Sierra Leone - Multiple Indicator Cluster Survey - 2005

Publication date: 2005

Monitoring the situation of children and women Sierra Leone Multiple Indicator Cluster Survey 2005 Statistics Sierra Leone United Nations Children’s Fund Sierra Leone Multiple Indicator Cluster Survey 2005 Statistics Sierra Leone UNICEF United Nations Children’s Fund In collaboration with members of the MICS3 Steering Committee, including representatives of the Ministry of Health and Sanitation and the Ministry of Education, Science and Technology August 2007 Contributors to the report include UNICEF-Sierra Leone Project Officers in Health, Education, Water and Sanitation, and HIV/AIDS sections; and, Paul Sengeh, UNICEF-Sierra Leone M&E Officer. The Sierra Leone Multiple Indicator Cluster Survey (MICS) was conducted by Statistics Sierra Leone in collaboration with UNICEF-Sierra Leone. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF) and the Government of Sierra Leone (through Statistics Sierra Leone). The survey has been conducted as part of the third round of MICS surveys (MICS3) that were carried out around the world in more than 50 countries in 2005-2006. The MICS3 follows the first two rounds of MICS surveys that were conducted in 1995 and 2000. Survey tools are based on the models and standards developed by the global MICS project and are designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Statistics Sierra Leone and UNICEF-Sierra Leone 2007. Sierra Leone Multiple Indicator Cluster Survey 2005, Final Report. Freetown, Sierra Leone: Statistics Sierra Leone and UNICEF-Sierra Leone. i Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Sierra Leone, 2005 Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY 1 13 Under-five mortality rate 267 per thousand Child mortality 2 14 Infant mortality rate 158 per thousand NUTRITION 6 4 Underweight prevalence 30 Percent 7 Stunting prevalence 40 Percent Nutritional status 8 Wasting prevalence 9 Percent 45 Timely initiation of breastfeeding 33 Percent 15 Exclusive breastfeeding rate 8 Percent 16 Continued breastfeeding rate at 12-15 months at 20-23 months 87 57 Percent Percent 17 Timely complementary feeding rate 52 Percent 18 Frequency of complementary feeding 37 Percent Breastfeeding 19 Adequately fed infants 23 Percent Salt iodization 41 Iodized salt consumption 45 Percent 42 Vitamin A supplementation (under-fives) 49 Percent Vitamin A 43 Vitamin A supplementation (post-partum mothers) 55 Percent 9 Low birth weight infants 24 Percent Low birth weight 10 Infants weighed at birth 29 Percent CHILD HEALTH 25 Tuberculosis immunization coverage 84 Percent 26 Polio immunization coverage 57 Percent 27 DPT immunization coverage 56 Percent 28 15 Measles immunization coverage 63 Percent 31 Fully immunized children 35 Percent Immunization 30 Yellow fever immunization coverage 61 Percent Tetanus toxoid 32 Neonatal tetanus protection 78 Percent 33 Use of oral rehydration therapy (ORT) 60 Percent 34 Home management of diarrhoea 23 Percent 35 Received ORT or increased fluids, and continued feeding 31 Percent 23 Care seeking for suspected pneumonia 48 Percent Care of illness 22 Antibiotic treatment of suspected pneumonia 21 Percent Solid fuel use 24 29 Solid fuels 99 Percent 36 Household availability of insecticide-treated nets (ITNs) 5 Percent 37 22 Under-fives sleeping under insecticide-treated nets 5 Percent 38 Under-fives sleeping under mosquito nets 20 Percent 39 22 Antimalarial treatment (under-fives) 45 Percent Malaria 40 Intermittent preventive malaria treatment (pregnant women) 2 Percent ii Topic MICS Indicator Number MDG Indicator Number Indicator Value ENVIRONMENT 11 30 Use of improved drinking water sources 47 percent 13 Water treatment 5 percent 12 31 Use of improved sanitation facilities 30 percent Water and Sanitation 14 Disposal of child's faeces 41 percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 5 percent 20 Antenatal care 81 percent 44 Content of antenatal care 94 percent 4 17 Skilled attendant at delivery 43 percent Maternal and newborn health 5 Institutional deliveries 19 percent Maternal mortality 3 16 Maternal mortality ratio 457 per 100,000 CHILD DEVELOPMENT 46 Support for learning 65 percent 47 Father's support for learning 65 percent 48 Support for learning: children’s books 11 percent 49 Support for learning: non-children’s books 29 percent 50 Support for learning: materials for play 52 percent Child development 51 Non-adult care 21 percent EDUCATION 52 Pre-school attendance 13 percent 53 School readiness 7 percent 54 Net intake rate in primary education 48 percent 55 6 Net primary school attendance rate 69 percent 56 Net secondary school attendance rate 19 percent 57 7 Children reaching grade five 92 percent 58 Transition rate to secondary school 52 percent 59 7b Primary completion rate 11 percent Education 61 9 Gender parity index primary school secondary school 1.01 0.78 ratio ratio Literacy 60 8 Adult literacy rate 25 percent CHILD PROTECTION Birth registration 62 Birth registration 48 percent 71 Child labour 48 percent 72 Labourer students 64 percent Child labour 73 Student labourers 45 percent Child discipline 74 Child discipline: Any psychological/physical punishment 92 percent 67 Marriage before age 15 Marriage before age 18 27 62 percent percent 68 Young women aged 15-19 currently married/in union 36 percent 70 Polygyny 43 percent Early marriage and polygyny 69 Spousal age difference Among women aged 15-19 Among women aged 20-24 58 56 percent percent iii Topic MICS Indicator Number MDG Indicator Number Indicator Value 66 Approval for continuation of secret societies 86 percent 63 Prevalence of membership in secret societies 94 percent Membership in secret societies (proxy for female genital cutting) 65 Prevalence of membership in secret societies among daughters 34 percent Domestic violence 100 Attitudes towards domestic violence 85 percent Disability 101 Child disability 23 percent HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN 82 19b Comprehensive knowledge about HIV prevention among young people 17 percent 89 Knowledge of mother- to-child transmission of HIV 54 percent 86 Positive attitude towards people with HIV/AIDS 5 percent 87 Women who know where to be tested for HIV 18 percent 88 Women who have been tested for HIV 6 percent 90 Counselling coverage for the prevention of mother- to-child transmission of HIV 41 percent HIV/AIDS knowledge and attitudes 91 Testing coverage for the prevention of mother-to- child transmission of HIV 5 percent 84 Age at first sex among young people 25 percent 92 Age-mixing among sexual partners 39 percent 83 19a Condom use with non-regular partners 20 percent Sexual behaviour 85 Higher-risk sex in the last year 43 percent 75 Prevalence of orphans 11 percent 78 Children’s living arrangements 20 percent 76 Prevalence of vulnerable children 18 percent 77 20 School attendance of orphans versus non-orphans 0.83 ratio 81 External support to children orphaned and made vulnerable by HIV/AIDS 1.3 percent 79 Malnutrition among children orphaned and made vulnerable by HIV/AIDS 0.96 ratio Support to orphaned and vulnerable children 80 Early sex among children orphaned and made vulnerable by HIV/AIDS 1.51 ratio iv Table of Contents Summary Table of Findings .i Table of Contents. iv List of Tables . vi List of Figures .viii List of Abbreviations . ix Acknowledgements .x Executive Summary . xi I. Introduction .1 Background.1 Survey Objectives .2 II. Sample and Survey Methodology .3 Sample Design.3 Questionnaires .3 Training and Fieldwork.4 Data Processing.5 III. Sample Coverage and the Characteristics of Households and Respondents .6 Sample Coverage .6 Characteristics of Households.7 Characteristics of Respondents .8 IV. Child Mortality.10 V. Nutrition Nutritional Status .12 Breastfeeding.14 Salt Iodization.18 Vitamin A Supplements .20 Low Birth Weight .22 VI. Child Health.24 Immunization.24 Tetanus Toxoid.27 Oral Rehydration Therapy.29 Care Seeking and Antibiotic Treatment of Pneumonia .32 Solid Fuel Use.33 Malaria.34 VII. Environment.37 Water and Sanitation.37 VIII. Reproductive Health .41 Contraception.41 Antenatal Care .42 Assistance at Delivery.43 Maternal Mortality .44 IX. Child Development.46 v X. Education .49 Pre-School Attendance and School Readiness.49 Primary and Secondary School Participation .50 Adult Literacy .54 XI. Child Protection.55 Birth Registration.55 Child Labour .56 Child Discipline .58 Early Marriage and Polygyny .59 Membership in Secret Societies.62 Domestic Violence .64 Child Disability .65 XII. HIV/AIDS, Sexual Behaviour, and Orphaned and Vulnerable Children .66 Knowledge of HIV Transmission and Condom Use.66 Sexual Behaviour Related to HIV Transmission .70 Orphans and Vulnerable Children .72 List of References.75 Appendix A. Sample Design. A1 Appendix B. List of Personnel Involved in the Survey . A8 Appendix C. Estimates of Sampling Errors. A11 Appendix D. Data Quality Tables . A20 Appendix E. MICS Indicators: Numerators and Denominators. A29 Appendix F. Questionnaires. A35 vi List of Tables Table HH.1: Results of household and individual interviews. T1 Table HH.2: Household age distribution by sex . T2 Table HH.3: Household composition. T3 Table HH.4: Women's background characteristics . T4 Table HH.5: Children's background characteristics . T5 Table CM.1: Child mortality . T6 Table CM.2: Children ever born and proportion dead . T6 Table NU.1: Child malnourishment. T7 Table NU.2: Initial breastfeeding. T8 Table NU.3: Breastfeeding . T9 Table NU.4: Adequately fed infants. T10 Table NU.5: Iodized salt consumption . T11 Table NU.6: Children's vitamin A supplementation. T12 Table NU.7: Post-partum mothers' vitamin A supplementation . T13 Table NU.8: Low birth weight infants . T14 Table CH.1: Vaccinations in first year of life . T15 Table CH.2: Vaccinations by background characteristics . T16 Table CH.3: Neonatal tetanus protection. T17 Table CH.4: Oral rehydration treatment . T18 Table CH.5: Home management of diarrhoea . T19 Table CH.6: Care seeking for suspected pneumonia . T20 Table CH.7: Antibiotic treatment of pneumonia . T21 Table CH.7A: Knowledge of the two danger signs of pneumonia. T22 Table CH.8: Solid fuel use. T23 Table CH.9: Solid fuel use by type of stove or fire . T24 Table CH.10: Availability of insecticide treated nets . T25 Table CH.11: Children sleeping under bednets . T26 Table CH.12: Treatment of children with anti-malarial drugs. T27 Table CH.13: Intermittent preventive treatment for malaria. T29 Table EN.1: Use of improved water sources . T30 Table EN.1b: Use of unimproved water sources . T31 Table EN.2: Household water treatment . T32 Table EN.3: Time to source of water . T34 Table EN.4: Person collecting water . T35 Table EN.5: Use of sanitary means of excreta disposal . T36 Table EN.6: Disposal of child's faeces . T38 Table EN.7: Use of improved water sources and improved sanitation . T39 Table RH.1: Use of contraception. T40 Table RH.2: Antenatal care provider . T42 Table RH.3: Antenatal care Content . T43 Table RH.4: Assistance during delivery. T44 Table RH.5: Maternal mortality ratio. T45 Table CD.1: Family support for learning . T46 Table CD.2: Learning materials . T47 Table CD.3: Children left alone or with other children. T48 Table ED.1: Early childhood education . T49 Table ED.2: Primary school entry . T50 Table ED.3: Primary school net attendance ratio . T51 Table ED.4: Secondary school net attendance ratio. T52 Table ED 4W Secondary school age children attending primary school . T53 vii Table ED.5: Children reaching grade 5 . T54 Table ED.6: Primary school completion and transition to secondary education . T55 Table ED.7: Education gender parity . T56 Table ED.8: Adult literacy. T57 Table CP.1: Birth registration . T58 Table CP.2: Child labour . T59 Table CP.3: Labourer students and student labourers . T60 Table CP.4: Child discipline . T61 Table CP.5: Early marriage and polygyny. T62 Table CP.6: Spousal age difference. T63 Table CP.7: Membership in secret societies . T64 Table CP.8: Membership in secret societies among daughters . T65 Table CP.8A: Membership in secret societies among daughters . T66 Table CP.9: Attitudes toward domestic violence. T67 Table CP.10: Child disability . T68 Table HA.1: Knowledge of preventing HIV transmission . T69 Table HA.2: Identifying misconceptions about HIV/AIDS. T70 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission. T71 Table HA.4: Knowledge of mother-to-child HIV transmission. T72 Table HA.5: Attitudes toward people living with HIV/AIDS. T73 Table HA.6: Knowledge of a facility for HIV testing . T74 Table HA.7: HIV testing and counselling coverage during antenatal care . T75 Table HA.8: Sexual behaviour that increases risk of HIV infection. T76 Table HA.9: Condom use at last high-risk sex . T77 Table HA.10: Children's living arrangements and orphanhood. T78 Table HA.11: Prevalence of orphanhood and vulnerability among children. T79 Table HA.12: School attendance of orphaned and vulnerable children . T80 Table HA.13: Support for children orphaned and vulnerable due to AIDS . T81 Table HA.14: Malnutrition among orphans and vulnerable children. T82 Table HA.15: Sexual behaviour among young women by orphanhood and vulnerability status due to AIDS. T82 viii List of Figures Figure HH.1: Age and sex distribution of household population .7 Figure CM.1: Under-5 mortality rates by background and demographic characteristics .11 Figure NU.1: Percentage of children under-5 who are undernourished.14 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth.15 Figure NU.3: Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern and age group .16 Figure NU.4: Percentage of households consuming adequately iodized salt .19 Figure NU.5: Percentage of infants weighing less than 2500 grams at birth .23 Figure CH.1: Percentage of children aged 12-23 months who received the recommended vaccinations by 12 months .25 Figure CH.2: Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus .28 Figure CH.3: Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment .30 Figure CH.4: Percentage of children aged 0-59 months with diarrhoea who received ORT or increased fluids, AND continued feeding .31 Figure EN.1: Percentage distribution of household members by source of drinking water.38 Figure HA.1: Percent of women who have comprehensive knowledge of HIV/AIDS transmission .69 Figure HA.2: Sexual behaviour that increases risk of HIV infection.72 ix List of Abbreviations AIDS Acquired Immune Deficiency Syndrome ANC Antenatal care ARI Acute respiratory infection BCG Bacillus-Cereus-Geuerin (Tuberculosis) CBIMCI Community-Based Integrated Management of Childhood Illnesses DD Diarrhoeal disease DPT Diphtheria Pertussis Tetanus EA Enumeration area ECD Early child development EPI Expanded Programme on Immunization FGC Female genital cutting GoSL Government of Sierra Leone HIV Human Immunodeficiency Virus IDD Iodine deficiency disorders IMCI Integrated Management of Childhood Illnesses IMR Infant mortality ratio IPT Intermittent preventive treatment (for malaria) ITN Insecticide-treated net IUD Intrauterine device LAM Lactational amenorrhea method LBW Low birth weight MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MMR Maternal mortality ratio MoH Ministry of Health MTCT Mother-to-child transmission NAR Net attendance rate NGO Non-governmental Organization ORS Oral rehydration solution ORT Oral rehydration therapy OPV Oral polio vaccine OVC Orphans and vulnerable children PMTCT Prevention of mother-to-child transmission ppm Parts per million PPVAS Postpartum vitamin A supplementation PRSP Poverty Reduction Strategy Paper RHF Recommended home fluid SBA Skilled birth attendant SPSS Statistical Package for Social Sciences SSL Statistics Sierra Leone STI Sexually transmitted infection TT Tetanus toxoid UFMR Under-five mortality rate UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund VAS Vitamin A supplementation WCA Western and Central Africa WFFC World Fit For Children WHO World Health Organization x Acknowledgements The people of Sierra Leone are acknowledged for the time they gave to provide information to surveyors and for the hospitality they showed towards survey personnel. The surveyors and their supervisors are acknowledged for their diligence and hard work, particularly while accessing hard-to-reach areas in the field by foot. Colleagues in the UNICEF regional and headquarters offices and the external consultant are acknowledged for their contributions to the design and conduct of the MICS3 survey and the production of the survey report. The MICS3 survey would not have achieved success without the support of many partner institutions and their dedicated personnel. Statistics Sierra Leone and UNICEF Sierra Leone acknowledge the following organizations and agencies for logistical and/or technical support that they provided to the MICS3 survey: Government of Sierra Leone Ministry of Development and Economic Planning Ministry of Education, Science and Technology Ministry of Energy and Power (Water Division) Ministry of Health and Sanitation Ministry of Information and Broadcasting Ministry of Local Government and Rural Development Ministry of Women, Gender and Children’s Affairs United Nations Agencies FAO UNFPA UNHCR WHO Non-governmental organizations Action Aid-Sierra Leone Christian Children’s Fund (CCF) Christian Health Association of Sierra Leone (CHASL) World Vision xi Executive Summary The 2005 Sierra Leone Multiple Indicator Cluster Survey (MICS3) is a nationally representative survey of households, women, and children. The main objectives of the survey are (i) to provide current information for assessing the present situation of women and children in Sierra Leone; (ii) to produce data to monitor progress toward the achievement of targets and goals that include the Millennium Development Goals (MDGs); and, (iii) to contribute to the improvement of data and monitoring systems in Sierra Leone. Interviews were successfully completed in 7,078 households drawn from all districts of Sierra Leone. The main results from the survey are summarized below. Child Mortality The MICS3 survey measured child mortality by using a methodology that produced retrospective estimates of the infant mortality rate (IMR) and under-five mortality rate (UFMR). The survey estimated the IMR to be 158 per 1000 and the UFMR to be 267 per 1000 with 2002 as the reference year. These estimates are little changed from those generated during the MICS2 survey in 2000 that produced estimates for 1997. It appears that child mortality in Sierra Leone has not decreased substantially between 1997 and 2002—although perhaps it should not have been expected to, given the conflict that was raging in the republic during that time. Nutrition Nutritional Status Thirty percent of children under age five in Sierra Leone are underweight or too thin for their age. Forty percent of children are stunted or too short for their age, while nine percent are wasted, or too thin for their height. The prevalence of undernourished children in Sierra Leone has increased modestly since 2000 and is slightly higher than norms in West and Central Africa. Breastfeeding Only 33 percent of newborns are given breastmilk within one hour of birth while a mere eight percent of children less than four months of age are exclusively breastfed. Fifty-two percent of children aged 6-9 months receive breast milk and solid or semi-solid foods. Continued breastfeeding rates are 88 and 57 percent among children 12-15 months and 20-23 months of age, respectively. All indicators except for continued breastfeeding fall well short of desired levels. Salt Iodization The percentage of households that consume adequately iodized salt in Sierra Leone has doubled in the past five years as 45 percent of households now consume salt that is adequately iodized. The lack of in-country facilities to iodize salt continues to hamper efforts to achieve universal salt iodization in Sierra Leone. Vitamin A Supplementation Forty-nine percent of children aged 6-59 months received a high dose vitamin A supplement during the six months prior to the MICS3 survey. The ten percent drop in the level of this indicator since 2000 is attributed to the termination of national vitamin A supplementation xii (VAS) campaigns and incorporation of VAS into the routine health services. VAS coverage among postpartum women has improved markedly during the past five years and is now estimated at 55 percent. Low Birth Weight The prevalence of low birth weight (LBW) infants was estimated to be 24 percent in the MICS3, a level that is well above the regional norm of 15 percent. Child Health Immunization Eighty-four percent of children aged 12-23 months were found to have received BCG vaccination by their first birthday. Vaccination coverage for these same children at age 12 months was 56 percent for DPT3, 57 percent for OPV3, 63percent for measles, and 61 percent for yellow fever. Only 35 percent of children received all recommended vaccinations by their first birthday. Comparison of these findings with MICS2 results shows that clear gains have been made in improving vaccination status of children in Sierra Leone during the past five years. Vaccination coverage in Sierra Leone is 8 to 21 percent above regional norms, suggesting that the EPI program is a relatively strong component of the health system in Sierra Leone. Vaccination rates are still far short of the UNICEF goal of 90 percent of children fully immunized at one year of age. Tetanus Toxoid Seventy-five percent of surveyed women who gave birth during the year prior to the MICS3 survey received at least two doses of tetanus toxoid (TT) vaccine during their pregnancy while an additional three percent were protected against neonatal tetanus due to previous TT vaccinations. This encouraging result represents a twenty percent increase in TT coverage over the past five years and is much higher than the regional norm. Oral Rehydration Treatment Approximately 60 percent of children with diarrhoea received either oral rehydration solution (ORS) and/or a recommended home fluid—a 26 percent decrease compared to the MICS2 result. Thirty-one percent of children with diarrhoea received home treatment as recommended: that is, they either received ORT or increased their fluid intake, while continuing feeding at the same time. Shortages in the supply of packaged ORS, on which Sierra Leonean caretakers appear to be over-reliant, may have been contributed to these results, along with low levels of awareness and knowledge among household members regarding the need for children to continue taking fluids and food while ill with diarrhoea. Care Seeking and Antibiotic Treatment of Pneumonia Forty-eight percent of surveyed children with suspected pneumonia during the two weeks preceding the survey were taken to an appropriate provider while only 21 percent were treated with an antibiotic. Just 14 percent of surveyed mothers knew the two key danger signs of pneumonia—fast and difficult breathing. Care for pneumonia is highly inequitable: children living in the poorest areas of the country, in the poorest households, and in households where the education level is the lowest, have the lowest access to services and antibiotics. xiii Solid Fuel Use Households in Sierra Leone make nearly universal (99 percent) use of solid fuels—primarily wood—for cooking purposes. Stoves that limit indoor pollution that are used in Sierra Leone include closed stoves with chimneys (used by less than one percent of households) and open stoves with chimneys or hoods (used by nine percent of households). Malaria MICS3 findings indicate that five percent of children under the age of five slept under an insecticide-treated mosquito net (ITN) the night prior to the survey while 20 percent slept under either an ITN or an untreated net. One-third of surveyed children were ill with fever in the two weeks prior to the MICS3. Among these children, 45 percent were treated with an appropriate anti-malarial drug within 24 hours of onset of symptoms and an additional 7 percent were treated at a later time. These findings suggest that caretakers of children in Sierra Leone emphasize a curative, rather than preventive, approach to malaria control. Environment Water and Sanitation The MICS3 estimates of the Sierra Leonean population’s access to improved sources of drinking water (47 percent) and improved sanitation facilities (30 percent) are lower than previous estimates. Enumerators were carefully trained on the different definitions of improved water and sanitation facilities and may have collected more accurate data than have been collected in the past. In addition, the low estimates may be due to a gradual population movement from urban areas (where improved sources are more readily available) to rural locations following the end of the conflict in 2002. Only 24 percent of households have both an improved source of drinking water and improved sanitation facilities. Differences in the level of this indicator vary widely among provinces, ranging from 13 percent in the North to 63 percent in the Western Area. Reproductive Health Contraception Current use of modern contraception was reported by four percent of surveyed women who were married or in union while one percent reported using a traditional method. The only methods with a notable level of use are the pill and injections. The prevalence of contraceptive-use in Sierra Leone even lags behind the low norms of the region (17 percent), suggesting that adequate efforts have not been made in Sierra Leone to promote contraception. Antenatal Care Eighty-one percent of pregnant women in Sierra Leone receive antenatal care from a skilled health provider (i.e., a doctor, nurse, or midwife) at least once during their pregnancies. The utilization of antenatal care is approximately 15 percentage points higher than regional estimates and the MICS2 estimate from 2000. Assistance at Delivery About 43 percent of births in Sierra Leone that occurred in the year prior to the MICS3 survey were delivered by skilled personnel—that is, a doctor, nurse, or midwife. This level of utilization, which is highest in the Western Area at 83 percent and lowest in the Northern province at 25 percent, remains unchanged since last measured in 2000 and is in line with xiv the regional value of 45 percent. Nineteen percent of deliveries in Sierra Leone take place in health facilities. Maternal Mortality Ratio The MMR in Sierra Leone was measured in the MICS3 using the indirect sisterhood method and estimated to be 457 maternal deaths per 100,000 live births. While this estimate of the MMR is substantially lower than the MICS2 estimate of 1,800 deaths per 100,000 live births, caution should be exercised while drawing conclusions from the comparison of these estimates due to the low precision of the estimates and the different methodologies used to calculate them. Child Development An adult engaged in at least five activities that promote learning and school readiness during the three days preceding the survey for two-thirds of surveyed under-five children. The same percentage of children engaged in these activities at least one time with their fathers during the same time period. Twenty-nine percent of children live in households where at least three non-children’s books are present while only 11 percent live in households where at least three children’s books are found. Fifty-two percent of children aged 0-59 months had three or more playthings to play with in their homes. Twenty percent of children aged 0-59 months were left in the care of other children under ten years of age during the week preceding the interview while six percent of children were left alone. Education Pre-School Attendance and School Readiness Thirteen percent of children aged 3-4 years attend pre-school. Among children who were aged six years and also attended the first grade of primary school at the time of the survey, merely seven percent attended pre-school the previous year. These levels represent a decrease from MICS2 estimates, suggesting a decline in the use of pre-school in Sierra Leone. Primary and Secondary School Participation School attendance in Sierra Leone among children of primary school age has increased notably during the past five years and now stands at 69 percent. Forty-eight percent of children in Sierra Leone begin to attend primary school at the stipulated school entry age (six years), foreshadowing the delayed educational status of many children. Ninety-two percent of children who enter the first grade of primary school eventually reach grade five. Many children leave school at this point; only 52 percent of children who successfully complete the last grade of primary school attend the first year of secondary school the following year. The picture regarding secondary education in Sierra Leone is much bleaker. Only 19 percent of children of secondary school age (12-17 years) attend secondary school while 46 percent attend primary school when they should be attending secondary school. The ratio of girls to boys attending primary school at the national level is 1.01. However, the indicator drops to 0.78 for secondary education. Adult Literacy The MICS3 found that 25 percent of women in Sierra Leone aged 15-24 are literate—well below the regional norm. A woman’s literacy status is positively associated with urban residence, higher levels of education, and higher household wealth. xv Child Protection Birth Registration Just under half of the births of children under five years of age in Sierra Leone have been registered, a level identical to that found in the MICS2 survey in 2000. There are no significant variations in birth registration across gender or age categories. Child Labour The MICS3 survey found that 48 percent of children aged 5-14 years in Sierra Leone perform child labour. Forty-one percent work for a family business while only two percent work on household chores for more than 28 hours per week. Some child protection specialists in Sierra Leone question the accuracy of the latter estimate. The percentage of children who perform child labour is equal among students (45 percent) and all children (48 percent). Sixty-eight percent of all children aged 5-14 attend school while 64 percent of children aged 5-14 who work also attend school, indicating that child labourers and non-labourers have equal access to school-based education. Child Discipline MICS3 findings clearly illustrate the punitive nature of child discipline techniques that are practiced in Sierra Leone. Ninety-two percent of children aged 2-14 years were subjected to at least one form of psychological or physical punishment by a household member during the month preceding the survey. Twenty-two percent of children experienced severe physical punishment while 76 percent received minor physical punishment. Fifty-six percent of surveyed caretakers stated that children should be punished physically. Early Marriage and Polygyny Early marriage, polygyny, and large spousal age differences are common in Sierra Leone. Twenty-seven percent of women aged 15-49 marry before fifteen years of age. The level of this indicator is lowest (15 percent) among women currently aged 15-19 years, suggesting that this practice is decreasing. Sixty-two percent of surveyed women aged 15-49 married before eighteen years of age. Forty-three percent of women who are currently married or in union report that their husband/partner has another wife. Among women aged 15-19 who are married or in union, 58 percent are with a man who is senior to them by ten or more years. Membership in Secret Societies The practice of female genital cutting (FGC) is deeply entrenched in societal norms in Sierra Leone, where it is conducted as an initiation rite by the secret Bondo Society. Given the secrecy that surrounds FGC, it was decided to use “membership in the Bondo Society” as a proxy for “have undergone FGC” in the MICS3 survey. Ninety-four percent of women aged 15-49 stated that they belong to the Bondo Society, which is interpreted to mean that the prevalence of FGC among this population is approximately 94 percent. Thirty-four percent of mothers reported that their daughters had been initiated into the Bondo Society. Domestic Violence Women aged 15-49 years were asked whether husbands are justified in hitting or beating their wives or partners under five different scenarios. Women who agree that their partners are justified in beating them tend to themselves be victims of domestic violence. For each of the five situations that were described, over half of the respondents said that beating is justified; the percent who felt so ranged from 54 percent for “if she burns the food” to 74 xvi percent for “if she neglects the children.” A full 85 percent of respondents felt that beating was justified under one or more of the scenarios. Child Disability A series of questions was asked to assess the prevalence of nine disabilities including sight impairment, deafness, and difficulties with speech in children aged two to nine years. Caretakers reported that 23 percent of their children suffer from at least one of the nine disabilities. This rate is higher than expected and should be confirmed through further research. HIV/AIDS, Sexual Behaviour, and Orphaned and Vulnerable Children Knowledge of HIV Transmission and Utilization of HIV Testing Services Only 17 percent of young women aged 15-24 years have “comprehensive correct knowledge of HIV”: that is, they correctly identify two ways of avoiding HIV infection and reject three common misconceptions about HIV transmission. Two-thirds of women aged 15-49 years have heard of AIDS. Sixty-three percent of respondents know that HIV can be transmitted from mother to child while 54 percent know all three ways that transmission can occur. Ninety-five percent of respondents agreed with at least one of four discriminatory statements regarding people living with HIV/AIDS (PLHA), a sign of high levels of discrimination towards PLHA. Only 16 percent of women could identify a HIV test site while six percent reported that they have been tested for HIV. Among respondents who received ANC from a trained provider during their pregnancy, 51 percent were provided with information about HIV prevention during the ANC visit. Seven percent of these same respondents were tested for HIV during an ANC visit while five percent received the results of their HIV test at an ANC visit. Sexual Behaviour Related to HIV Transmission Young women in Sierra Leone are at substantial risk of contracting HIV. Two in five sexually active women aged 15-24 report having engaged in high-risk sex during the year prior to the survey; among those women, only one in five reports that a condom was used during sex with the high-risk partner. Twenty-five percent of girls aged 15-19 first had sex before 15 years of age. Thirty-nine percent of women aged 15-24 stated that they had sex in the 12 months preceding the survey with a man who was ten or more years their senior, a practice that increases their risk of contracting HIV. Orphans and Vulnerable Children The MICS3 survey found that 11 percent of children aged 0-17 years are orphans (i.e., one or both parents dead) while 20 percent do not live with a biological parent. Twenty-seven percent of children aged 0-17 in Sierra Leone are classified as orphans or vulnerable children (OVC)1. Only one percent of households that provide care to OVC report receiving support from the government or outside agencies for their efforts. While the survey found that there is little or no difference in the nutritional status between OVC and non-OVC, girl OVC were found to be more likely to be sexually exploited than girls who are not OVC. Double- orphans—that is, children aged 10-14 years who have lost both parents—were found to be 1 OVC is defined as children under age 18 who are either (i) orphans; (ii) have a chronically ill parent; (iii) live in a household where an adult aged 18-59 years has died in the past year; or, (iv) live in a household where an adult aged 18-59 years has been chronically ill in the past year. xvii disadvantaged compared to children who are not orphans with respect to their access to educational opportunities. 1 I. Introduction Background This report is based on the Sierra Leone Multiple Indicator Cluster Survey that was conducted in 2005 by Statistics Sierra Leone with financial and technical support from UNICEF Sierra Leone. The survey provides valuable information on the situation of children and women in Sierra Leone and was based, in large part, on the need to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration that was adopted by all 191 United Nations Member States in September 2000 and the Plan of Action of A World Fit For Children that was adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to realize the rights of children enshrined in them, improve conditions for children and to monitor progress towards these ends. UNICEF was assigned a supporting role in this task (see box below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitor progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and sub-national levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” 2 The Government of Sierra Leone (GoSL), in collaboration with its development partners, is implementing several policies and strategies aimed at achieving national and international goals. The GoSL has recently developed its Poverty Reduction Strategy, the main goals of which are in line with the Millennium Development Goals (MDGs). MICS3 has been identified as a major effort to generate valid and reliable data and information that will be used to monitor key indicators that are being tracked by the GoSL to ensure the realization of major international commitments that include World Fit for Children (WFFC) goals, the Millennium Development Goals (MDGs), the UNGASS on HIV/AIDS, and the Abuja targets for malaria. Roughly 20 of the 48 MDG indicators have been estimated in the MICS3, offering the largest single source of data for MDG monitoring. The MICS3 effort will also contribute to the development of a monitoring and evaluation system for Sierra Leone’s Poverty Reduction Strategy and the United Nations Development Framework (UNDAF). This final report presents indicator estimates for the different topics covered in the survey. Survey Objectives The 2005 Sierra Leone Multiple Indicator Cluster Survey has the following primary objectives: 1. To provide up-to-date information for assessing the situation of children and women in Sierra Leone; 2. To furnish data needed for monitoring progress toward goals established by the Millennium Development Goals and the goals of A World Fit For Children (WFFC) as a basis for future action; 3. To contribute to the improvement of data and monitoring systems in Sierra Leone and to strengthen technical expertise in the design and implementation of these systems and analysis of the information they generate. 3 II. Sample and Survey Methodology Sample Design The sample for the 2005 Sierra Leone MICS3 Survey was designed to provide estimates of MICS3 indicators at the national level, for urban and rural areas, and for the four provinces. —Northern, Southern, Eastern and Western Areas. The sample was selected in two stages using a stratified cluster sampling methodology. In the first stage, 320 enumeration areas (EAs) were selected, using probability proportional to size methodology, through systematic sampling from a sample frame of all EAs in Sierra Leone that was ordered by province and, within provinces, by district. Using the comprehensive EA-level household lists that had been developed in the 2004 Sierra Leone national census, a random sample of 25 households was drawn within each of the 320 selected EAs to yield an overall sample of 8,000 households. A household was defined as “a group of people who all eat from the same pot”. The resulting sample was theoretically self-weighting, although sample weights have been employed to adjust for minor variations among provinces and rural/urban EAs with regards to the proportion of households, women, and children for whom the MICS3 interview was completed among sampled households found to be occupied and the eligible women and children who lived in them. Questionnaires Three questionnaires were used in the survey: the Household Questionnaire, the Questionnaire for Individual Women, and the Questionnaire for Children under Five. The questionnaires were based on the MICS3 model questionnaires. Within each interviewed household, the Household Questionnaire was used to collect information about all de jure household members, the household and the dwelling. The respondent for this questionnaire was the head-of-household or another adult who lived in the household. This questionnaire included the following modules: o Household listing o Education o Water and sanitation o Household characteristics o Insecticide treated bednets o Support to children orphaned and made vulnerable by HIV/AIDS o Child labour o Child discipline o Child disability o Maternal mortality o Salt iodization The Questionnaire for Individual Women was administered in each household to all women aged 15-49 years living in the households. This questionnaire included the following modules: o Child mortality 4 o Tetanus toxoid o Maternal and newborn health o Marriage/Union o Contraception o Female secret society (i.e., genital cutting) o Domestic violence o Sexual behaviour o HIV/AIDS The Questionnaire for Children Under Five was administered to mothers or caretakers of children under 5 years of age2 living in surveyed households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. This questionnaire included the following modules: o Birth registration and early learning o Child development o Vitamin A o Breastfeeding o Care of illness o Malaria o Immunization o Anthropometry English is the only written language in Sierra Leone; for this reason, questionnaires were written in English and verbally translated by enumerators into the language preferred by the respondent (generally Krio, Timne, Mende or Limba), using standardized, pre-tested key words. The questionnaires were pre-tested in the Western Area in September 2005. Based on the results of the pre-test, modifications were made to the wording of the questions, the response categories, and the key words. The Sierra Leone MICS questionnaires can be found in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content and measured the weights and heights of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork Fourteen supervisors and sixty-one enumerators were trained for ten days in early October 2005. Training included lectures on interviewing techniques and the contents of the questionnaires and mock interviews between trainees to gain practice in asking questions. During the training period, trainees spent three days conducting practice interviews in Freetown and rural parts of the Western Area. 2 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 5 The data were collected by fourteen teams, each composed of one or two female enumerators, two or three male enumerators, one driver and a supervisor. The fieldwork began in October 2005 and concluded in November 2005. Data Processing Completed questionnaires were checked in the field by supervisors and then transported to Freetown, where data entry personnel checked each questionnaire to make sure that it had been clearly and correctly completed. Data were entered on 30 microcomputers by 30 data entry operators and two data entry supervisors using CSPro software. In order to ensure quality control, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programs developed using CSPro software under the global MICS3 project and adapted to the Sierra Leone questionnaire were used throughout. Data entry and processing began in November 2005 and were completed in April 2006. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 14, and the model syntax and tabulation plans developed for by UNICEF for this purpose. 6 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 8,000 households selected for the sample, only 7,125 were found to be occupied. This surprisingly low rate of occupation is due to the following reasons: 1. The sample frame of households that was used to randomly select 25 households in each selected EA contained many households that consisted of people who had returned to their original homes at the time of the census only for the purpose of being registered there (for political reasons). Once the census was completed, they moved back to their “real homes” elsewhere. Sub-optimal performance of the task of verifying the presence of all households sampled for the MICS3 survey compounded this problem and led to many houses being classified as “not found / destroyed” at the time of data collection. 2. Names and/or addresses on the lists of sampled households were at times not adequately descriptive to permit identification of the households. 3. Some households had, after the census, dissipated following the death of the head of household. 4. The diamond mining clusters in the Eastern province had household heads who were miners and had moved from their places of registration in search of new areas where diamonds could be found. 5. Sample frames in EAs in border villages along the Sierra Leone/Liberia border included households that had returned to Liberia for registration in their national elections. 6. During the verification of households, some communities did not provide accurate information on existing households, thinking that the households may benefit from possible humanitarian assistance after the MICS3 exercise. During data collection, such households did not meet the standard definition of households. Of the 7,125 occupied households, 7,078 were successfully interviewed for a household response rate of 99.3 per cent. In the interviewed households, 9,257 eligible women (aged 15- 49) were identified. Of these, 7,654 were successfully interviewed, yielding a response rate of 82.7 per cent. The response rate for the Questionnaire for Children Under Five was 88.9 per cent; mothers/caretakers of 5,246 children under five were successfully interviewed, from among 5,904 children under five who were identified in the interviewed households. Overall response rates of 82.1 percent and 88.3 percent are calculated for the women’s and under-5’s interviews, respectively (Table HH.1). These rates, however, vary widely by province. Response rates for women’s interviews range from 70 percent in the East to 97 percent in the Western Area. Similarly, rates for children’s interviews vary from 78 percent in the East to 99.6 percent in the Western Area. Response rates in the Western Area were higher than in other provinces due to increased accessibility to respondents. Call-backs were easy to conduct there as most of the households were in Freetown and enumerators were able to make as many visits as necessary—even at night—without hampering their travel schedule. Difficulty in making follow-up visits in other provinces was the primary reason for lower response rates. Response rates were especially low in Kailahun and Kono districts in the Eastern province. MICS3 supervisors 7 reported that many mothers and caretakers, including their children, were out working in the fields during the day and were difficult to access for interviews. Characteristics of Households The age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 7,078 households that were successfully interviewed in the survey, 42,719 household members were listed. Of these, 21,034 were males, and 21,685 were females. These data also indicate that the survey estimated the average household size at 6.0 individuals per household, the same estimate that was calculated during the 2004 census of Sierra Leone. Figure HH.1: Age and sex distribution of household population, Sierra Leone, 2005 9 7 5 3 1 1 3 5 7 9 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Percent Males Females The table below compares the age and sex distribution of the MICS3 survey population with that from the 2004 Sierra Leone Census. Similarities in the population age distribution between the two surveys would suggest that the MICS3 survey represents a valid sample of the Sierra Leonean population. The MICS3 survey population has a slightly higher percentage of 0-14 year olds and a somewhat lower percentage of 15-64 year olds than the 2004 census. 8 Table 1: Population age distribution (percent) of MICS3 survey and 2004 Sierra Leone census MICS3 2004 Census Male Female Total Male Female Total 0-14 44.4 43.1 43.7 43.2 40.3 41.8 15-64 50.3 52.3 51.3 52.5 55.2 54.0 65+ 4.5 3.9 4.2 4.3 4.5 4.2 Missing / don’t know 0.8 0.7 0.7 - - - Total 100.0 100.0 99.9 100.0 100.0 100.0 Children aged 0-17 years compose 49.33 percent of the MICS3 survey population, indicating the young nature of the population in Sierra Leone. Table HH.3 provides basic background information on the households. Within households, the sex of the household head, province, urban/rural status, number of household members, and religion4 of the household head are shown in the table. These background characteristics are also used in subsequent tables in this report; the data in the table are also intended to show the numbers of observations by major categories of analysis in the report. The head of household is male in 77 percent of surveyed households. The Western Area and Eastern, Northern, and Southern Provinces comprise 16, 22, 36, and 25 percent of the sampled households, respectively. 71 percent of surveyed households are located in rural locations while 29 percent are in urban areas. The religion of the head of household is Muslim in 77 percent of households and Christian in 23 percent of households. The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The table also shows that 90 percent of surveyed households had at least one child under 18, 57 percent had at least one child under 5, and at least one eligible woman age 15-49 was found in 85 percent of surveyed households. Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to province, urban- rural areas, age, marital status, motherhood status, education5, wealth index quintiles6, and 3 The 2004 Sierra Leone Census found that 44.9 percent of the total population was aged 0-17 years. 4 This was determined by asking the respondent to the Household Questionnaire “What is the religion of the head of this household?” 5 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 6 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The assets or variables used in these calculations were as follows: [number of persons per sleeping room; type of floor; type of roof; type of wall; type of cooking fuel; presence of household assets including 9 religion of household head. 80 percent of sampled women are married or in union and 83 percent have given birth to at least one child. 74 percent of respondents are uneducated while 11 percent have completed primary education and 15 percent have completed secondary education. Some background characteristics of children under 5 are presented in Table HH.5. These include distribution of children by several attributes: sex, province and area of residence, age in months, mother’s or caretaker’s education, wealth, and religion of household head. 50.3 percent of the children represented in the MICS3 survey are female. The percentage of children aged 0, 1, 2, 3, and 4 years in the sample is 19, 21, 20, 23, and 17, respectively. electricity supply, radio, TV, mobile phone, phone, refrigerator, watch, bicycle, motorcycle, cart, car, and boat; source of drinking water; and, type of sanitary facility]). Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. 10 IV. Child Mortality Key indicators Estimates (deaths / 1,000 live births) West-Central Africa7 20058 (MICS3) 2000 (MICS2) 2004 Infant mortality rate 158 170 109 Under-five mortality rate 267 286 191 One of the overarching aims of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is important yet difficult. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time-consuming, expensive, and requires significant attention to training and supervision. Alternatively, indirect methods that have been developed to measure child mortality produce robust estimates that are comparable with estimates obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. The infant mortality rate (IMR) is the probability of dying before the first birthday. The under-five mortality rate (UFMR) is the probability of dying before the fifth birthday. In MICS3, the IMR and UFMR are calculated based on an indirect estimation technique: the so-called Brass method. The data used in the estimation are: the mean number of children ever born, and the proportion of those children who are dead, for five-year age groups of women from age 15 to 49. The technique converts these data into probabilities of dying by taking account of both the mortality risks to which children are exposed and their length of exposure to the risk of dying. Based on previous information on mortality in Sierra Leone, the North model life table was selected as most appropriate. Table CM.1 provides estimates of child mortality by various background characteristics, while Table CM.2 provides the basic data used in the calculation of the national mortality rate estimates. The IMR in Sierra Leone is estimated to be 158 per thousand while the U5MR is estimated to be 267 per thousand. The IMR and UFMR are approximately 20 and 14 percent higher, respectively, for males than females. Infant and under-5 mortality rates are lowest in the Western Area and highest in the East and South provinces. Mortality rates are lower among the richest 40 percent of the population, compared to the poorest 60 percent. Mortality rates are similarly low for children whose mothers have achieved a secondary education level. Differentials in under-5 mortality rates by background characteristics are displayed in Figure CM.1. 7 Source: The State of the World’s Children 2006. UNICEF, UNICEF House, 3 UN Plaza, New York, NY 10017, USA. (SOWCR 2006) 8 Note that the method used to produce estimates of UFMR and IMR actually produces a retrospective estimate that pertains to 2002 (for MICS3) and 1997 (for MICS2). Millennium Development Goal Indicator Under-five mortality rate Goal 100 deaths per 1,000 live births by 2015 11 Discussion: Child Mortality The UFMR in Sierra Leone is among the highest in the world and is far higher than the regional norm of 191 deaths per 1,000 live births. The comparison of the 2005 (UFMR = 267) and 2000 (UFMR = 286) estimates of the UFMR should be made with care, because the methodology that is used to calculate the UFMR generates retrospective estimates. For example, the UFMR estimate generated during the 2000 MICS2 is actually an estimate of the UFMR in Sierra Leone during 1997. Similarly, the 2005 MICS3 has generated an estimate of the UFMR in 2002—the year when the conflict ended. It can thus be concluded that child mortality in Sierra Leone did not reduce substantially between 1997 and 2002—although it perhaps should not have been expected to, given the conflict that was raging in the country during that time. The pertinent Sierra Leone MDG is to reduce the UFMR to 100 by 2015. While it is true that various interventions that are designed to support the achievement of this MDG under the Sierra Leone Poverty Reduction Strategy Paper (PRSP) are just now being put into place, the MICS3 result suggests that it will be very difficult for this MDG to be achieved. Efforts must be redoubled to fully and rapidly implement policies that are designed to integrate the country’s strategic approach to improving child survival, including the development and implementation of an integrated child survival strategy and scaling up the Community-Based Integrated Management of Child Illness initiative (CBIMCI) in all districts of the country. CM.1: Under-five mortality rates by background and demographic Characteristics [BASED ON NORTH], Sierra Leone, 2005 280 279 279 252 317 126 207 247 164 267 0 50 100 150 200 250 300 350 East North South West Regions Rural Urban Area No education Primary Secondary + Mother's Education Country Per 1,000 live births 12 V. Nutrition Nutritional Status Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1996-2004 Underweight prevalence (2 SD ≤ / 3 SD ≤) 30 / 8 27 / 9 28 / 9 Stunting prevalence (2 SD ≤ / 3 SD ≤) 40 / 20 34 / 16 35 / -- Wasting prevalence (2 SD ≤ / 3 SD ≤) 9 / 2 10 / 2 10 / -- Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments. Undernourished children who survive these illnesses often suffer from chronic disease and faltering growth. Three-quarters of the children who die from causes related to malnutrition are only mildly or moderately malnourished—and thus do not show outward signs of their vulnerability. A key Millennium Development Goal is to reduce the percentage of people who suffer from hunger by half between 1990 and 2015. The World Fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition supports the goal of reducing child mortality. There is a reference distribution of height and weight for children under age five in a well- nourished population. The extent of under- nourishment in a given population of children can be estimated by comparing their nutritional status to that of a reference population. The reference population used in the MICS3 analysis is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the survey was implemented. Each of the three nutritional status indicators—underweight, stunting, and wasting—is expressed in standard deviation units (z- scores) from the median of this reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight- for-age is more than two standard deviations below the median of the reference population are considered to be moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Millennium Development Goal Indicator Percentage of children under five years that are underweight Goal 12 percent by 2015 Source: SL PRSP 2004 13 Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. During the MICS3 survey, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population. The results shown in Table NU.1 do not include the 23 percent of children who were excluded from the analysis. These children were excluded for reasons that include “not measured” (4 percent), “missing weight or height” (0.2 percent), “missing month or year of birth” (12 percent), and “other flagged cases9” (6 percent). The percentage of cases that has been excluded is quite high and may affect the generalizability of the anthropometric results. About three in ten children (30 percent) under five years of age in Sierra Leone are moderately underweight and eight percent are classified as severely underweight (Table NU.1). Forty percent of children are stunted or too short for their age and nine percent are wasted or too thin for their height. The three indicators of malnutrition are similarly high in the Northern, Eastern and Southern provinces and are markedly lower in the Western Area. Those children whose mothers have secondary or higher education are less likely to be malnourished than children of mothers with no or primary-only education. Boys appear to be slightly more likely to be underweight, stunted, and wasted than girls. The age pattern shows that a higher percentage of children aged 12-23 months are undernourished according to all three indices in comparison to children who are younger and older10 (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and begin to be more broadly exposed to contamination in water, food, and environment. 9 For example, those cases for which the measurements are outside of a plausible range. 10 The exception to this pattern is an unusually high level of stunting among children aged 36-47 months. 14 Figure NU.1: Percentage of children under-5 who are undernourished, Sierra Leone, 2005] 0.0 10.0 20.0 30.0 40.0 50.0 60.0 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) Pe rc en t Underweight Stunted Wasted Breastfeeding Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1996-2004 Timely initiation of breastfeeding (within 1 hour of birth) 33 -- -- Exclusive breastfeeding (0-5 months) 8 2 20 Timely complementary feeding (6-9 months) 52 52 65 Adequate frequency of complementary feeding (6-11 months) 37 -- -- Adequately fed infants (0-11 months) 23 -- -- Continued breastfeeding (12-15 months / 20-23 months) 87 / 57 85 / 51 -- / 48 Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers do not practice exclusive breastfeeding for the first few months and introduce other liquids besides breastmilk (e.g., water); others stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if safe drinking water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding up to 2 years of age and beyond. 15 WHO and UNICEF make the following feeding recommendations: • Early initiation of breastfeeding (within one hour after birth). • Exclusive breastfeeding for first six months. • Continued breastfeeding for two years or more. • Safe, appropriate and adequate complementary foods beginning at 6 months. • Frequency of complementary feeding: 2 times per day for infants aged 6-8 months; 3 times per day for infants aged 9-11 months. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding (< 6 months & < 4 months) • Timely complementary feeding (6-9 months) • Continued breastfeeding (12-15 & 20-23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.2 and Figure NU.2 show that 33 percent of women started breastfeeding their infants within one hour of birth. This figure is relatively consistent among sub-populations of women as defined by background characteristics, although respondents from the South (22 percent) and those from the higher wealth quintiles report lower practice of this behaviour than their counterparts. Eighty-one percent of women started breastfeeding their infants within one day of birth. This indicator also shows little variation among respondents when analyzed by their background characteristics. In Table NU.3, the assessment of breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, Figure NU.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth. Sierra Leone, 2005 81.5 76.9 85.9 80.3 81.4 78.2 80.8 37.0 38.0 22.2 34.7 32.9 33.8 33.1 0 10 20 30 40 50 60 70 80 90 100 East North South West Rural Urban Country Percent Within one day Within one hour 16 mineral supplements, or medicine) during this time period. The table shows rates of exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Approximately 11 and 8 percent of children aged less than four and six months, respectively, are exclusively breastfed—levels that should be considered unacceptably low. At age 6-9 months, 52 percent of children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 88 percent of children are still being breastfed and by age 20-23 months, 57 percent are still breastfed. More females than males are exclusively breastfed before six months of age while more males than females continue breast feeding beyond 20 months of age. Among provinces, the North stands out as generally having the highest level of breastfeeding indicators, while the level of complementary feeding of children aged 6-9 months is highest in the South. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at very early ages, the majority of children are not exclusively breastfed and are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children who are exclusively breastfed is below five percent. Only about 40 percent of children receive breast milk at 2 years of age. Figure NU.3 Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Sierra Leone, 2005 0 10 20 30 40 50 60 70 80 90 100 Age (in Months) Pe rc en t Weaned (not breast fed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed The adequacy of infant feeding in children less than 12 months is described in Table NU.4. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding represents adequate feeding. Infants aged 6-8 months are considered to be adequately fed if they receive breastmilk and complementary 17 food at least two times per day, while infants aged 9-11 months are considered to be adequately fed if they receive breastmilk and complementary food at least three times a day. The low level of adequate feeding among infants aged 0-5 months has been described above in the discussion of exclusive breastfeeding. Among infants aged 6-8 and 9-11 months, only 41 and 31 percent, respectively, are adequately fed according to the definitions above. Levels of adequate feeding for infants aged 6-8 months are lowest in the North (30 percent) and in the Western Area (28 percent) and highest among children of poorer, uneducated mothers. The level of adequate feeding of infants aged 9-11 months is less than levels for infants aged 6-8 months in all provinces except for the Western Area, where it is higher. Higher levels of adequate feeding for infants aged 9-11 months are associated with urban residence, higher levels of maternal education, and very high (as well as very low) wealth status. Overall, 37 percent of children aged 6-11 months are adequately fed. Adequate feeding among all infants (aged 0-11 months) is only 23 percent. There is relatively little variation in this latter indicator among infants with different background characteristics. Discussion: Nutritional status and breastfeeding The prevalence of underweight, stunting and wasting among children under five years of age in Sierra Leone in 2005 is slightly higher than prevalence levels in Sierra Leone in 2000 and West and Central Africa (WCA) norms. This decline in nutritional status may be due to a variety of factors that include the limited awareness of mothers about proper child feeding and nutrition; lack of food and lack of food diversification linked to poverty; food insecurity; cultural misconceptions about breastfeeding; and, cultural practices and values relating to distribution of food within the family at household level. The practice of exclusive breastfeeding in Sierra Leone has improved from the meagre level of 2 percent in 2000 but remains extremely low at 8 percent, comparing unfavourably with the WCA norm of 20 percent. MICS3 estimates of complementary feeding and continued breastfeeding rates remain virtually unchanged from 2000 and are similar to WCA norms. Indicators that measure adequate feeding and timely initiation of breastfeeding fall well short of desired levels. There remains ample room for improvement of infant and young child feeding practices and promotion of growth monitoring and promotion in line with the life cycle of young children in Sierra Leone. Policy makers should focus on creating a conducive environment for national food production, income generation, and implementation of the food security component of the PRSP. Programmatic approaches that integrate nutritional interventions into other child survival strategies are called for. The Family Package—which includes interventions such as insecticide treated bednets, exclusive breastfeeding, immunizations, complementary feeding, nutritional supplements, etc.—should be promoted and introduced at the household level, especially through outreach services. 18 Salt Iodization Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1998-2004 Households that consume adequately iodized salt (> 15 parts per million) 45 23 68 Iodine Deficiency Disorders (IDD) are the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage among pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005 (the year in which the MICS3 survey was conducted). The primary international indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). GoSL policy states that all salts imported into the country should be iodized. However, local production of salt in costal communities continues and this salt is sold in the market. Locally produced salt is not iodized due to the lack of facilities to iodize salt in Sierra Leone. In about 94 percent of surveyed households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate. Table NU.5 shows that in a sizable percentage of households (5 percent), there was no salt available. In 45 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt was lowest in the Western Area and Southern region (37 percent) and highest in the East (59 percent) (Figure NU.4). The use of adequately iodized salt in urban and rural areas was similar. Similarly, the use of iodized salt was essentially equivalent across the five wealth quintiles. 19 Discussion: Salt iodization The goal of Universal Salt Iodization (USI) initiative is to achieve 90 percent iodization by 2005 in all countries. The Sierra Leone MICS3 result reported here is only half of that and must be considered to be disappointing. It is hopeful to see that there has been notable improvement in this indicator (23 to 45 percent) during the five years between MICS2 and MICS3. However, this increase is minor in light of the USI goal. It appears that the USI goal can best be achieved through an integrated approach. Policy makers should build the promotion of iodized salts into the Family Package. In this way, the promotion and monitoring of iodized salt consumption can be integrated into child survival activities at community-level health facilities and outreach services. There should be also movement in the direction of ensuring that locally produced salt is iodized and that families are empowered to purchase imported iodized salt (e.g., by packaging iodized salt in small quantities that are affordable to families). Figure NU.4 Percentage of households consuming adequately iodized salt. Sierra Leone, 2005 58.8 44.7 37.0 36.5 44.9 44.0 44.6 0 10 20 30 40 50 60 70 East North South West Rural Urban Country Regions Percent 20 Vitamin A Supplements Key indicators Estimate (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 2003 Children 6-59 months of age who received vitamin A supplement in last six months 49 58 60 Women who received high dose Vitamin A supplement within 8 weeks of delivery 55 33 -- Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables. The amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intake is further compromised by (i) increased requirements for the vitamin as children grow or during periods of illness and (ii) increased losses of the vitamin when children suffer from common infections. As a result, vitamin A deficiency is highly prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of vitamin A deficiency a primary component of child survival efforts and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation (VAS) every four to six months that targets all children between the ages of six to 59 months who live in affected areas. The provision of two high-dose vitamin A capsules a year to young children is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of vitamin A, which are depleted during pregnancy and lactation. For countries with VAS programs, the key indicator of interest is defined as the percentage of children 6-59 months of age who received at least one high dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Sierra Leone Ministry of Health (MoH) recommends that children aged 6-11 months be given one high dose Vitamin A capsules (100,000 IU) and children aged 12-59 months be given a vitamin A capsule (200,000 IU) every 6 months. In Sierra Leone, Vitamin A capsules are linked to immunization services (thus recognised as EPI+). VAS is also a component of the measles immunization protocol when children are brought for measles vaccination at 9 months of age and thereafter. The MoH also recommends that postpartum mothers take a Vitamin A supplement as soon as possible during the six weeks following delivery due to increased Vitamin A requirements during pregnancy and lactation. 21 Within the six months prior to the Sierra Leone MICS3, 49 percent of children aged 6-59 months received a high dose Vitamin A supplement (Table NU.6). Approximately 18 percent did not receive the supplement in the last 6 months but did receive one prior to that time. Approximately 15 percent of children received a Vitamin A supplement at some time in the past but their mother/caretaker was unable to specify when. VAS coverage among the provinces of Sierra Leone ranges from 42 percent in the South province to 55 percent in the East. The age pattern of VAS shows that supplementation in the last six months is highest among children aged 6-11 months at 58 percent and then declines steadily with age to its lowest level of 42 percent among children aged 48-59 months. The mother’s level of education does not appear to be associated with the likelihood of VAS. The degree of variation of VAS rates among the wealth quintiles is modest although rates are slightly higher in the wealthiest three quintiles compared to the lower two. Approximately 55 percent of mothers with a birth in the previous two years before the MICS3 survey received a Vitamin A supplement within eight weeks following the birth (Table NU.7). This percentage is highest in the Western Area (70 percent) and lowest in the South (51 percent). Vitamin A coverage is higher among mothers living in urban areas (63 percent) as compared to rural areas (52 percent) and is higher among women with secondary or higher education (70 percent) versus women with primary education or no education ( 52 and 53 percent, respectively). This indicator is also clearly associated with the wealth level of the family as it is lowest (49 percent) among mothers from the poorest wealth quintile and increases steadily to its highest level (69 percent) among mothers from the wealthiest quintile. Discussion: Vitamin A supplements VAS coverage among children in Sierra Leone needs to be improved. The coverage rate has dropped almost ten percent in the past five years and is below regional norms. Part of the reason for this decline is probably due to the recent inclusion of VAS in the routine service package, under which its provision has still not been fully established. Program managers in Sierra Leone should intensify efforts to standardize the routine provision of VAS as part of the Family Package and integrate the provision of VAS through outreach activities. Greater promotion of VAS is required at the community level given the observed drop in coverage. In contrast to VAS coverage among children, VAS coverage among postpartum women (PPVAS) has markedly improved during the past five years—although ample room remains for further gains. This increase may be due to increased sensitization for maternal VAS since the integration of PPVAS into the routine health services. Policy makers should consider further strengthening the coverage of this important service through the integration of PPVAS into the MCH postnatal package and the engagement of other health services delivery points (e.g., TBAs). Program managers should continue to monitor the coverage of PPVAS at the health facility and community and outreach levels while promoting PPVAS through outreach services. 22 Low Birth Weight Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1998-2004 Infants weighed at birth 29 6 -- Low birth weight infants 24 --11 15 Weight at birth is a good indicator not only of a mother's health and nutritional status but also of the newborn's potential for survival, growth, long-term health and psychosocial development. Low birth weight (LBW: defined as less than 2,500 grams at birth) carries a range of grave health risks for children. Babies who are undernourished in the womb face a greatly increased risk of dying during the early months and years of their lives. Those who survive often have impaired immune function and increased risk of disease. LBW infants are likely to remain undernourished, with reduced muscle strength, throughout their lives and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, LBW stems primarily from the mother's poor health and nutrition. Three factors have been found to predispose a newborn to be born with LBW: 1) the mother's poor nutritional status before conception, 2) her short stature (due mostly to poor nutrition and infections during her childhood), and 3) poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large percentage of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing LBW babies than do fully-developed individuals. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased in most developing countries because the majority of newborns are not delivered in facilities; those who are born in facilities represent a select sample of all births that is not representative of the overall population. Because many infants are not weighed at birth and those who are weighed are not representative of all infants, reported birth weights usually cannot be used to estimate the prevalence of LBW among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the MICS questionnaire: (i) the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large), and (ii) the mother’s recall of the child’s weight or the weight as recorded on a health card (if the child was weighed at birth12). Mothers are asked these questions regarding their most recent live birth. 11 A different technique was used to estimate this indicator in the MICS2 survey. The MICS2 estimate of this indicator, which is not comparable to the MICS3 estimate, was 52 percent. 12 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 23 A total of 2,375 women provided information about weighing practices and size at birth regarding their most recently born child during the 2 years preceding the survey. Overall, 29 percent of these children were weighed at birth. The probability of a child being weighed at birth was strongly associated with urban residence, higher levels of maternal education, and higher levels of wealth. Combining information on the measured birth weights and mothers’ perceptions on the size of the baby, it is estimated that 24 percent of the 2,375 respondents had a low birth weight baby. (Table NU.8). There was no significant variation in this latter indicator by any background characteristic (Figure NU.5). The approach used for the estimation of low birth weight prevalence assumes that the relationship between the measured birth weight and the mothers’ perceptions for these babies holds true for those whose birth weight was not measured but their mothers were asked to provide their perception on the size of the baby. In some categories, the proportion of babies measured are quite low – for these, the results should be regarded with caution. Figure NU.5 Percentage of Infants Weighing Less Than 2500 Grams at Birth, Sierra Leone, 2005 23.1 24.3 23.3 21.2 23.5 0.0 5.0 10.0 15.0 20.0 25.0 30.0 East North South West Country Regions Pe rc en t Discussion: Low birth weight The high prevalence of LBW newborns in Sierra Leone is well above the regional norm and represents a serious problem for public health officials. There is no simple solution to this issue. Efforts to lower the incidence of LBW should focus on advocacy for and implementation of the antenatal package, which contains interventions such as deworming, insecticide-treated bednets, and iron-folate supplementation that can have a positive influence on the incidence of LBW. Efforts should continue to address important topics that can positively contribute to reduction of LBW such as birth spacing and delayed age of pregnancy. 24 VI. Child Health Immunization Estimates (percent) 2005 (MICS3) 2005 (MICS3) 2000 (MICS2) West-Central Africa (2004) Numerator Imm. Status at first birthday Imm. Status at time of survey Imm. Status at time of survey Unclear Denominator # of 1-year-olds # of 1-year-olds # of 1-year-olds Unclear Column # 1 2 3 4 BCG coverage 84 86 73 67 Polio coverage (OPV3) 57 65 61 57 DPT coverage (DPT3) 56 64 46 52 Measles coverage 63 77 62 55 Yellow fever coverage 61 76 -- -- Fully immunized children 35 54 39 -- Note: Only estimates in columns 2 and 3 are directly comparable. The Millennium Development Goal (MDG) Number 4 is to reduce child mortality by two- thirds between 1990 and 2015. Immunization plays a key role in reaching this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children who do not receive routine immunizations. As a result, vaccine- preventable diseases cause more than 2 million deaths every year. The goal of A World Fit for Children with regards to EPI is to achieve full immunization for 90 percent of children under one year of age at the national level and corresponding coverage levels of at least 80 percent in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis; three doses of vaccine to protect against diphtheria, pertussis, and tetanus (DPT); three doses of oral polio vaccine (OPV); and, a measles vaccination—all by the age of 12 months. All of these vaccinations are provided in Sierra Leone through the Ministry of Health (MoH) and--together with the yellow fever vaccine—form the basic EPI package in Sierra Leone. The vaccine schedule is described in the table below. Table 2: EPI package and schedule in Sierra Leone Vaccine Age at vaccination BCG At birth OPV 0 At birth OPV1/DPT1 6 weeks after delivery OPV2/DPT2 10 weeks after delivery OPV3/DPT3 14 weeks after delivery Measles 9 months after delivery Yellow fever 9 months after delivery Caretakers of children under the age of five who were interviewed as part of the MICS3 were asked to show interviewers their children’s vaccination cards. When these cards were available, interviewers copied vaccination information from the cards onto the MICS3 25 questionnaire. When cards were not available, vaccination status was assessed through a structured oral history taken from the mother / caretaker. Overall, interviewers were shown health cards for 53 percent of children included in the MICS3 survey (Table CH.2). The percentage of children aged 12 to 23 months who received each of the vaccinations is shown in Table CH.1 and Figure CH.1. The denominator for the estimates presented in the table and figure is comprised of 1074 children aged 12-23 months; this approach ensures that only children who are old enough to be fully vaccinated are counted. In the coverage estimate presented in the third row of Table CH.1, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In order to generate the coverage estimate presented in the bottom row, only those children who were vaccinated before their first birthday are included. For children without vaccination cards, the percentage of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Approximately 84 percent of children aged 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 79 percent. The percentage declines for subsequent doses of DPT to 74 percent for the second dose and 56 percent for the third dose (Table CH.1). Similarly, 84percent of children received the first dose of polio vaccine (OPV1) by age 12 months and this declines to 57 percent for the third dose. The coverage for measles vaccine by 12 months is—at 63 percent—higher than for OPV3 or DPT3. Coverage for yellow fever vaccine at age 12 months is 61 percent. The percentage of children aged 12- Figure CH.1 Percentage of children aged 12-23 months who received the recommended vaccinations by 12 Months. Sierra Leone, 2005 84 79 74 56 84 76 57 63 35 0 10 20 30 40 50 60 70 80 90 BCG DPT1 DPT2 DPT3 OPV1OPV2OPV3 Measles All Percent Millennium Development Goal Indicator Percentage of children under one year immunized against measles Goal 100 percent by 2015 26 23 months who received all eight recommended vaccinations excluding yellow fever (BCG, DPT x 3, OPV x 3, and measles) by their first birthday is 35 percent. Table CH.2 shows vaccination coverage rates among children 12-23 months by background characteristics. These estimates represent coverage rates among surveyed children at the time of the survey (regardless of the age at which the vaccine was received) and are based on information from both the vaccination cards and mothers’/caretakers’ reports. Coverage rates among male children are slightly higher than for females. A comparison across provinces shows that coverage rates of polio are lowest in the more developed Western Area. For other antigens, coverage is generally higher in the South and in the Western Area. Coverage levels are slightly higher in urban areas as compared to rural locations for all antigens. The association of coverage and the education level of the mother does not follow a linear trend, as vaccination rates for most antigens are highest among women with primary education, followed by mothers with secondary education or higher. Coverage is lowest among children of uneducated women. Finally, there is a clear positive association between increasing wealth status and higher coverage levels. Coverage rates for most antigens are markedly lower for the two lowest wealth quintiles as compared with the three higher quintiles. Discussion: Immunization The MICS3 survey has introduced an approach to the measurement of immunization rates that differs from the approach taken during MICS2. Timely immunization—that is, completion of basic immunizations by an infant’s first birthday, as measured among 12-23 month-olds—is the basis of the MICS3 EPI assessment. This contrasts with the approach taken during MICS2, when indicators were defined based on current immunization status among surveyed 12-23 month-olds. This latter approach aggregates the vaccination status of children of different ages (between 12 and 23 months) in the calculation. Estimates of timely immunization are not available from MICS2; it is therefore necessary to examine current immunization status as measured during MICS3 and MICS2 (columns 2 and 3 in the table that can be found at the beginning of this section) in order to examine trends in vaccination status over time. A comparison of these data suggests that clear gains have been made in improving vaccination status of children in Sierra Leone during the past five years. This finding, along with data that show immunization rates in Sierra Leone to be 8-to-21 percent above regional norms (measles), suggests that the EPI program in Sierra Leone is a relatively strong component of the health system. Vaccination rates in Sierra Leone are still far short of the UNICEF goal of 90 percent of children fully immunized at one year of age or the MDG for measles vaccination of 100 percent at one year of age. Policy recommendations to strengthen the EPI program in Sierra Leone include prioritizing the placement of adequate personnel at the community-level to carry out EPI programs and supporting the integration of EPI activities in the broader Integrated Child Survival Strategies. EPI program managers should continue to focus on strengthening outreach EPI services and establishing appropriate technology for cold chain maintenance. 27 Tetanus Toxoid Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 2004 Mothers given at least two doses of tetanus toxoid vaccine within appropriate interval 75 58 57 A central MDG is to reduce the maternal mortality ratio by three-quarters. A key strategy to help reach this goal is to eliminate maternal tetanus. In addition, the global standard is to ensure that neonatal tetanus is reduced to less than one case of neonatal tetanus per 1000 live births in every district. A World Fit for Children goal is to eliminate maternal and neonatal tetanus by 2005. The best way to prevent maternal and neonatal tetanus is to ensure that all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during their current pregnancy, they (and their newborn) are also considered to be protected if any of the following conditions are met: • Received at least two doses of tetanus toxoid vaccine during lifetime, the last within the prior three years; • received at least three doses during lifetime, the last within the prior five years; • received at least four doses during lifetime, the last within ten years; or, • received at least five doses during lifetime Table CH.3 shows that 75 percent of surveyed women who had a live birth within 12 months prior to the survey received at least two doses of TT vaccine during their last pregnancy and 78 percent of surveyed women were protected against neonatal tetanus according to the conditions outlined directly above. Figure CH.2 below shows the protection status from tetanus of women by major background characteristics. Coverage of protection against tetanus is highest in the Western Area and East and notably lower in the North. Coverage levels are higher in urban than in rural areas. There is little difference in vaccination rates among different age groups of women; rates range from 75 percent (among 25-29 year-olds) to 82 percent (among 20-24 year-olds). Those differences that do exist among age groups do not follow a discernible trend. There is a direct association between higher levels of mothers’ education and higher vaccination rates. Similarly, increasing wealth status is positively associated with higher coverage levels. 28 Discussion: Tetanus toxoid Similar to the findings presented above for child vaccination, the results for TT vaccination of pregnant women are encouraging. Although key interventions to strengthen the vaccination program have only just begun, TT coverage has increased notably during the past five years and is much better than the regional norm. Policy recommendations to further strengthen the coverage of TT are similar to those presented above for children’s vaccination—that is, to prioritize adequate staffing at the community-level to implement EPI programs and support the integration of EPI activities in the broader Integrated Child Survival Strategies. EPI program managers should focus on strengthening outreach EPI services and cold chain maintenance. Figure CH.2 Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus. Sierra Leone, 2005 86 69 81 87 76 83 75 85 90 78 0 20 40 60 80 100 Regions East North South West Area Rural Urban Mother's Education No education Primary Secondary + Country Percent 29 Oral Rehydration Therapy Key indicators Estimates West-Central Africa 2005 (MICS3) 2000 (MICS2) 1996-2004 Prevalence of diarrhoea 14 25 -- Oral rehydration therapy (ORT) Children with diarrhoea that received oral rehydration solution and/or household solution 60 86 -- Home management of diarrhoea Children with diarrhoea that received more fluids AND continued eating food 23 28 -- ORT or increased fluids AND continued feeding 31 -- 30 Diarrhoea is the second leading cause of death worldwide among children under five years of age. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea—either through oral rehydration solution (ORS) or a recommended home fluid (RHF)—can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child during diarrhoeal episodes are also important strategies for managing diarrhoea. The goals with regards to diarrhoeal disease and management are to: 1) reduce deaths due to diarrhoea among children under five by one-half by 2010 compared to 2000 (A World Fit for Children); and, 2) reduce the mortality rate among children under five by two-thirds by 2015 compared to 1990 (Millennium Development Goal). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The primary indicators with regards to diarrhoeal disease and management that have been measured through the MICS3 are the following: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • (ORT or increased fluids) AND continued feeding In the MICS3 questionnaire, mothers (or caretakers) were asked to report whether their child had diarrhoea in the two weeks prior to the survey. If yes, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, 14 percent of children under five had diarrhoea in the two weeks preceding the survey (Table CH.4). Diarrhoea prevalence was lowest in the South and Western Area (11 percent) and highest in the North (18 percent). Among children of different age groups, the peak of diarrhoea prevalence (22 percent) occurs during the weaning period (i.e., among children aged 12-23 months). Table CH.4 also shows the percentage of children receiving various types of recommended liquids during diarrhoeal episodes. Since mothers were able to name more than one type of liquid, the percentages add to more than 100. About 51 percent received fluids from ORS 30 packets; 7 percent received pre-packaged ORS fluids; and, 12 percent received recommended homemade fluids. Approximately 60 percent of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or RHF), while 40 percent received no treatment. Figure CH.3 shows the disparities, by selected background variables, in the percentage of children with diarrhoea who received ORT. The use of ORT was found to be lowest in the North and South (55 and 58 percent, respectively) and highest in the Western Area (79 percent). Children of mothers with no education are less likely to receive ORT than children of mothers with primary or secondary-plus education. The utilization of ORT was higher in urban than rural areas (77 versus 55 percent) and much higher among children from households in the upper two wealth quintiles, as compared to the lower three quintiles. There was little variation in ORT use rates among children from different age groups. Slightly more than one-half (51 percent) of under-five children with diarrhoea drank more than usual during their illness while 47 percent drank the same or less (Table CH.5). Forty percent ate somewhat less, the same or more than usual (continued feeding) while sixty percent ate much less than usual or almost nothing. Combining these findings, only 23 percent of children with diarrhoea received increased fluids and at the same time continued feeding. Thirty-one percent of children received home treatment according to the recommendation: that is, they either received ORT or increased their fluid intake, and at the same time, continued feeding. There are modest differences by background characteristics in the percentage of children who received ORT or increased fluids and continued feeding. Among provinces, the percentage of children ranges from 30 to 37 percent in all provinces except for the Western Area, where it is a meagre 16 percent. Differences by gender, location (rural/urban), and mother’s education level are unremarkable and do not exceed five percent (see Figure CH.4). Children aged 24-48 months have a much higher level of appropriate management than do children of other age groups. Analysis of this indicator by household wealth status reveals Figure CH.3 Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment. Sierra Leone, 2005 67 55 58 79 58 70 69 60 0 10 20 30 40 50 60 70 80 90 East North South West None Primary Secondary + Country Percent 31 that mothers in the poorest quintile demonstrate a somewhat higher level of appropriate management as compared to mothers from the other four quintiles. Discussion: Oral rehydration therapy Due to a major decrease in the use of ORT over the last five years and steadily low levels of home management of diarrhoeal disease (DD), the results presented above are not encouraging. Child health specialists note that there have been shortages in the supply of ORT recently that may have contributed to the result. It appears that there may be an over- reliance on packaged ORS in Sierra Leone (it is easily caretakers’ preferred method of treatment) and that household members do not readily prepare homemade ORS if the packets are not available. The negative effects of this practice are exacerbated by low levels of awareness and knowledge among household members regarding the need for children to continue taking fluids and food during DD. Policy and programming recommendations with regards to improving the situation include considering the establishment of ORT corners in health centres and training Blue Flag Volunteers and community members regarding their use. The use of locally-made ORS formulas should be promoted in these corners as should the importance of increased fluid intake and continued feeding. 30 31 37 16 32 27 31 30 34 31 0 5 10 15 20 25 30 35 40 Regions East North South West Area Rural Urban Mother's Education No education Primary Secondary + Country Percent Figure CH.4 Percentage of children aged 0-59 months with diarrhoea who received ORT or increased fluids AND continued feeding. Sierra Leone, 2005 32 Care Seeking and Antibiotic Treatment of Pneumonia Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1998-2004 Prevalence of suspected pneumonia 11 9 10 Knowledge of danger signs of pneumonia 14 -- -- Care seeking for suspected pneumonia 48 50 35 Antibiotic treatment of suspected pneumonia 21 -- -- At the global level, pneumonia is the leading cause of death in children and the treatment of under-5s who have suspected pneumonia with antibiotics is an important intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. In the MICS3 survey, a child with suspected pneumonia is defined as a child whose caretaker reported that s/he had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The analysis below was limited to children who had suspected pneumonia during the two weeks prior to the survey. The indicators of interest are the following: • Prevalence of suspected pneumonia • Knowledge of the danger signs of pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia Table CH.6 presents the prevalence of suspected pneumonia and—if care was sought outside the home—the site of care. Eleven percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, 48 percent were taken to an appropriate provider. The types of facilities that provided services to a substantial percentage of children with suspected pneumonia include government hospitals (9 percent), health centers (22 percent) and health posts (7 percent), village health workers (6 percent), and private health centers ( 5 percent). The use of appropriate providers is somewhat higher for male children (50 percent) than female children (45 percent). Caretakers in the South make the highest use of appropriate providers (50 percent) while the lowest rate of use is in the Western Area (42 percent). Younger children are more likely to be taken to be seen by an appropriate provider than are older children. The association of the utilization of an appropriate provider with the variables mother’s education and wealth status is mixed and does not follow a linear trend. Table CH.7 presents data that describe the use of antibiotics for the treatment of suspected pneumonia in under-5s by sex, age, province, residence, and socioeconomic status. In Sierra Leone, 21 percent of under-5 children with suspected pneumonia during the two weeks prior to the survey were treated with an antibiotic. The percentage treated with an antibiotic was highest (47 percent) in the Western Area and varied among the other provinces from 27 percent in the East to 13 percent in the North. The table also shows that antibiotic treatment of suspected pneumonia is highest among children from the two highest wealth quintiles and among children whose mothers/caretakers have secondary education or higher. Mothers’ knowledge of danger signs of pneumonia is an important determinant of care- seeking behaviour. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7A. Only 14 percent of women knew both of the two key danger signs of pneumonia—fast breathing and difficult breathing. The most commonly identified symptom 33 for taking a child to a health facility is fever (83 percent). Twenty-one percent of mothers identified fast breathing and 27 percent of mothers identified difficult breathing as symptoms that require taking a sick child to see a health care provider immediately. Differences in the level of this indicator vary little by all background characteristics except for province, where huge variation is seen: three percent of mothers in the East and seven percent of mothers in the North demonstrate correct knowledge, as compared to 15 and 33 percent in the Western Area and South, respectively. Discussion: Care seeking and antibiotic treatment of pneumonia The results presented above suggest that the status of care for children with pneumonia in Sierra Leone is dismal. Caretakers do not know key symptoms of the disease, more than half of children with suspected pneumonia are not seen by a trained provider, and only ten percent (0.48 x 0.21) of children with suspected pneumonia receive antibiotics. Key indicators suggest that the situation is highly inequitable: children living in the poorest areas of the country, in the poorest households, and in households where the education level is the lowest, have the lowest access to services and antibiotics. The indicators antibiotic treatment of suspected pneumonia and knowledge of danger signs of pneumonia were not measured in the 2000 MICS2, making it impossible to assess trends in their level over time. A related indicator—the percentage of children with ARI taken to an appropriate health provider—was measured in the MICS2, and its value has remained static over the past five years (see table above). The value of this latter indicator remains higher in Sierra Leone than the WCA norm, suggesting that programs to raise awareness of Sierra Leonean caretakers regarding the need to seek care for severe ARI may have achieved a relative level of “success”. Policy makers should seek to increase demand for ARI services while also ensuring that quality ARI services are provided at the nation’s community-level health facilities. There is an urgent need to increase the access to treatment and antibiotics for children from disadvantaged households. Solid Fuel Use Key indicators Estimate (percent) 2005 (MICS3) Households using solid fuels as primary source of domestic energy for cooking 99 More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor pollution and is a major cause of ill-health in the world— particularly among under-5 children—through its contribution to acute respiratory illness. The main problem with the use of solid fuels is that it creates by-products of incomplete combustion that include CO, polyaromatic hydrocarbons, SO2, and other toxic elements. The use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, low birth weight, cataracts, asthma and possibly tuberculosis. The primary MICS3 indicator with regard to solid fuel use is the percentage of the population using solid fuels as the primary source of domestic energy for cooking. 34 Households in Sierra Leone make nearly universal (99 percent) use of solid fuels for cooking purposes. Some households use charcoal—these households are mostly located in the Western Area and represent households that lie in the highest wealth quintile and/or where the household head has achieved high levels of education. Residents of the rest of the country cook almost exclusively with wood. Table CH.8 presents relevant data. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants differs according to the type of stove or fire that is used. The use of closed stoves with chimneys minimizes indoor pollution, while the use of an open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. The type of stove used with a solid fuel is depicted in Table CH.9. Ninety percent of surveyed households cook using solid fuels over an open fire or stove with no chimney or hood—the most dangerous kind of stove with regards to generating indoor air pollution. Nine percent of households use an open fire or stove with a chimney or hood, which offers some protection from the harmful effects of solid fuel use. The use of a chimney or hood is highest in the East (21 percent) and South (11 percent). Discussion: Solid fuel use The overwhelming reliance on solid fuels for cooking in Sierra Leone is due to the ready availability of inexpensive wood products and the comparatively high price and limited availability of alternative fuels. Given the dire economic conditions in Sierra Leone at this time, it is probably not realistic to expect people to change their fuel source. Efforts to reduce ARI through control of indoor pollution should therefore focus on the promotion of stoves that limit indoor pollution, such as closed stoves with chimneys (used by less than one percent of households in Sierra Leone) or open stoves with chimneys or hoods (used by nine percent of households). Malaria Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1999-2004 Households with insecticide-treated bednets (ITNs) 5 2 -- Under-fives sleeping under ITNs 5 2 2 Under-fives sleeping under mosquito nets 20 15 15 Ant-malarial treatment (under-fives) ¾ Within 24 hours of onset of symptoms ¾ Any time 45 52 -- 61 -- 43 Pregnant women who received appropriate intermittent preventive therapy for malaria 2 -- -- Malaria is a leading cause of death of children under age five in Sierra Leone. It also contributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of insecticide-treated mosquito nets (ITNs), can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti-malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. Also, children recovering from malaria should be given extra liquids and food. Younger children should continue breastfeeding while recovering from malaria. 35 The MICS3 questionnaire incorporates questions on the availability and use of bed nets, both at household level and among children under five years of age. Other questions assess anti- malarial treatment and intermittent preventive therapy for malaria. Survey results indicate that only five percent of households in Sierra Leone have at least one ITN (Table CH.10). The ITNs that are available in Sierra Leone are the long-lasting variety that do not require treatment with an insecticide for five years. Results also indicate that 20 percent of children under the age of five slept under any type of mosquito net (i.e., treated or untreated) the night prior to the survey while 5 percent slept under an ITN (Table CH.11). The use of ITNs as well as the use of untreated bed nets by children under five declines steadily with increasing age of the child. There were no significant gender disparities in use of ITNs / bed nets among children under five. Questions on the prevalence of fever and its treatment were asked for all children under age five. Slightly more than one in three (35 percent) children were ill with fever in the two weeks prior to the MICS3 (Table CH.12). Fever prevalence was highest among children aged 12-23 months (41 percent) and thereafter declined slowly with increasing age. The prevalence of fever was relatively similar across all levels of mother’s education and wealth quintiles. Among provinces, fever was least prevalent in the Western Area (26 percent) and most prevalent in the North (39 percent). Among children who experienced fever in the two weeks prior to the survey, caretakers were asked to report all of the medicines that were given to their children to treat the fever, including medicines given at home and medicines given or prescribed at a health facility. Overall, 52 percent of children with fever in the last two weeks were treated with an “appropriate” anti-malarial drug and 45 percent received anti-malarial drugs within 24 hours of onset of symptoms. “Appropriate” anti-malarial drugs include Chloroquine, Fansidar, and artimisine combination drugs. In Sierra Leone, 46 percent of children with fever were given Chloroquine and 5 percent were given quinine. Only one percent received artimisine combination therapy. More than two-thirds of children with malaria (68 percent) were given other types of medicines that are not anti-malarials, including anti-pyretics such as paracetamol, aspirin or ibuprofen. Overall, children with fever in the East (54 percent) and South (53 percent) are the most likely to have received an appropriate anti-malarial drug within 24 hours of the onset of symptoms while those in the North, where malaria is most prevalent, are the least likely (35 percent) to receive an appropriate anti-malarial drug in timely fashion. Urban children are slightly more likely than rural children to be treated appropriately as are the children of mothers with secondary or higher education. Little difference was noted between the percentage of boys and girls receiving appropriate anti-malarial drugs. Pregnant women living in places where malaria is highly prevalent are four times more likely than other adults to get malaria and twice as likely to die of the disease. Once infected, pregnant women risk anemia, premature delivery and stillbirth. Their babies are more likely to be of low birth weight, which increases the risk that they may not survive their first year of life. For this reason, steps are taken to protect pregnant women by distributing ITNs and treatment during antenatal check-ups with drugs that prevent malaria infection (intermittent preventive treatment or IPT). In the Sierra Leone MICS3 survey, women were questioned 36 regarding the medicines they had received in their last pregnancy during the 2 years preceding the survey. Women are considered to have received IPT if they have received at least 2 doses of SP/Fansidar during the pregnancy. Data regarding the percentage of pregnant women who gave birth in the two years preceding the survey and who received IPT for malaria are presented in Table CH.13. Only two percent of eligible women received IPT. The few women who received IPT tended to be from the Western Area or from urban locations, to have been educated up through the secondary level or above, and to come from the highest wealth quintile. Discussion: Malaria One in six children in Sierra Leone takes malaria medication every two weeks. Since 2000, the use of mosquito nets—both ITNs as well as normal bednets—has increased slightly due to the program that distributes ITNs free of charge to families with pregnant women and children. However, the percentage of households that use bednets is still low. These findings suggest that the people of Sierra Leone continue to emphasize a curative, rather than preventive, approach to malaria control among children. Organizations and individuals working in child public health issues in Sierra Leone must make it a priority to change this approach and emphasize prevention over cure. Among the four provinces of Sierra Leone, the North has the highest level of malaria morbidity and highest use of bednets—but the lowest level of treatment of febrile children with an appropriate anti-malaria drug. These differences between the North and the other provinces are less stark than during MICS2—when the North had the highest morbidity but lowest use of antibiotics and bednets—suggesting that the emphasis on targeting the Northern Province with additional resources to control malaria has achieved some success and should be continued. Policy makers and programmers should allocate more resources to interventions that prevent malaria. Roughly equal disease burden and bednet use in the East, South and North suggest that resources be distributed equitably among these three provinces. ITNs must be made much more widely available to the public at the lowest possible cost through a sustainable mechanism. This process could be aided by tax waivers for ITNs and additional funding to support an increase in the coverage of ITN distribution programs and other strategies to prevent malaria. The promotion of ITNs for use by pregnant women and children under five should also be emphasized. On the curative side, malaria in children should be dealt with through an integrated approach to management of sick children—that is, through CBIMCI, the national roll-out of which should be prioritized. 37 VII. Environment Water and Sanitation Key indicators Estimates for Sierra Leone (percent) West-Central 2005 (MICS3) 2004 (census) 2002 (SOWC) 2000 (MICS2) Africa 2002 Use of improved drinking water sources 47 53 57 54 58 Use of adequate water treatment method 5 -- -- -- Use of improved sanitation facilities 30 -- 39 63 35 Sanitary disposal of child’s faeces 41 -- -- -- Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants that have harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children—especially in rural areas, where they often bear primary responsibility for carrying water for long distances. The MDG goal with regards to water and sanitation is to reduce the percentage of people who do not have sustainable access to safe drinking water and basic sanitation by half between 1990 and 2015. The World Fit for Children goal calls for a reduction in the percentage of households that do not have access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The MICS3 indicators that are related to water and sanitation are as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child’s faeces The distribution of the population by source of drinking water is shown in Tables EN.1 and EN.1b, and in Figure EN.1. The population that uses improved drinking water sources is defined as those who obtain water from any of the following sources: piped water (into dwelling, yard or plot), public tap/standpipe, tubewell/borehole, protected well, protected spring, or rainwater collection. Bottled water is considered to be an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. Overall, 47 percent of the population has access to improved drinking water sources—84 percent in urban areas and 32 percent in rural areas. Among provinces, the situation is best in the largely urban Western Area (87 percent) and worst in the North, 38 where only 30 percent of the population obtains its drinking water from an improved source. The sources of drinking water for the population of the North, South, and East follow similar patterns (Tables EN.1 and EN.1b). Surface water is the primary source of drinking water in all three provinces, especially in the North, where over half of the population gets their water from this unsafe source. Substantial percentages (15-18 percent) of the populations in these three provinces get their drinking water from unprotected wells or springs. The primary improved water sources in these provinces are public taps, tube wells, and protected wells. In the Western Area, the primary improved water source is piped water, whether it is piped into the dwelling, the yard, or at a public tap. Data that describe the practice of in-house water treatment are presented in Table EN.2. Households were asked to describe ways that they treat water at home to make it safer to drink—boiling, adding bleach or chlorine, using a water filter, and using solar disinfection are all considered to be proper treatment methods to prepare drinking water. Among these methods, by far the predominant practice in Sierra Leone is to add bleach or chlorine (4.6 percent out of a total of 5.0 percent). Table EN.2 also shows the percentage of household members using appropriate water treatment methods; this indicator is reported separately (i) for all households, (ii) for households using improved drinking water sources, and (iii) for households using unimproved drinking water sources. Appropriate water treatment is practiced by ten percent of households that use improved drinking water sources and less than one percent of households that use water from unimproved sources. Appropriate water treatment is most highly practiced in the North (six percent) and South (five percent) and among households that are in urban locations, households in which the head of household is educated to the secondary level or above, and households in the highest wealth quintile. Information regarding the amount of time that it takes to obtain water is presented in Table EN.3. Note that these results refer to the time needed to make one roundtrip from home to drinking water source. Information on the number of trips made in one day was not Figure EN.1 Percentage distribution of household members by source of drinking water. Sierra Leone, 2005 Piped into dwelling, yard or plot 7% Public tap/standpipe 13% Tubewell/borehole 6% Protected well or spring 21% Unprotected well or spring 15% Surface water 37% Other unimproved 1% 39 collected. Related data that describe the person who usually collects the water are presented in Table EN.4. Result in Table EN.3 shows that the drinking water source on the premises is only nine percent of households. It takes less than 30 minutes to get to the water source and bring water in almost seventy percent of all households, while another 18 percent of households spend 30-60 minutes for this purpose. Excluding those households with water on the premises, the average time for a roundtrip to the source of drinking water is more than 17 minutes. There is little variation in this figure when it is analyzed by background characteristics. The time spent collecting water in rural and urban areas is equal. Result in Table EN.4 shows that an adult female collects the water (when the source of drinking water is not on the premises) in 70 percent of households. Adult men collect water in only nine percent of households, children under age 15 collect water in the remaining households (21 percent). Children and men play a much greater role collecting water in the Western Area than in other provinces. Inadequate disposal of human excreta and poor personal hygiene are associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include the following: flush or pour flush to a piped sewer system, septic tank, or latrine; ventilated improved pit latrine or pit latrine with slab; and, composting toilet. Thirty percent of the population of Sierra Leone lives in households that use improved sanitation facilities (Table EN.5). This percentage is 64 in urban areas and 17 percent in rural areas. Residents of the East (20 percent) and North (22 percent) are the least likely to use improved facilities. In the East and South most of the population uses rivers, bush, fields, or has no facilities. In contrast, in the North the most common facility is a pit latrine without slab or an open pit. Fifty-four percent of the population in the Western Area uses a pit latrine with slab. The table indicates that use of improved sanitation facilities is strongly correlated with location (urban versus rural), increasing wealth status, and increasing educational level of the head of household. In the MICS3 survey, a child’s faeces are considered to be safely disposed of if the child’s last stool was rinsed into a toilet or latrine or if the child used a toilet to defecate. Data that describe the disposal of faeces of children 0-2 years of age are presented in Table EN.6. The table reveals that the stools of forty-one percent of surveyed children were disposed of safely. The practice of safe disposal was lowest in the South (28 percent) and highest in the Western Area (90 percent). The practice is strongly correlated with urban residence and increasing socioeconomic status. An overview of the percentage of households with improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. A combination indicator has been formed that measures the percentage of households that have both an improved source of drinking water and sanitary means of excreta disposal. Twenty-four percent of households in Sierra Leone meet this standard, ranging from 13 percent in the North to 63 percent in the Western Area. Similar to other water and sanitation indicators, high levels of Millennium Development Goal Indicator Population with access to safe drinking water Goal 82.5 percent by 2015 40 this indicator are associated with urban residence, increasing levels of education of the head of household, and increasing socioeconomic status. Discussion: Water and sanitation The MICS3 estimates of the Sierra Leonean population’s access to improved sources of drinking water (46 percent) and sanitation facilities (30 percent) are lower than previous estimates. Enumerators were carefully trained on the different definitions of improved water and sanitation facilities and may have collected more accurate data than have been collected in the past. Other reasons that the MICS3 estimates may be lower than previous estimates include the following: 1. There has been a gradual movement of population from urban (where improved sources are more readily available) to rural locations following the end of the conflict. The MICS2 survey was conducted in 2000 at the height of the war, when many people had moved temporarily to urban locations. There was massive destruction of water and sanitation facilities during the war until it ended in 2002. 2. Interviewers’ access to remote and rural locations (where improved sources of water and sanitation are less readily available) in MICS2 was limited, which may have led to an overestimation of access to improved sources of water and sanitation in that survey. The results above suggest that policy makers should consider prioritizing the allocation of resources to provide potable water to rural communities while emphasizing sustainability through support to community-based water system maintenance structures. Water and sanitation programs in Sierra Leone should emphasize the development of improved water sources while raising the public’s awareness regarding good hygiene practices. Policy makers should consider revitalizing and enforcing the GoSL act that stipulates that a house owner must first construct a latrine before building a house. Policies that provide incentives for the private sector to produce materials used to build basic sanitation facilities (e.g., latrine slabs, etc.) may also contribute to the improvement of the public’s access to improved sanitary facilities. The conduct of programs that promote and facilitate the construction of low-cost family latrines in rural communities would help to raise the percentage of households with access to improved sanitary facilities. 41 VIII. Reproductive Health Contraception Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1996-2004 Contraceptive prevalence (modern or traditional) 5 4 17 Appropriate family planning is important to the health of women and children through: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and, 3) limiting the number of children. A World Fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Current use of contraception was reported by only 5 percent of women currently married or in union in Sierra Leone (Table RH.1). Four percent of surveyed women reported that they or their partner uses a modern method of contraception while one percent reported using a traditional method. The most popular method is the pill which is used by 2.5 percent of married women in Sierra Leone. The next most popular method is injectable contraceptives that are used by 1.4 percent of married women. Contraceptive prevalence is highest in the Western Area at 20 percent and ranges from two to four percent in the remaining provinces. Adolescents are less likely to use contraception than older women. Only about 2 percent of married or in-union women aged 15-19 currently use a method of contraception compared to 4 percent of 20-24 year olds and a slightly higher percentage of older women. Women’s education level is strongly associated with contraceptive prevalence. The percentage of women using any method of contraception rises from 3 percent among those with no education to 8 percent among women with primary education, and to 20 percent among women with secondary or higher education. The method mix is fairly constant across the different strata of women’s educational status. Discussion: Contraception The astonishingly low contraceptive prevalence in Sierra Leone contributes directly to high birth rates as well as high rates of child and maternal mortality. The contraceptive prevalence in Sierra Leone lags well behind the low norms of the region (17 percent), suggesting that adequate efforts have not been made in Sierra Leone to promote contraception. Barriers to higher use of contraception in Sierra Leone include low awareness of the need for contraception, poor availability of contraceptives, and negative cultural perceptions regarding contraceptives. The promotion and provision of contraceptives must be integrated into all appropriate aspects of the health services, particularly delivery, postnatal and outreach services. Research is needed in order to identify barriers to contraception use, messages that will effectively increase demand for contraceptives, types of contraceptives that Sierra Leoneans find acceptable and culturally acceptable mechanisms to supply contraceptives to those who need them. 42 Antenatal Care Key indicators Estimates West-Central Africa 2005 (MICS3) 2000 (MICS2) 1996-2004 Received antenatal care at least once during pregnancy from skilled personnel 81 68 66 Received some type of antenatal care from skilled or unskilled personnel 94 -- -- The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to both their own health and well-being as well as to that of their infants. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential for antenatal care (ANC) to improve maternal and newborn health. For example, if women and their families are provided with information about the danger signs, symptoms and risks of labour and delivery during the antenatal period, this may in turn help to ensure that pregnant women seek the assistance of a skilled health care provider during delivery. The antenatal period also represents an important opportunity to supply pregnant women and their family members with information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and her infant. The prevention and treatment of malaria among pregnant women, the management of anaemia during pregnancy, and treatment of sexually transmitted infections (STIs) can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can also be reduced through a combination of interventions that improve women's nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care—in particular for the prevention of mother-to-child transmission of HIV (PMTCT), has led to renewed interest in access to and use of antenatal services. Based on a review of the effectiveness of different models of ANC, it is recommended by WHO that each pregnant woman makes a minimum of four antenatal visits. WHO recommends that the following services be included in the ANC visits: • Blood pressure measurement • Urine testing for bateriuria and proteinuria • Blood testing to detect syphilis and severe anaemia • Weight/height measurement (optional) ANC coverage by a skilled provider is relatively high in Sierra Leone as 81 percent of women receive ANC from a skilled provider (i.e., a doctor, nurse, or midwife) at least once during their pregnancies (Table RH.2). An additional 13 percent receive ANC from an unskilled provider. The percentage of women who receive ANC from a skilled provider varies from 73 percent in the North to 93 percent in the Western Area. The use of antenatal services is positively associated with increasing levels of education of the head of household and increasing household wealth status. ANC coverage is relatively constant across different age ranges of women although it is slightly higher among 15-19 year old women (86 percent). Pregnant women make greater use of antenatal services in urban than rural areas (88 versus 79 percent). 43 The type of personnel providing ANC to women aged 15-49 years who gave birth in the two years preceding the MICS3 survey is also presented in Table RH.2. The great majority of services that are given by skilled personnel are provided by nurses or midwives (68 percent). Auxiliary midwives (nine percent) and physicians (four percent) also provide ANC services to a substantial percentage of pregnant women. Wealthier women in urban locations who live in households with more highly educated heads of household have a greater tendency to receive ANC from physicians than do other women. The types of services that pregnant women receive during ANC visits are described in Table RH.3. Twenty-six percent of all pregnant women (including those who did not receive ANC and those who received ANC from an unskilled provider) had a blood sample taken while 28 percent had a urine sample taken. Sixty-eight and seventy-three percent of all pregnant women had their blood pressure and weight measured, respectively. Taken together, these data show that 94 percent of all women who gave birth during the two years preceding the survey received some kind of antenatal care. Discussion: Antenatal care The use of antenatal care is relatively high in Sierra Leone and is higher than regional estimates and the MICS2 estimate from 2000. Data presented regarding the services that pregnant women receive suggest that the quality of ANC services may not be as high as the coverage level. Efforts to make further improvements in antenatal care should include strengthening the quality of care (including the services that are provided through ANC) and strengthening coverage among population groups that current have lower ANC utilization rates: these groups include women who live in rural areas, come from poor households, and who live in the Northern province. Assistance at Delivery Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1996-2004 Skilled attendant at delivery 43 42 45 Delivered in health facility 19 -- -- Three quarters of all maternal deaths occur during delivery and the immediate postpartum period. The single most critical intervention for safe motherhood is to ensure that a competent health worker with midwifery skills is present at every birth—and that transport is available to a referral facility for obstetric care in case of emergency. The relevant goal from A World Fit for Children is to ensure that women have ready and affordable access to skilled attendance at delivery. The MICS3 indicators related to assistance at delivery are (i) the percentage of births that occur with a skilled attendant present and (ii) the percentage of deliveries that take place in health facilities. The indicator regarding skilled attendant at delivery is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015. The MICS3 questionnaire included a number of questions to assess the percentage of births that were attended by a skilled attendant. A skilled attendant is defined as a doctor, nurse, midwife or auxiliary midwife. 44 About 43 percent of births in Sierra Leone occurring in the year prior to the MICS3 survey were delivered by skilled personnel (Table RH.4). This percentage is highest in the Western Area at 83 percent and lowest in the North at 25 percent. Highly educated women are more likely to have delivered with the assistance of a skilled birth attendant than their less educated counterparts. Increased socioeconomic status is clearly associated with increased use of skilled birth attendants. Thirty-eight percent of births in Sierra Leone during the year prior to the MICS3 survey were delivered with assistance of a nurse or midwife. Auxiliary midwifes attended three percent of births while doctors assisted with the delivery of two percent of births. The relative percentages of different types of skilled birth attendants that were used were similar across the four provinces and varied primarily in magnitude. Among unskilled birth attendants, the most commonly used included traditional birth attendants (37 percent) and relative/friend (14 percent). An estimated nineteen percent of all deliveries in Sierra Leone take place in health facilities, reflecting the low access of the population to health facilities where deliveries can be managed. Discussion: Assistance at delivery The percentage of births attended by skilled birth attendants (SBAs) in Sierra Leone remains unchanged since last measured in 2000 and is in line with the regional value of 45 percent. Access to SBAs and health delivery services in institutions in Sierra Leone is limited by financial barriers (payments must be made to providers, even though delivery services are theoretically free of charge), difficulties reaching health facilities, perceptions that care is of poor quality, and a cultural preference for home births. Policy makers in Sierra Leone need to finalize and ratify the Reproductive Health Policy that, among other things, stipulates that mother-friendly facilities should be developed. Health officials and administrators should ensure that policies providing special facilities to vulnerable groups are realized in the field. Health workers must receive supportive supervision to strengthen the quality of the services they provide and adequate remuneration if they are not to seek under-the-table payments for delivery. Maternal Mortality Key indicators Estimates (deaths per 100,000 live births) West-Central Africa 2005 (MICS3) 2000 (MICS2) 2004 Maternal mortality ratio 457 1,800 900 Complications that occur during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. It is estimated that approximately 529,000 women die worldwide each year from maternal causes. For every woman who dies, additional 20 — over ten million women in total—suffer injuries, infection and disabilities during pregnancy or childbirth. The most common fatal maternal complication is postpartum haemorrhage. Sepsis, complications of unsafe abortion, prolonged or obstructed labour and the hypertensive disorders of pregnancy—especially eclampsia—claim further lives. These complications, 45 which can occur without forewarning at any time during pregnancy and childbirth, require prompt access to quality obstetric services that are equipped to (i) provide lifesaving drugs, antibiotics and transfusions and (ii) perform caesarean sections and other surgical interventions. A key MDG is to reduce the maternal mortality ratio (MMR) by three-quarters between 1990 and 2015. Maternal mortality is defined as the death of a woman from pregnancy-related causes either during pregnancy or within 42 days following the termination of pregnancy. The MMR is the number of maternal deaths per 100,000 live births. In the MICS3 survey, the MMR is estimated by using the indirect sisterhood method. In order to collect the information needed for the use of this estimation method, adult household members are asked a small number of questions regarding the survival of their sisters and the timing of death (for deceased sisters) relative to pregnancy, childbirth and the postpartum period. The information that is gathered is then used to calculate the lifetime risk of maternal death and the MMR13. The estimate of the MMR from the Sierra Leone MICS3 survey is 457 maternal deaths per 100,000 live births (Table RH.5). The estimate of the MMR that has been generated from the MICS3 is an unstratified national-level estimate, given the large sampling errors that are generally associated with the MMR. Discussion: Maternal mortality An initial comparison of the MMR estimates generated from the MICS2 and MICS3 surveys may suggest that the MMR may have decreased substantially during the past five years. However, caution should be exercised while drawing conclusions from the comparison of these estimates. Estimates of MMR tend to be very imprecise, with very large confidence intervals, and therefore are not suggested to be used for tracking changes. For example, the MMR estimate of 1800 per 100,000 live births from MICS2 had a margin or error of about 800. Compared to international estimates, though, the current estimate of MMR appears to be very low. The Sierra Leone public health community needs accurate information regarding the causes of maternal mortality, both from the clinical perspective as well as in terms of shortcomings of the health system. In addition to the implementation of the interventions mentioned throughout this report that are designed to reduce maternal mortality, it will almost certainly be necessary to accelerate the development of structures and human resources within the health system in order to achieve meaningful improvement in the situation. 13 For more information on the indirect sisterhood method, see WHO and UNICEF, 1997. Millennium Development Goal Indicator Maternal mortality ratio Goal 175 deaths per 100,000 live births by 2015 46 IX. Child Development Estimates (percent) Key indicators 2005 (MICS3) Adult’s support for learning and school readiness 65 Father’s support for learning and school readiness 65 Support for learning: Children’s books 11 Support for learning: Non-children’s books 29 Support for learning: Materials for play 52 Children left under inadequate care 21 It is well recognized that a period of rapid brain development occurs during the first three to four years of life. The quality of home care is the major determinant of the child’s development during this period. Important indicators of the quality of home care include the amount and nature of adult activities with children, the presence of children’s books in the home, and the conditions of care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning and child development was collected in the MICS3 survey. These activities include the involvement of adults with children in the following activities: reading books or looking at picture books; telling stories; singing songs; taking children outside the home, compound or yard; playing with children; and, spending time with children naming, counting, or drawing things. For almost two-thirds (65 percent) of surveyed under-five children, an adult engaged in more than four activities that promote learning and school readiness during the three days preceding the survey (Table CD.1). Adults engaged with children in an average of 3.8 activities. The table also indicates that fathers had engaged in one or more activities during the three days prior to the survey with 65 percent of children, suggesting that fathers in Sierra Leone are well-engaged in the process of promoting learning and readiness for school. One-quarter of children were living in a household without their natural fathers. There are only minor gender differentials in terms of adult activities with children. A somewhat larger percentage of adults engaged in learning and school readiness activities with children in urban areas (72 percent) than in rural areas (63 percent). Strong differentials by province are also observed: Adult engagement in activities with children was greatest in the Western Area (82 percent) and lowest in the South (56 percent). Adult engagement was highest in the richest wealth quintile (72 percent) and varied little in the remaining four quintiles. Father’s involvement in learning activities followed a somewhat different pattern, as it was highest in the East (76 percent), mid-range in the Western Area (62 percent) and lowest in the South (55 percent). Mothers and fathers with higher education engaged in these activities more frequently than did those with less education. Exposure to books in early years does more than provide the child with greater understanding of the nature of print. It also gives the child opportunities to see others reading—such as older siblings doing school work. The presence of books in the home can be an important determinant of a young child’s future school performance and intelligence. 47 In Sierra Leone, 29 percent of children live in households where at least three non-children’s books are present (Table CD.2). Only 11 percent of children aged 0-59 months live in households where at least three children’s books can be found. While no gender differentials are observed, urban children live in households where there is significantly more access to both types of books than exists in rural households. Fifty-five percent of under-5 children living in urban areas live in households with more than three non-children’s books, while the figure is 22 percent in rural households. The percentage of under-5 children who live in households with three or more children’s books is 27 percent in urban areas, compared to seven percent in rural areas. The presence of both non-children’s and children’s books does not differ significantly by child’s age. Fifty-two percent of children aged 0-59 months had 3 or more playthings to play with in their homes, while 12 percent did not have any of the playthings that were described to respondents (Table CD.2). The playthings that were read off to respondents by MICS3 enumerators included household objects (78 percent), homemade toys (50 percent), toys that came from a store (37 percent), and objects and materials found outside the home (71 percent). The percentage of children who have 3 or more playthings to play with differs by only two percentage points among male and female children. No urban-rural differentials are observed while only small differences are observed in terms of mother’s education. Differences in the value of this indicator are negligible among the five wealth quintiles but do vary notably by province from a high of 64 percent in the East to 40 percent in the North. The background variable age of child is strongly correlated with the number of playthings that a child has, as children aged 24-59 months are significantly more likely to have 3 or more playthings than are children less than two years of age. Leaving children alone or under the care of other young children is known to increase the risk of accidents. In the MICS3 survey, questions were asked to find out whether children aged 0-59 months were left alone during the week preceding the interview and whether they were left in the care of other children under 10 years of age. Table CD.3 shows that 20 percent of children aged 0-59 months were left in the care of other children under ten years of age during the week preceding the interview while six percent of children were left alone. Combining these two indicators, it is calculated that 21 percent of children were left under inadequate care during the week preceding the survey. This indicator does not differ among male and female children and varies only modestly by location (rural/urban). Inadequate care was more prevalent among children whose mothers had no education (21 percent) or a primary-level education (24 percent) as opposed to children whose mothers had studied to the secondary level or beyond (16 percent). Children aged 24-59 months were left with inadequate care more (24 percent) than those who were aged 0-23 months (15 percent). Differences in this indicator with regards to socioeconomic status of the household are minor. Discussion: Child development The survey results presented above present a mixed picture of the state of child development in Sierra Leone. If the data that describe adults’ support for learning and school readiness are accurate, they represent an encouraging finding regarding adults’ interest in and dedication to furthering their children’s education. The findings that describe the availability of books in households are discouraging, if predictable, and reflect the low literacy rate in Sierra Leone, ignorance regarding the value of reading materials, poverty and a general unavailability of children’s books. The low 48 availability of materials for children to play with is predictable, given that most families in Sierra Leone are simply trying to deal with poverty and survive, with the result that children’s toys are not considered a priority issue. Parental responsibility is a critical component of child protection; the levels of inadequate care of small children reflect families that are engrossed with survival issues, exacerbated by a breakdown in the extended family support system. Relevant policy makers in the GoSL should ensure that due priority is given to early child development (ECD) within the national development agenda. Educational policies should recognize and build on the links between adult literacy, ECD and parenting education. A thorough understanding of gender roles in the promotion of child learning in Sierra Leone is crucial for the strengthening of ECD. Policies should encourage the participation of both parents in parental education programs. The government should explore strategies to create an enabling environment for the provision of children’s books at minimal or no cost to needy children and schools; for example, they could remove all tariffs related to the import of children’s books. Policies related to child development should articulate the link between play and readiness for school, and also reinforce parental responsibility for child care despite difficult economic circumstances. Programmers should put in place interventions that build parenting skills into adult literacy and ECD programs. They should focus on the development of innovative approaches to strengthening parenting skills to ensure the involvement of men in ECD. Local authors should receive support to develop children’s books that are culturally relevant and interesting to the children of Sierra Leone. 49 X. Education Pre-School Attendance and School Readiness Estimates (percent) Key indicators 2005 (MICS3) Pre-school attendance among children aged 36-59 months 13 School readiness: Children in first grade that attended pre-school in previous year 7 Pre-school educational programs play an important role in increasing the readiness of children for school. One of the World Fit for Children goals is to promote early childhood education. Only 13 percent of children aged 36-59 months in Sierra Leone are attending pre-school (Table ED.1). Urban-rural and province-level differentials are significant—24 percent of children aged 36-59 months attend pre-school in urban areas, compared to ten percent in rural areas. The attendance level is highest in the Western Area (30 percent), and lowest in the North (six percent). Although this indicator does not vary by gender, increasing socioeconomic status is strongly correlated with increasing levels of attendance. Thirty-one percent of children living in the wealthiest households attend pre-school while only eight percent of children from the poorest households attend. Only eight percent of children aged 36-47 months attend pre-school as compared to 19 percent of children aged 48-59 months. An important indicator of school readiness is the percentage of children that currently attend the first grade of primary school who also attended pre-school the previous year (Table ED.1). Overall, only seven percent of children who are currently aged six years and who attend the first grade of primary school attended pre-school the previous year. The variation in the level of this indicator by background characteristics is almost identical to that described above for the indicator of pre-school attendance. Discussion: Pre-school attendance and school readiness The use of pre-school to increase children’s readiness for school in Sierra Leone was found to be extremely low in MICS2 and has dropped even further during the past five years. Those few pre-schools that do exist are costly private institutions to which the average family has only limited access. The data presented above show that early child development (ECD) is not a national priority in Sierra Leone. This has implications for primary school enrolment, performance, retention, and completion. These findings should represent an urgent wake-up call to the GoSL and its partners to become more involved in this sector. ECD is no longer an option for governments; it must be recognized as a national priority that supports the improvement of primary education. There is an urgent need for the approval and implementation of the draft GoSL ECD policy. Program planners need to marshal support (human, material and financial) for initiatives that increase the accessibility of the public to pre-school opportunities. 50 Primary and Secondary School Participation Key indicators Estimates West-Central Africa 2005 (MICS3) 2000 (MICS2) 1996-2004 Net intake rate in primary education (children of school-entry age that are currently attending first grade) 48 -- -- Primary school net attendance ratio (children of primary-school age currently attending primary or secondary school) 69 42 55 Secondary school net attendance ratio (children of secondary-school age currently attending secondary school or higher) 19 13 14 (1996-2004) 23 Net primary school attendance rate of children of secondary school age 46 -- -- Survival rate to grade five (children entering the first grade of primary school that eventually reach grade five) 92 85 87 Transition rate to secondary school (children that were in the last grade of primary school during the previous school year that attend secondary school) 52 -- -- Net primary completion rate (children aged 11 years attending the last grade of primary school (excluding repeaters)) 11 -- -- Gender parity index: ratio of [girls : boys] attending school (primary; secondary) 1.01; 0.78 -- 0.86; 0.8 Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the MDGs and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. The MICS3 indicators for primary and secondary school attendance include the following: • Net intake rate in primary education • Net primary school attendance rate • Net secondary school attendance rate • Net primary school attendance rate of children of secondary school age • Female to male gender parity index (GPI) The indicators of school progression include the following: • Survival rate to grade five 14 Source: SOWCR 2006. 51 • Transition rate to secondary school • Net primary completion rate Primary and secondary school attendance The degree to which children attend primary school in a timely manner is defined in the MICS3 survey as the percentage of children who are of primary school entry age (6 years) and who attend the first grade of primary school. The value of this indicator in Sierra Leone is 48 percent (Table ED.2). Differentials by gender do not exist; however, significant differentials are present by province and urban-rural areas. In the Western Area, for instance, the value of the indicator reaches 67 percent, while it is 40 percent in the North. Children’s participation to primary school is timelier in urban areas (60 percent) than in rural areas (44 percent). A positive correlation between this indicator and mother’s education and socioeconomic status is observed; for children age six whose mothers have at least primary school education, an estimated 69 percent attend the first grade. In households in the highest wealth quintile, the percentage is around 67 percent, while it is 36 percent among children living in the least wealthy households. Data presented in Table ED.3 show that 69 percent of children of primary school age in Sierra Leone (defined for this analysis as children aged 6-11 years) attend primary or secondary school. Eighty-five percent of children attend school in urban areas while 63 percent attend in rural areas. School attendance is highest in the Western Area at 89 percent and elsewhere ranges from 63 percent in the North to 72 percent in the East. There is no meaningful difference between male and female primary school attendance at any level or within any strata. The secondary school net attendance ratio is presented in Table ED.4. A huge decrease in this measure of age-appropriate attendance between primary and secondary school can be seen as only 19 percent of children of secondary school age (defined for this analysis as children aged 12-17 years) are attending secondary school. There is a huge gap in the value of this indicator between the Western Area (54 percent) and the remaining three provinces of the country (11-14 percent). The value of the indicator increases steadily by age of child from 10 percent for children aged 12 to 32 percent for children aged 17. Higher levels of this indicator are strongly associated with urban residence, high levels of mother’s education, and high socioeconomic status. Among the remaining 81 percent of children of secondary school age who do not attend secondary school, 46 percent attend primary school and 35 percent are out of school (see below for further details). The primary school net attendance ratio of children of secondary school age in Sierra Leone is presented in Table ED.4W. Almost half (46 percent) of the children of secondary school age are attending primary school when they should be attending secondary school. When we consider that 19 percent of children of secondary school age are attending secondary school, we can conclude that 35 percent of children in this age group do not attend school at all. Values of this indicator are highest outside of the Western Area and in rural locations. This indicator is negatively associated with the age of the child—65 percent of children aged 12 are in primary school, while only 19 percent of 17-year-olds are in primary school. Millennium Development Goal Indicator Net primary school attendance rate Goal 100 percent by 2015 Source: SL-PRSP, 2004. 52 Data presented in Table ED.5 show that 92 percent of all children who start grade one in Sierra Leone eventually reach grade five. This estimate includes children that repeat grades but persevere and eventually move up to reach grade five. The percentage of children passing to the subsequent grade between grades one and five varies between 97 and 99 percent. There is little variation in the “survival rate to grade five” by background characteristics such as sex of child, area (urban/rural), and household socioeconomic status. This variable ranges from 87 percent in the East to 96 percent in the Western Area. Primary school completion and transition to secondary school Data regarding the net primary school completion rate are presented in Table ED.6. This indicator is defined as the percentage of children of primary completion age (11 years) who are attending the last grade of primary education (grade six). As such, it is a measure of the percentage of children who are on a “normal track” to complete their primary school education on time. Data from MICS3 show that the estimate for the net primary school completion rate is 11 percent in Sierra Leone, suggesting that most children are either delayed in the completion of their primary education or are not attending school at all. There is little difference in the rate between boys (12 percent) and girls (10 percent). The rate is 28 percent in the Western Area and varies between six and nine percent in the other three provinces. This indicator is strongly positively correlated with urban residence, high levels of mother’s education and high socioeconomic status. Data that describe the transition rate to secondary education are also presented in Table ED.6. Slightly over half (52 percent) of surveyed children who successfully completed the last grade of primary school during the year prior to the MICS3 survey were attending the first year of secondary school at the time of the survey. This rate varies little by gender but does vary notably among provinces; its value is 34 percent in the East, 43 percent in the South, 48 percent in the North, and 78 percent in the Western Area. Higher levels of the rate are strongly associated with urban residence, households where the mother’s education is secondary level or higher and high socioeconomic status. The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. This ratio is better known as the Gender Parity Index (GPI). It should be noted that the results presented here are obtained from net attendance rates rather than gross attendance rates. The table shows that gender parity for primary school is 1.01, indicating virtually no difference in the attendance of girls and boys to primary school. However, the indicator drops to 0.78 at the national level for secondary education. This represents a divide between rural and urban locations—and perhaps even more so, between Freetown and the rest of Sierra Leone. The value of the GPI is 0.64 in all three provinces other than the Western Area (where it is 0.90) and 0.56 in rural areas as opposed to 0.82 in urban areas. Increasing wealth status of households is strongly associated with increases in gender parity for secondary school attendance. Discussion: Primary and secondary school participation Primary school attendance in Sierra Leone has increased substantially over the past five years and has now surged ahead of the regional norm. This is most likely due to improved access to education in areas that were held by the rebels at the time of the MICS2 survey as well as increased support to primary education throughout the country. Only half of the children six years of age enter primary school “on time”, foreshadowing the “late” or “delayed” educational status of most children in Sierra Leone. The MICS3 result showing an extremely high survival rate to grade five is questioned by some education experts in Sierra Leone who note that their experience from the field suggests that the drop-out rate is still 53 very high between grades one and five, especially among girls. Educational policy as it pertains to primary education appears to be achieving success and should be continued. Policies related to increasing school enrolment—especially among girls—should be strengthened while the abolition of all hidden costs that create barriers to school enrolment must be pursued. Current policy calls for an effective coordination mechanism to be established as responsibility for educational programs is devolved from the Ministry of Education (MoE) to district and local councils. The GoSL and its partners supporting primary education in Sierra Leone must ensure that the coordination mechanism functions effectively and resources are distributed equitably if the goal of universal primary education by 2015 is to be met. The results above present a much bleaker picture regarding secondary education in Sierra Leone. Not even one in five children of secondary school age attends secondary school—the remaining four are either delayed in primary school or do not attend school altogether. One- half of the children attending grade six do not advance to secondary school, due to factors that include limited physical access to secondary schools, cost-related factors, and the difficult secondary school entrance examination. The need now is to undertake a strategic reorientation in program planning and implementation for secondary education. Most of the current support for education in Sierra Leone goes to the primary level with little reaching the secondary and tertiary levels. The GoSL and its partners must intensify the development and implementation of diversified programs and activities for the secondary sector nationwide. The gender parity index shows an encouraging situation at the primary level, with equivalent attendance rates for girls and boys. Although past figures are not available in Sierra Leone to assess trends, gender parity for primary education in Sierra Leone appears to be ahead of the rest of the region. Support for girls’ education has been strongest at the primary level and gender parity at the secondary level may have suffered as a result. The MoE needs to enforce the Girls Education policy—especially at the second and tertiary levels—and otherwise intensify efforts that promote secondary and tertiary-level girls’ education. 54 Adult Literacy Key indicators Estimates West-Central Africa 2005 (MICS3) 2000 (MICS2) 2004 Literacy rate among women aged 15-24 years 25 [20 15] [48] Note: MICS3 estimates not directly comparable with MICS2 or regional estimates. Please see footnote. One of the World Fit for Children goals is to assure adult literacy. Increasing adult literacy is also an MDG for both men and women. In the MICS3 survey, results pertaining to literacy are reported for females age 15-24 in Table ED.8. Literacy was assessed based on (i) respondents’ ability to read a simple, short statement that was written on a card or on (ii) school attendance (women who had completed at least one year at secondary level were assumed to be literate). The survey found that the literacy rate among Sierra Leonean females aged 15-24 is 25 percent. Similar to other educational indicators, the literacy rate is strongly and positively associated with urban residence, higher levels of education, and higher household wealth. The literacy rate is 31 percent among 15-19 year-olds but drops to 19 percent among 20-24 year-olds. Among provinces, literacy is highest in the Western Area (68 percent) but ranges between 15 and 20 percent in the remaining three provinces. Discussion: Adult literacy The low adult literacy rate among the young women of Sierra Leone lags well behind the regional norm. Support for female adult literacy programs has been in gradual decline over the past decade and must be reinvigorated, given the importance of adult literacy interventions--especially for women—to national development. 15 MICS2 and regional estimates of literacy are for women aged 15-49 years. Literacy measured in MICS2 by asking heads of household if women could “read a newspaper or letter easily, with difficulty, or not at all.” It is not clear which method(s) was used to generate regional estimate. 55 XI. Child Protection Birth Registration Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 1999-2004 Birth registration of children 48 47 41 The Convention on the Rights of the Child states that every child has the right to a name and nationality and the right to protection from being deprived of his or her own identity. Birth registration is a fundamental means of securing these rights. The corresponding goal of A World Fit for Children is to develop systems to ensure the registration of every child at or shortly after birth, thereby fulfilling his or her right to acquire a name and a nationality in accordance with national laws and relevant international instruments. The relevant MICS3 indicator is the percentage of children under 5 years of age whose birth is registered. The births of 48 percent of children under five years of age in Sierra Leone have been registered (Table CP.1). There are no significant variations in birth registration across gender or age categories. Increasing mother’s education status is positively associated with birth registration status. Birth registration status varies sharply by province; the highest level of birth registration is found in the South (72 percent), followed by the Western Area (67 percent), the East (45 percent), and the North (29 percent). Caretakers whose children’s births had not been registered were asked why; common responses include “didn’t know child should be registered” (33 percent), “costs too much” (21 percent), “doesn’t know where to register” (20 percent), and “must travel too far” (15 percent). Discussion: Birth registration There has been no progress in expanding the coverage of birth registration in Sierra Leone over the past five years. Eighty-four percent of infants receive the BCG vaccination by their first birthday; registering the births of most or all of these infants should dramatically boost the percentage of births that are registered and strengthen this important aspect of child’s rights. The government should implement the official policy to integrate birth registration into the BCG vaccination process. 56 Child Labour Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 2000 (MICS2) 2004 Child labour (children aged 5-14 years that are involved in child labour) 48 [72 16] 41 Labourer students (children aged 5-14 years involved in child labour activities that attend school) 64 -- -- Student labourers (children aged 5-14 years attending school that are involved in child labour activities) 45 -- -- Note: MICS3 and regional estimates not directly comparable with MICS2 estimates. Article 32 of the Convention on the Rights of the Child states: "Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child's education, or to be harmful to the child's health or physical, mental, spiritual, moral or social development." The World Fit for Children document mentions nine strategies to combat child labour, while the MDGs call for the protection of children against exploitation. In the MICS questionnaire, a number of questions were asked to document the issue of child labour—that is, the involvement of children 5-14 years of age in labour activities. A child was considered to be involved in child labour activities if they met the following criteria during the week preceding the survey: • Ages 5-11: at least one hour of economic work or 28 hours of domestic work per week. • Ages 12-14: at least 14 hours of economic work or 28 hours of domestic work per week. These definitions make it possible to differentiate child labour from child work, which in turn allows organizations working in child protection to identify the types of work that should be eliminated. The assessment described below yields a minimum estimate of the prevalence of child labour, as some children may be involved in hazardous labour activities (and thus be performing child labour) for a smaller number of hours than is specified in the criteria above. Table CP.2 presents the results of child labour by the type of work. A total of 48 percent of surveyed children perform child labour. Forty-one percent of children work for a family business, while only two percent work on household chores for over 28 hours per week. Among those children who work outside the household, 16 percent perform unpaid work while two percent are paid for their efforts. Although the percentage of children performing child labour does not vary by gender, it is associated strongly with rural residence, younger age (5-11 years), lack of participation in school, lower mother’s educational level, and low socioeconomic status. The percentage of children involved in child labour varies from 28 percent in the Western Area to 57 percent in the North. Table CP.3 presents data that describe the percentage of children classified as student labourers or as labourer students. The indicator student labourer is defined as the percentage of children who are involved in child labour activities among all children who attend school at the time of the MICS3 survey. The MICS3 survey found that among the 68 percent of children 5-14 years of age attending school in Sierra Leone, 45 percent are also involved in child labour activities. The association of this indicator with background 16 Child labour was measured in the MICS2 survey using a definition different than that used in MICS3. 57 variables is very similar to that described in the preceding paragraph for the indicator of child labour. The indicator labourer student is defined as the percentage of children who attend school among all children who are involved in child labour activities at the time of the MICS3 survey. In Sierra Leone, among the 48 percent of the children classified as child labourers, the majority of them (64 percent) also attend school. The association of this indicator with background variables is essentially the inverse of that described for student labourers; while it does not vary notably by gender or age of child, it is associated strongly with urban residence, higher levels of mother’s education, and higher socioeconomic status. The percentage of labourer students varies from 88 percent in the Western Area to 58 percent in the North. Discussion: Child labour Child protection experts in Sierra Leone find the estimate of children performing labour (48 percent) to be lower than they had expected. Particularly surprising is the finding that only two percent of children work 28+ hours per week on household chores. This may reflect a systematic underestimation by respondents of the time children spend on household chores. At the same time, it should be noted that the overall estimate of child labour is higher than regional norm. The percentage of children who participate in child labour is approximately equal among students (45 percent) and among the general population of children (48 percent). This suggests that being a student does not stop children from working. Perhaps more important is the question: Does being a child labourer stop children from going to school? Table CP.3 shows that among all children aged 5-14, 68 percent are currently attending school, as compared to a 64 percent attendance rate among labourer students. This latter finding suggests that child labourers and non-labourers alike have roughly equal attendance rates at school. One conclusion that might be drawn here is that performing labour is so firmly entrenched in the lives of the children of Sierra Leone that it does not affect other activities such as school attendance—many children somehow manage to attend school despite the burden of their jobs. In order to protect children from being exploited as labourers, the GoSL should ratify the International Labour Organization conventions 138 (regarding the minimum age that a child should reach before being eligible for labour) and 182 (which requires countries to commit themselves to take immediate action to prohibit and eliminate the worst forms of child labour and reflect this in both criminal and labour laws). It should also ensure alignment and harmonization between the laws and policies in the labour, education and social welfare sectors and the enactment of the Child Rights Bill. With regards to students and labour, the GoSL must maintain and enhance all children’s access to school. This involves the creation of a school environment that caters to children who are involved in labour and that support child labourers’ attendance in school. The amount of non-school-related labour that is performed by students should be limited; fully half of the children who attend school perform labour, a situation that demands a response. 58 Child Discipline Key indicators Estimates (percent) 2005 (MICS3) Child discipline: Any psychological or physical punishment 92 Child discipline: Non-violent aggression only 6 Child discipline: Psychological aggression 82 Child discipline: Minor physical punishment 76 Child discipline: Severe physical punishment 23 Mother / caretaker believes that physical punishment is necessary 56 As stated in A World Fit for Children, “children must be protected against any acts of violence.” The Millennium Declaration likewise calls for the protection of children against abuse, exploitation and violence. In the Sierra Leone MICS3 survey, mothers and caretakers of children age 2-14 years were asked a series of questions regarding how parents discipline their children when they misbehave. This line of inquiry was pursued because violence against children is practiced through “child discipline” in many countries. During the administration of the survey in the field, one child aged 2-14 years was selected randomly in each household. The respondent was then asked a series of questions regarding whether / how they had recently disciplined the selected child. Responses to these questions were used to construct two principle indicators that describe aspects of child discipline: 1) the percentage of children 2-14 years that experience psychological aggression as punishment or physical punishment (see Row 1 in table above); and, 2) the percentage of parents / caretakers of children 2-14 years of age that believe that in order to raise their children properly, they need to physically punish them (last row in table above). In Sierra Leone, 92 percent of children aged 2-14 years were subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members (Table CP.4). Twenty-two percent of children were subjected to severe physical punishment while 76 percent of children received minor physical punishment. Fifty-six percent of mothers/caretakers stated that children should be physically punished. Only minor associations were discovered between the various types of discipline that were estimated and the background variables measured in the MICS3 survey. Discussion: Child discipline These results clearly show the punitive nature of child discipline techniques that are used by the caretakers of the children of Sierra Leone. Psychological and physical punishments are common cultural practices in Sierra Leone and people do not consider them necessarily to be bad ways to discipline children. The GoSL should pass the Child Rights Bill which deals directly with the issue of excessive punishment for children. Supporters of child rights and protection need to advocate for the passage of this Bill while also supporting activities designed to improve child discipline practices in Sierra Leone. Further study of these practices and programme initiatives should be coordinated with the UN study on violence against children. 59 Early Marriage and Polygyny Key indicators Estimates (percent) West-Central Africa 2005 (MICS3) 1986-2004 Women first married before age 15 / before age 18 27 / 62 -- / 45 Women aged 15-19 currently married or in union 36 -- Women aged [15-19 / 20-24 years] whose age differs from current spouse’s by 10 or more years 58 / 56 -- Women in polygynous union 43 -- Marriage before the age of 18 is a reality for many young girls. According to UNICEF's worldwide estimates, over 60 million women aged 20-24 were married or in union before the age of 18. Factors that influence child marriage rates include: the state of the country's civil registration system, which provides proof of age for children; the existence of an adequate legislative framework that is supported by an enforcement mechanism to address cases of child marriage; and, the existence of cultural or religious norms that condone the practice. In many parts of the world parents encourage the marriage of their daughters while they are still children. They do so with the hope that the marriage will benefit them both financially and socially, while also relieving financial burdens on the family. In fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation. Girls who marry as children receive little or no education or vocational training which only reinforces the gendered nature of poverty. The right to “free and full” consent to marriage is recognized in the Universal Declaration of Human Rights—with the recognition that consent cannot be “free and full” when one of the involved parties is not sufficiently mature to make an informed decision about a life partner. The Convention on the Elimination of all Forms of Discrimination against Women mentions the right to protection from child marriage. Article 16 of the Convention states: "The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.” While marriage is not considered directly in the Convention on the Rights of the Child, child marriage is linked to other rights—such as the right to express their views freely, the right to protection from all forms of abuse, and the right to be protected from harmful traditional practices. Child marriage is also frequently addressed by the Committee on the Rights of the Child. Other international agreements related to child marriage are the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages and the African Charter on the Rights and Welfare of the Child, and the Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa. Child marriage was also identified by the Pan-African Forum against the Sexual Exploitation of Children as a type of commercial sexual exploitation of children. Young married girls are a unique, though often invisible, group. Required to perform heavy amounts of domestic work, under pressure to demonstrate fertility, and responsible for raising children while still children themselves, married girls and child mothers face constrained decision-making power and reduced life choices. Boys are also affected by child marriage, but the issue impacts girls in far larger numbers and with more intensity. Cohabitation—when a couple lives together as if married—raises the same human rights concerns as marriage. When a girl lives with a man and takes on the role of caregiver for him, the assumption is often that she has become an adult woman, even if she has not yet reached the age of 18. Additional concerns due to the informality of the relationship—for 60 example, inheritance, citizenship and social recognition—might make girls in informal unions vulnerable in different ways than those who are in formally recognized marriages. Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered to be significant factors that help to determine a girl's risk of becoming married while still a child. Women who marry at young ages are more likely to believe that it is sometimes acceptable for a husband to beat his wife and are more likely to experience domestic violence themselves. The age gap between partners is thought to contribute to abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy-related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the younger members of this cohort. There is evidence to suggest that girls who marry at young ages are more likely to marry older men, which puts them at increased risk of HIV infection. Parents may seek to marry off their girls to protect their honour, and men often seek younger women (or girls) as wives as a means to avoid choosing a wife who may already be infected. The pressure on this young wife to reproduce combined with the power imbalance that results from the age differential between husband and wife can contribute to very low levels of condom use among such couples. Two of the indicators that are widely used to measure the degree to which early marriage is practiced are (i) the percentage of women married before 15 years of age, and (ii) the percentage married before 18 years of age. Twenty-seven percent of women interviewed during the MICS3 were married before fifteen years of age (Table CP.5). Among different age strata of respondents, this indicator is lowest among women currently aged 15-19 years (15 percent), indicating that the practice of early marriage in Sierra Leone is declining. The percentage of women married before fifteen years of age is highest in rural areas, in households that have low socioeconomic status, and where the mother’s educational level is lower. Sixty-two percent of all women interviewed during the MICS3 were married before eighteen years of age while thirty-six percent of women respondents currently aged 15-19 years reported that they were currently married or in union. The patterns of these two indicators among different sub-populations (e.g., rural/urban, by province, etc.) are similar to those described in the paragraph above for marriage below fifteen years of age. Data presented in Table CP.5 also show that polygyny is widely practiced in Sierra Leone. Forty-three percent of the women interviewed during the MICS3 who are currently married or in union reported that their husband/partner has another wife. Among provinces, the practice of polygyny is by far the lowest in the Western Area (12 percent)—in the remaining provinces, it ranges from 38 percent in the East to 53 percent in the North. The percentage of women whose partners are in polygynous relationships increases with the increasing age category of the women. Increasing women’s educational status is associated with a decreasing percentage of women reporting polygyny. Women in the richest wealth quintile report the lowest prevalence of polygyny (27 percent). The percentage of women reporting polygyny in the remaining four quintiles is similar, ranging from 43 to 48 percent. 61 The dangers inherent in the practice of marriage between young girls and older men were discussed above. The indicator that has been constructed to measure spousal age difference is the percentage of women who are currently married/in union with a man older by ten or more years than them (see Table CP.6). The estimate of this indicator among women aged 15-19 is 58 percent while it is 56 percent among women aged 20-24. Among women aged 15- 19 years, the practice is lowest in the Western Area (43 percent) and highest in the South (61 percent). Higher levels of high spousal age difference are found in rural communities and households where the head of household is uneducated. The practice of women marrying men who are ten or more years senior to them is clearly widespread across all strata of society in Sierra Leone. Discussion: Early marriage and polygyny The data presented above paint a disturbing picture of early marriage, widespread polygyny, and a common practice of women marrying men who are much senior to them. Local experts concur that cultural norms, early pregnancy and forced marriage are all likely contributing factors to these practices in Sierra Leone. Efforts to estimate the indicators reported above have only recently begun at the global level. The MICS3 survey has generated the first estimate of many of these indicators in Sierra Leone. Levels of marriage before age 18 are higher in Sierra Leone than the regional average, suggesting that this aspect of child protection has been inadequately addressed by policy makers and program managers. The Child Rights Bill of the GoSL makes m

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