burning the food is a justifiable reason for a man to beat his wife. Men age 15-49 are somewhat less likely than women to report that they find physical violence against women justifiable (Table 15.6.2). Overall, 58 percent of Sierra Leonean men agree with at least one of the reasons for why a man is justified in beating his wife. Men are most likely to justify beating a wife if she goes out without telling him (41 percent) and if she neglects the children (40 percent). Like women, men are least likely to say that burning food (16 percent) or refusing to have sex with the husband (23 percent) are grounds for wife beating. More than one-third of men (36 percent) feel that arguing with her husband is a justifiable reason for wife beating. Tables 15.6.1 and 15.6.2 also show attitudes toward wife beating among women and men, respectively, by background characteristics. Women age 35-39 and employed women who do not earn cash are more likely than women from other age groups and employment status to agree with at least one of the specified reasons. Furthermore, women with five or more children and those who are currently in union are more likely than other women to agree with at least one of the reasons for justifying wife hitting or beating. Rural women are more likely than urban women to agree with one or more of the specified reasons that justify wife eating (70 percent versus 56 percent). Among regions, the proportion of women who agree with at least one of the specified reasons is lowest in the Southern Region (52 percent) and highest in the Northern Region (76 percent). The percentage of women who justify wife beating for any of the specified reasons decreases with an increase in the woman’s educational attainment, from 70 percent among women with no education to 49 percent among those with secondary or higher education. The relationship between this indicator and wealth is not linear. However, the percentage of women who agree with one of the specified reasons that justify wife beating is highest among women in the three middle wealth quintiles (68 to 71 percent) and lowest among women in the highest quintile (52 percent). The variation in the attitude of men toward wife beating by background characteristics is similar to women. Men who are employed but do not earn cash, those with five or more children, and men who are currently in union are more likely than other men to agree with at least one specified reason for wife beating. Acceptance of wife beating among men is higher in rural areas and among men in the Northern Region when compared with other men, and it declines as the level of education increases. Looking at wealth quintile, the proportion of men who agree with wife beating is lowest among men in the highest wealth quintile (43 percent). Women’s Empowerment and Demographic and Health Outcomes | 245 Table 15.6.1 Attitude toward wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Sierra Leone 2008 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number of women Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 20.4 42.6 40.4 41.2 27.0 54.6 1,198 20-24 22.2 52.9 48.9 47.5 36.2 64.0 1,186 25-29 26.1 57.2 52.9 53.6 41.7 68.3 1,643 30-34 24.8 52.1 49.0 50.3 40.7 63.0 1,043 35-39 29.2 58.3 54.5 52.1 46.4 70.7 1,131 40-44 23.1 56.1 49.1 49.3 42.3 63.6 652 45-49 24.5 57.3 54.1 52.0 43.8 68.5 520 Employment (past 12 months) Not employed 19.0 42.9 39.9 40.1 26.9 53.2 1,682 Employed for cash 20.9 47.2 46.7 48.7 31.7 61.2 1,330 Employed, not for cash 27.8 59.7 54.6 53.6 46.5 70.4 4,286 Number of living children 0 18.2 42.6 39.4 38.6 26.1 54.0 1,592 1-2 24.0 53.6 49.5 50.4 39.7 64.4 2,639 3-4 28.0 57.3 55.2 53.8 43.9 69.5 1,954 5+ 28.0 61.5 54.7 54.6 48.0 71.1 1,189 Marital status Never married 13.9 35.3 31.0 35.0 17.8 46.1 1,399 Married or living together 27.5 58.5 54.5 53.3 44.9 69.4 5,525 Divorced/separated/widowed 19.3 48.5 48.2 47.6 36.5 62.7 450 Residence Urban 19.0 45.2 41.2 41.9 27.9 55.7 2,655 Rural 27.5 58.1 54.5 53.7 45.6 69.6 4,719 Region Eastern 24.6 55.3 50.1 51.0 44.0 63.7 1,325 Northern 32.4 63.4 61.8 59.4 50.4 75.8 3,001 Southern 14.7 39.8 34.0 35.9 25.9 52.3 1,542 Western 18.6 46.0 41.3 42.0 26.4 55.6 1,506 Education No education 28.0 58.6 54.5 53.4 46.8 69.5 4,860 Primary 23.5 52.0 49.8 49.3 33.8 65.0 960 Secondary or higher 14.0 38.3 34.4 37.1 19.0 48.9 1,554 Wealth quintile Lowest 22.7 54.5 49.5 48.2 44.7 66.4 1,382 Second 28.7 56.4 53.9 53.6 46.0 68.6 1,368 Middle 31.0 60.8 56.4 55.8 47.6 70.8 1,428 Fourth 24.2 56.5 53.4 52.5 37.2 68.0 1,472 Highest 17.3 41.7 37.7 39.3 24.2 51.8 1,723 Total 24.5 53.5 49.7 49.4 39.2 64.6 7,374 Note: Total includes 77 women with information missing on employment in the past 12 months. 246 | Women’s Empowerment and Demographic and Health Outcomes Table 15.6.2 Attitude toward wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Sierra Leone 2008 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number of men Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 21.0 40.3 42.4 38.4 24.6 57.4 526 20-24 15.4 36.3 38.4 40.3 20.8 54.6 403 25-29 13.4 38.0 42.4 45.6 22.8 62.9 446 30-34 13.8 36.0 41.6 41.7 22.8 58.7 373 35-39 14.9 35.7 39.8 37.9 22.5 58.3 525 40-44 12.3 35.4 41.2 39.9 20.2 56.3 336 45-49 16.8 30.9 40.4 37.8 22.6 56.1 335 Employment (past 12 months) Not employed 14.3 28.0 32.6 28.6 17.8 44.5 415 Employed for cash 11.4 28.9 33.1 34.4 15.4 50.5 837 Employed, not for cash 18.1 42.2 46.9 45.9 27.2 65.0 1,680 Number of living children 0 18.5 38.2 40.6 39.1 23.7 56.6 1,137 1-2 13.7 35.0 40.8 39.2 21.4 58.5 715 3-4 10.7 32.1 39.9 41.8 18.8 57.8 551 5+ 17.1 38.9 42.7 42.1 25.1 60.0 541 Marital status Never married 18.5 36.9 40.0 39.3 23.3 55.3 1,085 Married or living together 13.9 36.0 41.6 41.3 21.9 59.5 1,767 Divorced/separated/widowed 14.9 38.4 39.0 29.2 23.7 57.5 92 Residence Urban 10.0 28.7 30.4 30.8 14.5 47.4 1,123 Rural 19.1 41.2 47.4 45.9 27.4 64.4 1,822 Region Eastern 11.1 35.5 42.9 39.5 17.6 58.0 557 Northern 24.8 45.0 49.4 51.3 32.1 68.2 1,131 Southern 11.2 30.2 40.6 30.5 24.3 52.4 617 Western 7.4 28.0 24.6 30.4 8.0 44.9 639 Education No education 18.5 41.0 48.7 46.4 29.2 65.8 1,426 Primary 15.3 38.2 38.0 38.4 19.0 57.5 414 Secondary or higher 12.0 29.9 32.1 32.8 15.1 47.9 1,104 Wealth quintile Lowest 20.1 40.0 48.8 42.7 30.1 64.2 558 Second 21.0 42.3 50.4 48.7 32.2 66.5 520 Middle 15.3 39.3 44.7 45.6 23.8 65.6 530 Fourth 15.4 36.2 39.9 41.1 19.5 56.5 597 Highest 8.8 27.7 26.4 27.6 11.3 42.8 739 Total 15-49 15.6 36.4 40.9 40.2 22.5 57.9 2,944 50-59 14.9 35.2 44.0 39.0 26.3 54.8 336 Total 15-59 15.5 36.3 41.2 40.0 22.9 57.6 3,280 Note: total includes 13 men with information missing on employment in the past 12 months 15.5 ATTITUDES TOWARD REFUSING SEX WITH HUSBAND Women’s sexual empowerment has important implications for demographic and health outcomes such as transmission of HIV and other sexually transmitted infections (STI). It is also an indicator of women’s empowerment overall because it measures women’s level of acceptance of norms in certain societies that socialize them to believe that women do not have the right to refuse sexual intercourse with their husband for any reason. The number of reasons a wife can refuse to have sexual intercourse with her husband reflects perceptions of sexual roles and women’s rights over their bodies, and relates positively to women’s sense of self-esteem. Women’s Empowerment and Demographic and Health Outcomes | 247 To measure beliefs about women’s sexual empowerment, the 2008 SLDHS included questions on whether the respondent thinks that a wife is justified in refusing to have sexual intercourse with her husband under three circumstances: she knows her husband has a sexually transmitted disease; she knows her husband has sexual intercourse with other women; or she is tired or not in the mood. These three circumstances for which women’s opinions are sought have been chosen because they are effective in combining the issues of women’s rights and consequences for women’s health. Tables 15.7.1 and 15.7.2 show the responses of women and men, respectively. Table 15.7.1 Attitudes towards a wife refusing to have sexual intercourse with husband: Women Percentage of all women age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Sierra Leone 2008 Background characteristic Wife is justified in refusing intercourse with her husband if she: Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of women Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Age 15-19 54.4 46.8 53.1 33.8 32.7 1,198 20-24 63.4 52.6 61.1 37.3 22.0 1,186 25-29 63.7 49.2 56.9 33.8 23.9 1,643 30-34 62.8 50.8 57.5 34.8 22.5 1,043 35-39 62.5 49.9 55.8 33.4 24.7 1,131 40-44 65.1 49.2 57.1 33.2 22.3 652 45-49 64.9 49.2 55.4 34.2 24.9 520 Employment (past 12 months) Not employed 60.6 53.9 59.4 40.8 26.7 1,682 Employed for cash 69.5 59.4 66.9 41.3 15.0 1,330 Employed, not for cash 60.6 45.2 52.8 29.9 27.0 4,286 Marital status Never married 61.6 53.6 60.5 41.4 27.2 1,399 Married or living together 61.5 48.1 54.9 32.1 25.0 5,525 Divorced/separated/widowed 69.4 57.7 67.8 41.8 16.4 450 Number of living children 0 58.6 49.0 54.1 35.7 29.8 1,592 1-2 63.6 50.9 58.5 34.8 23.0 2,639 3-4 63.6 50.9 57.9 35.0 22.6 1,954 5+ 60.4 45.9 54.7 31.0 26.3 1,189 Residence Urban 66.2 55.7 63.4 41.8 20.8 2,655 Rural 59.7 46.3 53.0 30.3 27.2 4,719 Region Eastern 63.6 54.3 56.9 35.5 22.7 1,325 Northern 55.7 43.7 48.6 26.9 30.8 3,001 Southern 66.0 50.9 62.5 40.2 23.2 1,542 Western 69.3 56.5 67.1 42.6 16.8 1,506 Education No education 59.4 45.9 52.4 29.5 27.3 4,860 Primary 62.8 50.7 58.2 38.3 24.7 960 Secondary or higher 69.6 61.0 69.6 47.4 17.5 1,554 Wealth quintile Lowest 59.5 46.2 54.1 31.3 28.0 1,382 Second 60.3 46.8 52.8 28.0 25.6 1,368 Middle 57.9 45.0 50.3 29.2 29.4 1,428 Fourth 62.9 49.6 58.1 36.2 24.3 1,472 Highest 68.2 58.9 66.4 44.8 18.6 1,723 Total 62.0 49.7 56.8 34.4 24.9 7,374 Note: Total includes 77 women with information missing on employment in the past 12 months. 248 | Women’s Empowerment and Demographic and Health Outcomes Table 15.7.2 Attitudes towards a wife refusing to have sexual intercourse with husband: Men Percentage of all men age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Sierra Leone 2008 Background characteristic Wife is justified in refusing intercourse with her husband if she: Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of men Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Age 15-19 63.8 51.5 60.1 46.2 30.9 526 20-24 75.4 61.7 71.1 53.8 17.3 403 25-29 74.0 58.8 69.2 50.6 19.9 446 30-34 77.0 57.8 73.6 50.4 16.0 373 35-39 82.4 63.3 78.8 56.0 11.0 525 40-44 84.0 66.3 75.2 58.4 10.4 336 45-49 75.4 61.4 74.6 49.8 13.8 335 Employment (past 12 months) Not employed 71.3 60.5 67.9 54.4 24.9 415 Employed for cash 82.1 69.0 76.2 58.9 10.3 837 Employed, not for cash 73.4 55.1 69.9 48.2 19.5 1,680 Marital status Never married 68.6 55.8 64.3 48.4 25.1 1,085 Married or living together 79.3 61.5 75.5 53.5 13.3 1,767 Divorced/separated/widowed 85.2 70.6 75.9 65.5 13.1 92 Number of living children 0 69.0 54.8 64.0 47.6 24.9 1,137 1-2 78.8 60.9 74.6 52.7 14.3 715 3-4 80.7 61.9 76.1 54.3 12.4 551 5+ 79.9 66.2 77.9 57.9 12.1 541 Residence Urban 80.6 67.6 76.6 60.7 14.3 1,123 Rural 72.5 54.8 68.2 46.6 19.8 1,822 Region Eastern 86.4 52.6 80.9 46.5 7.7 557 Northern 68.1 57.5 64.8 50.9 26.3 1,131 Southern 67.4 52.6 63.2 41.6 20.6 617 Western 87.2 76.7 82.7 68.8 8.1 639 Education No education 73.6 55.6 68.4 47.7 18.9 1,426 Primary 65.5 49.2 64.0 40.8 25.3 414 Secondary or higher 81.9 69.0 78.0 61.8 13.2 1,104 Wealth quintile Lowest 66.4 45.7 62.1 36.6 23.6 558 Second 75.9 58.2 69.3 50.9 17.6 520 Middle 74.5 58.1 70.6 48.8 17.3 530 Fourth 76.4 64.7 75.0 58.2 17.3 597 Highest 82.3 68.5 77.6 61.7 13.8 739 Total 15-49 75.6 59.7 71.4 52.0 17.7 2,944 50-59 80.2 60.4 74.3 54.6 13.2 336 Total 15-59 76.0 59.8 71.7 52.3 17.2 3,280 Note: Total includes 13 men with information missing on employment in the past 12 months. Overall, around one-third of women (34 percent) and half of men (52 percent) agree with all of the specified reasons for a woman to refuse sexual intercourse with her husband. One in four women (25 percent) and one in six men (18 percent) agree with none of the specified reasons. The most accepted reason for refusing to have sex, among both women and men, is if the wife knows her husband has a sexually transmitted disease (62 percent and 76 percent, respectively). For both women and men, the least acceptable reason for a wife to refuse sex is when she knows that her husband has intercourse with other women (50 percent of women and 60 percent of men). Women’s Empowerment and Demographic and Health Outcomes | 249 Among women, those who are employed but not for cash (30 percent), women who are currently in union (32 percent), and those with five or more children (31 percent) are least likely to think that all of the reasons for refusing sex are acceptable. Urban women (42 percent) and those living in the Western (43 percent) and Southern (40 percent) regions are more likely than other women to agree with all the specified reasons. The proportion of women who think that all of the reasons for refusing sex are acceptable is highest among those with secondary or higher education (47 percent) and women in the highest wealth quintile (45 percent). Among men, those in the youngest (15-19 years) age group are somewhat less likely than other men to agree with all of the reasons for a woman to refuse having sexual intercourse with her husband. Similar to women, men employed not for cash are less likely than other men to agree with all of the reasons. Previously married men, those with five or more children, men with secondary or higher education and men in the highest wealth quintile are more likely to agree with all the reasons that justify a woman to refuse having sexual intercourse with her husband. Finally, urban men and those living in the Western Region are considerably more likely to agree with the specified reasons for a woman to refuse sex with her husband than rural men and those living in other regions. Women’s empowerment is closely associated with the support she receives from her husband and family members. The 2008 SLDHS explored men’s attitude toward a husband’s rights when his wife refuses to have sexual intercourse. Men were asked whether, when a wife refuses to have sexual intercourse with him, a husband has a right to get angry and reprimand her, refuse her financial support, use force to have sex, and have sex with another woman. Table 15.7.3 indicates that the majority of men tend to be supportive of women’s interests. Nationally, only 5 percent of men age 15-49 agree with all of the specified husband’s behaviours. Overall, men age 15-24, men who are employed but do not earn cash, never-married men, those with no children, men with primary or no education, and men in the lowest wealth quintile are more likely than other men to agree with all of the specified behaviours that a man has a right to exhibit if his wife refuses to have sex with him. Further, more men in rural areas (6 percent) and those living in the Northern Region (7 percent) agree with all the specified behaviours than men in urban areas or those in other regions. 250 | Women’s Empowerment and Demographic and Health Outcomes Table 15.7.3 Men’s attitudes towards a husband’s rights when his wife refuses to have sexual intercourse Percentage of men age 15-49 who consider that a husband has the right to certain behaviours when his wife refuses to have sex with him when he wants her to, by background characteristics, Sierra Leone 2008 Background characteristic When a woman refuses to have sex with her husband, he has the right to: Percentage who agree with all of the specified behaviours Percentage who agree with none of the specified behaviours Number of men Get angry and reprimand her Refuse her financial support Use force to have sex Have sex with another woman Age 15-19 31.6 19.5 11.7 27.4 6.6 55.6 526 20-24 30.1 18.5 13.0 25.9 6.7 55.8 403 25-29 35.5 21.0 10.3 32.3 4.1 46.5 446 30-34 35.3 16.1 9.7 26.8 3.5 49.4 373 35-39 38.8 19.5 12.5 26.5 4.3 45.1 525 40-44 37.0 16.8 11.8 21.9 3.3 51.5 336 45-49 39.7 18.9 12.8 19.9 3.3 49.7 335 Employment (past 12 months) Not employed 24.2 11.2 5.6 18.6 3.8 67.6 415 Employed for cash 30.3 18.6 9.2 22.0 3.7 57.5 837 Employed, not for cash 40.6 20.9 14.5 30.2 5.4 42.7 1,680 Marital status Never married 31.9 20.3 11.8 28.1 6.6 54.5 1,085 Married or living together 37.0 17.3 11.8 24.7 3.5 48.5 1,767 Divorced/separated/widowed 43.4 29.4 9.5 33.8 4.4 40.0 92 Number of living children 0 32.2 21.1 12.6 27.7 6.7 54.1 1,137 1-2 35.7 16.1 9.0 25.4 3.5 49.7 715 3-4 35.2 16.7 9.4 23.7 2.6 50.6 551 5+ 41.2 19.5 15.7 26.7 4.1 43.5 541 Residence Urban 25.6 12.7 6.5 19.5 2.7 62.1 1,123 Rural 41.3 22.5 14.9 30.4 5.9 43.3 1,822 Region Eastern 53.0 19.9 10.0 22.1 4.7 39.4 557 Northern 36.2 24.5 16.9 29.8 7.1 44.7 1,131 Southern 35.7 18.0 12.9 34.8 4.3 49.3 617 Western 17.8 8.4 2.8 15.2 0.6 71.3 639 Education No education 40.6 22.6 14.7 28.4 5.6 44.5 1,426 Primary 32.3 20.2 12.6 28.8 5.7 50.2 414 Secondary or higher 29.5 13.3 7.4 22.4 3.1 58.2 1,104 Wealth quintile Lowest 39.4 23.8 16.9 30.3 6.9 44.9 558 Second 45.0 22.5 14.3 31.4 5.1 38.2 520 Middle 41.9 21.8 14.1 28.2 4.4 42.8 530 Fourth 32.1 17.2 10.6 27.6 4.9 52.1 597 Highest 23.2 11.5 5.0 17.0 2.7 67.4 739 Total 15-49 35.3 18.8 11.7 26.2 4.7 50.4 2,944 50-59 40.2 20.0 16.5 21.6 6.8 50.4 336 Total 15-59 35.8 18.9 12.2 25.7 4.9 50.4 3,280 Note: Total includes 13 men with information missing on employment in the past 12 months. 15.6 WOMEN’S EMPOWERMENT INDICATORS The three sets of empowerment indicators, namely women’s participation in making household decisions, their attitudes towards wife beating, and their attitudes towards a wife’s right to refuse sexual intercourse with her husband, can be summarized into three separate indices. All three indices are based on women’s responses. The first index shows the number of decisions (see Table 15.5.1 for the list of decisions) in which women participate alone or jointly with their husband/partner. This index ranges in value from 0 to 4 and is positively related to women’s empowerment. It reflects the degree of decision-making control that women are able to exercise in areas that affect their own lives and environments. Women’s Empowerment and Demographic and Health Outcomes | 251 The second index, which ranges in value from 0 to 5, is the total number of reasons (see Table 15.6.1 for the list of reasons) for which the respondent feels that a husband is justified in beating his wife. A lower score on this indicator is interpreted as reflecting a greater sense of entitlement and self- esteem and a higher status of women. The final index, which ranges in value from 0 to 3, is the number of circumstances (see Table 15.7.1 for the list of the circumstances) in which the respondent feels that a woman is justified in refusing sexual intercourse with her husband or partner. This indicator reflects perceptions of sexual roles and women’s rights over their bodies and relates positively to women’s sense of self and empowerment. Table 15.8 shows how these three indicators relate to each other. It gives the percentage of married women age 15-49 who participate in all decision-making, the percentage of women who disagree with all the specified reasons for justifying wife beating, and the percentage of women who agree with all the specified reasons for a wife’s refusing to have intercourse with her husband, by the value on each of the indicators of women’s empowerment. In general, the expectation is that women who participate in making household decisions are more likely to have gender-egalitarian beliefs. The findings indicate that women who participate in three or four of the specified household decisions more often tend to justify their right to refuse sexual intercourse with their husband for all reasons (37 percent) or to disagree with all the reasons for justifying wife beating (34 percent). Similarly, women who do not support wife beating for any reason at all are most likely to participate in all the decision-making in the household (47 percent), although the relationship is not linear with regard to reasons for refusing sexual intercourse with their husband. At the other end of the spectrum, women who agree with all five reasons for wife beating are least likely to participate in all four of the specified decisions and least likely to agree with all reasons justifying refusing the husband sex. The three empowerment indicators are not consistently related to each other. In particular, women’s attitude toward refusing sexual intercourse with their husband and women’s participation in decision-making, and their attitude toward wife beating do not bear the expected negative relationship. For example, women who agree with all three reasons for refusing the husband sex are just slightly more likely to participate in all four decisions (47 percent) than women who agree with none of the reasons refusing sexual intercourse with their husband (45 percent). Further, women who agree with all reasons justifying refusing the husband sex are slightly less likely to disagree with all the reasons for wife beating (40 percent) compared with women who agree with none of reasons for refusing sexual intercourse with their husband (45 percent). 252 | Women’s Empowerment and Demographic and Health Outcomes Table 15.8 Indicators of women’s empowerment Percentage of women age 15-49 who participate in all decision-making, percentage who disagree with all of the reasons justifying wife beating, and percentage who agree with all the reasons for refusing sexual intercourse with husband, by value on each of the indicators of women’s empowerment, Sierra Leone 2008 Empowerment indicator Currently married women Percentage who disagree with all the reasons justifying wife beating Percentage who agree with all the reasons for refusing sexual intercourse with husband Number of women Percentage who participate in all decision- making1 Number of women Number of decisions in which women participate1 0 na na 28.4 23.4 1,479 1-2 na na 24.9 31.2 1,298 3-4 na na 34.4 37.1 2,748 Number of reasons for which wife beating is justified2 0 47.2 1,690 na 38.5 2,611 1-2 40.0 1,066 na 35.5 1,430 3-4 36.5 1,538 na 38.7 1,907 5 33.1 1,232 na 20.1 1,425 Number of reasons given for refusing to have sexual intercourse with husband3 0 45.4 1,382 44.6 na 1,835 1-2 31.0 2,372 26.3 na 3,001 3 46.9 1,771 39.6 na 2,538 1 Restricted to currently married women. See Table 15.5.1 for the list of decisions. na = Not applicable 2 See Table 15.6.1 for the list of reasons. 3 See Table 15.7.1 for the list of reasons. 15.7 CURRENT USE OF CONTRACEPTION BY WOMEN’S STATUS A woman’s desire and ability to control her fertility and her choice of contraceptive method are in part affected by her status in the household and her own sense of empowerment. A woman who feels that she is unable to control her life may be less likely to feel she can make and carry out decisions about her fertility. She may also feel the need to choose methods that are less obvious or which do not depend on her husband’s cooperation. Table 15.9 shows the distribution of currently married women by contraceptive method use, according to the three empowerment indicators. The data indicate that there is a positive relationship between use of contraception and participation in household decision-making. For example, current use of modern contraceptive methods rises from 5 percent among women who participate in none of the household decisions to 8 percent among women who participate in one or more household decisions. Also noteworthy is the finding that women who believe that wife beating is justified for all of the five specified reasons are least likely to use a method of contraception. A similar association is seen between contraceptive use and a woman’s rights to refuse sexual intercourse with her husband. Women who agree with all three reasons for a woman to refuse intercourse with her husband are more likely to use any contraception and any modern contraception than other women. Women’s Empowerment and Demographic and Health Outcomes | 253 Table 15.9 Current use of contraception by women’s empowerment Among currently married women age 15-49, percentage using any method of contraception, percentage using any modern method, and percent distribution by contraceptive method currently used, according to indicators of women’s empowerment, Sierra Leone 2008 Empowerment indicator Any method Any modern method Modern methods Any traditional method Not using any method Total Number of women Female sterili- zation Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 5.4 4.8 0.1 4.1 0.7 0.7 94.6 100.0 1,479 1-2 7.0 5.6 0.0 5.0 0.6 1.5 93.0 100.0 1,298 3-4 10.2 8.4 0.0 7.8 0.6 1.9 89.8 100.0 2,748 Number of reasons for which wife beating is justified3 0 10.4 9.0 0.0 7.9 1.1 1.4 89.6 100.0 1,690 1-2 7.8 6.2 0.1 5.9 0.2 1.6 92.2 100.0 1,066 3-4 7.7 6.0 0.0 5.3 0.7 1.7 92.3 100.0 1,538 5 6.2 5.0 0.0 4.9 0.0 1.2 93.8 100.0 1,232 Number of reasons given for refusing to have sexual intercourse with husband4 0 5.2 4.2 0.0 3.8 0.4 0.9 94.8 100.0 1,382 1-2 7.5 5.8 0.0 5.3 0.4 1.8 92.5 100.0 2,372 3 11.5 10.0 0.0 9.1 1.0 1.4 88.5 100.0 1,771 Total 8.2 6.7 0.0 6.1 0.6 1.5 91.8 100.0 5,525 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly and lactational amenorrhoea method 2 See Table 15.5.1 for the list of decisions. 3 See Table 15.6.1 for the list of reasons 4 See Table 15.7.1 for the list of reasons 15.8 REPRODUCTIVE HEALTH CARE BY WOMEN’S STATUS Table 15.10 shows women’s use of antenatal, delivery, and postnatal care services by the three indicators of women’s empowerment. In societies where health care is widespread, women’s empowerment may not affect their access to reproductive health services. In other societies, however, increased empowerment of women is likely to increase their ability to seek out and use health services to better meet their own reproductive health goals, including the goal of safe motherhood. The data indicate that there is a correlation between women’s status, as measured by the number of reasons wife beating is justified, and utilization of health services. Women who believe that wife beating is justified for five reasons are less likely to receive maternity care services than women who believe that wife beating is justified for 1-2 reasons or not at all. Similarly, utilization of maternal and reproductive health services is highest among women who agree with all 3 reasons for a woman to refuse sexual intercourse with her husband than women who agree with none or 1-2 reasons. The relationship between number of household decisions in which a woman participates and utilization of health care is less clear. 254 | Women’s Empowerment and Demographic and Health Outcomes Table 15.10 Reproductive health care by women’s empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance and postnatal care from health personnel for the most recent birth, by indicators of women’s empowerment, Sierra Leone 2008 Empowerment indicator Received antenatal care from health personnel Received delivery assistance from health personnel Received postnatal care from health personnel in the two days following delivery1 Number of women with a child born in the past five years Number of decisions in which women participate2 0 82.2 44.8 35.6 936 1-2 86.5 40.6 36.0 896 3-4 88.6 42.4 36.1 1,760 Number of reasons for which wife beating is justified3 0 87.9 51.3 42.2 1,284 1-2 88.4 46.5 34.4 776 3-4 86.0 41.3 38.9 1,142 5 85.4 36.3 31.7 901 Number of reasons given for refusing to have sexual intercourse with husband4 0 83.2 37.0 26.8 996 1-2 86.4 45.9 39.3 1,735 3 90.2 47.6 42.9 1,372 Total 86.9 44.3 37.5 4,103 Note: ‘Health personnel’ includes doctor, nurse, midwife, or MCH aid. 1 Includes deliveries in a health facility and not in a health facility 2 Restricted to currently married women. See Table 15.5.1 for the list of decisions. 3 See Table 15.6.1 for the list of reasons. 4 See Table 15.7.1 for the list of reasons. Female Circumcision | 255 FEMALE CIRCUMCISION 16 Female Circumcision (FC), also known as Female Genital Cutting (FGC) or Female Genital Mutilation (FGM), is prevalent in Sierra Leone and many other countries in East and West Africa. Nearly universal in a few countries, it is practiced by various groups in at least 25 African countries, in Yemen, and in some immigrant African populations in Europe and North America. In a few societies, the procedure is routinely carried out when a girl is a few weeks or a few months old (e.g. Eritrea, Yemen), while in most others, it occurs later in childhood or adolescence. In the case of the latter, FGC may be part of a ritual initiation into womanhood that includes a period of seclusion and education about the rights and duties of a wife. In many countries, however, the ritual or ceremonial elements that accompany female circumcision are decreasing in importance. In Sierra Leone, female circumcision is part of the initiation rites into the Bondo or Sande secret societies for women. Girls are taken to the bush where they are taught local customs, sex education, feminine hygiene, housekeeping, and childrearing skills. As part of this rite of passage to womanhood, girls undergo FGC, which in Sierra Leone usually consists of removing all or part of the clitoris. The 2008 Sierra Leone Demographic and Health Survey (SLDHS) collected data on the practice of female circumcision in Sierra Leone. The Women’s Questionnaire included a series of questions on FGC; fewer questions on the topic were included in the Men’s Questionnaire. All female respondents were asked whether they had heard of the Bondo, Sande, or other secret societies, or female circumcision. Women who had heard of a secret society or female circumcision were asked whether they had been initiated/circumcised. Those who had been circumcised were asked what age they were at the time of circumcision, what type of circumcision was performed, who performed the operation, and a series of questions about their opinions regarding the practice. Respondents were asked whether they had a daughter who was circumcised and, if so, the type of circumcision and age at circumcision of the daughter. Both women and men were asked about the perceived benefits of girls undergoing female circumcision and the whether they thought that the practice was required by their religion. The responses were aggregated by background characteristics. In this chapter, topics discussed include knowledge, prevalence, and type of circumcision; age at circumcision; person who performed the circumcision; and attitudes towards the practice. 16.1 KNOWLEDGE AND PREVALENCE OF FEMALE CIRCUMCISION Knowledge of female circumcision in Sierra Leone is universally high (Table 6.1). Almost all (99 percent) of Sierra Leonean women age 15-49 and 96 percent of men age 15-49 have heard of the practice. There are no substantial variations in knowledge of FGC by residence, region, education, and wealth status. The youngest cohort of men (age 15-19) showed a slightly lower level of knowledge of female circumcision (92 percent). Table 16.1 also shows the prevalence of female circumcision by background characteristics. In general, the differentials are similar to those for knowledge of female circumcision. The prevalence of female circumcision is universally high (95-96 percent) among women age 25-49. Prevalence is lower among women in the younger cohorts: 89 percent for women age 20-24 and 76 percent for women age 15-19. Prevalence is highest in the Northern Region (97 percent) and lowest in the Western Region (80 percent); it is higher in rural areas (95 percent) than in urban areas (85 percent). Women with the most education and those in wealthier households are less likely to be circumcised than those with less education and those who live in poorer households. 256 | Female Circumcision Table 16.1 Knowledge and prevalence of female circumcision Percentage of men and women who have heard of female circumcision, percentage of women circumcised, and the percent distribution of circumcised women by type of circumcision, according to background characteristics, Sierra Leone 2008 Background characteristic Percentage of men who have heard of female circumcision Number of men Percentage of women who have heard of female circumcision Percentage of women circumcised Number of women Type of circumcision Number of women Cut, flesh removed Nicked, no flesh removed Genital area sewn closed Not deter- mined Age 15-19 91.2 526 98.2 75.5 1,198 81.1 2.4 2.2 14.3 904 20-24 96.7 403 99.1 89.4 1,186 82.3 1.9 2.3 13.5 1,060 25-29 97.1 446 99.0 95.2 1,643 83.2 2.6 2.1 12.1 1,565 30-34 97.1 373 99.0 94.9 1,043 81.6 3.8 3.0 11.6 990 35-39 97.2 525 99.1 96.4 1,131 81.6 3.3 3.2 12.0 1,091 40-44 98.7 336 99.7 96.1 652 81.2 4.5 2.5 11.7 627 45-49 93.7 335 98.0 95.9 520 82.3 5.6 3.5 8.6 498 Residence Urban 95.9 1,123 99.1 84.5 2,655 83.6 0.9 1.7 13.8 2,244 Rural 95.8 1,822 98.8 95.2 4,719 81.3 4.3 3.0 11.4 4,491 Region Eastern 95.8 557 98.7 92.1 1,325 89.6 0.9 3.3 6.2 1,220 Northern 95.4 1,131 99.0 97.0 3,001 80.3 0.3 2.2 17.2 2,910 Southern 95.2 617 98.8 91.2 1,542 77.8 12.7 3.5 5.9 1,406 Western 97.0 639 98.9 79.6 1,506 83.4 1.2 1.8 13.7 1,199 Education No education 95.8 1,426 98.9 96.5 4,860 81.9 3.4 2.8 11.9 4,692 Primary 92.5 414 98.3 87.1 960 83.9 3.1 2.3 10.8 836 Secondary or higher 97.1 1,104 99.2 77.7 1,554 81.2 2.3 2.1 14.5 1,207 Ethnic group Temne 97.1 1,060 99.3 95.2 2,564 81.9 1.2 2.1 14.8 2,440 Mende 94.2 901 98.7 90.0 2,331 83.1 6.2 3.5 7.1 2,098 Other 95.8 984 98.7 88.6 2,479 81.1 2.4 2.3 14.2 2,197 Religion Christian 97.4 642 98.8 79.9 1,625 83.2 3.0 2.4 11.4 1,299 Muslim 95.3 2,289 98.9 94.6 5,665 81.7 3.1 2.7 12.5 5,358 Other * 14 99.7 93.7 84 86.3 7.6 0.0 6.1 79 Wealth quintile Lowest 95.8 558 98.9 95.4 1,382 82.0 6.6 2.7 8.7 1,318 Second 93.2 520 98.6 95.1 1,368 83.8 3.6 3.1 9.5 1,302 Middle 98.0 530 98.6 95.3 1,428 81.9 1.8 4.3 12.0 1,361 Fourth 94.5 597 99.3 92.2 1,472 80.5 2.8 1.5 15.2 1,357 Highest 97.1 739 99.0 81.1 1,723 82.0 1.2 1.4 15.4 1,397 Total 15-49 95.8 2,944 98.9 91.3 7,374 82.0 3.2 2.6 12.2 6,735 50-59 94.8 336 na na na na na na na na Total 15-59 95.7 3,280 na na na na na na na na Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 16.2 FLESH REMOVAL AND INFIBULATION Women who reported that they had been circumcised were asked questions aimed at determining the type of circumcision received. Table 16.1 shows that most women (82 percent) reported that their circumcision involved both cutting and removal of flesh; 3 percent said they were nicked but no flesh was removed, and 3 percent said that their vagina was sewn closed during circumcision (infibulation). Infibulation is the most radical procedure reported. The differentials for infibulation do not vary much by region or other background characteristics. Type of circumcision could not be determined for 12 percent of the women who did not know what had been done to them during circumcision. Female Circumcision | 257 16.3 AGE AT CIRCUMCISION The percent distribution of women by age at circumcision is presented in Table 16.2. One of the possible answers to the question about age at circumcision was ‘during infancy,’ which most likely refers to girls less than two years old (non-numerical answer). Twenty-two percent of women said they had been cut during infancy, and another 1 percent fit into the category of less than four years old. Therefore, 23 percent of women in Sierra Leone were circumcised before their fifth birthday. Circumcision is most common at age 10-14 (36 percent); 19 percent of women were age 15 or older when circumcised; and 9 percent of women did not know their age at the time of circumcision. Table 16.2 Age at circumcision Percent distribution of women who have been circumcised by age at circumcision, according to background characteristics, Sierra Leone 2008 Background characteristic Age at circumcision in years Total Number of women During infancy 0-1 2-4 5-9 10-14 15+ Don’t know Age 15-19 19.6 0.2 1.2 13.6 40.7 19.1 5.6 100.0 904 20-24 24.1 0.2 1.0 15.4 31.6 20.2 7.6 100.0 1,060 25-29 22.9 0.0 1.2 15.6 33.0 17.7 9.7 100.0 1,565 30-34 20.8 0.1 0.7 11.9 37.8 17.9 10.8 100.0 990 35-39 21.2 0.0 0.7 12.5 38.4 18.1 9.1 100.0 1,091 40-44 24.1 0.0 0.6 8.3 33.6 23.0 10.4 100.0 627 45-49 23.4 0.2 0.3 8.7 35.0 20.2 12.2 100.0 498 Residence Urban 16.9 0.1 1.5 15.7 34.5 24.2 7.0 100.0 2,244 Rural 24.9 0.1 0.6 11.7 36.1 16.5 10.2 100.0 4,491 Region Eastern 16.7 0.1 0.3 14.1 40.7 24.8 3.3 100.0 1,220 Northern 29.0 0.1 0.9 14.1 34.2 9.5 12.1 100.0 2,910 Southern 17.6 0.1 0.3 7.1 35.9 28.2 10.9 100.0 1,406 Western 16.7 0.2 2.0 16.3 33.3 25.6 5.9 100.0 1,199 Education No education 24.8 0.1 0.8 12.3 35.7 15.6 10.7 100.0 4,692 Primary 20.0 0.1 0.9 13.1 34.9 24.3 6.7 100.0 836 Secondary or higher 13.7 0.2 1.0 15.8 35.5 28.9 4.8 100.0 1,207 Ethnic group Temne 29.3 0.0 1.0 14.3 32.7 12.7 10.0 100.0 2,440 Mende 16.6 0.0 0.3 8.0 35.8 30.9 8.3 100.0 2,098 Other 19.7 0.3 1.3 16.4 38.6 14.8 9.0 100.0 2,197 Religion Christian 16.8 0.1 0.5 13.0 37.2 24.9 7.5 100.0 1,299 Muslim 23.4 0.1 1.0 13.1 35.2 17.7 9.5 100.0 5,358 Other 28.5 0.0 0.0 12.7 33.0 11.9 13.8 100.0 79 Wealth quintile Lowest 23.1 0.1 0.3 9.8 37.9 19.3 9.5 100.0 1,318 Second 24.4 0.1 0.8 12.2 34.8 15.8 12.0 100.0 1,302 Middle 25.3 0.1 1.1 14.0 34.0 14.0 11.5 100.0 1,361 Fourth 22.7 0.1 0.7 12.5 37.4 18.6 8.0 100.0 1,357 Highest 15.7 0.2 1.5 16.5 33.9 27.2 5.0 100.0 1,397 Total 22.2 0.1 0.9 13.0 35.6 19.1 9.1 100.0 6,735 There are marked variations in the proportions of women circumcised in infancy by residence and ethnicity. For instance, 29 percent of the Temne were circumcised during infancy, compared with 17 percent of the Mende and 20 percent of those in other ethnic groups. Similarly, among the Mende, 31 percent of girls were cut at age 15 or above, while among the Temne, that figure is 13 percent. 258 | Female Circumcision 16.4 PERSON PERFORMING CIRCUMCISION Table 16.3 shows that almost all of the women were circumcised by traditional circumcisers (95 percent), with no difference by the type of circumcision. It should be noted that only a negligible proportion of circumcisions were performed by a trained health professional (0.3 percent). Four percent of women reported that they did not know who performed their circumcision. This lack of knowledge is probably due to the young age at which many girls are circumcised; it is likely they were too young to remember the details of the operation. Table 16.3 Person performing circumcision Percent distribution of women who have been circumcised by person performing the circumcision, according to type of circumcision, Sierra Leone 2008 Person performing circumcision Type of circumcision Total Cut, flesh removed Genital area nicked Genital area sewn closed Not determined Health professional 0.3 0.0 0.8 0.0 0.3 Doctor 0.1 0.0 0.8 0.0 0.1 Trained nurse/midwife 0.3 0.0 0.0 0.0 0.2 Traditional practitioner 96.9 97.9 97.1 85.2 95.5 Traditional ‘circumciser’ 96.2 96.8 95.8 84.7 94.8 Traditional birth attendant 0.5 1.1 1.3 0.2 0.5 Other traditional 0.2 0.0 0.0 0.3 0.2 Don’t know/missing 2.7 2.1 2.1 14.7 4.2 Total 100.0 100.0 100.0 100.0 100.0 Number of women 5,525 213 175 822 6,735 16.5 CIRCUMCISION OF DAUGHTERS Women interviewed in the 2008 SLDHS who had living daughters were asked if any of their daughters had been circumcised, and if not, whether they intended to have a daughter circumcised. Table 16.4 shows that about one-third (33 percent) of women have at least one circumcised daughter and more than half (52 percent) intend to have a daughter circumcised. Just 9 percent of women do not intend to have a daughter circumcised in the future. The proportion of women who have at least one daughter circumcised increases with age because daughters of older women are more likely to have reached the age considered appropriate for circumcision. The proportion of mothers with at least one daughter circumcised varies by residence and ethnicity: women in rural areas, those in the Northern Region, and the Temne age the most likely to have daughters circumcised. Women with secondary or higher education and those in the highest wealth quintile are least likely to have circumcised daughters or to intend to have their daughters circumcised, compared with women with no education and those in the lower wealth quintiles. Table 6.4 shows wide variation in the proportion of women (with daughters) who say they do not intend to have their daughters circumcised, although they remain in the minority. Twenty-seven percent of Christians, compared with 4 percent of Muslims, do not intend to have their daughters circumcised, and 20 percent of urban women, compared with 4 percent of rural women, do not plan to have their daughters circumcised. By region, 27 percent of women in the Western Region, compared with 4 percent in the Northern Region, do not intend to have their daughters circumcised. Additionally, women’s education is a strong indicator of intention: 34 percent of women with secondary or higher education do not want their daughters to be circumcised, compared with 4 percent of women with no education. Likewise, 27 percent of women in households in the highest wealth quintile, compared with 3 percent of those in the lowest wealth quintile, do not intend to have their daughters circumcised. Female Circumcision | 259 Table 16.4 Practice of female circumcision among respondent’s daughters Percent distribution of women with daughters by whether they have at least one daughter circumcised or by whether or not they intend to have daughter(s) circumcised, according to circumcision status of mother and background characteristics, Sierra Leone 2008 Background characteristic Among women with at least one daughter, percentage: Total Number of women with daughter(s) With at least one daughter circumcised Who intend to have daughter(s) circumcised Who do not intend to have daughter(s) circumcised Not determined Who do not know circumcision Circumcision status of woman Never heard of circumcision (0.0) (0.0) (0.0) (0.0) 100.0 100.0 40 Circumcised 33.7 54.0 7.0 5.3 0.0 100.0 4,402 Not circumcised 5.6 14.7 66.1 13.7 0.0 100.0 148 Age 15-19 0.4 76.5 10.9 10.4 1.8 100.0 155 20-24 6.8 73.3 12.4 6.7 0.8 100.0 549 25-29 12.4 71.2 8.6 7.0 0.8 100.0 1,107 30-34 26.6 54.1 11.8 6.7 0.9 100.0 814 35-39 44.2 43.7 7.7 3.7 0.8 100.0 939 40-44 60.7 28.1 7.3 3.4 0.4 100.0 575 45-49 74.6 16.8 3.7 3.2 1.7 100.0 451 Residence Urban 28.5 42.6 20.3 7.9 0.6 100.0 1,405 Rural 34.3 56.5 3.8 4.5 1.0 100.0 3,185 Region Eastern 26.0 59.6 8.9 4.2 1.3 100.0 847 Northern 40.1 52.0 3.8 3.3 0.9 100.0 2,002 Southern 27.0 60.0 4.5 8.0 0.6 100.0 949 Western 26.9 35.6 27.0 9.6 0.8 100.0 793 Education No education 35.5 54.5 4.2 5.0 0.8 100.0 3,448 Primary 22.3 57.9 10.6 7.4 1.8 100.0 521 Secondary or higher 24.6 34.7 33.6 6.8 0.3 100.0 622 Ethnic group Temne 39.7 50.0 5.8 4.2 0.4 100.0 1,667 Mende 25.6 60.5 6.9 6.2 0.8 100.0 1,439 Other 31.2 46.7 14.2 6.4 1.5 100.0 1,484 Religion Christian 20.8 43.5 27.2 7.4 1.1 100.0 917 Muslim 35.6 54.3 4.3 5.0 0.8 100.0 3,628 Other (22.9) (66.1) (1.8) (8.7) (0.5) 100.0 45 Wealth quintile Lowest 30.4 59.2 3.3 5.6 1.5 100.0 920 Second 34.3 57.0 4.2 3.6 0.9 100.0 964 Middle 34.8 54.6 4.1 5.9 0.7 100.0 942 Fourth 34.6 51.3 7.7 5.8 0.6 100.0 898 Highest 28.1 37.9 26.5 6.9 0.6 100.0 867 Total 32.5 52.2 8.9 5.5 0.9 100.0 4,590 Note: Figures in parentheses are based on 25 to 49 unweighted cases. Table 16.5 shows the percent distribution of most recently circumcised daughters by type of circumcision. The results show that circumcision involving the cutting and removal of flesh is the most common practice in Sierra Leone, accounting for 78 percent of all circumcisions; 3 percent of circumcised daughters had no flesh removed, and 6 percent were infibulated. Infibulation, while not prevalent, occurs most frequently in the Southern Region (8 percent) and least frequently in the Western Region (3 percent). A total of 13 percent of mothers did not know what had been done to their daughters. 260 | Female Circumcision Table 16.5 Type of female circumcision among daughters Percent distribution of most recently circumcised daughters by type of circumcision, according to circumcision status of mother and background characteristics, Sierra Leone 2008 Background characteristic Type of circumcision Total Number of daughters circumcised Flesh removed Genital area nicked Genital area sewn closed Don’t know Circumcision status of mother Flesh removed 92.3 0.4 4.4 3.0 100.0 1,197 Genital area nicked 10.3 78.7 0.1 10.9 100.0 50 Genital area sewn closed (32.3) (0.0) (59.0) (8.7) 100.0 57 Don’t know 19.1 0.7 0.9 79.3 100.0 187 Age 15-24 (71.7) (0.0) (14.2) (14.2) 100.0 38 25-29 76.8 0.8 10.1 12.3 100.0 137 30-34 75.1 2.7 6.8 15.4 100.0 216 35-39 78.4 1.9 5.1 14.6 100.0 415 40-44 77.8 3.2 5.9 13.1 100.0 349 45-49 81.1 5.7 3.6 9.5 100.0 337 Residence Urban 83.0 0.5 3.7 12.7 100.0 401 Rural 76.2 4.0 6.7 13.1 100.0 1,092 Region Eastern 86.7 1.8 6.7 4.8 100.0 220 Northern 78.7 0.1 5.8 15.4 100.0 803 Southern 67.3 15.0 8.3 9.4 100.0 256 Western 79.5 1.0 2.7 16.8 100.0 213 Education No education 78.2 3.2 5.8 12.8 100.0 1,223 Primary 82.1 1.6 3.3 13.0 100.0 116 Secondary or higher 73.8 2.5 8.7 15.0 100.0 153 Ethnic group Temne 80.0 0.7 6.0 13.3 100.0 661 Mende 76.2 7.5 8.3 8.0 100.0 368 Other 76.7 2.8 3.8 16.7 100.0 463 Religion Christian 76.2 5.7 5.7 12.5 100.0 190 Muslim 78.5 2.6 5.9 13.0 100.0 1,292 Other * * * * 100.0 10 Wealth quintile Lowest 81.1 5.2 5.2 8.4 100.0 280 Second 75.0 5.5 8.2 11.3 100.0 331 Middle 77.5 1.7 7.0 13.7 100.0 327 Fourth 79.0 1.8 3.3 15.9 100.0 311 Highest 78.2 0.5 5.3 16.0 100.0 244 Total 78.0 3.0 5.9 13.0 100.0 1,492 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. Table 16.6 shows that among most recently circumcised daughters, 19 percent were circumcised during infancy and 9 percent were circumcised between the ages of 1 and 4 years. Thus, 28 percent of daughters were cut before the age of five. The majority (67 percent) were circumcised after their fifth birthday, with 58 percent circumcised between the ages of 5 and 14. Circumcision is rarely performed by a trained health professional (0.4 percent). Traditional circumcisers carried out 97 percent of circumcisions (data not shown). Female Circumcision | 261 Table 16.6 Daughter’s age at circumcision Percent distribution of most recently circumcised daughters by age of daughter at the time of circumcision, according to background characteristics, Sierra Leone 2008 Background characteristic Age at circumcision in years Total Number of daughters circumcised During infancy 0-1 2-4 5-9 10-14 15+ Not deter- mined Age of respondent 15-24 (38.7) (9.0) (14.2) (27.0) (0.0) (0.0) (11.0) 100.0 38 25-29 18.5 4.2 16.9 44.4 8.2 1.1 6.7 100.0 137 30-34 15.0 3.8 13.6 36.2 20.0 1.6 9.8 100.0 216 35-39 21.0 1.1 8.6 28.3 27.0 9.0 5.0 100.0 415 40-44 20.4 0.0 2.9 26.7 29.8 14.4 5.8 100.0 349 45-49 13.7 0.4 1.7 33.5 34.9 12.5 3.4 100.0 337 Residence Urban 13.1 1.3 7.1 32.7 25.9 12.4 7.4 100.0 401 Rural 20.6 1.7 7.4 31.3 26.0 7.8 5.3 100.0 1,092 Region Eastern 10.7 1.3 3.9 28.9 37.7 14.3 3.2 100.0 220 Northern 24.4 2.1 7.2 34.8 20.5 4.5 6.5 100.0 803 Southern 11.3 0.0 8.8 26.1 33.5 16.7 3.6 100.0 256 Western 13.5 1.5 9.8 29.5 25.6 11.5 8.7 100.0 213 Education No education 20.7 1.3 7.5 30.7 25.6 7.9 6.2 100.0 1,223 Primary 9.0 0.9 5.2 39.2 25.9 15.6 4.2 100.0 116 Secondary or higher 8.6 4.0 7.6 33.4 29.6 12.7 4.1 100.0 153 Ethnic group Temne 25.2 1.5 8.9 33.8 18.2 5.6 6.8 100.0 661 Mende 11.9 0.7 6.0 23.3 36.8 17.6 3.7 100.0 368 Other 14.4 2.3 6.1 35.3 28.6 7.1 6.2 100.0 463 Religion Christian 12.0 3.4 4.1 29.8 30.8 16.2 3.7 100.0 190 Muslim 19.4 1.2 7.8 32.1 25.4 7.9 6.2 100.0 1,292 Other * * * * * * * 100.0 10 Wealth quintile Lowest 22.7 0.5 7.2 31.5 23.3 10.2 4.7 100.0 280 Second 21.9 3.4 9.2 25.5 25.6 8.8 5.7 100.0 331 Middle 19.2 0.5 4.5 37.1 25.4 6.0 7.2 100.0 327 Fourth 17.9 1.4 9.8 31.5 29.5 6.7 3.3 100.0 311 Highest 9.3 1.9 5.7 33.3 26.0 15.0 8.8 100.0 244 Total 18.6 1.6 7.3 31.7 26.0 9.0 5.8 100.0 1,492 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. 16.6 PERCEIVED BENEFITS OF UNDERGOING FEMALE CIRCUMCISION In the 2008 SLDHS, women and men were asked about the benefits to girls themselves if they undergo circumcision. Respondents were able to cite more than one benefit if they wished. Social acceptance was the most common response given; it was cited by 55 percent of women and 40 percent of men in the survey (Tables 16.7.1 and 16.7.2). Cleanliness/hygiene was given as a benefit of female circumcision by 22 percent of women and 23 percent of men. An additional 19 percent of women and 17 percent of men said that a circumcised female would have better marriage prospects. On the other hand, more than one-third of men age 15-49 (37 percent) and 25 percent of women reported that there were no benefits from female circumcision. 262 | Female Circumcision Table 16.7.1 Perceived benefits of female circumcision: Women Among women who have heard of female circumcision, percentage who report specific benefits of the practice for girls, by circumcision status of mother and background characteristics, Sierra Leone 2008 Background characteristic Perceived benefits of female circumcision Number of women who have heard of female circumcision No benefits Cleanliness/ hygiene Social acceptance Better marriage prospects Preserve virginity More sexual pleasure for the man Religious approval Other Type of circumcision of the mother Cut, flesh removed 23.2 22.7 57.7 18.8 8.7 1.5 4.6 12.8 5,525 Genital area nicked 13.9 10.3 72.0 7.2 5.0 0.0 0.1 9.8 213 Genital area sewn closed 22.1 32.0 63.1 39.0 19.1 2.2 3.6 2.1 175 Type not known 35.2 18.7 41.9 17.3 6.7 0.7 5.1 17.2 1,380 Age 15-19 35.2 19.1 44.5 12.7 7.3 0.8 3.9 11.7 1,176 20-24 30.7 20.2 50.1 18.3 6.7 1.9 4.0 12.1 1,176 25-29 23.4 20.6 58.7 18.8 8.4 1.2 4.3 13.2 1,627 30-34 25.8 22.5 55.3 18.1 8.4 0.8 5.5 13.2 1,033 35-39 19.4 24.3 60.3 21.5 10.1 1.7 4.4 14.1 1,121 40-44 19.2 24.9 60.5 21.5 11.5 1.2 5.7 13.4 650 45-49 14.3 24.3 63.4 24.1 8.0 1.3 4.9 17.9 509 Residence Urban 41.0 17.0 38.9 7.9 6.9 0.6 2.7 13.0 2,632 Rural 16.3 24.5 64.5 24.7 9.3 1.6 5.6 13.4 4,660 Region Eastern 26.8 23.6 57.4 22.1 11.4 1.0 9.2 1.7 1,307 Northern 15.6 20.6 65.6 22.0 6.5 0.9 2.4 18.4 2,973 Southern 20.1 27.4 55.8 24.6 12.2 3.0 7.3 13.5 1,523 Western 48.0 16.8 32.3 2.9 5.9 0.5 1.8 13.0 1,490 Education No education 16.5 24.6 63.8 23.3 9.3 1.5 5.2 13.7 4,808 Primary 32.7 18.3 49.2 14.0 7.1 0.8 4.8 12.7 943 Secondary or higher 47.8 15.0 32.2 7.0 6.6 0.9 2.4 12.3 1,541 Ethnic group Temne 22.8 17.3 59.7 16.0 3.5 0.5 1.5 17.4 2,546 Mende 21.7 29.5 56.0 25.7 13.4 2.5 9.5 9.7 2,301 Other 30.9 19.2 50.1 14.8 8.9 1.0 3.0 12.4 2,446 Religion Christian 42.6 15.5 41.1 12.0 7.4 1.3 1.3 11.5 1,606 Muslim 20.4 23.5 59.1 20.7 8.7 1.3 5.5 13.8 5,603 Other 14.4 28.1 73.7 13.0 8.5 0.0 0.8 13.6 84 Wealth quintile Lowest 18.6 28.2 65.4 24.4 9.6 2.1 7.0 10.5 1,367 Second 13.7 27.1 65.3 25.9 9.1 2.0 6.4 14.3 1,349 Middle 18.4 18.9 63.7 23.2 9.3 1.2 4.4 12.3 1,408 Fourth 25.0 21.2 53.2 16.5 7.0 0.8 3.7 15.7 1,462 Highest 45.3 15.4 34.1 6.4 7.6 0.5 1.9 13.4 1,707 Total 25.2 21.8 55.3 18.7 8.5 1.3 4.5 13.3 7,292 Maintaining virginity before marriage was cited as a benefit of female circumcision by only 9 percent of women and 8 percent of men. Interestingly, the maintenance of virginity to prevent premarital sex has always been the third or fourth most frequently cited benefit of female circumcision in many African countries, except for Niger (Yoder et al., 2004). It should be noted that just 4 percent of men cited greater sexual pleasure for the man as a perceived benefit of female circumcision, and among women this was the least cited benefit (1 percent). These low figures are not surprising, given that the question asks about the benefits for ‘girls themselves.’ Religious approval is cited by 5 percent of women, while among men this is the least cited benefit of female circumcision Female Circumcision | 263 Table 16.7.2 Perceived benefits of female circumcision: Men Among men who have heard of female circumcision, percentage who report specific benefits of the practice for girls, by background characteristics, Sierra Leone 2008 Background characteristic Perceived benefits of female circumcision Number of men who have heard of female circumcision No benefits Cleanliness/ hygiene Social acceptance Better marriage prospects Preserve virginity More sexual pleasure for the man Religious approval Other Age 15-19 37.2 26.5 38.6 14.4 2.7 1.8 1.8 15.8 480 20-24 40.2 21.4 34.8 18.2 8.6 3.1 2.2 11.4 389 25-29 35.5 22.7 40.6 17.1 9.0 4.0 2.2 13.5 433 30-34 34.7 19.8 40.3 17.6 8.6 4.0 3.7 13.2 362 35-39 36.3 21.1 42.4 18.9 9.4 4.7 2.4 11.6 511 40-44 36.3 24.0 43.9 16.9 9.0 4.5 2.3 11.0 332 45-49 35.9 27.8 43.1 19.0 5.6 3.0 2.2 10.3 314 Residence Urban 44.5 19.3 33.1 12.2 6.2 4.4 1.3 13.1 1,077 Rural 31.8 25.7 44.9 20.6 8.3 3.1 3.0 12.2 1,744 Region Eastern 37.4 9.3 40.9 12.7 6.3 3.8 1.7 15.6 533 Northern 28.3 38.1 52.2 26.5 8.6 1.6 2.1 7.2 1,080 Southern 38.1 19.5 39.3 17.5 8.3 5.7 4.5 14.7 588 Western 49.1 12.8 20.6 5.3 5.9 4.7 1.4 17.4 620 Education No education 31.7 26.0 45.4 19.9 7.6 3.4 2.7 11.8 1,365 Primary 34.9 17.4 40.2 17.3 10.0 4.8 2.8 14.5 383 Secondary or higher 43.5 21.8 34.1 14.2 6.5 3.3 1.8 12.8 1,073 Ethnic group Temne 34.9 34.6 41.6 20.0 7.1 1.7 1.9 11.0 1,029 Mende 39.3 16.9 36.4 14.7 7.8 5.1 3.9 17.3 849 Other 36.0 16.5 42.7 16.8 7.7 4.1 1.4 10.0 942 Religion Christian 44.6 16.7 35.9 13.7 7.4 4.3 0.9 12.3 625 Muslim 34.2 25.2 41.8 18.4 7.6 3.4 2.8 12.6 2,182 Other * * * * * * * * 14 Wealth quintile Lowest 31.7 21.6 41.3 21.9 7.8 5.3 4.0 13.7 534 Second 33.2 31.3 47.3 22.4 8.2 1.8 2.7 9.1 485 Middle 27.2 27.3 50.0 21.9 9.6 4.0 2.6 12.7 520 Fourth 41.4 22.3 39.0 13.3 5.9 2.1 1.7 11.7 564 Highest 45.6 16.8 29.3 10.5 6.7 4.2 1.2 14.6 717 Total 36.6 23.2 40.4 17.4 7.5 3.6 2.4 12.6 2,821 50-59 28.4 29.1 50.7 19.7 8.6 3.4 4.4 11.4 318 Total 15-59 35.8 23.8 41.5 17.6 7.6 3.5 2.6 12.5 3,139 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. (2 percent). It has been observed by some researchers that female circumcision is a cultural rather than a religious practice (Toubia, 1995; Caldwell et al., 2000). However, when asked directly, some Sierra Leonean respondents reported that religious approval has a part in circumcision (Tables 16.7.1 and 16.7.2). Overall, younger respondents, those who are Christians, urban residents, and those living in the Western Region, are more likely than other respondents to report that there are no benefits to female circumcision. Similarly, more educated and wealthier respondents are least likely to cite any benefits of female circumcision. 264 | Female Circumcision 16.7 ATTITUDES TOWARD FEMALE CIRCUMCISION Women and men who had heard of female circumcision were asked if they thought the practice was required by their religion, and whether it should be continued or stopped. Table 16.8 shows that among respondents who had heard of female circumcision, 43 percent of women and 30 percent of men age 15-49 think that the practice is required by religion. Overall, younger respondents, urban residents, those living in the Western Region, those with more education, those in the wealthiest households, and those who are Christians are less likely than other respondents to think that the practice is required by religion. Table 16.8 Beliefs about female circumcision Among women and men who have heard of female circumcision (FGC), percentage who think that the practice is required by religion, by background characteristics, Sierra Leone 2008 Background characteristic Women Men Percentage who think FGC is required by religion Number of women Percentage who think FGC is required by religion Number of men Circumcision status of respondent Circumcised 45.4 6,735 na na Not circumcised 18.4 557 na na Age 15-19 36.5 1,176 26.8 480 20-24 40.9 1,176 22.6 389 25-29 43.7 1,627 31.7 433 30-34 43.7 1,033 32.1 362 35-39 47.7 1,121 31.5 511 40-44 47.2 650 33.2 332 45-49 48.2 509 36.1 314 Residence Urban 35.3 2,632 25.5 1,077 Rural 47.9 4,660 33.3 1,744 Region Eastern 49.2 1,307 27.0 533 Northern 40.2 2,973 31.4 1,080 Southern 57.0 1,523 35.5 588 Western 30.4 1,490 26.3 620 Education No education 48.3 4,808 34.5 1,365 Primary 38.5 943 29.6 383 Secondary or higher 30.7 1,541 25.2 1,073 Ethnic group Temne 40.2 2,546 31.5 1,029 Mende 55.5 2,301 34.1 849 Other 35.2 2,446 25.6 942 Religion Christian 22.4 1,606 14.3 625 Muslim 49.4 5,603 35.0 2,182 Other 36.9 84 * 14 Wealth quintile Lowest 46.3 1,367 32.7 534 Second 49.5 1,349 40.9 485 Middle 48.5 1,408 26.6 520 Fourth 43.3 1,462 30.1 564 Highest 31.8 1,707 24.1 717 Total 43.3 7,292 30.3 2,821 50-59 na na 38.3 318 Total 15-59 na na 31.1 3,139 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable Female Circumcision | 265 Table 16.9.1 shows that among women who had heard of female circumcision, two-thirds (66 percent) think that the practice should be continued, while 26 percent think the practice should be discontinued. Approximately one in ten women expressed conditional approval, or were unsure of their opinion. Continuation of female circumcision finds the greatest support among women in the Eastern and Southern regions (76 and 73 percent, respectively). Women in the Western Region are the least likely to support the practice (48 percent). However, even there, 44 percent of women think it should be continued. Women in urban areas, those with more education, and those in the wealthiest households are more likely than other women to think that the practice should be stopped. Table 16.9.1 Attitudes towards female circumcision: Women Percent distribution of women who have heard of female circumcision by opinion on whether female circumcision should be continued, according to background characteristics, Sierra Leone 2008 Background characteristic Attitude towards female circumcision Total Number of women Should be discontinued Should be continued Depends Don’t know Age 15-19 37.9 52.9 3.6 5.5 100.0 1,176 20-24 31.4 60.1 4.3 4.1 100.0 1,176 25-29 23.8 67.9 3.8 4.6 100.0 1,627 30-34 24.4 68.0 3.7 3.9 100.0 1,033 35-39 18.8 72.6 5.1 3.4 100.0 1,121 40-44 20.4 72.9 3.8 2.8 100.0 650 45-49 13.4 75.4 5.3 5.9 100.0 509 Residence Urban 42.5 49.6 4.6 3.3 100.0 2,632 Rural 16.0 75.2 3.9 4.9 100.0 4,660 Region Eastern 17.8 76.2 3.4 2.6 100.0 1,307 Northern 24.0 68.6 4.6 2.8 100.0 2,973 Southern 13.5 73.2 4.1 9.1 100.0 1,523 Western 47.9 44.2 4.0 3.9 100.0 1,490 Education No education 15.3 75.9 4.2 4.6 100.0 4,808 Primary 31.6 59.6 4.5 4.3 100.0 943 Secondary or higher 54.1 38.7 3.7 3.5 100.0 1,541 Ethnic group Temne 27.7 64.9 4.5 2.9 100.0 2,546 Mende 15.9 74.2 3.2 6.6 100.0 2,301 Other 32.5 59.2 4.6 3.6 100.0 2,446 Religion Christian 45.6 46.2 4.3 3.8 100.0 1,606 Muslim 19.9 71.6 4.2 4.3 100.0 5,603 Other 19.4 68.3 0.0 12.3 100.0 84 Wealth quintile Lowest 12.4 76.9 4.2 6.5 100.0 1,367 Second 14.9 76.8 3.7 4.7 100.0 1,349 Middle 18.6 73.0 4.3 4.1 100.0 1,408 Fourth 28.4 63.6 4.5 3.5 100.0 1,462 Highest 47.9 44.8 4.1 3.2 100.0 1,707 Total 25.6 65.9 4.2 4.3 100.0 7,292 266 | Female Circumcision Men who had heard of female circumcision were asked the same questions as women about whether the practice should continue. Table 16.9.2 shows that 41 percent of men are against continuation of female circumcision while 45 percent favour continuation. Thus, in Sierra Leone, the proportion of men who oppose FGC is higher than the proportion of women who oppose FGC—41 and 26 percent, respectively—a pattern seen in many other parts of West Africa (Yoder et al., 2004). As seen for women, men in urban areas and those in the Western Region are the most likely to support discontinuation of female circumcision. Likewise, more educated men and wealthier men are more likely to favour stopping the practice than men with no education and those in the poorest households. Table 16.9.2 Attitudes towards female circumcision: Men Percent distribution of men who have heard of female circumcision by opinion on whether female circumcision should be continued, according to background characteristics, Sierra Leone 2008 Background characteristic Attitude towards female circumcision Total Number of men Should be discontinued Should be continued Depends Don’t know Age 15-19 38.7 43.5 7.1 10.6 100.0 480 20-24 46.6 37.7 9.0 6.7 100.0 389 25-29 41.2 45.4 8.4 5.0 100.0 433 30-34 41.5 46.7 5.7 6.1 100.0 362 35-39 42.0 43.6 7.2 7.2 100.0 511 40-44 44.3 46.6 4.7 4.4 100.0 332 45-49 34.9 51.5 8.3 5.3 100.0 314 Residence Urban 50.7 36.6 6.1 6.7 100.0 1,077 Rural 35.6 49.7 8.0 6.7 100.0 1,744 Region Eastern 41.9 46.0 7.8 4.3 100.0 533 Northern 35.5 50.6 8.2 5.7 100.0 1,080 Southern 35.7 43.5 9.7 11.1 100.0 588 Western 56.5 34.2 2.8 6.4 100.0 620 Education No education 34.9 50.9 7.0 7.2 100.0 1,365 Primary 36.6 46.9 8.7 7.9 100.0 383 Secondary or higher 51.3 36.0 7.0 5.7 100.0 1,073 Ethnic group Temne 43.2 46.5 5.5 4.9 100.0 1,029 Mende 41.8 42.0 8.4 7.8 100.0 849 Other 39.0 45.1 8.1 7.7 100.0 942 Religion Christian 50.6 36.1 6.1 7.2 100.0 625 Muslim 38.7 47.2 7.5 6.6 100.0 2,182 Other * * * * * 14 Wealth quintile Lowest 32.5 52.8 5.8 9.0 100.0 534 Second 33.7 55.1 6.8 4.5 100.0 485 Middle 36.1 46.8 9.4 7.7 100.0 520 Fourth 46.1 39.6 9.9 4.5 100.0 564 Highest 53.3 34.1 5.0 7.6 100.0 717 Total 15-49 41.4 44.7 7.2 6.7 100.0 2,821 50-59 32.3 54.8 5.5 7.4 100.0 318 Total men 15-59 40.4 45.7 7.1 6.8 100.0 3,139 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Adult and Maternal Mortality | 267 ADULT AND MATERNAL MORTALITY 17 17.1 INTRODUCTION Maternal mortality has become an important measure of human and social development. It is particularly revealing of women’s overall status, access to health care, and the responsiveness of the health care system to their needs. Therefore, knowledge of maternal mortality levels is very important not only for identifying the risks associated with pregnancy and childbearing, but also for what it says about women’s health and, indirectly, their economic and social status. Determining the level maternal mortality and the associated risk factors is necessary for both diagnosing issues and assessing the progress and effectiveness of existing programmes. The 2008 SLDHS is the first DHS survey to collect data for use in estimating maternal mortality using the direct sisterhood method. Maternal mortality is calculated using data on the sisters of respondents. The information gathered on each of the respondent’s sisters included current age and, if the sister was dead, age at death (AD), and the number of years since the death (YSD). For dead sisters, additional questions were asked to determine whether the death was related to childbearing, i.e., whether the death occurred during pregnancy, childbirth, or in the two months following the birth or end of the pregnancy. The direct method of calculating maternal mortality presented here relies on detailed information about respondents’ sisters, including the current age of all surviving sisters, the age at death of dead sisters, and the number of years since the death occurred. To obtain well defined reference periods, the data are aggregated to determine the number of person-years of exposure to mortality risk and the number of maternal deaths occurring in the defined reference periods. Maternal mortality rates are then estimated directly by dividing the number of maternal deaths by the number of person-years of exposure. The result of this calculation is the proportion of sisters, among all of the respondents’ sisters, who died from maternity-related causes. This estimate of the probability of dying from maternity-related causes is unbiased, provided that the risk of dying is identical for all sisters (Trussel and Rodriguez, 1990). 17.2 DATA COLLECTION The questionnaire used to gather data on maternal mortality is presented in Appendix E (Section 10 of the individual questionnaire). First, the woman is asked to list all of her siblings, i.e., all of the children born to her biological mother beginning with the first born. Next, the respondent is asked the survival status of each of her siblings, and the current age of those still living. For dead siblings, the respondent is asked the age of the sibling at death and the number of years since the death occurred. If the exact age or number of years could not be obtained, interviewers were authorized to accept approximate answers. For sisters who died at the age of 12 or older, the respondent is asked further questions to determine whether the death was maternity-related: • Was (NAME) pregnant when she died? If the answer is no or don’t know, the respondent is asked: • Did (NAME) die during childbirth? If the answer is no, the respondent is asked: • Did (NAME) die within two months after the end of a pregnancy or childbirth? 268 | Adult and Maternal Mortality These questions are structured to encourage the respondent to report all deaths following a pregnancy regardless of the outcome, including a pregnancy ending in induced abortion, while avoiding posing direct questions regarding such events. All such deaths are considered maternal deaths. 17.3 DATA QUALITY The estimation of maternal mortality rates requires accurate reporting of the number of sisters the respondent ever had, the number who died, and the number who died of maternity-related causes. There is no definitive procedure for establishing the completeness or accuracy of retrospective data on sister survivorship. The direct approach requires not only accurate data on sister survivorship, but on age at death and number of years since the death of a sister—information that may embarrass respondents or require them to provide details they do not have. The number of brothers and sisters reported by the respondent and the completeness of the reported data on current age, age at death, and years since death are presented in Table 17.1. Table 17.1 Data on siblings Number of siblings reported by survey respondents and completeness of the reported data on age, age at death (AD), and years since death (YSD), Sierra Leone 2008 Sibling status and completeness of reporting Sisters Brothers Total Number Percentage Number Percentage Number Percentage All siblings 14,619 100.0 14,750 100.0 29,370 100.0 Living 11,755 80.4 11,370 77.1 23,124 78.7 Dead 2,802 19.2 3,328 22.6 6,129 20.9 Status unknown 63 0.4 53 0.4 116 0.4 Living siblings 11,755 100.0 11,370 100.0 23,124 100.0 Age reported 11,291 96.1 10,931 96.1 22,222 96.1 Age missing 464 3.9 439 3.9 903 3.9 Dead siblings 2,802 100.0 3,328 100.0 6,129 100.0 AD and YSD reported 2,463 87.9 2,843 85.4 5,306 86.6 Missing only AD 122 4.3 207 6.2 328 5.4 Missing only YSD 72 2.6 70 2.1 142 2.3 Missing both AD and YSD 145 5.2 208 6.3 353 5.8 Complete data were obtained for nearly all sisters, regardless of survival status. Current age was reported for 96 percent surviving sisters, and age at death as well as number of years since death were reported for 88 percent of dead sisters. These percentages are indicative of relatively good data quality. Rather than exclude siblings with missing data from further analysis, information on the birth order of siblings was used in conjunction with other information to impute the missing data.1 Sibling survivorship data, including cases with imputed values, were used to directly estimate adult and maternal mortality. 1 The imputation procedure is based on the assumption that the reported birth order of brothers and sisters is correct. The first step is to calculate birth years for each living sibling whose age is known, and for each dead sibling for whom the age at death and years since death are known. For siblings missing these data, a date of birth is imputed within a range defined by the birth dates of the ‘bracketing’ siblings. In the case of living siblings, an age was then calculated from the imputed birth date. In the case of dead siblings, if either the age at death or years since death was reported, this information was combined with the imputed birth date to produce the missing information. If both pieces of information were missing, the distribution of age at death of siblings for whom years since death were unreported but age at death was known, was used as the basis for imputing age at death. Adult and Maternal Mortality | 269 Missing date information is only one indicator of overall data quality. Completeness of basic information, such as number of siblings, is much more important. Table 17.2 shows other indicators of data completeness. First, it is expected that the distribution of respondents’ birth years will be roughly equivalent to that of their sibship.2 A median sibship year of birth that is much later than that the respondent’s median birth year indicates that older siblings have been systematically omitted, perhaps because some of them died before the respondent was born. Such omissions would affect adult mortality estimates. For Sierra Leone, respondents and siblings have the median year of birth,3 1973 and 1972 respectively, indicating that there is no serious underreporting of siblings. However, for maternal mortality assessments, the completeness of sibling reporting is not what’s most important; rather, it is the completeness of data relating to those who are exposed to the risk of dying from maternity-related causes: sisters of childbearing age. It is crucial that these data be as complete as possible. Two other tests, sex ratio of births (defined as number of males per 100 females) and mean sibship size, can be used to assess the completeness of sibling reporting. The results appear in Table 17.2. For all siblings, the sex ratio of births is 101 males to 100 females. This is slightly lower than generally observed, because the sex ratio of births is around 105 males per 100 females, with only slight variations, for all populations. In Sierra Leone, the sex ratio of births varies by respondent’s year of birth, from 98 to 106. Given the well known variability of sex ratios in small sample sizes, this indicates there has been no serious underreporting of sisters. However, it is clear that reporting of sisters is relatively more accurate among younger than older respondents. The data indicate a mean sibship size (including the respondent) of 5.0, which is very close to the past final parity of Sierra Leonean women. Variations in sibship size by respondent’s year of birth range from 4.3 to 5.1 children, confirming that fertility has changed very little in Sierra Leone between 1955 and 1994, with the exception of fertility of 4.3 and 4.6 for the periods 1955-59 and 1960-64 respectively. These exceptions show that there was a slight underreporting of births for the siblings of older respondents. It can be generally said, however, that there is a relative stability of mean sibship size, which suggests that, as with the previous results, there has been no serious underreporting of siblings. General and maternal mortality estimates cover the past seven years (i.e., 0-6 years preceding the survey). This seven-year reference period was chosen to obtain the most recent estimate of maternal mortality while still retaining a sufficient number of maternal deaths (which, nevertheless, remains relatively low) to reduce sampling errors to a minimum and ensure a reliable estimate. 2 The term sibship used here refers to all of a respondent’s siblings born of the same biological mother. 3 It should be noted that the distribution of birth years is not the same for siblings as for respondents: respondent birth years are distributed over 35 years (1958 to 1993); sibling birth years are distributed over 76 years (1932 to 2008). Table 17.2 Indicators on data quality Percent distribution of respondents and siblings by year of birth, median birth year, mean sibship size and sex ratio of births, Sierra Leone 2008 Birth year Percent distribution Respondents Siblings Before 1960 0.8 5.5 1960-64 7.7 5.2 1965-69 9.1 9.7 1970-74 15.7 11.5 1975-79 15.2 15.9 1980-84 22.0 15.2 1985-89 17.1 14.2 1990-94 12.3 9.8 1995 or after 0.0 13.0 Total 100.0 100.0 Interval 1958-1993 1932-2008 Median 1973 1972 Number 7,374 29,198 Respondent’s year of birth Mean sibship size Sex ratio at birth of siblings 1955-59 4.3 100.9 1960-64 4.6 98.9 1965-69 5.0 102.2 1970-74 4.9 98.4 1975-79 5.0 98.5 1980-84 5.1 98.8 1985-89 5.1 104.6 1990-94 5.0 106.0 Total 5.0 100.9 270 | Adult and Maternal Mortality 17.4 DIRECT ESTIMATES OF ADULT MORTALITY The total number of deaths (397 brothers and 613 sisters) occurring between the ages of 15 and 49 in the seven-year reference period (i.e., 0-6 years preceding the survey) is sufficiently large to ensure a reliable esti- mate of adult mortality. The data for this period are presented in Table 17.3. The results show a relatively high rate of adult mortality: 5.8 per 1,000 for all women and 6.6 per 1,000 for all men. It is important to evaluate the reliability of direct estimates of adult mortality because the data on sister mortality serve as the basis of maternal mortality data. If the adult mortality estimate is incorrect, the maternal mortality estimate will also be erroneous. In the absence of precise mortality data for Sierra Leone, the reliability of the adult mortality estimate is assessed by comparing it to a series of direct rates extrapolated from United Nations model life tables (United Nations, 1982). Age-specific mortality rates obtained from model life tables are presented in Table 17.3. The model life table rates are taken from the United Nations ‘General’ pattern because these most closely approxi- mate the infant and child mortality models of Sierra Leone. They correspond to the probability of dying between birth and exact age one (1q0) estimated for the ten years preceding the survey.4 Underreporting of events and erroneous dating of reported events can affect the validity of retrospective data. The estimates in this survey are subject to underreporting, especially for less recent events. Although the quality assessments indicate no major problem of this type, a closer evaluation is required. Evaluation shows that general mortality rates of siblings are relatively higher for younger ages and underestimated for older ages, in particular adult mortality for sisters age 45-49, in comparison to those of the United Nations mortality models (Figures 17.1 and 17.2). 4 The probability of dying between birth and exact age 1 (1q0) estimated for the 10 years preceding the survey is 105 per 1,000 female births and 118 per 1,000 male births, according to the 2008 SLDHS (see Chapter 8). Table 17.3 Estimates of age-specific female and male adult mortality Direct estimates of age-specific female and male adult mortality based on the survivorship of siblings of survey respondents, for the period 2001-2008, and model life table rates, Sierra Leone 2008 Age 2001-2008 Model life table rates Deaths Years of exposure Mortality rates (‰) WOMEN 15-19 71 12,094 5.9 4.0 20-24 72 13,239 5.5 5.5 25-29 67 12,633 5.3 6.4 30-34 58 10,135 5.7 7.4 35-39 44 7,382 6.0 8.4 40-44 33 4,230 7.7 9.6 45-49 12 2,368 5.1 11.8 15-49 357 62,082 5.8a MEN 15-19 75 11,423 6.5 3.5 20-24 94 13,040 7.2 5.0 25-29 73 12,361 5.9 5.7 30-34 61 9,857 6.2 6.8 35-39 41 7,053 5.8 8.4 40-44 28 4,203 6.6 10.9 45-49 26 2,391 10.9 14.5 15-49 397 60,328 6.6a Note: The model life table rates come from the United Nations Model Life Tables for Developing Countries, ‘General’ mortality pattern, using a level of mortality approximately corresponding to a probability of dying between birth and exact age 1 estimated for the ten years preceding the survey (i.e., 1q0 of 104 per 1,000 female births and 117 per 1,000 male births). a Age adjusted Adult and Maternal Mortality | 271 Figure 17.1 Female Mortality Rates for the Period 2001-2008 and Model Life Table Rates, by Age Group Sierra Leone, 2008 + + + + + + + , ,, , , , , 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age (years) 0 2 4 6 8 10 12 14 Deaths per 1,000 women Calculated rates Model life table rates, + Figure 17.2 Male Mortality Rates for the Period 2001-2008 and Model Life Table Rates, by Age Group Sierra Leone, 2008 + + + + + + + , , , , , , , 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age (years) 0 2 4 6 8 10 12 14 16 Deaths per 1,000 men Calculated rates Model life table rates, + 17.5 DIRECT ESTIMATES OF MATERNAL MORTALITY Direct estimates of maternal mortality obtained from reports of sister survivorship are presented in Table 17.4. The number of maternal deaths among women age 15-49 is estimated at 97 for the period 0-6 years preceding the survey. Age-specific proportions dying of maternal causes display, with the exception the age group 15-19 a consistent pattern, increasing with age up to age 30-34, then decreasing in the older age groups. Given the relatively low number of events, the method used was to estimate a single rate corresponding to the reproductive years. The estimate for all 272 | Adult and Maternal Mortality mortality due to maternal causes, expressed per 1,000 women-years of exposure to maternal risk, is 1.5 for the 2001-2008 period. The maternal mortality rate can be converted to a maternal mortality ratio (MMR), expressed per 100,000 live births, by dividing the rate by the general fertility rate associated with the same time period (Table 17.4). This brings out the obstetrical risks of pregnancy and childbearing. Using this method, the MMR is estimated to be 857 maternal deaths per 100,000 live births for the period 0-6 years preceding the survey. The estimated age-specific proportions of deaths due to maternal causes for the period 2001- 2008 display a plausible pattern, being higher for age group 30-34, when more than four in ten deaths (41 percent) are related to maternal causes. Unlike the other measures of mortality presented earlier, these proportions are not affected by underreporting because it can be assumed that underreporting does not affect maternal deaths any more than deaths due to other causes. Therefore, it can be estimated that more than one in four deaths (27 percent) among women of childbearing age (15-49) is due to maternal causes. Table 17.4 Maternal mortality Maternal mortality rates for the period 2001-2008, based on the survivorship of sisters of survey respondents, Sierra Leone 2008 Age Maternal deaths Years of exposure Mortality rates (‰) Proportion dying of maternal causes 15-19 21 12,094 1.7 29.3 20-24 19 13,239 1.4 26.6 25-29 19 12,633 1.5 28.2 30-34 24 10,135 2.3 41.2 35-39 9 7,382 1.2 20.5 40-44 4 4,230 0.9 11.3 45-49 1 2,368 0.5 10.0 15-49 97 62,082 1.5a 27.1 General Fertility Rate (GFR)a 173 Maternal mortality ratio (MMR)b 857 a Age adjusted b Per 100,000 births; calculated as maternal mortality rate divided by the general fertility rate. References | 273 REFERENCES Althabe, F., and J.M. Belizan. 2006. Caesarean section: The paradox. Lancet 368(9546): 1472-1473. Caldwell, J.J., I.O. Orubuloye, and P. Caldwell. 2000. Female genital cutting: Conditions of decline, Social Science and Medicine 19: 233-254. 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Appendix A | 275 SAMPLE DESIGN Appendix A A.1 OBJECTIVES OF THE SURVEY The 2008 Sierra Leone Demographic and Health Survey (SLDHS 2008) is the first DHS survey carried out in the country, although it shares many similarities with previous surveys such as MICS-1 (1995), MICS-2 (2000), and MICS-3 (2005). Based on a nationally representative sample of approximately 8,000 households and 10,000 complete women interviews, the main objectives of the SLDHS 2008 were to provide up-to-date information on fertility and childhood mortality levels; fertility preferences; awareness, approval, and use of family planning methods; maternal and child health; knowledge and attitudes towards HIV/AIDS and other sexually transmitted infections (STI); prevalence level of HIV/AIDS. All women age 15-49 who slept in the selected households the night before the survey were eligible to be interviewed with the Woman’s Questionnaire. The survey results are representative for the country as a whole, for urban and rural areas, and for each of the four provinces. Separate from the main survey of women and children, a survey of men was conducted in one of every two households selected for the main survey. All men age 15-59 who slept in the households selected for the men’s survey were interviewed using the Men’s Questionnaire. All eligible men age 15-59 and all eligible women age 15-49 in the households selected for male survey were eligible for HIV testing. A.2 SAMPLING FRAME Administratively, Sierra Leone is divided into 4 provinces. Each province is divided into districts, each district is divided into chiefdoms, and each chiefdom is divided into sections. In total, there are 14 districts, 149 chiefdoms, and 1,320 sections. Among the 14 districts, Bo City from Bo district, Bonthe City from Bonthe district, Kenema City from Kenema district, Koidu City from Kono district and Makeni City from Bombali district were separated from the district to form 5 city councils; the rest of the 5 districts form 5 local councils; the other 9 districts each forms a local council. So in total, there are 19 local councils. The five city councils together form a domain of study. For the purpose of the SLDHS, the local councils were adopted as a secondary domain of study. Samples were allocated to each local council and by urban-rural residence within each council. In addition to these administrative units, during the 2004 Sierra Leone Population and Housing Census (SSL, 2006b), each section was subdivided into convenient area units called Enumeration Areas (EAs), which were compiled electronically into a complete list of all the EAs. The list contains census information on household, population, urban-rural specifications, and administrative matters, etc. for every EA. The census EAs were used as the primary sampling units (PSUs), also called clusters, for the 2008 SLDHS. The sample was selected from the frame of PSUs provided by Statistics Sierra Leone (SSL). The frame excluded the population living in collective housing units, such as hotels, hospitals, work camps, prisons, and the like. Table A.1 shows the distribution of EAs and their average size by local council and by urban-rural specification. In total, there are 9,671 EAs in Sierra Leone; 2,903 EAs are located in urban areas and 6,768 EAs are located in rural areas. On average, a census EA has 102 households in urban areas and 77 households in rural areas, with an overall average of 85 households per EA. Table A.2 and Table A.3 show the distribution of the household population and the distribution of households by domain, local council, and by urban-rural specification. In Sierra Leone, 35.8 percent of the household population lives in urban areas and they occupy 36.3 percent of the households, according to the sampling frame. The statistics from the sampling frame show no differences when compared with the 2004 Population and Housing Census; this indicates that the sampling frame covers the whole country. 276 | Appendix A Table A.1 Distribution of Enumeration Areas (EAs) by domain and local council, and by urban-rural specification Domain/Local council Number of EAs Average number of households per EA Urban Rural Total Urban Rural Total Eastern 235 1,805 2,040 106 85 87 Kailahun District 86 618 704 109 90 92 Kenema District 101 691 792 103 84 86 Kono District 48 496 544 109 79 82 Northern 415 3,004 3,419 80 72 73 Bombali District 44 644 688 74 72 72 Kambia District 84 422 506 81 72 73 Koinadugu District 41 468 509 91 85 86 Port Loko Distri 124 767 891 85 72 74 Tonkolili District 122 703 825 74 62 64 Southern 211 1,873 2,084 77 76 76 Bo District 59 586 645 106 80 82 Bonthe District 36 310 346 67 70 70 Moyamba District 67 549 616 57 75 73 Pujehun District 49 428 477 76 75 75 Western 1,439 86 1,525 105 145 108 Western Area Urban 1,349 1,349 99 99 Western Rural District 90 86 176 196 145 171 Local councils 603 603 118 118 Bo Town 192 192 118 118 Bonthe Town 17 17 75 75 Kenema Town 211 211 97 97 Koidu/New Sembehun Town 61 61 237 237 Makeni Town 122 122 100 100 Sierra Leone 2,903 6,768 9,671 102 77 85 Note: Sampling frame is from the 2004 Population and Housing Census (SSL, 2006b). Table A.2 Distribution of the household population by domain and local council, and by urban- rural specification Domain/Local council Household population Proportion Urban Rural Total Urban Domain/ Council Eastern 139,730 835,193 974,923 0.143 0.198 Kailahun District 52,155 305,020 357,175 0.146 0.072 Kenema District 56,795 306,668 363,463 0.156 0.074 Kono District 30,780 223,505 254,285 0.121 0.052 Northern 220,546 1,439,665 1,660,211 0.133 0.337 Bombali District 21,493 303,184 324,677 0.066 0.066 Kambia District 46,820 223,556 270,376 0.173 0.055 Koinadugu District 22,486 243,197 265,683 0.085 0.054 Port Loko Distri 72,090 380,929 453,019 0.159 0.092 Tonkolili District 57,657 288,799 346,456 0.166 0.070 Southern 95,941 818,072 914,013 0.105 0.185 Bo District 37,522 262,734 300,256 0.125 0.061 Bonthe District 13,827 116,051 129,878 0.106 0.026 Moyamba District 22,148 236,358 258,506 0.086 0.052 Pujehun District 22,444 202,929 225,373 0.100 0.046 Western 864,230 70,061 934,291 0.925 0.189 Western Area Urban 764,484 764,484 1.000 0.155 Western Rural District 99,746 70,061 169,807 0.587 0.034 Local councils 447,094 447,094 1.000 0.091 Bo Town 148,705 148,705 1.000 0.030 Bonthe Town 9,727 9,727 1.000 0.002 Kenema Town 126,966 126,966 1.000 0.026 Koidu/New Sembehun Town 79,981 79,981 1.000 0.016 Makeni Town 81,715 81,715 1.000 0.017 Sierra Leone 1,767,541 3,162,991 4,930,532 0.358 1.000 Note: Sampling frame is from the 2004 Population and Housing Census (SSL, 2006b). Appendix A | 277 Table A.3 Distribution of households by domain and local council, and by urban-rural specification Domain/Local council Households Proportion Urban Rural Total Urban Domain/ Council Eastern 24,966 152,530 177,496 0.164 0.216 Kailahun District 9,353 55,573 64,926 0.144 0.079 Kenema District 10,400 57,773 68,173 0.153 0.083 Kono District 5,213 39,184 44,397 0.117 0.054 Northern 33,360 215,581 248,941 0.134 0.304 Bombali District 3,243 46,408 49,651 0.065 0.061 Kambia District 6,793 30,346 37,139 0.183 0.045 Koinadugu District 3,714 39,986 43,700 0.085 0.053 Port Loko Distri 10,552 55,038 65,590 0.161 0.080 Tonkolili District 9,058 43,803 52,861 0.171 0.064 Southern 16,229 141,945 158,174 0.103 0.193 Bo District 6,233 46,868 53,101 0.117 0.065 Bonthe District 2,427 21,784 24,211 0.100 0.030 Moyamba District 3,857 41,366 45,223 0.085 0.055 Pujehun District 3,712 31,927 35,639 0.104 0.043 Western 151,755 12,443 164,198 0.924 0.200 Western Area Urban 134,138 134,138 1.000 0.164 Western Rural District 17,617 12,443 30,060 0.586 0.037 Local councils 71,045 71,045 1.000 0.087 Bo Town 22,699 22,699 1.000 0.028 Bonthe Town 1,274 1,274 1.000 0.002 Kenema Town 20,383 20,383 1.000 0.025 Koidu/New Sembehun Town 14,429 14,429 1.000 0.018 Makeni Town 12,260 12,260 1.000 0.015 Sierra Leone 297,355 522,499 819,854 0.363 1.000 Note: Sampling frame is from the 2004 Population and Housing Census (SSL, 2006b). A.3 SAMPLE ALLOCATION AND SAMPLE SELECTION The 2008 SLDHS sample was a stratified sample selected in two stages from the 2004 census frame. Stratification was achieved by separating each local council into urban and rural areas. The West Urban Area and the 5 city councils have only urban areas; in total, 32 sampling strata were constructed. The samples were selected independently in each stratum, using a two-stage selection procedure. By sorting the sampling frame according to administrative order and by using a probability proportional to size selection in the first stage sampling, an implicit stratification and proportional allocation was achieved at each administrative level. The sample allocation takes into account precision at the domain level. While it would be best to allocate the 10,000 completed women’s interviews proportionally to each sampling stratum by stratum size, such a proportional allocation would allocate too small a sample size for the domain Local Councils. DHS surveys in the other countries show that to obtain reasonable precision for most DHS indicators at the domain level, at least 800 completed interviews of women 15-49 are needed for each domain. On the other hand, for survey precision to be comparable across domains, the samples should (as much as possible) be similar in size. This means that the proportional allocation cannot be used. Instead, a power allocation was used—allocation proportional to a power of the stratum size; it is between the proportional allocation and the equal size allocation. The sample allocation was done in two steps: first, a power allocation was used to allocate the target number of complete women 15-49 to each domain; then the domain sample size was proportionally allocated to each sampling stratum—that is, the urban and rural areas of each local council—within the domain. The sample allocation was then converted to number of households by applying the average number of women 15-49 per household and response rates at household level and the individual level, respectively. The 2004 Population and Housing Census shows that there are 1.53 women age 15-49 per household (SSL, 2006b). By assuming a response rate of 95 percent for both households and women, and a sample take of 22 households per EA, the sample allocation of EAs and households by domain and local council, and by urban-rural specification was carried out (Table 4). In total, 353 EAs were selected with 145 EAs in urban areas and 208 EAs in rural areas; 7,766 households were selected with 3,190 households in urban areas and 4,576 households in rural 278 | Appendix A areas. Table 5 shows the expected numbers of completed interviews for women age 15-49 and men age 15-59 by domain and local council, and by urban-rural specification: 10,727 completed interviews of women age 15-49, 4,408 in urban areas and 6,319 in rural areas. The sampling procedure for the men’s survey was to interview men age 15-59 in one of every two households selected for the women’s survey. The 2004 Population and Housing Census showed an average of 1.5 men age 15-59 per household (SSL, 2006b). By assuming a response rate of 90 percent, the expected number of completed interviews for men age 15-59 was 4,976 (2,042 in urban areas and 2,934 in rural areas). Urban areas were slightly over sampled because of the creation of the five city councils as a domain. Prior to the main survey, a household listing operation was carried out in all of the selected EAs, and the resulting lists of households served as the sampling frame for the selection of households in the second stage. Some of the selected EAs were large in size; to minimize the task of household listing, selected EAs that had more than 200 households were segmented. Only one segment was selected for the survey with probability proportional to the segment size. The household listing was conducted only in the selected segment; therefore, a SLDHS 2008 cluster is either an EA or a segment of an EA. Household selection in the second stage was an equal probability systematic selection of fixed size: 22 households per cluster. The fixed second stage sample size facilitates allocation of workloads to different interviewers and as well as quality control during fieldwork. In the central office, a spreadsheet with the selected household numbers for each cluster was prepared for the household selection. Survey interviewers were asked to interview only the pre- selected households. To prevent bias, no replacements and no changes in the pre-selected households were allowed in the implementing stages. All women age 15-49 who slept in the selected households the night before the survey were eligible to be interviewed; all men age 15-59 who slept in the households selected for the survey of men were eligible to be interviewed. Table A.4 shows the sample allocation of clusters (EAs) and households by domain and local councils, and by urban-rural specification. Table A.5 shows the expected number of completed interviews for women and men by domain and local councils, and by urban-rural specification. The results of the survey are presented in Table A.6 for women and Table A.7 for men. The survey yielded a smaller number of completed interviews for both women and men because there were fewer eligible women and men per household, compared with the census numbers. Table A.4 Sample allocation of Enumeration Areas (EAs) and households by domain and local council, and by urban-rural specification Number of EAs Number of households Domain/Local council Urban Rural Total Urban Rural Total Eastern 12 61 73 264 1,342 1,606 Kailahun District 4 22 26 88 484 572 Kenema District 5 23 28 110 506 616 Kono District 3 16 19 66 352 418 Northern 15 79 94 330 1,738 2,068 Bombali District 2 17 19 44 374 418 Kambia District 3 11 14 66 242 308 Koinadugu District 2 15 17 44 330 374 Port Loko Distri 4 20 24 88 440 528 Tonkolili District 4 16 20 88 352 440 Southern 9 60 69 198 1,320 1,518 Bo District 3 20 23 66 440 506 Bonthe District 2 10 12 44 220 264 Moyamba District 2 17 19 44 374 418 Pujehun District 2 13 15 44 286 330 Western 67 8 75 1,474 176 1,650 Western Area Urban 57 57 1,254 1,254 Western Rural District 10 8 18 220 176 396 Local councils 42 42 924 924 Bo Town 13 13 286 286 Bonthe Town 3 3 66 66 Kenema Town 11 11 242 242 Koidu/New Sembehun Town 8 8 176 176 Makeni Town 7 7 154 154 Sierra Leone 145 208 353 3,190 4,576 7,766 Appendix A | 279 Table A.5 Expected number of completed interviews for women and men by domain and local council, and by urban-rural specification Expected number of completed interviews for women 15-49 Expected number of completed interviews for men 15-59 Domain/Local council Urban Rural Total Urban Rural Total Eastern 365 1,853 2,218 169 860 1,029 Kailahun District 122 668 790 56 310 366 Kenema District 152 699 851 71 324 395 Kono District 91 486 577 42 226 268 Northern 457 2,400 2,857 210 1,115 1,325 Bombali District 61 516 577 28 240 268 Kambia District 91 334 425 42 155 197 Koinadugu District 61 456 517 28 212 240 Port Loko Distri 122 608 730 56 282 338 Tonkolili District 122 486 608 56 226 282 Southern 274 1,823 2,097 126 846 972 Bo District 91 608 699 42 282 324 Bonthe District 61 304 365 28 141 169 Moyamba District 61 516 577 28 240 268 Pujehun District 61 395 456 28 183 211 Western 2,036 243 2,279 945 113 1,058 Western Area Urban 1,732 1,732 804 804 Western Rural District 304 243 547 141 113 254 Local councils 1,276 1,276 592 592 Bo Town 395 395 183 183 Bonthe Town 91 91 42 42 Kenema Town 334 334 155 155 Koidu/New Sembehun Town 243 243 113 113 Makeni Town 213 213 99 99 Sierra Leone 4,408 6,319 10,727 2,042 2,934 4,976 A.4 SELECTION PROBABILITY AND SAMPLING WEIGHT Because of the non-proportional allocation of the sample to the different districts and to their urban-rural areas, sampling weights are required for any analysis of the SLDHS 2008 data; this is to ensure the representativeness of the survey results at both the national level and the district level. Because the SLDHS 2008 sample was a two-stage stratified cluster sample, sampling weights (based on sampling probabilities) were calculated separately for each sampling stage and for each cluster. The following notations were used: P1hi: first-stage sampling probability of the ith cluster in stratum h P2hi: second-stage sampling probability within the ith cluster (household selection) Let ah be the number of clusters selected in stratum h, Mhi the number of households according to the sampling frame in the ith cluster, and M hi∑ the total number of households in the stratum. The probability of selecting the ith cluster in the SLDHS 2008 sample is calculated as follows: M M a hi hih ∑ Let hib be the proportion of households in the selected segment compared with the total number of households in the EA i in stratum h if the EA is segmented, otherwise 1=hib . Then the probability of selecting cluster i in the sample is: hi hi hih 1hi b M M a = P ×∑ 280 | Appendix A Let hiL be the number of households listed in the household listing operation in cluster i in stratum h, let hig be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster is calculated as follows: hi hi hi L gP =2 The overall selection probability of each household in cluster i of stratum h is therefore the production of the two stages selection probabilities: hihihi PPP 21 ×= The sampling weight for each household in cluster i of stratum h is the inverse of its overall selection probability: hihi PW /1= A spreadsheet containing all sampling parameters and selection probabilities was prepared to facilitate the calculation of sampling weights. Sampling weights were adjusted for household non- response and for individual non-response, for women and men, respectively. The differences of the household weights and the individual weights are introduced by individual non-response. The final weights were normalized to make the total number of unweighted cases equal to the total number of weighted cases at the national level, for both household weights and individual weights. A set of weights for HIV testing were calculated in the same way, but normalized in a slightly different way for individual weights. The individual weights for HIV testing were normalized for women and men together at national level. This allows unbiased estimates of HIV prevalence that can be calculated for women and men together or separately. A.5 SURVEY RESULTS Table A.6 and Table A.7 show the results of the sample implementation for women and men, respectively. Appendix A | 281 Table A.6 Sample implementation: Women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall women response rates, according to urban-rural residence and region (unweighted), Sierra Leone 2008 Result Residence Region Total Urban Rural Eastern Northern Southern Western Selected households Completed (C) 92.8 94.6 92.5 92.5 97.1 93.9 93.9 Household present but no competent respondent at home (HP) 1.7 0.7 0.5 1.3 0.4 2.3 1.1 Refused (R) 0.5 0.2 0.2 0.5 0.2 0.2 0.3 Dwelling not found (DNF) 1.4 0.6 1.3 0.9 0.3 1.0 0.9 Household absent (HA) 1.5 2.1 2.7 2.3 1.2 1.1 1.9 Dwelling vacant/address not a dwelling (DV) 1.4 0.9 1.3 1.5 0.6 0.7 1.1 Dwelling destroyed (DD) 0.4 0.8 1.1 0.8 0.2 0.3 0.6 Other (O) 0.3 0.2 0.3 0.1 0.0 0.5 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 3,184 4,574 2,020 2,222 1,866 1,650 7,758 Household response rate (HRR)1 96.3 98.5 97.8 97.1 99.1 96.4 97.6 Eligible women Completed (EWC) 93.4 94.5 96.2 91.3 97.2 91.9 94.0 Not at home (EWNH) 3.2 2.8 1.6 4.3 1.3 4.7 3.0 Postponed (EWP) 0.1 0.0 0.0 0.1 0.1 0.1 0.1 Refused (EWR) 1.3 0.9 0.5 1.9 0.5 1.2 1.1 Partly completed (EWPC) 0.3 0.2 0.1 0.5 0.1 0.2 0.2 Incapacitated (EWI) 0.6 0.9 0.8 1.7 0.2 0.3 0.8 Other (EWO) 1.2 0.5 0.8 0.3 0.7 1.7 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 3,385 4,460 1,828 2,372 1,888 1,757 7,845 Eligible women response rate (EWRR)2 93.4 94.5 96.2 91.3 97.2 91.9 94.0 Overall women response rate (OWRR)3 89.9 93.1 94.1 88.6 96.3 88.6 91.8 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: DNFRHPC C100 +++ ∗ 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: EWOEWIEWPCEWREWPEWNHEWC EWC100 ++++++ ∗ 3 The overall response rate (ORR) is calculated as: OWRR = HRR * EWRR/100 282 | Appendix A Table A.7 Sample implementation: Men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men and overall men response rates, according to urban-rural residence and region (unweighted), Sierra Leone 2008 Result Residence Region Total Urban Rural Eastern Northern Southern Western Selected households Completed (C) 92.5 94.9 92.3 93.3 96.9 93.5 93.9 Household present but no competent respondent at home (HP) 1.8 0.4 0.6 1.1 0.1 2.3 1.0 Refused (R) 0.6 0.3 0.3 0.6 0.4 0.1 0.4 Dwelling not found (DNF) 1.4 0.4 1.4 0.6 0.1 1.1 0.8 Household absent (HA) 1.6 1.9 2.0 2.2 1.4 1.3 1.8 Dwelling vacant/address not a dwelling (DV) 1.4 1.0 1.7 1.4 0.8 0.7 1.2 Dwelling destroyed (DD) 0.6 0.9 1.5 0.7 0.3 0.4 0.7 Other (O) 0.3 0.2 0.3 0.1 0.0 0.6 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 1,593 2,287 1,010 1,112 933 825 3,880 Household response rate (HRR)1 96.1 98.9 97.6 97.6 99.3 96.4 97.7 Eligible men Completed (EMC) 90.0 94.7 95.4 89.2 97.4 88.7 92.6 Not at home (EMNH) 5.6 2.5 2.6 4.7 1.6 6.6 3.8 Postponed (EMP) 0.1 0.1 0.0 0.2 0.0 0.0 0.1 Refused (EMR) 2.4 1.1 0.7 3.5 0.1 2.3 1.7 Partly completed (EMPC) 0.5 0.2 0.0 0.6 0.0 0.6 0.3 Incapacitated (EMI) 0.4 0.3 0.0 0.9 0.0 0.4 0.3 Other (EMO) 1.0 1.2 1.3 1.0 0.9 1.4 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,559 1,982 857 1,014 880 790 3,541 Eligible men response rate (EMRR)2 90.0 94.7 95.4 89.2 97.4 88.7 92.6 Overall men response rate (ORR)3 86.5 93.6 93.2 87.0 96.7 85.5 90.5 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: DNFRHPC C100 +++ ∗ 2 Using the number of eligible men falling into specific response categories, the eligible man response rate (EMRR) is calculated as: EMOEMIEMPCEMREMPEMNHEMC EMC100 ++++++ ∗ 3 The overall response rate (ORR) is calculated as: OMRR = HRR * EMRR/100 Appendix B | 283 ESTIMATES OF SAMPLING ERRORS Appendix B The estimates from a sample survey are affected by two types of errors: nonsampling errors and sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2008 Sierra Leone Demographic and Health Survey (SLDHS 2008) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the SLDHS 2008 is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the SLDHS 2008 sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the SLDHS 2008 is a Macro SAS procedure. This procedure used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = = ⎥⎦ ⎤⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ − − − == H h h h m i hi h h m zz m m x frvarrSE h 1 2 1 2 2 2 1 1)()( in which hihihi rxyz −= , and hhh rxyz −= where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. 284 | Appendix B The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the SLDHS 2008, there were 353 non-empty clusters. Hence, 353 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − = ∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 353 clusters, r(i) is the estimate computed from the reduced sample of 352 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, the design effect (DEFT) for each estimate is calculated, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. The relative standard error and confidence limits for the estimates are also calculated. Sampling errors for the SLDHS 2008 are calculated for selected variables considered to be of primary interest for the women’s survey and for the men’s surveys, respectively. The results are presented in this appendix for the country as a whole, for urban and rural areas, for each of the four geographical regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.8 present the value of the statistic (R), its standard error (SE), the number of unweighted (N-UNWE) and weighted (N-WEIG) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate and total abortion rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to child-bearing. The confidence interval (e.g., as calculated for children ever born to women aged 40-49) can be interpreted as follows: the overall average from the national sample is 5.538 and its standard error is 0.114. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 5.538±2×0.114. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 5.310 and 5.766. For the total sample, the value of the DEFT, averaged over all variables, is 1.5. This means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.5 over that in an equivalent simple random sample. Appendix B | 285 Table B.1 List of selected variables for sampling errors, Sierra Leone 2008 Variable Estimate Base population WOMEN Urban residence Proportion All women 15-49 No education Proportion All women 15-49 With secondary education or higher Proportion All women 15-49 Never married (in union) Proportion All women 15-49 Currently married (in union) Proportion All women 15-49 Had first sex before age 18 Proportion All women 20-49 Currently pregnant Proportion All women 15-49 Children ever born to women 15-49 Mean All women 15-49 Children ever born to women 40-49 Mean All women 40-49 Children surviving Mean All women 15-49 Knowing any contraceptive method Proportion Currently married women 15-49 Knowing any modern contraceptive method Proportion Currently married women 15-49 Ever used any contraceptive method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using condom Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using periodic abstinence Proportion Currently married women 15-49 Using public sector source Proportion Current users of modern methods Want no more children Proportion Currently married women 15-49 Want to delay at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean All women 15-49 with numeric response Mother protected against tetanus Proportion Last births in last 5 years Mother received medical assistance at delivery Proportion Births in last 5 years Child had diarrhea in the last 2 weeks Proportion Children under 5 Child treated with ORS packets Proportion Children under 5 with diarrhea in last 2 weeks Child consulted with medical personnel Proportion Children under 5 with diarrhea in last 2 weeks Child having health card, seen Proportion Children 12-23 months Child received BCG vaccination Proportion Children 12-23 months Child received DPT vaccination (3 doses) Proportion Children 12-23 months Child received polio vaccination (3 doses) Proportion Children 12-23 months Child received measles vaccination Proportion Children 12-23 months Child fully immunized Proportion Children 12-23 months Height-for-age (-2SD) Proportion Children under 5 who are mea