Sierra Leone - Multiple Indicator Cluster Survey - 2010

Publication date: 2010

Sierra Leone Multiple Indicator Cluster Survey 2010 Final Report December 2011 Sierra Leone Multiple Indicator Cluster Survey 2010 Statistics Sierra Leone UNICEF United Nations Children’s Fund December 2011 The Sierra Leone Multiple Indicator Cluster Survey (MICS) was carried out in 2010 by Statistics Sierra Leone. The United Nations Children’s Fund (UNICEF) provided financial and technical support. MICS is an international household survey programme developed by UNICEF. The Sierra Leone MICS was conducted as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed-upon commitments. An additional objective of the MICS4 survey in Sierra Leone is for the survey effort to contribute to the development of the national statistical system, data and monitoring systems, and to strengthen national capacity in the design, implementation, and analysis of such monitoring systems. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Statistics Sierra Leone and UNICEF-Sierra Leone. 2011. Sierra Leone Multiple Indicator Cluster Survey 2010, Final Report. Freetown, Sierra Leone: Statistics Sierra Leone and UNICEF-Sierra Leone. i Summary Table of Findings Multiple Indicator Cluster Survey (MICS4) and Millennium Development Goals (MDG) Indicators, Sierra Leone, 2010 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1.1 4.1 Under-five mortality rate 217 per thousand 1.2 4.2 Infant mortality rate 128 per thousand NUTRITION Nutritional status 2.1a 2.1b 1.8 Underweight prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 22 8 percent percent 2.2a 2.2b Stunting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 44 24 percent percent 2.3a 2.3b Wasting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 8 3 percent percent Breastfeeding and infant feeding 2.4 Children ever breastfed 95 percent 2.5 Early initiation of breastfeeding 45 percent 2.6 Exclusive breastfeeding under 6 months 32 percent 2.7 Continued breastfeeding at 1 year 84 percent 2.8 Continued breastfeeding at 2 years 48 percent 2.9 Duration (median) of predominant breastfeeding (children 0-36 months) 5.5 months 2.10 Duration (median) of exclusive breastfeeding 0.7 months 2.11 Bottle feeding 10 percent 2.12 Introduction of solid, semi-solid or soft foods 25 percent 2.13 Minimum meal frequency 20 percent 2.14 Age-appropriate breastfeeding 40 percent 2.15 (Adequate) milk feeding frequency for non-breastfed children 18 percent Salt iodization 2.16 Iodized salt consumption 63 percent Vitamin A 2.17 Vitamin A supplementation (children under age 5) 91 percent Low birth weight 2.18 Low-birth weight infants 10 percent 2.19 Infants weighed at birth 40 percent CHILD HEALTH Vaccinations (among 12-23 month old children vaccinated at any time before the survey) 3.1 Tuberculosis immunization coverage 96 percent 3.2 Polio immunization coverage (OPV3) 63 percent 3.3 Immunization coverage for diphtheria, pertussis and tetanus (DPT1) 92 percent 3.4 4.3 Measles immunization coverage 82 percent 3.5 Hepatitis B immunization coverage (HepB3) 69 percent 3.6 Yellow fever immunization coverage 82 percent Tetanus toxoid 3.7 Neonatal tetanus protection 87 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 55 percent 3.9 Care seeking for suspected pneumonia 74 percent 3.10 Antibiotic treatment of suspected pneumonia 58 percent Solid fuel use 3.11 Solid fuels 99 percent ii Topic MICS4 Indicator Number MDG Indicator Number Indicator Value Malaria 3.12 Household availability of insecticide-treated nets (ITNs) 36 percent 3.13 Households protected by a vector control method 37 percent 3.14 Children under age 5 sleeping under any mosquito net 32 percent 3.15 6.7 Children under age 5 sleeping under insecticide-treated nets (ITNs) 30 percent 3.16 Malaria diagnostics usage 26 percent 3.17 Anti-malarial treatment of children under 5 the same or next day 50 percent 3.18 6.8 Anti-malarial treatment of children under age 5 62 percent 3.19 Pregnant women sleeping under insecticide-treated nets (ITNs) 28 percent 3.20 Intermittent preventive treatment for malaria 41 percent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 57 percent 4.2 Water treatment 2 percent 4.3 7.9 Use of improved sanitation facilities 40 percent 4.4 4.5 4.6 Safe disposal of child's faeces Place for Handwashing Availability of Soap 54 20 42 Percent Percent Percent REPRODUCTIVE HEALTH Contraception and unmet need 5.1 5.4 Adolescent fertility rate 122 per 1,000 5.2 Early childbearing 38 percent 5.3 5.3 Contraceptive prevalence rate 11 percent 5.4 5.6 Unmet need 27 Percent Maternal and newborn health 5.5a 5.5b 5.5 Antenatal care coverage At least once by skilled personnel At least four times by any provider 93 75 percent percent 5.6 Content of antenatal care 50 percent 5.7 5.2 Skilled attendant at delivery 62 percent 5.8 Institutional deliveries 50 percent 5.9 Caesarean section 4 percent CHILD DEVELOPMENT Child development 6.1 Support for learning 54 percent 6.2 Father's support for learning 42 percent 6.3 Learning materials: children’s books 2 percent 6.4 Learning materials: playthings 35 percent 6.5 Inadequate care 32 percent 6.6 Early child development index 45 percent 6.7 Attendance to early childhood education 14 percent iii Topic MICS4 Indicator Number MDG Indicator Number Indicator Value EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women aged 15-24 years 48 percent 7.2 School readiness 6 percent 7.3 Net intake rate in primary education 45 percent 7.4 2.1 Primary school net attendance rate (adjusted) 74 percent 7.5 Secondary school net attendance rate (adjusted) 37 percent 7.6 2.2 Children reaching last grade of primary 92 percent 7.7 Primary completion rate 117 percent 7.9 Gender parity index (primary school) 1.04 ratio 7.10 Gender parity index (secondary school) 0.83 ratio CHILD PROTECTION Birth registration 8.1 Birth registration 78 percent Child labour 8.2 Child labour 50 percent 8.3 School attendance among child labourers 76 percent 8.4 Child labour among students 52 percent Child discipline 8.5 Violent discipline 82 percent Early marriage and polygyny 8.6 Marriage before age 15 16 percent 8.7 Marriage before age 18 50 percent 8.8 Young women age 15-19 currently married or in union 23 percent 8.9 Polygyny 34 percent 8.10a 8.10b Spousal age difference Women age 15-19 Women age 20-24 35 36 percent percent Female genital mutilation/ Cutting 8.11 Approval for female genital mutilation/cutting (FGM/C) 72 percent 8.12 Prevalence of female genital mutilation/cutting (FGM/C) among women 88 percent 8.13 Prevalence of female genital mutilation/cutting (FGM/C) among daughters 10 percent Domestic violence 8.14 Attitudes towards domestic violence 73 percent iv Topic MICS4 Indicator Number MDG Indicator Number Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANHOOD HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention 20 percent 9.2 6.3 Comprehensive knowledge about HIV prevention among young people 23 percent 9.3 Knowledge of mother-to-child transmission of HIV 46 percent 9.4 Accepting attitude towards people with HIV 6 percent 9.5 Women who know where to be tested for HIV 46 percent 9.6 Women who have been tested for HIV and know the results 8 percent 9.7 Sexually active young women who have been tested for HIV and know the results 9 percent 9.8 HIV counselling during antenatal care 41 percent 9.9 HIV testing during antenatal care 26 percent Sexual behaviour 9.10 Never-married women (aged 15-24 years) who have had sex 65 percent 9.11 Sex before age 15 among young women 24 percent 9.12 Age-mixing among sexual partners 26 percent 9.13 Sex with multiple partners 8 percent 9.14 Condom use during sex with multiple partners 10 percent 9.15 Sex with non-regular partners 37 percent 9.16 6.2 Condom use with non-regular partners 12 percent Orphaned children 9.17 Children not living with biological parent 22 percent 9.18 Prevalence of children with at least one parent dead 13 percent 9.19 6.4 School attendance of orphans 74 percent 9.20 6.4 School attendance of non-orphans 84 percent v Table of Contents Summary Table of Findings. i Table of Contents . v List of Tables……………………………………………………………………………………………………………………………………………………vii List of Figures……………………………………………………………………………………………………………………………………………………ix List of Abbreviations………………………………………………………………………………………………………………………………………….x Acknowledgements…………………………………………………………………………………………………………………………………………xii Executive Summary……………………………………………………………………………………………………………………………………….xiii 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 . 8 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 11 IV. Child Mortality . 14 V. Nutrition . 18 Nutritional Status . 18 Breastfeeding and Infant and Young Child Feeding . 21 Salt Iodization . 31 Children’s Vitamin A Supplementation . 33 Low Birth Weight . 35 VI. Child Health . 37 Vaccinations . 37 Neonatal Tetanus Protection . 41 Oral Rehydration Treatment . 42 Care Seeking and Antibiotic Treatment of Pneumonia . 47 Solid Fuel Use . 50 Malaria . 52 VII. Water and Sanitation . 59 Use of Improved Water Sources . 59 Use of Improved Sanitation Facilities . 64 Handwashing…………………………………………………………………………………………………………………………………….68 VIII. Reproductive Health . 71 Fertility . 71 Contraception . 73 Unmet Need . 75 Antenatal Care . 77 Assistance at Delivery . 81 Place of Delivery . 82 vi IX. Child Development . 84 Early Childhood Education and Learning . 84 Early Childhood Development . 88 X. Literacy and Education . 90 Literacy among Young Women . 90 School Readiness . 91 Primary and Secondary School Participation . 92 XI. Child Protection . 99 Birth Registration . 99 Child Labour . 100 Child Discipline . 103 Early Marriage and Polygyny . 105 Female Genital Mutilation/Cutting . 108 Domestic Violence . 112 XII. HIV/AIDS, Sexual Behaviour, and Orphans . 114 Knowledge about HIV Transmission and Misconceptions about HIV/AIDS . 114 Attitudes toward People Living with HIV/AIDS . 118 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . 120 Sexual Behaviour Related to HIV Transmission . 122 Orphans . 127 Appendix A. Sample Design . 130 Appendix B. List of Personnel Involved in the Survey. 136 Appendix C. Estimates of Sampling Errors . 139 Appendix D. Data Quality Tables . 149 Appendix E. MICS4 Indicators: Numerators and Denominators . 171 vii List of Tables Table HH.1: Results of household, women's and under-five interviews, etc……………………………………………….7 Table HH.2: Household age distribution by sex………………………………………………………………………………………………….8 Table HH.2.1: Population age distribution (percent)………………………………………………………………………………………….9 Table HH.3: Household Composition……………………………………………………………………………………………………………….10 Table HH.3.1: Household Composition…………………………………………………………………………………………………………….11 Table HH.4: Women’s background Characteristics………………………………………………………………………………….……….12 Table HH.5: Under-fives background Characteristics………………………………………………………………………………….……13 Table CM.1: Children ever born, Children surviving and proportion dead……………………………………………………….14 Table CM.2: Child mortality – Infant and under-five mortality rates……………………………………………………………….15 Table NU.1: Nutritional status of children……………………………………………………………………………………………………….19 Table NU.2: Initial breastfeeding…………………….……………………………………………………………………………………………….22 Table NU.3: Breastfeeding……………………………………………………………………………………………………………………………….24 Table NU.4: Duration of breastfeeding…………………………………………………………………………………………………………….26 Table NU.5: Age-appropriate breastfeeding…………………………………………………………………………………………………….27 Table NU.6: Introduction of solid, semi-solid or soft food……………………………………………………………………………… 28 Table NU.7: Minimum meal frequency……………………………………………………………………………………………………………29 Table NU.8: Bottle feeding…………………………………………………………………………………………………………………………….30 Table NU.9: Iodised salt consumption…………………………………………………………………………………………………………….32 Table NU.10: Children’s vitamin A supplementation……………………………………………………………………………………….34 Table NU.11: Low birth weight infants…………………………………………………………………………………………………………….36 Table CH.1: Vaccination in first year of life………………………………………………………………………………………………………38 Table CH.2: Vaccinations by background characteristics………………………………………………………………………………….40 Table CH.3: Neonatal tetanus protection…………………………………………………………………………………………………………41 Table CH.4: Oral rehydration solutions and recommended homemade fluids………………………………………………….43 Table CH.5: Feeding practices during diarrhoea……………………………………………………………………………………………….45 Table CH.6: Oral rehydration therapy with continued feeding and other treatments………………………………………46 Table CH.7: Care seeking for suspected pneumonia and antibiotic treatment…………………………………………………48 Table CH.8: Knowledge of the two danger signs of pneumonia……………………………………………………………………….49 Table CH.9: Solid fuel use……………………………………………………………………………………………………………………………….50 Table CH.10: Solid fuel use by place of cooking……………………………………………………………………………………………….51 Table CH.11: Household availability of insecticide treated nets and protection by a vector control……………….52 Table CH.12: Children sleeping under mosquito nets………………………………………………………………………………………53 Table CH.13: Pregnant women sleeping under mosquito nets……………………………………………………………………….54 Table CH.14: Anti-malarial treatment of children with anti-malarial drugs…………………………………………………….55 Table CH.15: Malaria diagnostics usage………………………………………………………………………………………………………….56 Table CH.16: Intermittent preventive treatment for malaria………………………………………………………………………….57 Table WS.1: Use of improved water sources………………………………………………………………………………………………….60 Table WS.2: Household water treatment……………………………………………………………………………………………………….62 Table WS.3: Time to source of drinking water…………………………………………………………………………………………………63 Table WS.4: Person collecting water……………………………………………………………………………………………………………….63 Table WS.5: Types of sanitation facilities…………………………………………………………………………………………………………65 Table WS.6: Use and sharing of sanitation facilities…………………………………………………………………………………………66 Table WS.7: Disposal of child’s faeces…………………………………………………………………………………………………………….67 Table WS.8: Drinking water and sanitation ladders………………………………………………………………………………………….68 Table WS.9: Water and soap at place for handwashing……………………………………………………………………………………69 Table WS.10: Availability of Soap…………………………………………………………………………………………………………………….70 Table RH.1: Adolescent birth rate and total fertility rate…………………………………………………………………………………71 Table RH.2: Early childbearing………………………………………………………………………………………………………………………….72 Table RH.3: Trends in early childbearing………………………………………………………………………………………………………….73 Table RH.4: Use of contraception…………………………………………………………………………………………………………………….74 Table RH.5: Unmet need for contraception…………………………………………………………………………………………………….76 Table RH.6: Antenatal Care provider……………………………………………………………………………………………………………….78 Table RH.7: Number of antenatal care visits…………………………………………………………………………………………………….79 viii Table RH.8: Content of antenatal care…………………………………………………………………………………………………………….80 Table RH.9: Assistance during delivery…………………………………………………………………………………………………………. 81 Table RH.10: Place of delivery………………………………………………………………………………………………………………………….83 Table CD.1: Early childhood education…………………………………………………………………………………………………………….84 Table CD.2: Support for learning…………………………………………………………………………………………………………………….85 Table CD.3: Learning materials……………………………………………………………………………………………………………………….86 Table CD.4: Inadequate care……………………………………………………………………………………………………………………………87 Table CD.5: Early child development index………………………………………………………………………………………………………88 Table ED.1: Literacy among young women………………………………………………………………………………………………………90 Table ED.2: School readiness………………………………………………………………………………………………………………………….91 Table ED.3: Primary School entry…………………………………………………………………………………………………………………….92 Table ED.4: Primary school attendance……………………………………………………………………………………………………………93 Table ED.5: Secondary school attendance……………………………………………………………………………………………………….94 Table ED.6: Children reaching last grade of primary school…………………………………………………………………………….95 Table ED.7: Primary School completion and transition to secondary school…………………………………………………….96 Table ED.8: Education gender parity……………………………………………………………………………………………………………….97 Table CP.1: Birth Registration………………………………………………………………………………………………………………………….99 Table CP.2: Child Labor……………….……………………………………………………………………………………………………………….101 Table CP.3: Child Labor and school attendance…………………………………………………………………………………………….102 Table CP.4: Child discipline…………………………………………………………………………………………………………………………….103 Table CP.4.1: Child discipline.……………………………………………………………………………………………………………………….104 Table CP.5: Early marriage and polygyny……………………………………………………………………………………………………….106 Table CP.6: Trends in early marriage…………………………………………………………………………………………………………….107 Table CP.7: Spousal age difference……………………………………………………………………………………………………………….108 Table CP.8: Female genital mutilation/cutting (FGM/C) among women…………………………………………………………109 Table CP.9: Female genital mutilation/cutting (FGM/C) among daughters………………………………………………….110 Table CP.10: Approval of female genital mutilation/cutting (FGM/C)…………………………………………………………….111 Table CP.11: Attitudes towards domestic violence…………………………………………………………………………………………113 Table HA.1: Knowledge about HIV transmission, misconceptions and comprehensive knowledge among Women age 15-49 years……………………………………………………………………………………………………….….114 Table HA.2: Knowledge about HIV transmission, misconceptions and comprehensive knowledge among Young people age 15-24 years……………………………………………………………………………………………………115 Table HA.3: Knowledge of mother-to-child HIV transmission…………………………………………………………………………117 Table HA.4: Accepting attitudes toward people living with HIV/AIDS…………………………………………………………….119 Table HA.5: Knowledge of a place for HIV testing………………………………………………………………………………………….120 Table HA.6: Knowledge of a place for HIV testing among sexually active young women……………………………….121 Table HA.7: HIV counseling and testing during antenatal care……………………………………………………………………….122 Table HA.8: Sexual behavior that increases the risk of HIV infection………………………………………………………………123 Table HA.9: Sex and multiple partners………………………………………………………………………………………………………….124 Table HA.10: Sex with multiple partners (Young people 15-24 years old)………………………………………………………125 Table HA.11: Sex with non-regular partners………………………………………………………………………………………………….126 Table HA.12: Children’s living arrangements and orphanhood.……….……………………………………………………….…128 Table HA.13: School attendance of orphans and non-orphans…………………………………………………………………….129 Appendix A: ………………………………………………………………………………………………………………………………………………….130 Appendix B: ………………………………………………………………………………………………………………………………………………….136 Appendix C: ………………………………………………………………………………………………………………………………………………….139 Appendix D: ………………………………………………………………………………………………………………………………………………….149 Appendix E: ………………………………………………………………………………………………………………………………………………….158 Appendix F: ………………………………………………………………………………………………………………………………………………….171 ix List of Figures Figure HH.1: Age and sex distribution of household population, Sierra Leone, 2010………………………………………….9 Figure CM.1: Under-five mortality rates by background characteristics………………………………………………………….16 Figure CM.2: Trend in under-5 mortality rates…………………………………………………………………………………………………17 Figure NU.1: Percentage of children under age 5 who are underweight, stunted and wasted…………………………20 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of Birth…………………………………………………………………………………………………………………………………………….23 Figure NU.3: Percent distribution of children under age 2 by feeding pattern and by age group…………………….25 Figure NU.4: Percentage of households consuming adequately iodized salt……………………………………………………32 Figure NU.5: Percentage of infants weighing less than 2500 grams at birth…………………………………………………….35 Figure CH.1: Percentage of children aged 12-23 months who receive the recommended vaccinations By age 12 months……………………………………………………………………………………………………………………….39 Figure CH.2: Percentage of women with a live birth in the last 12 months who are protected against Neonatal tetanus…………………………………………………………………………………………………………………………42 Figure CH.3: Percentage of children under age 5 with diarrhoea who received oral rehydration treatment……44 Figure WS.1: Percent distribution of household members by source of drinking water………………………………….61 Figure HA.1: Percentage of women who have comprehensive knowledge of HIV/AIDS transmission By mother’s education……………………………………………………………………………………………………………….116 Figure HA.2: Sexual behaviour that increases risk of HIV infection……………………………………………………………….124 x List of Abbreviations ABR Adolescent birth rate ABC Abstinence, Be faithful, use a Condom ACT Artemisinin combination therapy AIDS Acquired Immune Deficiency Syndrome ANC Antenatal care ARI Acute respiratory infection BCG Bacillis-Cereus-Geuerin (Tuberculosis) CB-IMCI Community-Based Integrated Management of Childhood Illnesses CHV Community health volunteer CLTS Community-led total sanitation CMAM Community-based management of acute malnutrition DD Diarrhoeal disease DPT Diphtheria Pertussis Tetanus EA Enumeration area ECDI Early child development index EPI Expanded Programme on Immunization FGM/C Female genital mutilation / cutting FHCI Free health care initiative FSU Family support unit GoSL Government of Sierra Leone GPI Gender parity index HepB Hepatitis B Hib Haemophilus influenzae type b HIV Human Immunodeficiency Virus IDD Iodine deficiency disorders IMCI Integrated Management of Childhood Illnesses IMR Infant mortality rate IPT Intermittent preventive treatment (for malaria) IRS Indoor residual spraying ITN Insecticide-treated net IUD Intrauterine device IYCF Infant and young child feeding JMP WHO/UNICEF Joint Monitoring Program LAM Lactation amenorrhea method LBW Low birth weight MCH Maternal and child health MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS4 Multiple Indicator Cluster Survey – Round 4 MMR Maternal mortality ratio MoH Ministry of Health NAR Net attendance rate NGO Non-governmental organization ORS Oral rehydration solution ORT Oral rehydration therapy OPV Oral polio vaccine PHU Peripheral health unit PMTCT Prevention of mother-to-child transmission ppm Parts per million PRSP2 Poverty Reduction Strategy Paper – 2 RHF Recommended home fluid SP Fansidar (combination of sulfadoxine and pyrimethamine) xi SPSS Statistical Package for Social Sciences SSL Statistics Sierra Leone SWC The State of the World’s Children 2011 TFR Total fertility rate U5MR Under-five mortality rate UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF WASH United Nations Children’s Fund Water, Sanitation and Hygiene WFFC World Fit For Children WHO World Health Organization xii Acknowledgements The people of Sierra Leone are acknowledged for all that they gave so generously to the survey effort: their invaluable time, personal information, hospitality to the field workers, and other assistance as was required. The surveyors, supervisors and other members of the support team are acknowledged for the long hours they spent working and their dedication to making the MICS4 survey the best possible. Colleagues in the UNICEF country, regional and headquarters offices and the external consultant are acknowledged for their efforts to design, conduct, and document the MICS4 survey. Many other institutions contributed to the success of the MICS4 survey effort. Statistics Sierra Leone and UNICEF Sierra Leone acknowledge the following organizations and agencies for the support that they provided to the MICS4 survey: Government of Sierra Leone Ministry of Finance and Economic Development Ministry of Education, Science and Technology Ministry of Energy and Water Resources (Water Division) Ministry of Health and Sanitation Ministry of Information and Communications Ministry of Local Government and Rural Development Ministry of Social Welfare, Gender and Children’s Affairs United Nations Agencies and other multilateral institutions UNFPA WFP WHO World Bank xiii Executive Summary The 2010 Sierra Leone Multiple Indicator Cluster Survey (MICS4) 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—including the identification of vulnerable groups and of disparities among groups—in order to inform policies and interventions; (ii) to produce data to monitor progress toward the achievement of targets and goals that include the Millennium Development Goals (MDGs) and World Fit For Children; and, (iii) to contribute to the improvement of national statistical, data and monitoring systems in Sierra Leone and to strengthen national capacity and technical expertise in the design and implementation of such systems. Interviews were successfully completed in 11,394 households drawn from all districts of Sierra Leone. The main results from the survey are summarized below. Child Mortality The MICS4 survey measured child mortality through the use of a methodology that produced retrospective estimates (for the year 2008) of the infant mortality rate (IMR) and under-five mortality rate (U5MR). The survey estimated the IMR to be 128 per 1000 live births and the U5MR to be 217 per 1000 live births. These estimates suggest that the IMR and U5MR have decreased notably between 2002 and 2008 (MICS3 estimates: IMR = 267, U5MR = 158 in 2002), although they remain high. Mortality rates are equally high in the Northern, Eastern and Southern Provinces and are notably lower in the West. Nutrition Nutritional Status Twenty-two percent of children under age five in Sierra Leone are underweight, or too thin for their age. Forty-four percent of children are stunted, or too short for their age, while eight percent are wasted, or too thin for their height. The prevalence of undernourished children in Sierra Leone is similar to norms in West and Central Africa as documented in The State of the World’s Children 2011 (SWC). Breastfeeding Forty-five percent of newborns are given breast milk within one hour of birth while 32 percent of children less than six months of age are exclusively breastfed. Only 24 percent of children receive soft, and solid or semi-solid foods at this key age of 6-8 months when supplementary foods must be given to complement breast milk. Continued breastfeeding rates are 84 and 48 percent among children 12-15 months and 20-23 months of age, respectively, which represents a slight decrease from MICS3. Only 20 percent of children aged 6-23 months receive a minimum adequate diet. Taken together, these indicators suggest that infant and young child feeding practices in Sierra Leone are grossly deficient and contribute to its children’s poor nutritional status. Salt Iodization The percentage of households that consume adequately iodized salt in Sierra Leone continues to increase. The MICS4 survey found that 63 percent of households consume salt that is adequately iodized. Challenges to the achievement of universal salt iodization in Sierra Leone include the local production and high utilization of non-iodized salt in some districts, difficulties monitoring the import of non-iodized salt from neighbouring countries, and a weak national monitoring and surveillance system. xiv Vitamin A Supplementation There has been a dramatic surge in the coverage of the vitamin A supplementation program in Sierra Leone. Ninety-one percent of children aged 6-59 months were found to have received a high dose vitamin A supplement during the six months prior to the MICS4 survey, almost double the 49 percent coverage that was estimated in MICS3 and higher than the regional average of 84 percent (SWC). Vitamin A supplementation coverage is moderately lower in the Southern Province as compared to other regions; Moyamba (80 percent) and Pujehun (86 percent) are the districts with the lowest levels of supplementation. Coverage is lowest among children aged 6-11 months (76 percent) and is relatively constant at a level above 90 percent for all other age groups. Low Birth Weight Weight at birth is an excellent indicator of both a mother's health and nutritional status and also a newborn's chances for survival, growth, long-term health and psychosocial development. Ten percent of newborns in Sierra Leone are estimated to weigh less than 2500 grams at birth and thus be classified as low birth weight. Child Health Immunization Ninety-six 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 (i.e., timely vaccination) was 67 percent for DPT3, 58 percent for OPV3, 68 percent for measles, and 68 percent for yellow fever. Comparison of these findings with MICS3 results shows modest increases in timely vaccination status of children in Sierra Leone during the past five years. Vaccination rates are still far short of the goal of 90 percent of children fully immunized at one year of age. Vaccination rates for BCG and the DPT series show that the program is successful in delivering the early vaccinations in the series but does not do as well in completing vaccine series due to substantial drop-out. The Sierra Leone EPI program provides good access to its services but needs to be strengthened if the goal of achieving high levels of timely vaccination of all antigens is to be achieved. Tetanus Toxoid Eighty-three percent of surveyed women who gave birth during the year prior to the MICS4 survey received at least two doses of tetanus toxoid (TT) vaccine during their pregnancy while an additional four percent were protected against neonatal tetanus due to previous TT vaccinations. This encouraging result represents an almost ten percent increase in TT coverage over the past five years and is almost ten percent higher than the regional average (SWC). Oral Rehydration Treatment Approximately 84 percent of children with diarrhoea in the two weeks prior to the survey received oral rehydration solution (ORS) and/or a recommended home fluid and/or increased fluids—a 24 percent increase compared to the MICS3 result. Fifty-five percent of children with diarrhoea received home treatment as recommended (a 24 percent increase over MICS3): that is, they either received ORT or increased their fluid intake, while continuing feeding at the same time. These improvements in diarrhoea management are part of a general trend of strengthened household management of major childhood diseases—diarrhoea, pneumonia and malaria—as compared to 2005. xv Care Seeking and Antibiotic Treatment of Pneumonia Seventy-four percent of surveyed children with suspected pneumonia during the two weeks preceding the survey were taken to an appropriate provider while 58 percent were treated with an antibiotic. Almost all children who were seen by an appropriate provider were seen at a government health facility. Children with suspected pneumonia were somewhat more likely to be seen by an appropriate provider if their mothers were uneducated, if they were from a younger age category, or if they were from households in the mid-level wealth quintiles. Only eight percent of surveyed mothers knew the two key danger signs of pneumonia—fast and difficult breathing. The introduction of the Community-Based Integrated Management of Childhood Illnesses (CB-IMCI) program has led to more effective community-based treatment of child illnesses using a holistic approach. The success of this approach is reflected in the increased treatment rates of suspected pneumonia. Malaria The MICS4 survey was conducted just before a mass distribution of insecticide-treated mosquito nets (ITNs) to every household in Sierra Leone that took place in December 2010. The results presented here represent the situation with respect to ITN availability and use just prior to the distribution campaign. MICS4 findings indicate that 30 percent of children under the age of five slept under an ITN the night prior to the survey. Thirty-seven percent of surveyed children aged 0-59 months were ill with fever in the two weeks prior to the MICS4. Among these children, 50 percent were treated with an anti-malarial drug within 24 hours of onset of symptoms and an additional 12 percent were treated at a later time. Solid Fuel Use Households in Sierra Leone make nearly universal (99 percent) use of solid fuels—primarily wood— for cooking purposes. Eighty-four percent of households cook either in a structure separate from their home or outdoors. Water and Sanitation The MICS4 estimates of the Sierra Leonean population’s access to improved sources of drinking water (57 percent) and improved sanitation facilities (40 percent) represent improvement in access compared to past studies in recent years. Only ten percent of households have both an improved source of drinking water and improved sanitation facilities where the latter are not shared with other households. Differences in the level of this indicator vary widely among provinces, ranging from seven percent in the East and North to 28 percent in the West. Reproductive Health Contraception Current use of modern contraception was reported by ten percent of surveyed women who were married or in union while one percent reported using a traditional method; Sierra Leone lags behind an already low regional contraceptive prevalence rate of 17 percent (SWC). The only methods with a notable level of use are the pill (four percent) and injections (five percent). Unmet need for spacing is 18 percent and unmet need for limiting is ten percent, yielding a total unmet need for contraception of 27 percent (total does not add to 28 due to rounding). Total unmet need varies little across the background variables that were measured in MICS4. xvi Antenatal Care Ninety-three percent of pregnant women in Sierra Leone receive antenatal care (ANC) from a skilled health provider (i.e., a doctor, nurse, or midwife) at least once during their pregnancies; this estimate is approximately 20 percentage points higher than the regional estimate (SWC). Among women who gave birth during the two years preceding the survey, 66 percent reported that a blood sample was taken during ANC, 82 percent reported that their blood pressure was checked and 56 percent reported that a urine specimen was taken; 50 percent of respondents reported that they received all three services during ANC. Coverage of ANC is high in Sierra Leone but concerns remain regarding its quality. Assistance at Delivery About 62 percent of births in Sierra Leone that occurred during the two years prior to the MICS4 survey were delivered by skilled personnel—that is, a doctor, nurse, or MCH Aide—which represents a twenty percent increase during the past five years. This increase has taken place entirely in the provinces, as the level of this indicator in the West remains unchanged since 2005. Fifty percent of deliveries in Sierra Leone take place in health facilities—a 31 percent increase since 2005. Child Development For slightly over half (54 percent) of children aged 36-59 months, an adult household member engaged in four or more activities that promote learning and school readiness during the three days preceding the survey. The average number of activities that adults engaged in during those three days with children was 3.4. Fathers’ involvement in such activities was somewhat limited; 42 percent of children engaged in activities with their fathers and the average number of activities that fathers engaged in was 0.9. In Sierra Leone, two percent of children aged 0-59 months live in households where at least three children’s books are present. Thirty-two percent of children were left with inadequate care during the week preceding the survey, either by being left alone or in the care of another child. Literacy and Education Adult Literacy The MICS4 found that 48 percent of women in Sierra Leone aged 15-24 are literate. Women aged 15-19 years had a much higher level of literacy (59 percent) than did women aged 20-24 (36 percent). Women’s literacy status is positively associated with urban residence, higher levels of education, and higher household wealth. Only 143 out of 866 respondents who had attended some level of primary school could read a simple statement and were thus classified as “literate”, raising concern about the quality of primary school education in Sierra Leone. Pre-School Attendance and School Readiness Fourteen percent of children aged 36-59 months in Sierra Leone 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 six percent attended pre-school the previous year. These levels do not suggest that the increases in school attendance as documented below have had a corresponding effect on pre- school attendance. xvii Primary and Secondary School Participation The majority of children of primary school age in Sierra Leone are attending school (74 percent). Only 45 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. The picture regarding secondary education in Sierra Leone is less promising. Only 37 percent of children of secondary school age (12-17 years) attend secondary school while another 37 percent attend primary school although they are of secondary school age. The ratio of girls to boys attending primary school at the national level is 104:100. However, the indicator drops to 83:100 for secondary education. Child Protection Birth Registration The births of 78 percent of children under five years of age in Sierra Leone have been registered. The percentage of children whose births have been registered increases with increasing age of child and increasing levels of mother’s education and household wealth. Child Labour According to the definition of “child labour” that was used in MICS4, a child aged 5-11 years was considered to be involved in child labour activities if s/he, during the week preceding the survey, performed at least one hour of economic work or 28 hours or more of domestic work per week. For a child aged 12-14 years the cut-off points to be considered a “child labourer” were at least 14 hours of economic work or 28 hours or more of domestic work per week. Fifty percent of children aged 5- 14 were found to be involved in child labor—63 percent of children aged 5-11 years and 15 percent of children aged 12-14 years. Among children aged 5-11 years, the overwhelming majority that perform child labour are classified as such due to performing one or more hours of economic work per week. Similarly, almost all children aged 12-14 who perform child labour are classified as such due to performing more than 14 hours of economic work per week. Given that school attendance is higher among child labourers (76 percent) than among non-labourers (71 percent), it is difficult to argue that child labour has a dramatically negative effect on school attendance in Sierra Leone. Child Discipline MICS4 found that 82 percent of children aged 2-14 years in Sierra Leone were subjected to at least one form of psychological or physical punishment by household members in the month prior to the survey. More importantly, 65 percent of children were subjected to some type (minor and/or severe) of physical punishment while 19 percent of children were subjected to severe physical punishment. There are virtually no differences across all of the background variables for any of the discipline- related indicators, indicating a high degree of uniformity in the practice of child discipline across different strata of Sierra Leonean society. Although only 42 percent of respondents stated that it is necessary to physically punish children in order to raise them properly, in practice 65 percent of children receive physical punishment. Early Marriage and Polygyny Early marriage, polygyny, and large spousal age differences are common in Sierra Leone although their prevalence appears to be decreasing. Sixteen percent of respondents (women aged 15-49) first married before the age of 15 while 50 percent of respondents (aged 18-49) were married before the age of 18. Among women aged 15-19 who are married or in union, 35 percent are with a man who is ten or more years senior to them. One in three women (34 percent) aged 15-49 years is in a xviii polygynous union. Indicators of early marriage are highest in the north and lowest in the West. Higher levels of early marriage are associated with rural residence and lower levels of women’s education and household wealth. Membership in Secret Societies The practice of female genital mutilation / cutting (FGM/C) is deeply entrenched in societal norms in Sierra Leone. Eighty-eight percent of female respondents aged 15-49 years reported having undergone some form of female genital mutilation. The practice appears to be more common in rural areas, in the Northern Province, among households in the poorest three quintiles and among uneducated women. Respondents reported that ten per cent of their daughters aged 0-14 years had undergone FGM/C. Higher levels of the practice of FGM/C on daughters are correlated with lower levels of household wealth and mother’s education, higher age of child, mothers who have had FGM/C performed on them, and residence in the Northern Province. Seventy-two percent of women state that the practice of FGM/C should be continued while 22 percent believe it should be discontinued. Domestic Violence Women aged 15-49 years were asked whether husbands are justified in hitting or beating their wives or partners according to five different scenarios. Researchers have found that 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 one-third of the respondents said that beating is justified; the percentage who felt this ranged from 34 percent for “if she burns the food” to 62 percent for “if she neglects the children.” A full 73 percent of respondents felt that beating was justified under one or more of the scenarios. HIV/AIDS, Sexual Behaviour, and Orphanhood Knowledge of HIV Transmission and Utilization of HIV Testing Services Eighty percent of women in Sierra Leone aged 15-49 years have heard of AIDS. Only 20 percent 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. Sixty-four percent of respondents know that HIV can be transmitted from mother to child while 46 percent know all three ways that transmission can occur. Ninety-four 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. Apart from the percentage of respondents who have heard of AIDS, none of these indicators have changed notably in the last five years. Forty-six percent of women could identify a HIV test site while 28 percent reported that they have been tested for HIV at some point during their lives. Forty-one percent of women who gave birth in the two years preceding the survey received HIV counselling during antenatal care while 26 percent were offered an HIV test, were then tested for HIV during antenatal care and received the results. Sexual Behaviour Related to HIV Transmission Young women in Sierra Leone are at substantial risk of contracting HIV. Premarital sex at a young age is common; sixty-five percent of never-married women aged 15-24 in Sierra Leone have had sex. Twenty-four percent of women aged 15-24 report that they first had sex before the age of 15. The practice of high-risk sex by young women is also common. Twenty-six percent of women aged 15-24 report that they had sex in the previous 12 months with a man ten or more years older. Eight percent of women 15-49 years of age—and nine percent of women aged 15-24—reported having had sex with more than one partner during the year prior to the MICS4 survey. Among these two xix groups of women, only ten and twelve percent, respectively, reported using a condom the last time they had sex. Thirty-seven percent of women aged 15-24 years report that they had sex with a non- marital, non-cohabiting partner in the previous year. Among these women, only twelve percent reported that a condom was used the last time they had sex with such a partner. Orphanhood The MICS4 survey found that 13 percent of children aged 0-17 years are orphans (i.e., one or both parents dead) while 22 percent do not live with a biological parent. A key measure that has been developed to assess the status of orphaned children relative to their peers compares the school attendance of children aged 10-14 years for children who have lost both parents versus children whose parents are alive (and who live with at least one of their parents). In Sierra Leone, 2.5 percent of children aged 10-14 have lost both parents, and 74 percent of these orphans are currently attending school. Among children aged 10-14 years who have not lost a parent and who live with at least one parent, 84 percent are attending school. These two statistics can be combined to calculate an orphan: non-orphan school attendance ratio of 0.88 (74/84). This finding suggests that orphans are somewhat disadvantaged in terms of school attendance compared to the non-orphaned children. 1 I. Introduction Background This report is based on the Sierra Leone Multiple Indicator Cluster Survey (MICS4), conducted in 2010 by Statistics 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 that include (i) the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000 and (ii) the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for children in their countries and monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see box below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child- focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and 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 To address the above commitments, Sierra Leone has progressively implemented development programmes during the past two decades that have been aligned to the millennium development goals. These programmes have been underpinned by development and strategic plans that include the First and Second Generation Poverty Reduction Strategy Papers that have addressed social development challenges in the spheres of health, education and child protection. Four rounds of MICS surveys have been carried out in Sierra Leone (in 1995, 2000 2005 and 2010). The fourth round of MICS (MICS4) is the subject of this report and is focused on providing a monitoring tool for the World Fit for Children, the Millennium Development Goals (MDGs), as well as for other major international commitments, such as the UNGASS on HIV/AIDS and the Abuja targets for malaria. Roughly 20 of the 48 MDG indicators have been measured in MICS4, offering the largest single source of data for MDG monitoring. Results from MICS4 will be used to fill data gaps for national MDG reporting as well as to develop a monitoring and evaluation system for Sierra Leone’s the Second Generation Poverty Reduction Strategy Paper (PRSP2), document was developed in 2009 and is dubbed “Agenda for Change” in Sierra Leone. Survey Objectives The 2010 Sierra Leone Multiple Indicator Cluster Survey has the following primary objectives:  To provide up-to-date information for assessing the current situation of children and women in Sierra Leone—including the identification of vulnerable groups and of disparities among groups—to inform policies and interventions;  To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals such as World Fit For Children (WFFC), as a basis for future action; and,  To contribute to the improvement of the national statistical, data and monitoring systems in Sierra Leone and to strengthen national capacity and technical expertise in the design and implementation of such systems. 3 II. Sample and Survey Methodology Sample Design The sample for Round Four of the Sierra Leone Multiple Indicator Cluster Survey (MICS4) was designed to provide estimates for a large number of indicators that describe the situation of children and women at the national level, in urban and rural areas, and in the four provinces of Sierra Leone and the 14 districts that lie within them. In order to produce district-level estimates of moderate precision, a minimum of 30 enumeration areas (EAs) were selected in each district, resulting in a sample that was not self-weighting. The urban and rural areas within each district were identified as the main sampling strata and the sample was selected in two stages. In the first stage, within each stratum, a specified number of EAs were selected systematically with probability proportional to size. In the second stage, after a household listing was carried out within the selected enumeration areas, a systematic sample of 25 households was drawn in each selected EA. All of the selected EAs were visited during the fieldwork period. The sample was thus stratified by district and then by urban / rural areas. For reporting national and regional-level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire that was used to collect information on all de jure household members (i.e., usual residents of the household), the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years; and, 3) an under-5 questionnaire, administered to mothers or caretakers for all children under 5 years of age living in the household. The content of the three questionnaires is described below. The Household Questionnaire includes the following modules: o Household Listing Form o Education o Water and Sanitation o Household Characteristics o Insecticide-Treated Nets o Indoor Residual Spraying o Child Labour o Child Discipline o Handwashing o Salt Iodization The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the sampled households and includes the following modules: o Women’s Background o Child Mortality o Tetanus Toxoid o Desire for Last Birth o Maternal and Newborn Health o Illness Symptoms o Contraception o Unmet Need o Female Genital Mutilation/Cutting 4 o Attitudes Towards Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS The Questionnaire for Children Under Five was administered to mothers or caretakers of children under 5 years of age1 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire includes the following modules: o Age o Birth Registration o Early Childhood Development o Breastfeeding o Care of Illness o Malaria o Immunization o Anthropometry The questionnaires are based on the English version of the MICS4 model questionnaire2. The questionnaires were pre-tested in Freetown and its rural environs during June 2010. Based on the results of the pre-test, modifications were made to the wording of the questionnaires. A copy of the Sierra Leone MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place where household members usually wash their hands, 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 this report. Training and Fieldwork Supervisors and enumerators participated in separate trainings prior to the MICS4 fieldwork. The three-day training of supervisors was conducted in September 2010. All supervisors then participated as trainers in the nine-day training of enumerators. Training included lectures on interviewing techniques and the contents of the questionnaires, interviews of respondents by groups of trainees to gain practice in asking questions, and then community-level interviews with actual respondents. Towards the end of the training period, trainees spent a full day conducting practice interviews in the rural West outside of Freetown. Actual survey data were collected by 24 teams; each team was comprised of four enumerators, one driver and a supervisor. Fieldwork began in early October 2010 and concluded in December 2010. 1 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 2 The model MICS4 questionnaires can be found at www.childinfo.org . 5 Data Processing Data were entered using CSPro software. Data processing was carried out by 30 data entry operators and 2 data entry supervisors. In order to ensure quality control, all questionnaires were double- entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS programme and adapted to the Sierra Leone questionnaire were used throughout. Data processing began simultaneously with data collection in October 2010 and was completed in June 2011. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program (Version 18). The analysis was carried out using the model syntax and tabulation plans developed by UNICEF. 6 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 11,923 households selected for the sample, 11,578 were found to be occupied. Of these, 11,394 were successfully interviewed for a household response rate of 98.4 percent. In the interviewed households, 14,068 women (age 15-49 years) were identified. Of these, 13,359 were successfully interviewed, yielding a response rate of 95.0 percent within interviewed households. In addition, 8,799 children under age five were listed in the household questionnaire. Questionnaires were completed for 8,600 of these children, which corresponds to a response rate of 97.7 percent within interviewed households. Overall response rates of 93.5 and 96.2 percent are calculated for the women’s and under-5’s interviews respectively (Table HH.1). Ninety-seven percent of sampled households were found to be occupied. The household response rate was slightly lower in the West as compared to other provinces, primarily due to difficulties finding household members at home in Freetown. Response rates for women and children were very similar across provinces and areas of residence. Overall response rates were at an acceptable level. 7 Table HH.1: Results of household, women's and under-five interviews Numbers of households, women and children under 5 by results of the household, women's and under-5's interviews, and household, women's and under-5's response rates, Sierra Leone, 2010 Area Region District Total Urban Rural East North South West Kailahun Kenema Kono Bombali Kambia Koinadugu Port Loko Tonkolili Bo Bonthe Moyamba Pujehun Western Rural Western Urban Households Sampled 4077 7846 2610 3771 3163 2379 795 1065 750 748 734 746 793 750 921 750 743 749 747 1632 11923 Households Occupied 3948 7630 2512 3688 3061 2317 780 1015 717 721 705 739 777 746 892 729 692 748 729 1588 11578 Households Interviewed 3856 7538 2486 3665 3006 2237 778 1002 706 711 696 736 777 745 872 715 672 747 706 1531 11394 Household response rate 97.7 98.8 99.0 99.4 98.2 96.5 99.7 98.7 98.5 98.6 98.7 99.6 100.0 99.9 97.8 98.1 97.1 99.9 96.8 96.4 98.4 Women Eligible 5166 8902 3005 4629 3531 2903 974 1187 844 948 1035 862 1002 782 1131 886 720 794 831 2072 14068 Women Interviewed 4892 8467 2831 4435 3359 2734 938 1129 764 927 968 811 982 747 1057 858 677 767 799 1935 13359 Women's response rate 94.7 95.1 94.2 95.8 95.1 94.2 96.3 95.1 90.5 97.8 93.5 94.1 98.0 95.5 93.5 96.8 94.0 96.6 96.1 93.4 95.0 Women's overall response rate 92.5 94.0 93.2 95.2 93.4 90.9 96.1 93.9 89.1 96.4 92.3 93.7 98.0 95.4 91.4 95.0 91.3 96.5 93.1 90.0 93.5 Children under 5 Eligible 2555 6244 1942 3310 2410 1137 661 726 555 615 802 612 711 570 691 657 526 536 439 698 8799 Children under 5 Mother/Caretaker Interviewed 2490 6110 1896 3250 2356 1098 654 715 527 609 778 595 706 562 667 647 518 524 429 669 8600 Under-5's response rate 97.5 97.9 97.6 98.2 97.8 96.6 98.9 98.5 95.0 99.0 97.0 97.2 99.3 98.6 96.5 98.5 98.5 97.8 97.7 95.8 97.7 Under-5's overall response rate 95.2 96.7 96.6 97.6 96.0 93.2 98.7 97.2 93.5 97.7 95.8 96.8 99.3 98.5 94.4 96.6 95.6 97.6 94.6 92.4 96.2 8 Characteristics of Households The weighted distribution of the survey population, stratified by age and sex, is provided in Table HH.2. In the 11,394 households that were successfully interviewed in the survey, 66,707 household members were listed. Of these, 33,176 were males, 33,507 were females, and 23 were of unknown gender. These numbers do not add to the total due to rounding. Table HH.2: Household age distribution by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Sierra Leone, 2010 Males Females Missing Total Number Percent Number Percent Number Percent Number Percent Age group 0-4 4418 13.3 4389 13.1 4 16.1 8811 13.2 5-9 5293 16.0 5257 15.7 1 6.0 10552 15.8 10-14 3952 11.9 4650 13.9 2 6.9 8605 12.9 15-19 3746 11.3 2724 8.1 2 7.5 6472 9.7 20-24 2408 7.3 2366 7.1 0 .0 4774 7.2 25-29 2258 6.8 2698 8.1 2 9.0 4958 7.4 30-34 1984 6.0 2190 6.5 1 4.5 4175 6.3 35-39 2029 6.1 2119 6.3 0 .0 4149 6.2 40-44 1500 4.5 1181 3.5 0 1.1 2681 4.0 45-49 1436 4.3 854 2.5 2 7.2 2292 3.4 50-54 995 3.0 1911 5.7 1 3.7 2907 4.4 55-59 748 2.3 797 2.4 0 .0 1544 2.3 60-64 756 2.3 830 2.5 1 2.5 1587 2.4 65-69 500 1.5 466 1.4 0 .0 966 1.4 70-74 480 1.4 470 1.4 0 .0 950 1.4 75-79 291 .9 201 .6 0 .0 491 .7 80-84 191 .6 192 .6 0 .0 382 .6 85+ 167 .5 188 .6 0 .0 355 .5 Missing/DK 24 * 24 * 8 35.6 56 .1 Dependency age groups 0-14 13664 41.2 14296 42.7 7 28.9 27967 41.9 15-64 17860 53.8 17671 52.7 8 35.4 35539 53.3 65+ 1628 4.9 1517 4.5 0 .0 3145 4.7 Missing/DK 24 * 24 * 8 35.6 56 .1 Children and adult populations Children age 0-17 years 15983 48.2 15816 47.2 7 28.9 31806 47.7 Adults age 18+ years 17169 51.8 17668 52.7 8 35.4 34845 52.2 Missing/DK 24 * 24 * 8 35.6 56 .1 Total 33176 100.0 33507 100.0 23 100.0 66707 100.0 [*] Based on less than 25 unweighted cases and has been suppressed. Data from Table HH.2 are used to create the population pyramid in Figure HH.1. Examination of this figure reveals that females aged 40-49 are underrepresented or “missing” while there is a large bulge of women aged 50-54. Children aged 5-9 of both genders appear to be overrepresented. This suggests that enumerators may have introduced data quality errors by overstating the age of children aged under five years and women aged 40-49, possibly in order to minimize the number of interviews that they had to conduct. 9 Children aged 0-17 years comprise 47.73 percent of the MICS4 survey population, indicating the young nature of the population in Sierra Leone. The table below compares the composition of the MICS4 survey sample with that from the MICS3 survey and the 2004 Sierra Leone Census. Similarities in the population age distribution among the three surveys suggest that the MICS4 survey is a representative sample of the population of Sierra Leone. TABLE HH.2.1: POPULATION AGE DISTRIBUTION (PERCENT) OF MICS4 AND MICS3 SURVEYS AND 2004 SIERRA LEONE CENSUS Age MICS4 (2010) MICS3 (2005) 2004 Census Male Female Total Male Female Total Male Female Total 0-14 41.9 42.7 41.9 44.4 43.1 43.7 43.2 40.3 41.8 15-64 53.3 52.7 53.3 50.3 52.3 51.3 52.5 55.2 54.0 65+ 4.7 4.5 4.7 4.5 3.9 4.2 4.3 4.5 4.2 Missing 0.1 0.1 0.1 0.8 0.7 0.7 0 0 0 Total 100 100 100 100 100 99.9 100 100 100 Tables HH.3 - HH.5 provide basic information about the households, female respondents aged 15-49, and children under-5 that served as respondents in MICS4. Information on the basic characteristics of households, women and children under-5 who were interviewed in the survey is essential for the interpretation of findings presented later in the report and also can provide an indication of the 3 The 2004 Sierra Leone Census and the MICS3 survey found that 44.9 percent and 49.3 percent of the total population was aged 0-17 years, respectively. 10 degree to which the survey is representative. The remaining tables in this report are presented using only weighted numbers. See Appendix A for more details about how the weighting of MICS4 results was carried out. Table HH.3: Household composition Percent distribution of households by selected characteristics, Sierra Leone, 2010 Weighted percent Number of households Weighted Unweighted Sex of household head Male 77.3 8809 8680 Female 22.7 2585 2714 Region East 27.0 3072 2486 North 33.0 3761 3665 South 24.2 2760 3006 West 15.8 1801 2237 District Kailahun 8.7 991 778 Kenema 11.3 1287 1002 Kono 7.0 793 706 Bombali 7.5 849 711 Kambia 3.6 411 696 Koinadugu 4.5 517 736 Port Loko 8.5 971 777 Tonkolili 8.9 1013 745 Bo 9.7 1100 872 Bonthe 4.1 466 715 Moyamba 5.0 569 672 Pujehun 5.5 625 747 Western Rural 3.1 355 706 Western Urban 12.7 1447 1531 Area Urban 31.7 3608 3856 Rural 68.3 7786 7538 Number of household members 1 3.3 376 396 2 5.6 633 657 3 11.5 1307 1332 4 15.7 1783 1763 5 17.4 1986 1919 6 12.8 1463 1448 7 10.3 1174 1189 8 7.6 867 862 9 4.5 513 521 10+ 11.3 1291 1307 Education of household head None 65.5 7460 7392 Primary 9.3 1056 1033 Secondary + 25.1 2864 2953 Missing/DK * 14 16 Total 100.0 11394 11394 [*] Based on less than 25 unweighted cases and has been suppressed. Table HH.3 provides basic background information on the surveyed households. Within households, the sex of the household head, region, district, area, number of household members, education of household head, and ethnicity4 of the household head are shown in the table. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The head of household is male in 77 percent of surveyed households. The Eastern, Northern, and Southern Provinces and West comprise 27, 33, 24 and 16 percent of the surveyed households, respectively. Sixty-eight percent of surveyed households are located in rural locations while the two most predominant ethnic groups are Mende and Temne which comprise 44 and 34 percent of heads of households, respectively. 4 This was determined by asking the respondent two key questions: (i) what is the mother tongue of the head of this household and (ii) to what ethnic group does the head of this household belong? 11 Table HH.3.1: Household composition Percent distribution of households by selected characteristics, Sierra Leone, 2010 Number of households Weighted percent Weighted Unweighted Households with at least: one child age 0-4 years 55.1 11,394 11,394 Households with at least: one child age 0-17 years 88.1 11,394 11,394 Households with at least: one woman age 15-49 years 82.6 11,394 11,394 Mean household size (persons) 5.9 11,394 11,394 Table HH.3.1 shows the proportions of households with at least one child under 18, at least one child under 5, and at least one eligible woman aged 15-49 years. The table also shows the weighted average household size as estimated by the survey. The table shows that 88 percent of surveyed households had at least one child under 18, 55 percent had at least one child under 5, and at least one eligible woman age 15-49 was found in 83 percent of surveyed households. The mean household size was found to be 5.9 persons. Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal5, since sample weights have been normalized (standardized). 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 found in this report. 5 Any differences are due to rounding errors. 12 Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected characteristics, Sierra Leone, 2010 Weighted percent Number of women Weighted Unweighted Region East 25.9 3459 2831 North 33.9 4531 4435 South 23.5 3137 3359 West 16.7 2232 2734 District Kailahun 8.8 1177 938 Kenema 10.6 1412 1129 Kono 6.5 870 764 Bombali 8.3 1102 927 Kambia 4.3 570 968 Koinadugu 4.5 597 811 Port Loko 9.2 1231 982 Tonkolili 7.7 1031 747 Bo 10.2 1368 1057 Bonthe 4.2 565 858 Moyamba 4.3 569 677 Pujehun 4.7 634 767 Western Rural 2.9 390 799 Western Urban 13.8 1842 1935 Area Urban 34.9 4658 4892 Rural 65.1 8701 8467 Age 15-19 19.1 2549 2611 20-24 16.9 2263 2237 25-29 19.2 2571 2570 30-34 15.6 2086 2026 35-39 15.0 1997 2020 40-44 8.3 1115 1117 45-49 5.8 777 778 Marital/Union status Currently married/in union 67.5 9012 8912 Widowed 2.9 383 381 Divorced .7 92 81 Separated 4.3 576 628 Never married/in union 24.6 3292 3351 Missing * 4 6 Motherhood status Ever gave birth 77.4 10335 10290 Never gave birth 22.6 3024 3069 Births in last two years Had a birth in last two years 25.9 3460 3414 Had no birth in last two years 73.8 9863 9913 Missing (.3) 36 32 Education None 60.7 8108 7958 Primary 13.2 1765 1724 Secondary + 26.1 3486 3677 Total 100.0 13,359 13,359 [*] Based on less than 25 unweighted cases and has been suppressed. 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 region, district, area, age, marital status, motherhood status, births in last two years, education6, and ethnicity. Sixty-eight percent of sampled women are married or in union and 77 percent have given birth to at least one child. Sixty- one percent of MICS4 respondents are uneducated while 13 and 26 percent have completed primary and secondary education, respectively. The large differences between weighted and unweighted numbers for region and district are due to the oversampling of smaller districts as described in Chapter Two. 6 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 13 Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Sierra Leone, 2010 Weighted percent Number of children Weighted Unweighted Sex Male 49.9 4288 4276 Female 50.1 4306 4319 Missing * 4 3 Region East 27.6 2371 1895 North 37.4 3218 3250 South 24.8 2132 2356 West 10.2 877 1097 District Kailahun 9.7 837 654 Kenema 10.6 908 715 Kono 7.3 627 526 Bombali 8.2 705 609 Kambia 5.3 460 778 Koinadugu 4.9 424 595 Port Loko 10.1 873 706 Tonkolili 8.8 757 562 Bo 9.9 851 667 Bonthe 4.8 411 647 Moyamba 5.0 431 518 Pujehun 5.1 440 524 Western Rural 2.7 233 428 Western Urban 7.5 644 669 Area Urban 27.4 2359 2489 Rural 72.6 6240 6109 Age 0-5 9.9 848 831 6-11 11.3 975 987 12-23 17.5 1502 1455 24-35 18.8 1621 1632 36-47 22.9 1970 1978 48-59 19.4 1666 1701 Missing * 16 14 Mother's education None 73.1 6289 6271 Primary 13.2 1133 1089 Secondary 13.7 1176 1238 Wealth index quintiles Poorest 22.7 1951 1983 Second 22.3 1916 1817 Middle 20.7 1783 1721 Fourth 19.5 1677 1678 Richest 14.8 1271 1399 Total 100.0 8598 8598 [*] Based on less than 25 unweighted cases and has been suppressed. Some background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region, district and area, age, mother’s or caretaker’s education, wealth, and ethnicity of household head. 50.1 percent of the children represented in the MICS4 survey are female. The percentage of children aged 0, 1, 2, 3, and 4 years in the sample is 21, 18, 19, 23, and 19, respectively. Only 15 percent of children live in households in the wealthiest quintile while 23 percent of children live in households in the least wealthy quintile. 14 IV. Child Mortality One of the overarching goals among the Millennium Development Goals (MDGs) is the reduction of infant and under-five mortality. Specifically, the MDGs call for a two-thirds reduction in under-five mortality between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. The use of direct techniques to measure child mortality through the collection of birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with estimates obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. Table CM.1: Children ever born, children surviving and proportion dead Mean and total numbers of children ever born, children surviving and proportion dead by age of women, Sierra Leone, 2010 (Total) Mean number of children ever born Total number of children ever born Mean number children surviving Total number of children surviving Proportion dead Number of women Age 15-19 .342 872 .282 718 .185 2549 20-24 1.380 3124 1.143 2587 .178 2263 25-29 2.631 6765 2.108 5418 .199 2571 30-34 3.813 7955 2.966 6189 .223 2086 35-39 4.986 9960 3.772 7535 .244 1997 40-44 5.576 6219 4.052 4519 .273 1115 45-49 5.992 4653 4.395 3413 .266 777 Total 2.960 39547 2.274 30380 .233 13359 The infant mortality rate is defined as the probability of dying before the first birthday. The under- five mortality rate is the probability of dying before the fifth birthday. In MICS surveys, infant and under-five mortality rates are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). The data used in these estimations are the mean number of children ever born for five year age groups of women from age 15 to 49, and the proportion of these children who are dead, also for five-year age groups of women (Table CM.1). The technique converts the proportions dead among children of women in each age group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model of the age pattern of mortality. Based on previous information on mortality in Sierra Leone, the North model life table was selected as most appropriate for MICS4. 15 Table CM.2: Child mortality Infant and under-five mortality rates, Sierra Leone, 2010 Infant Mortality Rate [1] Under- five Mortality Rate [2] Sex Male 137 225 Female 118 206 Region East 133 224 North 129 219 South 133 224 West 92 150 District Kailahun 104 172 Kenema 160 269 Kono 121 202 Bombali 160 269 Kambia 138 233 Koinadugu 106 175 Port Loko 105 173 Tonkolili 135 227 Bo 144 243 Bonthe 99 163 Moyamba 99 163 Pujehun 146 247 Western Rural 83 133 Western Urban 94 153 Area Urban 120 202 Rural 130 220 Mother's education None 128 216 Primary 126 213 Secondary+ 102 168 Wealth index quintiles Poorest 131 221 Second 137 232 Middle 132 222 Fourth 117 196 Richest 110 182 Wealth index quintiles Poorest 60% 133 226 Richest 40% 114 190 Total 128 217 [1] MICS indicator 1.2; MDG indicator 4.2 [2] MICS indicator 1.1; MDG indicator 4.1 Table CM.2 provides estimates of child mortality from MICS4. The infant mortality rate (IMR) is estimated at 128 per thousand live births, while the probability of dying under age 5 (U5MR) is 217 per thousand live births. These estimates have been calculated by averaging mortality estimates obtained from women age 25-29 and 30-34, and refer to mid-2008. The IMR and U5MR are 16 and 9 percent higher, respectively, for males as compared to females. The IMR and U5MR differ little between the Eastern, Southern and Northern provinces, but are approximately 30 percent lower in the West as compared to the other provinces. Mortality rates are lower among the wealthiest 40 percent of the population and among children whose mothers have achieved a secondary education. 16 Differentials in under-5 mortality rates by selected background characteristics are shown in Figure CM.1. 17 Figure CM.2 shows the series of U5MR estimates over time as calculated using MICS4 data. As described above, these estimates are based on responses of women from different age groups and refer to various points in time. These data can thus be used to show the estimated trend in U5MR in Sierra Leone over the past 30 years. Similar data are included from the DHS 2008, MICS2 and MICS3 surveys; it should be noted that the DHS calculates mortality estimates using direct estimation techniques (through the completion of a birth history for each respondent), unlike the MICS surveys. Taken together, these data suggest that the U5MR in Sierra Leone rose gradually until the late 1990s (coinciding with the height of the internal conflict) and have gradually declined since then. Further research is required to interpret trends in infant and child mortality in Sierra Leone and to better understand differences between findings from different studies. 18 V. Nutrition Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered to be 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 and—among those who survive—to suffer from recurring illnesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition are only mildly or moderately malnourished and show no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on new WHO growth standards7. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and/or 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 classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In MICS, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (www.childinfo.org). Findings in this section are based on the results of these measurements. 7 http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf 19 Table NU.1: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Sierra Leone, 2010 Weight for age: Weight for age: Weight for age: Weight for age: Height for age: Height for age: Height for age: Height for age: Weight for height: Weight for height: Weight for height: Weight for height: Weight for height: % below -2 sd [1] % below -3 sd [2] Mean Z-Score (SD) Number of children % below -2 sd [3] % below -3 sd [4] Mean Z-Score (SD) Number of children % below -2 sd [5] % below -3 sd [6] % above +2 sd Mean Z-Score (SD) Number of children Sex Male 23.6 9.3 -1.1 4054 47.2 26.8 -1.8 3854 9.6 3.9 9.4 .0 3953 Female 19.8 7.3 -.9 4046 41.7 21.9 -1.6 3876 7.4 2.5 9.8 .1 3999 Missing . . . 0 . . . 0 . . . . 0 Area Urban 20.1 8.7 -.9 2211 40.9 22.2 -1.6 2110 9.6 3.5 10.4 .1 2136 Rural 22.3 8.2 -1.1 5889 45.7 25.2 -1.8 5620 8.1 3.1 9.3 .1 5816 Region East 22.0 8.8 -1.1 2199 41.5 21.5 -1.7 2068 7.9 3.2 7.3 .1 2167 North 24.6 9.2 -1.1 3040 48.6 28.5 -1.9 2930 9.6 3.7 9.5 .0 3065 South 18.6 6.5 -.9 2046 42.7 22.3 -1.7 1944 6.7 2.5 10.3 .1 1961 West 17.7 8.2 -.8 816 40.4 21.4 -1.5 788 10.1 3.1 14.9 .2 759 District Kailahun 22.0 8.3 -1.1 789 39.5 20.1 -1.7 758 8.6 3.1 5.7 -.1 767 Kenema 22.1 8.8 -1.2 863 46.3 23.6 -1.8 816 6.7 2.8 7.3 .1 855 Kono 21.8 9.4 -1.0 548 36.6 20.1 -1.4 494 8.7 3.9 9.5 .2 545 Bombali 19.4 7.2 -1.0 646 46.7 24.4 -1.7 619 8.5 3.3 9.5 .1 661 Kambia 24.9 7.6 -1.2 426 45.3 22.2 -1.7 411 7.5 2.3 5.8 -.1 439 Koinadugu 16.5 7.1 -.8 404 50.8 29.3 -1.9 381 5.0 1.6 21.1 .7 397 Port Loko 31.5 12.2 -1.3 839 50.6 32.4 -2.0 828 13.2 5.8 8.1 -.2 853 Tonkolili 25.6 9.7 -1.3 725 48.9 31.0 -1.9 691 10.3 3.3 6.8 -.1 715 Bo 18.4 5.9 -.9 811 37.9 17.3 -1.5 790 4.8 1.0 3.6 -.1 792 Bonthe 15.9 5.9 -.6 401 50.4 29.8 -2.0 364 5.8 2.1 21.1 .7 364 Moyamba 24.2 8.9 -1.0 406 43.5 25.6 -1.7 393 12.2 6.8 11.3 .0 404 Pujehun 16.0 6.1 -.9 428 44.4 22.3 -1.7 397 5.9 1.3 12.8 .1 402 Western Rural 27.9 15.3 -1.2 226 56.7 31.9 -2.2 221 11.4 6.3 19.4 .2 220 Western Urban 13.7 5.5 -.7 590 34.1 17.4 -1.3 567 9.5 1.9 13.1 .2 539 Age 0-5 12.3 4.6 -.4 795 21.2 9.5 -.6 743 10.9 4.1 12.0 .0 719 6-11 24.1 9.7 -1.0 936 24.6 13.1 -.9 881 16.5 5.0 7.8 -.4 888 12-23 25.0 9.9 -1.0 1454 43.7 25.2 -1.6 1374 12.6 4.4 7.9 -.2 1403 24-35 22.0 8.5 -1.0 1543 51.5 29.1 -2.1 1478 6.0 2.7 9.5 .2 1522 36-47 21.0 8.1 -1.1 1838 52.8 29.8 -2.1 1773 5.2 1.8 9.7 .3 1846 48-59 22.3 8.0 -1.2 1534 51.3 26.7 -2.1 1481 5.5 2.7 11.0 .2 1560 Missing . . . 0 . . . 0 * * * .6 16 Mother's education None 22.6 8.4 -1.1 5911 46.5 25.7 -1.8 5645 8.6 3.3 9.9 .1 5850 Primary 19.2 8.4 -.9 1080 40.3 22.9 -1.6 1024 8.1 2.8 8.3 .1 1034 Secondary 19.3 7.6 -.9 1108 37.3 18.6 -1.5 1061 8.0 3.2 9.3 .1 1067 Wealth index quintiles Poorest 21.5 8.6 -1.0 1837 46.8 28.1 -1.8 1725 8.3 3.4 11.4 .1 1788 Second 24.8 9.0 -1.2 1817 48.9 28.4 -2.0 1744 8.3 2.8 9.2 .1 1804 Middle 24.4 9.6 -1.1 1696 47.8 25.8 -1.9 1612 9.1 3.3 8.9 .0 1669 Fourth 20.4 7.3 -1.0 1565 41.5 20.6 -1.6 1520 7.8 3.0 7.1 .0 1561 Richest 14.9 6.3 -.7 1185 32.8 15.4 -1.3 1129 9.0 3.5 11.9 .1 1130 Total 21.7 8.3 -1.0 8100 44.4 24.4 -1.7 7730 8.5 3.2 9.6 .1 7952 [1] MICS indicator 2.1a and MDG indicator 1.8 [2] MICS indicator 2.1b [3] MICS indicator 2.2a, [4] MICS indicator 2.2b [5] MICS indicator 2.3a, [6] MICS indicator 2.3b [*] Based on less than 25 unweighted cases and has been suppressed. 20 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 greater than 2 standard deviations from the median of the reference population. Children whose full birth date (month and year) was not obtained and children whose measurements are outside a plausible range are excluded from Table NU.1. Children are excluded from one or more of the anthropometric indicators—whichever is applicable—when their weights and heights have not been measured. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality tables DQ.6 and DQ.7 (Appendix D). Overall 98.1 percent of children had both their weights and heights measured (Table DQ.6). This compares favourably with other surveys that were conducted in Sierra Leone; for example, in the DHS 2008 survey, 94.8 percent of children had both height and weight measured. Table DQ.7 shows that due to incomplete dates of birth, implausible measurements, and missing weight and/or height, 5.7 percent of children have been excluded from calculations of the weight-for-age indicator, while the figures are 10.0 percent for the height-for-age indicator, and 10.0 percent for the weight-for-height indicator. Almost one in four children under the age of five in Sierra Leone is moderately or severely underweight (22 percent) and eight percent are classified as severely underweight (Table NU.1). Almost one in two children (44 percent) is moderately or severely stunted (i.e., too short for his age) and eight percent are moderately or severely wasted (i.e., too thin for their height). Children in the Northern Province are more likely to be malnourished than children from other regions. Those children whose mothers have secondary or higher education are generally less likely to be malnourished compared to children of mothers with only primary or no education. Boys are 21 more likely to be underweight, stunted, and wasted than girls. The age pattern shows that the highest levels of wasting are found among children aged 6-11 months, the highest levels of underweight exist in children aged 12-23 months, while the highest levels of stunting are found among children aged 36-47 months (Figure NU.1). It is not unusual for levels of malnutrition to rise among children above five months of age; this pattern is expected and is related to the age at which the recommended introduction of complementary (solid, semi-solid or soft) foods begins. The food that is given to the infant is often inadequate in terms of quality (dietary diversity, minimum acceptable diet) and quantity (frequency) and the infant can be exposed to contamination as a result of poor food hygiene practices; all of these issues can result in malnutrition. However, the peaking of wasting and near-peaking of underweight among children aged 6-11 months is unusual and of significant concern and is supported by the finding (reported below) of extremely low levels of consumption of solid, semi-solid or soft foods among children aged 6-8 months. Levels of wasting are relatively equal across children from all wealth quintiles while lower levels of stunting and underweight are prevalent among children from the wealthiest 40 percent of households. Discussion: Nutritional status of children MICS data were collected at the end of the monsoon in the so-called “hungry season” in Sierra Leone; this may partially explain the high levels of wasting and underweight, both of which are affected by acute malnutrition. Child malnutrition is recognized by the government of Sierra Leone as a serious problem that requires a multi-sectoral response; the REACH (Renewed Effort Against Child Hunger—Ending Child Hunger and Under-Nutrition) initiative is an example of a current inter- sectoral effort to reduce nutritional deficiencies. National nutrition policy is being revised to include high-impact interventions and to intensify efforts in the area of infant and young-child feeding (IYCF). Community-Based Management of Acute Malnutrition (CMAM) activities have been introduced in Peripheral Health Units (PHU) for children with severe acute malnutrition. Recent data show that coverage of CMAM activities was not as high as originally thought and efforts are being intensified to improve quality and increase coverage of the intervention. Policy makers and program managers are also working to develop a response to the high level of children with moderate malnutrition. Breastfeeding and Infant and Young Child Feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon; there are often pressures to introduce other liquids and soft foods, and also to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at 6 months • Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds It is also recommended that breastfeeding be initiated within one hour of birth. The MICS4 indicators that are related to recommended child feeding practices are as follows: • Early initiation of breastfeeding (within 1 hour of birth) • Exclusive breastfeeding rate (< 6 months) 22 • Predominant breastfeeding (< 6 months) • Continued breastfeeding rate (at 1 year and at 2 years) • Duration of breastfeeding • Age-appropriate breastfeeding (0-23 months) • Introduction of solid, semi-solid and soft foods (6-8 months) • Minimum meal frequency (6-23 months) • Milk feeding frequency for non-breastfeeding children (6-23 months) • Bottle feeding (0-23 months) Table NU.2 describes the proportion of children born in the last two years who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a pre- lacteal feed. Ninety-five percent of children have been breastfed and this percentage is similarly high across all strata. Initiating breastfeeding as soon as possible after birth is a very important step in the management of lactation and the establishment of a physical and emotional relationship between the baby and mother and is also an important method for controlling the newborn’s temperature and preventing hypothermia, especially for the low birth weight babies. However, only 45 percent of babies in Sierra Leone are breastfed for the first time within one hour of birth, while 86 percent of newborns start breastfeeding within one day of birth. The timely initiation of breastfeeding is higher in the Northern Province as compared to other provinces (Figure NU.2); lower maternal educational levels and rural location are also associated with higher levels of timely initiation. This indicator demonstrates an increasing trend as evidenced by the comparison of timely initiation of breastfeeding among children aged 0-11 months versus those aged 12-23 months. Table NU.2: Initial breastfeeding Percentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a pre-lacteal feed, Sierra Leone, 2010 Percentage ever breastfed [1] Percentage who were first breastfed: Within one hour of birth [2] Percentage who were first breastfed: Within one day of birth Percentage who received a pre- lacteal feed Number of last- born children in the two years preceding the survey Region East 95.1 42.2 85.4 13.7 1005 North 96.4 49.8 87.0 31.2 1219 South 93.6 40.7 86.1 21.5 885 West 92.7 42.8 82.2 49.2 351 Area Urban 92.9 38.9 83.0 33.1 970 Rural 95.7 46.8 86.9 22.5 2491 Months since last birth 0-11 months 95.7 45.7 86.4 23.1 1815 12-23 months 94.6 43.0 85.4 28.6 1523 Assistance at delivery Skilled attendant 95.4 46.5 86.6 23.5 2164 Traditional birth attendant 97.4 42.7 87.4 30.0 1239 Other/Missing 25.9 11.7 20.6 2.7 58 Place of delivery Public sector health facility 96.0 48.0 87.5 20.3 1615 Private sector health facility 88.3 28.1 73.3 35.0 119 Home 97.1 44.1 87.7 30.6 1658 Other/Missing 27.2 4.9 21.5 6.0 68 Mother’s education None 96.1 46.5 87.4 24.9 2345 Primary 94.9 41.2 84.8 27.7 511 Secondary + 90.6 39.8 80.5 26.0 604 Wealth index quintiles Poorest 96.2 42.2 87.9 29.3 756 Second 96.7 49.5 88.0 22.6 752 Middle 93.6 45.5 84.9 19.4 762 Fourth 94.6 42.2 85.3 22.4 663 Richest 93.1 42.5 81.7 36.7 527 Total 94.9 44.6 85.8 25.5 3460 [1] MICS indicator 2.4 [2] MICS indicator 2.5 23 Twenty-six percent of children are given something other than breast milk to eat or drink during the first three days of life (i.e., were given a pre-lacteal feed); although this indicator is undesirably high it is decreasing with age as shown by the comparison of children aged 0-11 and 12-23 months. Higher levels of this indicator are associated with living in the Northern Province or West, urban location, and living in a household in the poorest or richest quintiles. It appears that private sector facilities are not effectively promoting good breastfeeding practices, as the level of all indicators related to breastfeeding is better in public sector facilities as compared to private facilities. Indicators of breastfeeding status that are reported in Table NU.3 are based on the reports of mothers/caretakers regarding children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table displays estimates of rates of exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12-15 and 20-23 months of age. 24 Table NU.3: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Sierra Leone, 2010 Children 0-5 months Children 12-15 months Children 20-23 months Percent exclusively breastfed [1] Percent predomina ntly breastfed [2] Number of children Percent breastfed (Continued breast feeding at 1 year) [3] Number of children Percent breastfed (Continued breast feeding at 2 years) [4] Number of children Sex Male 31.4 71.6 440 87.0 236 55.5 244 Female 32.0 74.6 407 80.9 250 40.3 227 Missing * * 1 . 0 . 0 Region East 42.3 77.3 290 81.5 136 57.1 134 North 29.7 75.8 300 90.2 163 61.8 169 South 27.6 70.0 189 82.7 127 29.8 123 West 6.1 50.6 69 74.3 60 (20.9) 46 District Kailahun 40.0 80.9 97 (80.8) 49 (59.5) 49 Kenema 37.1 70.8 116 73.1 57 (52.6) 49 Kono 53.1 82.6 77 (98.1) 31 (60.1) 36 Bombali 42.2 72.2 76 (95.6) 37 (56.3) 29 Kambia (17.8) (84.7) 41 * 18 * 19 Koinadugu (30.8) (84.9) 27 * 18 * 16 Port Loko 16.4 84.7 78 (92.9) 44 61.9 50 Tonkolili 36.7 62.4 78 (87.3) 47 59.1 54 Bo 23.7 66.9 83 88.4 61 (22.6) 47 Bonthe (31.7) (74.5) 32 * 23 (32.7) 28 Moyamba (30.5) (73.0) 42 (85.8) 27 * 24 Pujehun (29.9) (69.5) 32 * 16 * 24 Western Rural * * 15 * 14 * 9 Western Urban 5.4 49.1 54 (69.7) 47 (15.6) (37) Area Urban 27.3 64.7 222 82.3 141 38.7 135 Rural 33.2 75.9 625 84.5 346 52.0 337 Mother's education None 31.6 75.7 592 82.8 334 52.1 327 Primary 33.0 71.6 121 87.8 78 52.2 61 Secondary 30.5 62.0 134 84.7 75 29.9 83 Wealth index quintiles Poorest 26.7 75.3 197 84.6 108 56.4 87 Second 40.8 82.6 183 84.3 112 55.3 129 Middle 36.8 77.6 183 84.5 81 54.6 115 Fourth 31.9 69.7 172 88.2 112 42.7 78 Richest 16.8 50.9 113 74.8 73 16.9 62 Total 31.6 73.0 848 83.9 486 48.2 471 [1] MICS indicator 2.6 [2] MICS indicator 2.9 [3] MICS indicator 2.7 [4] MICS indicator 2.8 [*] Based on less than 25 unweighted cases and has been suppressed. Approximately 32 percent of children aged less than six months are exclusively breastfed. By age 12- 15 months, 84 percent of children are still being breastfed and by age 20-23 months, 48 percent are still breastfed. Girls and boys are equally likely to be exclusively breastfed. Rates of exclusive breastfeeding are highest in the Eastern Province and lowest in the West, moderately higher in rural locations, and highest among mid-level wealth quintiles. In contrast, rates of continued breastfeeding are high in the Northern Province and lowest in the West, generally higher among less wealthy households, and—specifically for continued breastfeeding at two years of age—higher in rural locations and among children of mothers with lower educational levels. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is below eleven percent. Only about 38 percent of children are receiving breast milk after 2 years. 25 0% 20% 40% 60% 80% 100% 0 -1 2 -3 4 -5 6 -7 8 -9 1 0 -1 1 1 2 -1 3 1 4 -1 5 1 6 -1 7 1 8 -1 9 2 0 -2 1 2 2 -2 3 Age in months Figure NU 3. Percent distribution of children under age 2 by feeding pattern by age group, Sierra Leone, 2010 Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk/ formula Breastfed and other foods Not breastfed Table NU.4 shows the median duration of breastfeeding by selected background characteristics. Among children under the age of three years, the median duration is 21.0 months for any breastfeeding, 0.7 months for exclusive breastfeeding, and 5.5 months for predominant breastfeeding. While the median duration of exclusive breastfeeding is higher in the Eastern Province, the duration of predominant breastfeeding is higher in the Northern Province. As noted above for other breastfeeding-related indicators, desired practices are generally higher in rural locations, among children of mothers with lower educational levels, and among less wealthy households. 26 Table NU.4: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Sierra Leone, 2010 Median duration (in months) of Number of children age 0-35 months Any breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Sex Male 21.8 .7 5.3 2464 Female 20.4 .6 5.8 2480 Region East 21.6 1.9 5.8 1422 North 22.3 .6 7.6 1795 South 19.3 .6 5.0 1224 West 17.6 .4 2.6 505 District Kailahun 21.5 1.9 5.9 511 Kenema 21.4 1.3 5.2 554 Kono 22.3 2.9 6.4 358 Bombali 21.6 1.6 6.7 389 Kambia 23.0 .5 7.7 265 Koinadugu 23.0 .6 7.9 201 Port Loko 22.4 .5 11.6 520 Tonkolili 22.9 .9 6.5 421 Bo 19.3 .5 4.7 520 Bonthe 15.4 1.1 6.4 222 Moyamba 20.2 .6 4.8 256 Pujehun 19.4 1.2 5.0 226 Western Rural 19.8 . 3.2 116 Western Urban 16.8 .4 2.4 390 Area Urban 19.7 .6 4.2 1388 Rural 21.4 .7 6.0 3558 Mother's education None 21.4 .6 6.1 3509 Primary 21.4 1.1 4.9 677 Secondary+ 18.4 .7 4.0 759 Wealth index quintile Poorest 21.7 .6 7.1 1063 Second 21.5 1.7 6.9 1089 Middle 21.7 .7 5.7 1046 Fourth 20.6 .7 5.4 987 Richest 17.7 .5 2.6 761 Median 21.0 .7 5.5 4946 Mean for all children (0-35 months) 20.4 2.4 7.6 4946 [1] MICS indicator 2.10 The level of appropriate feeding of children less than 24 months of age is provided in Table NU.5. Different criteria of appropriate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as appropriate feeding, while infants aged 6-23 months are considered to be appropriately fed if they are receiving breast milk and solid, semi-solid or soft food. Overall, 40 percent of children aged 0-23 months are appropriately breastfed. Among these children, 42 percent of those aged 6-23 months are being appropriately fed while 32 percent of infants aged 0-5 months are appropriately fed. Background variables that are associated with the practice of exclusive breastfeeding have been described above and mirror the associations with appropriate breastfeeding; correct practices are highest in the Eastern Province, in rural locations, among mothers with lower levels of education, and among less wealthy households. 27 Table NU.5: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Sierra Leone, 2010 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed [1] Number of children Percent currently breastfeeding and receiving solid, semi-solid or soft foods Number of children Percent appropriately breastfed [2] Number of children Sex Male 31.3 440 44.2 1229 40.8 1670 Female 31.9 407 40.4 1246 38.3 1654 Missing * 1 * 1 * 1 Region East 42.4 287 48.9 672 47.0 958 North 29.7 302 40.1 882 37.5 1185 South 27.3 190 41.0 640 37.9 830 West 6.1 69 36.1 283 30.2 352 District Kailahun 40.2 97 49.6 229 46.8 326 Kenema 37.1 114 47.5 268 44.4 383 Kono 53.1 76 50.2 174 51.1 250 Bombali 42.1 76 44.8 172 44.0 248 Kambia (17.8) 40 40.7 132 35.4 172 Koinadugu * 28 47.2 92 43.4 120 Port Loko 16.4 79 37.2 275 32.6 353 Tonkolili 36.7 80 36.6 212 36.6 292 Bo 23.7 83 48.4 264 42.5 347 Bonthe (30.0) 34 24.3 122 25.5 155 Moyamba (30.5) 41 37.0 140 35.5 181 Pujehun (29.9) 33 46.8 114 43.0 147 Western Rural * 15 36.7 60 31.2 75 Western Urban 5.4 54 35.9 223 29.9 277 Area Urban 27.2 223 38.1 713 35.5 935 Rural 33.1 626 44.0 1764 41.1 2390 Mother's education None 31.5 594 43.7 1698 40.6 2291 Primary 32.9 121 41.4 378 39.3 498 Secondary 30.5 134 37.0 402 35.4 536 Wealth index quintiles Poorest 26.6 197 43.0 522 38.5 719 Second 41.1 182 41.8 555 41.6 737 Middle 36.3 184 44.8 532 42.6 716 Fourth 31.7 172 45.9 470 42.1 642 Richest 16.7 113 34.5 398 30.6 511 Total 31.5 848 42.3 2477 39.5 3325 [1] MICS indicator 2.6 [2] MICS indicator 2.14 [*] Based on less than 25 unweighted cases and has been suppressed. Adequate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and the prevention of under-nutrition. Continued breastfeeding beyond six months should be accompanied by the consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breast milk is no longer sufficient. Children who are breastfed should receive two or more meals per day of solid, semi-solid or soft foods if they are 6-8 months old and three or more meals if they are 9-23 months of age. Children who are not breastfed and who are aged between 6-23 months require four or more meals daily of solid, semi-solid or soft foods or milk feeds. 28 Overall, 25 percent of infants aged 6-8 months receive solid, semi-solid, or soft foods (Table NU.6). Twenty-four percent of currently breastfeeding infants receive solid, semi-solid, or soft foods while 78 percent of infants who are not currently breastfeeding receive them. There are no meaningful associations between the level of this indicator among breastfeeding children and location. The sample size of children who are not currently breastfeeding is too small to make any statements about associations with location. Table NU.6: Introduction of solid, semi-solid or soft food Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day, Sierra Leone, 2010 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6- 8 months Percent receiving solid, semi-solid or soft foods Number of children age 6- 8 months Percent receiving solid, semi-solid or soft foods [1] Number of children age 6- 8 months Sex Male 25.2 241 * 4 26.1 247 Female 22.9 229 * 7 24.1 240 Area Urban 24.0 115 * 4 24.6 123 Rural 24.1 354 * 8 25.2 364 Total 24.1 470 * 12 25.1 487 [*] Based on less than 25 unweighted cases and has been suppressed. Table NU.7 presents the proportion of children aged 6-23 months who received semi-solid or soft foods the minimum number of times or more during the previous day according to breastfeeding status (see the note in Table NU.7 for a definition of minimum number of times for different age groups). Overall, only one in five children aged 6-23 months (20 percent) receive solid, semi-solid and soft foods the minimum number of times. The level of this indicator varies little among children who are currently breastfeeding and those who are not breastfeeding. Among children currently breastfeeding, the percentage that receives at least minimum amounts of supplementary food is low across all strata although it is somewhat higher among older children and in the Southern Province. Among children who are not currently breastfeeding, the percentage that at least receives minimum amounts is highest among younger children, among children in the West and in urban locations, among children whose mothers are more highly educated, and among children residing in wealthier households. 29 Table NU.7: Minimum meal frequency Percentage of children aged 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Sierra Leone, 2010 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds [1] Percent receiving solid, semi-solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal frequency [2] Number of children age 6-23 months Sex Male 20.7 994 19.2 22.0 235 21.0 1229 Female 19.2 946 16.8 19.4 301 19.3 1246 Missing * 1 . . 0 * 1 Age 6-8 months 16.3 470 50.1 * 17 17.1 487 9-11 months 11.3 446 26.6 (23.5) 42 12.3 488 12-17 months 24.3 609 17.5 19.4 139 23.4 748 18-23 months 27.2 416 15.2 19.7 338 23.8 754 Region East 22.4 537 11.0 11.4 135 20.2 672 North 13.5 744 9.1 19.9 139 14.5 882 South 28.2 471 9.1 13.6 169 24.3 640 West 18.3 190 56.4 47.4 93 27.9 283 District Kailahun 22.9 177 4.0 2.2 52 18.1 229 Kenema 29.2 217 8.0 12.2 51 26.0 268 Kono 11.4 143 27.6 (25.3) 31 13.9 174 Bombali 7.9 147 7.1 (11.4) 25 8.4 172 Kambia 11.0 118 19.3 * 14 11.6 132 Koinadugu 10.3 76 9.8 * 16 13.3 92 Port Loko 17.5 238 6.0 (25.8) 37 18.6 275 Tonkolili 15.9 165 9.3 (18.1) 48 16.4 212 Bo 31.9 198 21.1 31.3 66 31.7 264 Bonthe 12.6 76 3.0 (3.0) 46 9.0 122 Moyamba 24.4 114 .0 (3.2) 26 20.4 140 Pujehun 38.7 83 .0 (.0) 31 28.2 114 Western Rural (14.9) 48 26.2 * 13 15.6 60 Western Urban 19.4 142 61.3 52.1 80 31.2 223 Area Urban 18.5 518 36.8 37.1 194 23.6 713 Rural 20.5 1423 7.0 11.1 341 18.7 1764 Mother's education None 20.6 1359 9.1 13.2 339 19.1 1698 Primary 17.6 304 17.3 19.9 74 18.0 378 Secondary 19.8 279 42.1 41.2 123 26.3 402 Wealth index quintiles Poorest 20.8 434 .0 1.4 89 17.5 522 Second 18.4 440 5.3 13.1 115 17.3 555 Middle 21.3 430 8.5 15.1 102 20.1 532 Fourth 20.5 369 7.7 15.7 101 19.5 470 Richest 18.4 268 56.2 48.3 130 28.2 398 Total 20.0 1941 17.8 20.5 536 20.1 2477 [1] MICS indicator 2.15 [2] MICS indicator 2.13 [*] Based on less than 25 unweighted cases and has been suppressed. 30 The continued practice of bottle-feeding children is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.8 shows that bottle-feeding is moderately prevalent in Sierra Leone. Twelve percent of children aged less than six months are fed using a bottle with a nipple while ten percent of children aged 0-23 months are fed using a bottle with a nipple. Levels of bottle-feeding are highest among children aged 6-11 months, children living in urban locations and in the West, among children whose mothers are more highly educated, and among children residing in wealthier households. Table NU.8: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Sierra Leone, 2010 Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months: Sex Male 10.8 1670 Female 10.2 1654 Missing * 2 Age 0-5 months 12.3 848 6-11 months 16.2 975 12-23 months 5.7 1502 Region East 4.2 958 North 8.1 1185 South 8.0 830 West 41.5 352 District Kailahun 6.3 326 Kenema 3.0 383 Kono 3.3 250 Bombali 3.7 248 Kambia 5.6 172 Koinadugu 7.2 120 Port Loko 15.8 353 Tonkolili 4.3 292 Bo 11.3 347 Bonthe 6.3 155 Moyamba 7.2 181 Pujehun 3.1 147 Western Rural 21.9 75 Western Urban 46.8 277 Area Urban 20.7 935 Rural 6.5 2390 Mother's education None 7.6 2291 Primary 10.5 498 Secondary 22.8 536 Wealth index quintiles Poorest 3.8 719 Second 5.7 737 Middle 5.2 716 Fourth 9.9 642 Richest 35.0 511 Total 10.5 3325 [1] MICS indicator 2.11 31 Discussion: Breastfeeding and infant and young child feeding There has been a major national-level effort from 2008 to 2010 to increase levels of exclusive breastfeeding. Much of the effort has been made through community-based mother-to-mother support groups. While the results presented above suggest that these efforts have achieved positive results, the extremely low levels of introduction of foods to children aged 6-8 months suggests that messages on exclusive breastfeeding may have crowded out messages on the introduction of foods to children above the age of six months, resulting in low levels of complementary feeding. A general trend that is seen across most of the IYCF indicators presented above is higher levels of correct feeding practice among rural populations, less-wealthy households and among children of women with lower educational levels. A national strategy for infant and young child feeding (IYCF) is currently being developed. This strategy will provide clear guidelines for nutrition programming and guide the effort to train 2700 counselors for community-level counseling on IYCF. Health facility staff will also be trained as part of this effort. A policy to prevent the harmful promotion of breast milk substitutes is also under development. Salt Iodization Iodine Deficiency Disorder (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability and impaired work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In Sierra Leone, concerted efforts to increase the use and consumption of iodized salt began in 2003- 04. Challenges to the achievement of universal salt iodization include the local production and high utilization of non-iodized salt in some districts, difficulties monitoring the import of non-iodized salt from neighbouring countries, and a weak national monitoring and surveillance system. Current activities to strengthen the national salt iodization program include the conduct of ongoing assessments of the prevalence of iodized salt in markets and households, strengthened monitoring of the iodization status of imported salt, sensitizing the population regarding the importance of consuming iodized salt, and the development of a national policy on salt iodization by the Sierra Leone Standards Bureau. Salt used for cooking was tested for iodine content in about 92 percent of surveyed households by using salt test kits. The table above shows that salt was found to be adequately iodized for household consumption in 63 percent of households. Use of iodized salt was lowest in the Northern Province (54 percent) and highest in the Eastern Province (75 percent). There was little difference between urban and rural areas in the percentage of households found to be using adequately iodized salt (Figure NU.4). The districts of Kambia (6 percent), Port Loko (21 percent), Moyamba (35 percent) and Western Rural (33 percent) stood out for the low levels of consumption of iodized salt. There was a ten percent difference between the richest and poorest households (66 percent versus 56 percent, respectively) in terms of iodized salt consumption. 32 Table NU.9: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Sierra Leone, 2010 Percent of households in which salt was tested Number of households Percent of households with no salt Percent of households with salt test result Total Number of households in which salt was tested or with no salt Not iodized 0 PPM >0 and <15 PPM 15+ PPM [1] Region East 89.9 3072 8.2 2.9 14.3 74.7 100.0 3008 North 95.3 3761 3.5 30.2 12.3 54.0 100.0 3714 South 92.1 2760 5.8 14.7 13.4 66.0 100.0 2698 West 86.6 1801 11.6 12.0 21.3 55.0 100.0 1765 District Kailahun 93.7 991 4.6 1.8 7.4 86.1 100.0 974 Kenema 87.4 1287 10.9 3.0 17.4 68.7 100.0 1264 Kono 89.1 793 8.3 4.0 17.8 69.9 100.0 770 Bombali 93.9 849 3.6 3.1 7.6 85.7 100.0 828 Kambia 91.0 411 8.5 83.6 2.3 5.6 100.0 409 Koinadugu 96.4 517 2.1 31.5 5.3 61.1 100.0 509 Port Loko 96.7 971 2.5 56.6 19.8 21.1 100.0 963 Tonkolili 96.4 1013 2.8 4.9 16.7 75.6 100.0 1005 Bo 90.2 1100 7.3 2.0 17.5 73.2 100.0 1070 Bonthe 96.2 466 1.7 26.4 9.5 62.5 100.0 455 Moyamba 89.5 569 10.3 43.5 11.5 34.8 100.0 567 Pujehun 94.7 625 2.2 1.4 10.9 85.5 100.0 606 Western Rural 93.2 355 5.5 39.3 21.9 33.3 100.0 350 Western Urban 85.0 1447 13.1 5.3 21.2 60.4 100.0 1416 Area Urban 89.6 3608 8.7 11.3 16.6 63.4 100.0 3540 Rural 92.7 7786 5.6 18.5 13.6 62.3 100.0 7645 Wealth index quintiles Poorest 93.0 2481 5.3 24.3 13.8 56.6 100.0 2435 Second 92.5 2322 5.3 17.8 14.3 62.6 100.0 2268 Middle 91.7 2180 6.8 18.1 11.4 63.8 100.0 2143 Fourth 92.8 2088 5.7 14.7 15.3 64.3 100.0 2055 Richest 88.6 2323 9.9 5.8 17.8 66.5 100.0 2285 Total 91.7 11394 6.6 16.3 14.5 62.6 100.0 11185 [1] MICS indicator 2.16 33 Children’s Vitamin A Supplementation Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as by increased losses of vitamin A reserves during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted to all children between the ages of six to 59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programs, the definition of the indicator is the percentage of children 6-59 months of age receiving at least one high-dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Sierra Leone Ministry of Health recommends that children aged 6-59 months be given a high-dose vitamin A capsule every 6 months. In some parts of the country, Vitamin A capsules are linked to immunization services and are given when the child has contact with these services after six months of age. It is also recommended that mothers take a Vitamin A supplement within eight weeks of giving birth due to increased Vitamin A requirements during pregnancy and lactation. Within the six months prior to the MICS, 91 percent of children aged 6-59 months received a high dose Vitamin A supplement (Table NU.10). Vitamin A supplementation coverage is moderately lower in the Southern Province as compared to other regions; Moyamba (80 percent) and Pujehun (86 percent) are the districts with the lowest levels of supplementation. The age pattern of Vitamin A supplementation shows that supplementation in the last six months rises from 76 percent among children aged 6-11 months to 91 percent among children aged 12-23 months and then maintains that level among older children. Gender, location, mother’s education and household wealth status are not associated with supplementation levels. 34 Table NU.10: Children's vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Sierra Leone, 2010 Percentage who received Vitamin A according to: Percentage of children who received Vitamin A during the last 6 months [1] Number of children age 6-59 months Child health book / card / vaccination card Mother's report Sex Male 4.1 90.0 90.1 3840 Female 4.2 90.9 91.1 3891 Missing * * * 3 Region East 7.6 92.1 92.4 2075 North 1.7 91.0 91.2 2909 South 4.6 86.9 87.0 1942 West 2.6 92.5 92.6 807 District Kailahun 14.8 94.6 95.0 740 Kenema 5.7 91.5 91.8 789 Kono .6 89.6 89.7 546 Bombali 3.7 88.2 89.2 627 Kambia .4 92.5 92.5 420 Koinadugu .1 91.8 91.8 396 Port Loko 1.4 91.9 91.9 793 Tonkolili 2.1 91.0 91.0 674 Bo 4.8 89.6 89.6 768 Bonthe 4.7 90.4 90.4 377 Moyamba 4.3 79.7 79.9 390 Pujehun 4.3 85.6 85.8 407 Western Rural 2.1 93.0 93.0 218 Western Urban 2.8 92.3 92.5 589 Area Urban 3.7 91.1 91.3 2132 Rural 4.3 90.2 90.3 5601 Age in Months 6-11 8.3 75.4 76.0 975 12-23 10.3 90.4 91.0 1502 24-35 2.6 92.6 92.8 1621 36-47 1.2 93.9 93.9 1970 48-59 1.0 92.9 92.9 1666 Mother's education None 3.9 90.0 90.2 5682 Primary 4.5 91.6 91.7 1010 Secondary 4.9 91.3 91.6 1042 Wealth index quintiles Poorest 3.9 88.0 88.1 1750 Second 4.4 89.7 90.0 1731 Middle 4.2 90.5 90.8 1595 Fourth 4.7 92.3 92.5 1501 Richest 3.0 92.5 92.6 1157 Total 4.1 90.4 90.6 7734 [1] MICS indicator 2.17 [*] Based on less than 25 unweighted cases and has been suppressed. 35 Low Birth Weight Weight at birth is a good indicator of both a mother's health and nutritional status and also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have the highest impact: the mother's poor nutritional status before conception, short stature (due mostly to under-nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. 36 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. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of new-borns are not delivered in facilities, and those who are usually represent a highly selective sample of all births. Because many infants are not weighed at birth and those who are weighed may represent a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth8 . Overall, 40 percent of newborns were weighed at birth and approximately ten percent of newborns are estimated to have weighed less than 2500 grams at birth (Table NU.11). The percentage of low birth weight infants varies little across regions (Figure NU.5) or by any of the other background variables. Table NU.11: Low birth weight infants Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Sierra Leone, 2010 Percent of live births: Number of live births in the last 2 years Below 2500 grams [1] Weighed at birth [2] Region East 11.5 46.8 993 North 10.2 27.9 1230 South 10.5 42.8 885 West 8.8 54.3 353 Area Urban 9.8 42.5 971 Rural 10.8 38.8 2491 Education None 10.4 36.7 2348 Primary 10.8 44.8 511 Secondary + 10.4 47.8 603 Wealth index quintiles Poorest 10.7 32.3 757 Second 11.6 37.1 750 Middle 10.5 39.8 765 Fourth 10.0 41.8 663 Richest 9.1 52.3 526 Total 10.5 39.9 3462 [1] MICS indicator 2.18 [2] MICS indicator 2.19 8 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 37 VI. Child Health Vaccinations The Millennium Development Goal 4 (MDG4) is to reduce child mortality by two-thirds between 1990 and 2015. Immunization plays a key part in achieving 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 overlooked by routine immunization; as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of 90 percent of children under one year of age at the national level, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, 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) along with the Hepatitis B, Hib and yellow fever vaccines and together form the country’s basic EPI package. DPT, Hepatitis B and the Hib vaccines are delivered together through the “penta” combination vaccine. The vaccine schedule in Sierra Leone is described in the chart below. CHART: EPI PACKAGE AND SCHEDULE IN SIERRA LEONE Vaccine Age at vaccination BCG At birth OPV 0 At birth OPV1 & Penta-1 (DPT1 / HepB1 and Hib1) 6 weeks after birth OPV2 & Penta-2 (DPT2 / HepB2 and Hib2) 10 weeks after birth OPV3 & Penta-3 (DPT3 / HepB3 and Hib3) 14 weeks after birth Measles 9 months after birth Yellow fever 9 months after birth During the MICS4 survey, mothers / caretakers were asked to provide vaccination cards for their children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. If the child did not have a card, the mother / caretaker was asked to recall whether or not the child had received each of the vaccinations and, for DPT, polio, Hepatitis B and Penta, how many times. 38 Table CH.1: Vaccinations in first year of life Percentage of children age 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, Sierra Leone, 2010 Vaccinated at any time before the survey according to: Vaccination card Vaccinated at any time before the survey according to: Mother's report Vaccinated at any time before the survey according to: Either Vaccinated by 12 months of age BCG [1] 66.9 28.6 95.5 94.8 Polio 0 66.3 19.9 86.2 85.6 Polio 1 60.6 27.2 87.8 85.8 Polio 2 58.8 20.8 79.5 76.2 Polio 3 [2] 54.0 8.9 62.9 58.3 DPT 1/Penta 63.9 28.0 91.9 88.8 DPT 2/Penta 61.9 25.6 87.5 83.2 DPT 3/Penta [3] 58.4 13.4 71.8 66.6 Measles [4] 52.5 29.3 81.8 67.9 HepB 1 / Hib 1 60.5 25.5 86.1 83.2 HepB 2 / Hib 2 59.2 20.8 79.9 75.0 HepB 3 [5] / Hib 3 55.9 13.2 69.1 63.7 Yellow fever [6] 52.3 29.3 81.7 67.5 No vaccinations .0 2.9 2.9 2.9 Number of children age 12-23 months 1502 1502 1502 1502 [1] MICS indicator 3.1 [2] MICS indicator 3.2 [3] MICS indicator 3.3 [4] MICS indicator 3.4; MDG indicator 4.3 [5] MICS indicator 3.5 [6] MICS indicator 3.6 Overall, 68 percent of children had health cards (Table CH.2). The percentage of children age 12 to 23 months who received each of the vaccinations is shown in Table CH.1. The denominator for the table is comprised of children age 12-23 months, those who are old enough to be fully vaccinated. In the fourth column from the left, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the column on the far right, only those who were vaccinated before their first birthday, as recommended, are included in the numerator; the calculation of this indicator is based only on children who have vaccination cards. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Approximately 95 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 89 percent. The percentage declines for subsequent doses of DPT to 83 percent for the second dose, and 67 percent for the third dose (Figure CH.1). Eighty-six percent of children received Polio 1 by age 12 months and this declines to 58 percent by the third dose. The coverage for measles vaccine by 12 months is 68 percent. 39 Table CH.2 shows vaccination coverage rates among children 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey and are based on information from both the vaccination cards and mothers’/caretakers’ reports. Vaccination rates do vary somewhat by background variables but they do not however follow any discernible pattern. Discussion: Vaccinations The high rate of BCG vaccination indicates that the population has a high level of access to vaccination services in Sierra Leone. Vaccination rates for the DPT series highlight the population’s utilization of the EPI program and show that the program is successful in delivering the early vaccinations in the series but does not do as well in completing it due to substantial drop-out. The measles vaccination rate is generally interpreted as an indicator of the overall strength of the EPI program. The timely measles vaccination rate of 66 percent is lower than desired and the overall rate of 82 percent is also less than the goal of 90 percent national coverage. The secondary goal of achieving at least 80 percent measles coverage in every district has not been met as five districts— Kailahun, Kenema, Kono, Kambia and Port Loko—all have estimated measles vaccination rates below 80 percent. Viewed in this light, the Sierra Leone EPI program appears to be successful in providing access to its services but needs to be strengthened if the goal of achieving high levels of timely vaccination of all antigens is to be achieved. 40 Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against childhood diseases, Sierra Leone, 2010 Percentage of children who received: Percentage with vaccination card seen Number of children age 12-23 months BCG Polio at birth Polio 1 Polio 2 Polio 3 DPT 1 DPT 2 DPT 3 Measl es HepB 1 / Hib 1 HepB 2 / Hib 2 HepB 3 / Hib 3 Yello w fever None All Sex Male 95.6 85.6 87.0 78.2 64.8 91.8 86.9 72.4 84.4 86.4 79.7 71.4 84.4 2.9 48.2 69.2 750 Female 95.4 86.8 88.6 80.8 61.0 92.1 88.2 71.3 79.2 85.8 80.1 67.0 79.0 2.9 44.3 66.3 752 Region East 95.8 90.0 84.8 76.1 61.5 92.1 86.2 70.3 74.8 89.6 83.3 71.0 75.5 3.2 46.6 73.2 429 North 94.4 78.8 89.9 80.0 62.4 90.8 86.0 65.3 80.3 86.2 78.3 68.2 80.2 3.5 45.0 61.7 522 South 96.0 88.9 87.0 82.8 67.1 91.3 89.4 78.1 89.8 79.2 75.0 67.1 88.6 1.8 47.2 74.5 394 West 97.1 93.5 91.4 79.2 57.7 96.9 91.8 81.5 86.2 93.6 88.3 72.6 86.2 2.1 47.0 55.8 156 District Kailahun 96.4 88.1 85.2 77.0 62.0 92.9 86.2 72.1 76.6 89.8 80.3 70.0 75.0 2.8 46.0 73.2 150 Kenema 96.7 94.8 82.2 74.7 68.5 94.4 88.3 80.0 79.0 94.3 90.5 81.7 79.2 2.5 56.4 82.0 170 Kono 93.5 85.4 88.4 76.9 50.1 87.3 83.0 53.0 65.7 81.7 76.2 54.9 70.3 5.0 32.0 59.7 109 Bombali 94.3 87.8 84.9 74.8 50.3 93.0 89.0 69.9 81.1 85.9 79.0 65.1 81.1 5.7 44.5 60.7 96 Kambia 96.0 83.2 86.9 74.4 54.5 91.8 84.2 66.4 78.7 84.8 77.4 64.4 78.9 1.4 38.9 56.6 70 Koinadugu 92.8 47.3 93.0 89.6 71.4 83.7 80.4 37.3 81.6 78.9 80.2 71.9 82.8 7.0 27.7 32.5 58 Port Loko 90.8 82.4 91.8 76.6 62.9 91.5 85.8 63.7 75.9 89.0 73.4 62.7 74.9 5.2 48.1 65.3 153 Tonkolili 98.4 79.6 91.2 85.9 70.1 90.8 87.0 73.7 84.6 87.0 82.9 76.6 84.6 .0 51.5 72.7 145 Bo 97.2 89.6 84.4 81.5 62.5 94.2 92.9 80.4 92.7 80.2 75.4 69.1 91.0 .7 43.4 76.0 167 Bonthe 96.7 91.3 90.9 90.6 70.6 95.2 92.7 83.6 88.2 92.4 92.1 80.5 88.0 2.5 64.2 75.3 76 Moyamba 90.3 80.3 86.4 78.1 71.7 89.4 87.1 77.1 81.3 79.3 75.1 67.5 79.7 3.7 51.4 71.4 79 Pujehun 98.3 94.4 89.4 82.9 69.0 82.6 80.2 68.3 93.6 62.8 55.9 47.6 93.6 1.7 33.5 73.4 72 Western Rural (96.2) (95.1) (88.0) (68.9) (57.6) (93.3) (93.3) (76.4) (79.5) (93.3) (91.1) (74.5) (76.8) (2.2) (40.7) (57.9) 33 Western Urban 97.3 93.1 92.3 81.9 57.7 97.8 91.4 82.8 88.0 93.6 87.6 72.1 88.8 2.1 48.7 55.2 124 Area Urban 94.9 88.7 83.4 73.4 56.7 93.1 88.6 76.3 86.5 87.8 80.8 71.1 86.9 3.0 44.8 61.7 433 Rural 95.7 85.2 89.6 82.0 65.4 91.5 87.1 70.1 79.9 85.4 79.6 68.3 79.6 2.8 46.8 70.2 1068 Mother's education None 94.9 85.4 88.1 79.8 63.1 90.5 86.5 69.1 80.9 84.8 78.3 67.7 80.9 3.4 46.0 68.6 1042 Primary 97.5 88.1 88.0 80.0 63.8 95.4 88.6 75.4 84.4 88.9 83.3 73.6 82.6 2.2 49.4 70.1 218 Secondary 96.4 88.1 86.4 78.1 61.1 94.9 91.3 80.4 83.4 88.9 83.6 71.5 84.1 .9 44.5 62.0 242 Wealth index quintiles Poorest 94.0 84.2 86.8 77.7 64.1 89.1 86.2 72.8 82.8 82.2 76.6 69.9 82.8 3.1 45.8 68.4 311 Second 95.3 84.2 89.2 82.0 66.0 88.9 85.2 69.3 79.4 84.0 78.1 66.1 79.1 3.6 46.8 69.9 352 Middle 95.8 85.2 90.5 79.9 63.7 93.8 87.6 68.6 80.0 89.3 78.7 69.1 79.2 2.8 46.5 67.9 329 Fourth 95.2 87.5 86.7 80.0 59.3 93.7 91.3 73.1 82.3 86.5 85.8 70.6 82.3 2.8 44.7 69.3 297 Richest 97.9 92.2 84.5 77.0 59.8 95.8 88.2 77.9 86.6 89.6 81.5 71.3 87.4 1.5 47.5 60.8 214 Total 95.5 86.2 87.8 79.5 62.9 91.9 87.5 71.8 81.8 86.1 79.9 69.1 81.7 2.9 46.2 67.7 1502 41 Neonatal Tetanus Protection MDG 5 aims to reduce the maternal mortality ratio by three quarters. The elimination of maternal tetanus is one of the primary strategies for achieving this goal. Another MDG target is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1000 live births in every district. Prevention of maternal and neonatal tetanus can be assured if a woman receives at least two doses of tetanus toxoid vaccine during her pregnancy at least two weeks before delivery. Alternatively, a woman and her newborn are also considered to be protected if any one of the following conditions is met:  Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years;  Received at least 3 doses, the last within the previous 5 years;  Received at least 4 doses, the last within 10 years;  Received at least 5 doses during lifetime. Table CH.3 shows the status of women’s protection from tetanus among women who have had a live birth within the last 2 years. Figure CH.2 shows the status of women’s protection from tetanus by major background characteristics. Overall, 87 percent of pregnant women in Sierra Leone are protected against tetanus. By far the predominant form of protection (83 percent) comes from receiving two doses of vaccine during the most recent pregnancy. Higher levels of mother’s education and higher levels of household wealth have only very modest positive associations with higher levels of protection. There is no difference between rural and urban areas with regards to protection levels but some differences do exist among regions—these are highest in the West and East and modestly lower in the North and South. Table CH.3: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Sierra Leone, 2010 Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus [1] Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Area Urban 82.5 4.5 .0 .0 .0 87.0 971 Rural 83.0 3.7 .1 .0 .0 86.8 2491 Region East 86.3 2.8 .0 .0 .0 89.1 993 North 80.6 4.9 .0 .0 .0 85.5 1230 South 80.4 3.6 .2 .0 .0 84.2 885 West 87.1 4.5 .0 .0 .0 91.7 353 District Kailahun 88.0 2.2 .0 .0 .0 90.2 330 Kenema 89.1 2.8 .0 .0 .0 92.0 391 Kono 80.2 3.6 .0 .0 .0 83.8 272 Bombali 82.1 6.8 .0 .0 .0 88.9 269 Kambia 71.1 9.0 .0 .0 .0 80.1 171 Koinadugu 75.1 3.2 .0 .0 .0 78.2 129 Port Loko 79.4 4.8 .0 .0 .0 84.2 360 Tonkolili 88.5 1.8 .0 .0 .0 90.3 302 Bo 82.4 4.3 .4 .0 .0 87.1 378 Bonthe 76.4 4.6 .0 .0 .0 81.0 158 Moyamba 77.3 3.1 .0 .0 .0 80.4 188 Pujehun 83.5 1.6 .0 .0 .0 85.2 161 Western Rural 86.4 1.8 .0 .0 .0 88.2 73 Western Urban 87.4 5.2 .0 .0 .0 92.6 281 Education None 81.2 3.9 .0 .0 .0 85.1 2348 Primary 86.6 4.1 .3 .0 .0 91.0 511 Secondary + 86.3 3.8 .0 .0 .0 90.1 603 Wealth index quintiles Poorest 81.1 3.0 .0 .0 .0 84.1 757 Second 82.4 3.3 .0 .0 .0 85.6 750 Middle 80.8 5.2 .2 .0 .0 86.1 765 Fourth 85.8 3.3 .0 .0 .0 89.1 663 Richest 85.5 5.3 .0 .0 .0 90.8 526 Total 82.9 3.9 .0 .0 .0 86.9 3462 [1] MICS indicator 3.7 42 Oral Rehydration Treatment Diarrhoea is the second leading cause of death worldwide among children under five. Most diarrhoea-related deaths in children are due to dehydration from the loss of large quantities of water and electrolytes from the body. Management of diarrhoea—either through intake of oral rehydration salts (ORS) or a recommended home fluid (RHF)—can prevent many of these deaths. Preventing dehydration and malnutrition by increasing overall fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. Goals that relate to the management of diarrhoea in children include 1) the reduction by fifty percent of deaths among children under five due to diarrhoea by 2010 compared to 2000 (A World Fit for Children); and 2) the two-thirds reduction of the mortality rate due to diarrhoea among children under five by 2015 compared to 1990 (Millennium Development Goals). The indicators that are measured in the MICS4 survey regarding the management of diarrhoea are related to:  Prevalence of diarrhoea  Use of oral rehydration therapy (ORT) to manage diarrhoea  Home management of diarrhoea  Management of diarrhoea using ORT with continued feeding In the MICS questionnaire, mothers/caretakers were asked to report whether their child had diarrhoea in the two weeks prior to the survey. Mothers of children who had experienced diarrhoea were 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. 43 Overall, 16 percent of under five children had diarrhoea in the two weeks preceding the survey (Table CH.4). Diarrhoea prevalence was highest (18%) in the north and lowest (11.4%) in the south. The highest level of diarrhoea occurs in the weaning period, among children aged 12-23 months. Table CH.4: Oral rehydration solutions and recommended homemade fluids Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recommended homemade fluids, Sierra Leone, 2010 Had diarrhoea in last two weeks Number of children age 0-59 months Children with diarrhoea who received: Number of children aged 0-59 months with diarrhoea ORS (Fluid from ORS packet or pre- packaged ORS fluid) Recommended homemade fluids ORS or any recommended homemade fluid Pre- pack ORS fluid with zinc Gov’t recommended homemade SSS fluid Any recommended homemade fluid Sex Male 16.1 4288 72.2 6.7 9.6 15.2 77.9 690 Female 14.8 4306 72.9 5.4 9.4 13.7 78.6 639 Missing * 4 100.0 * * * * 2 Region East 16.2 2371 69.5 5.0 8.5 11.9 74.6 383 North 18.0 3218 77.0 4.6 11.3 15.1 79.6 579 South 11.4 2132 69.0 8.9 7.0 15.9 80.9 243 West 14.4 877 68.8 10.6 9.1 16.7 78.4 126 District Kailahun 13.0 837 62.0 9.0 5.2 13.1 67.4 108 Kenema 19.1 908 72.8 2.9 7.2 9.4 78.0 173 Kono 16.2 627 71.7 4.2 14.4 14.9 76.4 101 Bombali 14.0 705 77.2 8.3 7.8 14.5 83.1 99 Kambia 32.6 460 74.5 1.8 25.7 26.7 75.1 150 Koinadugu 16.2 424 75.3 4.0 9.5 12.5 84.5 68 Port Loko 14.1 873 70.2 .0 .0 .0 70.2 123 Tonkolili 18.2 757 86.4 9.5 9.1 17.6 87.8 138 Bo 11.2 851 60.9 15.6 11.1 26.6 84.9 95 Bonthe 13.2 411 73.9 .0 3.3 3.3 77.2 54 Moyamba 10.7 431 (67.9) (5.3) (9.1) (14.3) (76.0) 46 Pujehun 10.8 440 (80.8) (9.0) (1.3) (10.3) (82.1) 48 Western Rural 15.4 233 (57.8) (19.1) (6.0) (25.1) (77.9) 36 Western Urban 14.0 644 73.1 7.2 10.3 13.4 78.6 90 Area Urban 14.2 2359 65.9 8.2 11.8 18.6 76.9 334 Rural 16.0 6240 74.8 5.3 8.7 13.1 78.7 997 Age 0-11 14.5 1824 67.8 10.3 4.0 13.7 73.8 264 12-23 19.4 1502 75.1 5.5 6.2 11.1 79.9 292 24-35 17.7 1621 71.4 4.3 9.8 12.5 78.7 286 36-47 14.4 1970 78.3 4.2 9.2 12.8 80.9 283 48-59 12.2 1666 69.4 6.4 21.5 25.6 78.1 204 DK/Missing * 16 * * * * * 1 Mother's education None 15.4 6289 73.6 5.9 9.9 14.9 78.8 971 Primary 17.0 1133 70.5 7.2 6.1 12.5 77.1 193 Secondary 14.2 1176 68.9 5.4 10.9 14.3 76.4 167 Wealth index quintiles Poorest 15.7 1951 74.5 6.9 7.0 13.7 78.5 306 Second 16.1 1916 72.7 5.2 10.8 14.7 77.1 309 Middle 17.4 1783 69.9 3.8 9.0 11.9 74.0 310 Fourth 13.8 1677 75.7 6.3 11.7 17.3 84.7 232 Richest 13.7 1271 69.5 9.8 9.5 16.4 78.9 174 Total 15.5 8598 72.6 6.1 9.5 14.5 78.3 1331 [*] Based on less than 25 unweighted cases and has been suppressed. Table CH.4 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. About 73 percent received fluids from ORS packets or pre-packaged ORS fluids and 14 percent received recommended homemade fluids. Approximately 78 percent of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or any recommended homemade fluid), while 22 percent received no treatment. Only minor differences were observed in the management of diarrhoea among the various background characteristics of respondents. Slightly less than one-third (32 percent) of under five children with diarrhoea drank more than usual while 68 percent drank the same or less (Table CH.5). Sixty-five percent ate somewhat less, same or more (continued feeding), while 35 percent ate much less or nothing. Children with diarrhoea were more likely to be given more to drink than usual if they lived in the east or if their mothers were 44 uneducated; the level of this indicator was very low in the West. The pattern for continued feeding is somewhat different; it is highest in the West and lowest in the east, is positively associated with increasing levels of mother’s education, and is highest among households in the highest wealth quintile. 45 Table CH.5: Feeding practices during diarrhoea Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Sierra Leone, 2010 Had diarrhoea in last two weeks Number of children age 0- 59 months Drinking practices during diarrhoea: Eating practices during diarrhoea: Number of children aged 0-59 months with diarrhoea Given much less to drink Given somewhat less to drink Given about the same to drink Given more to drink Given nothing to drink Missing/ DK Total Given much less to eat Given somewhat less to eat Given about the same to eat Given more to eat Stopped food Had never been given food Missing/ DK Total Sex Male 16.1 4288 24.0 18.7 22.2 32.8 1.6 .5 100 28.5 29.3 25.5 9.7 5.4 1.6 .1 100 690 Female 14.8 4306 20.7 23.8 21.6 31.4 1.8 .7 100 25.6 33.4 21.7 9.9 6.3 2.6 .5 100 639 Missing * 4 * * * * * * * * * * * * * * * 2 Region East 16.2 2371 23.3 16.2 16.9 40.2 2.7 .7 100 28.8 35.0 17.8 6.9 9.0 2.0 .5 100 383 North 18.0 3218 22.2 22.9 22.1 31.4 1.2 .2 100 26.8 29.6 23.4 12.9 5.0 2.3 .0 100 579 South 11.4 2132 23.4 22.1 23.6 27.9 2.1 .9 100 27.0 33.1 22.6 9.3 5.8 2.0 .2 100 243 West 14.4 877 18.6 26.5 33.9 19.5 .0 1.5 100 23.5 23.6 45.3 5.2 .2 1.4 .8 100 126 District Kailahun 13.0 837 36.4 18.9 10.9 29.5 3.5 .8 100 30.9 45.0 16.7 3.9 3.5 .0 .0 100 108 Kenema 19.1 908 22.9 14.7 12.5 49.0 .9 .0 100 31.0 40.4 12.2 7.1 8.4 .9 .0 100 173 Kono 16.2 627 10.0 15.7 30.6 36.8 5.0 1.9 100 22.9 15.0 28.6 9.9 15.7 5.9 1.9 100 101 Bombali 14.0 705 32.2 21.0 26.2 20.6 .0 .0 100 24.5 21.8 36.7 5.0 9.4 2.6 .0 100 99 Kambia 32.6 460 16.3 14.9 20.3 45.2 2.9 .4 100 28.2 27.3 17.1 19.3 4.3 3.9 .0 100 150 Koinadugu 16.2 424 16.9 16.3 29.4 34.1 2.3 1.0 100 28.2 15.2 41.1 7.4 5.0 3.1 .0 100 68 Port Loko 14.1 873 19.4 23.9 26.5 30.2 .0 .0 100 13.7 40.6 26.2 11.6 5.8 2.1 .0 100 123 Tonkolili 18.2 757 26.4 35.3 13.7 23.8 .8 .0 100 38.1 35.0 9.5 15.4 2.0 .0 .0 100 138 Bo 11.2 851 34.6 26.8 13.3 25.3 .0 .0 100 28.1 39.5 20.5 5.2 6.7 .0 .0 100 95 Bonthe 13.2 411 12.0 17.8 42.5 26.8 .9 .0 100 29.1 30.7 26.9 8.1 2.2 2.9 .0 100 54 Moyamba 10.7 431 (27.8) (22.1) (28.2) (15.5) (1.9) (4.5) (100) (19.3) (26.9) (27.9) (17.4) (4.0) (3.3) (1.2) 100 46 Pujehun 10.8 440 (9.7) (17.6) (18.2) (46.5) (8.1) (.0) (100) (29.6) (29.0) (16.9) (10.8) (10.0) (3.7) (.0) 100 48 Western Rural 15.4 233 (29.4) (26.2) (33.2) (11.2) (.0) (.0) (100) (32.3) (15.4) (40.5) (6.1) (.7) (5.0) (.0) 100 36 Western Urban 14.0 644 14.3 26.7 34.1 22.9 .0 2.0 100 20.0 26.8 47.2 4.8 .0 .0 1.1 100 90 Area Urban 14.2 2359 17.5 22.9 21.1 35.1 2.4 1.0 100 23.5 27.5 29.5 10.4 7.2 1.4 .5 100 334 Rural 16.0 6240 24.0 20.6 22.3 31.2 1.5 .5 100 28.3 32.5 21.8 9.6 5.4 2.3 .2 100 997 Age 0-11 14.5 1824 24.4 21.6 20.0 30.8 2.4 .9 100 24.8 30.5 23.5 10.3 2.3 7.7 .9 100 264 12-23 19.4 1502 22.5 18.3 23.3 33.3 2.3 .2 100 30.8 32.7 20.2 9.2 6.2 1.0 .0 100 292 24-35 17.7 1621 21.5 21.4 22.8 32.2 1.3 .8 100 25.7 31.5 25.5 9.2 8.1 .0 .0 100 286 36-47 14.4 1970 22.1 18.7 22.2 35.2 1.3 .5 100 29.3 27.1 26.6 10.0 6.3 .8 .0 100 283 48-59 12.2 1666 21.6 27.9 20.5 28.4 1.1 .5 100 24.1 35.5 22.7 10.6 5.5 1.0 .5 100 204 DK/Missing * 16 * * * * * * * * * * * * * * * 1 Mother's education None 15.4 6289 23.2 19.8 21.1 33.6 1.7 .7 100 28.7 30.1 22.1 10.8 6.4 1.7 .3 100 971 Primary 17.0 1133 23.2 23.5 22.7 28.2 2.4 .0 100 24.1 36.9 24.6 5.2 6.3 2.9 .0 100 193 Secondary 14.2 1176 17.0 26.4 26.2 28.7 1.2 .6 100 21.2 31.3 32.2 9.1 2.3 3.3 .6 100 167 Wealth index quintiles Poorest 15.7 1951 21.4 23.4 21.4 30.0 3.1 .7 100 30.7 31.4 20.2 10.7 5.1 1.7 .2 100 306 Second 16.1 1916 26.3 20.1 21.9 29.4 1.2 1.0 100 25.1 33.1 21.7 10.6 7.7 1.3 .6 100 309 Middle 17.4 1783 22.4 18.0 21.5 36.2 1.6 .3 100 29.1 30.1 25.4 9.7 3.1 2.5 .0 100 310 Fourth 13.8 1677 21.6 22.5 18.3 35.6 2.0 .0 100 25.5 34.8 19.3 8.1 9.1 3.1 .0 100 232 Richest 13.7 1271 18.1 23.0 28.7 29.1 .0 1.0 100 23.1 24.8 36.3 9.0 4.4 1.8 .6 100 174 Total 15.5 8598 22.4 21.2 22.0 32.2 1.7 .6 100 27.1 31.2 23.7 9.8 5.8 2.1 .3 100 100 [*] Based on less than 25 unweighted cases and has been suppressed. 46 Table CH.6 describes the percentage of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy (ORT), the percentage who received ORT with continued feeding, and percentage of children who received other treatments. Overall, 80 percent of children with diarrhoea received ORS or increased fluids while 84 percent received ORT (defined as ORS or recommended homemade fluids or increased fluids). Figure CH.3 displays the percentage of children with diarrhoea who received ORT by several key background characteristics. Combining the information in Table CH.5 with data from Table CH.4 on oral rehydration therapy, it is observed that 55 percent of children received ORT and, at the same time, feeding was continued, as is the recommendation. Management of diarrhoea with ORT and continued feeding was lower in the east and roughly the same in the other three regions. Higher levels of recommended management of diarrhoea are slightly associated with increasing levels of mother’s education (see Figure CH.4). Table CH.6: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and percentage of children with diarrhoea who received other treatments, Sierra Leone, 2010 Children with diarrhoea who received: Other treatment: Not given any treat ment or drug Numb er of childr en aged 0-59 mont hs with diarrh oea ORS or increa sed fluids ORT (ORS or recomm ended homem ade fluids or increase d fluids) ORT with contin ued feedin g [1] Pill or syrup: Antibi otic Pill or syrup: Antim otility Pill or syrup: Zinc Pill or syrup: Other Pill or syrup: Unkno wn Injecti on: Antibi otic Injecti on: Non- antibi otic Injecti on: Unkno wn Intrav enous Home remed y/Her bal medic ine Other Sex Male 79.5 83.6 54.8 37.6 2.4 .7 1.0 10.8 5.7 1.1 2.0 .0 10.0 14.0 7.0 690 Female 80.1 84.8 54.8 31.7 2.8 1.9 .5 11.7 6.7 .4 2.2 .3 8.2 15.6 5.7 639 Missing * * * * * * * * * * * * * * * 2 Region East 78.8 81.6 48.8 34.3 5.0 1.5 .2 10.4 3.8 .1 1.8 .0 6.7 19.7 7.8 383 North 84.0 86.2 57.1 33.8 1.4 1.4 1.3 15.0 6.7 1.3 2.5 .2 10.7 11.1 6.9 579 South 75.6 85.9 56.9 32.5 2.1 .8 .0 4.5 5.9 .0 2.0 .0 11.4 16.3 3.7 243 West 71.7 79.6 58.2 45.1 1.7 1.3 1.2 9.0 11.6 1.6 1.7 .9 4.5 13.7 4.5 126 District Kailahun 65.7 71.1 49.3 39.1 .9 .0 .0 12.9 4.4 .0 3.0 .0 4.1 23.5 12.2 108 Kenema 88.2 89.0 52.8 25.7 6.7 .0 .0 12.2 4.3 .0 2.1 .0 10.7 23.6 4.3 173 Kono 76.9 80.0 41.5 43.8 6.4 5.6 .6 4.7 2.2 .4 .0 .0 2.6 9.0 9.0 101 Bombali 82.3 88.2 55.0 28.2 .0 .0 1.4 13.0 1.4 .0 1.6 .0 6.4 20.1 1.7 99 Kambia 85.3 85.7 56.2 26.1 2.9 2.8 1.0 9.2 6.3 .0 1.8 .6 18.4 6.4 6.6 150 Koinadugu 84.8 91.2 61.2 41.4 .0 .5 .0 12.9 1.0 .0 .8 .0 7.1 7.2 5.2 68 Port Loko 77.7 77.7 58.7 33.0 3.1 1.2 1.4 16.2 11.8 1.8 2.7 .0 3.7 7.1 11.5 123 Tonkolili 89.1 90.5 56.0 43.3 .0 1.4 2.3 22.8 9.4 3.9 4.4 .0 13.5 15.2 7.6 138 Bo 68.8 88.8 60.1 41.2 4.1 1.4 .0 4.3 3.9 .0 .0 .0 9.9 23.4 .0 95 Bonthe 78.5 81.7 52.8 30.7 2.1 1.0 .0 3.7 3.0 .0 3.7 .0 13.5 8.2 4.6 54 Moyamba (72.4) (80.5) (58.4) (26.5) (.0) (.0) (.0) (2.1) (12.0) (.0) (3.8) (.0) (17.0) (16.7) (12.8) 46 Pujehun (89.0) (90.3) (53.8) (23.0) (.0) (.0) (.0) (8.3) (7.3) (.0) (2.2) (.0) (6.4) (10.7) (1.2) 48 Western Rural (59.7) (79.8) (48.9) (30.8) (.0) (1.4) (2.5) (9.0) (23.1) (3.3) (5.8) (.9) (12.2) (10.1) (5.3) 36 Western Urban 76.5 79.5 61.9 50.8 2.4 1.2 .7 9.1 7.1 .9 .0 .9 1.5 15.1 4.1 90 Area Urban 74.2 82.3 55.8 37.5 2.4 1.1 1.0 9.0 6.9 .7 1.6 .3 6.2 16.3 4.9 334 Rural 81.7 84.8 54.4 33.9 2.6 1.3 .7 12.0 5.9 .8 2.3 .1 10.1 14.3 6.8 997 Age in months 0-11 76.2 81.8 52.9 31.6 2.2 2.3 2.5 14.5 5.3 .4 2.3 .1 5.7 9.9 9.2 264 12-23 82.2 84.9 51.8 35.3 1.7 .9 .5 13.8 5.0 .6 2.1 .0 7.2 19.5 5.9 292 24-35 79.2 85.4 57.7 34.7 3.7 .5 .0 9.5 7.9 .7 1.3 .3 8.6 15.1 5.9 286 36-47 84.9 86.2 55.6 32.2 4.4 .7 .6 11.0 7.1 .6 2.6 .1 12.4 14.6 5.2 283 48-59 75.5 82.4 56.7 41.3 .5 2.3 .0 6.3 5.4 1.7 2.3 .4 12.3 14.1 5.7 204 DK/Missing * * * * * * * * * * * * * * * 1 Mother's education None 81.6 85.4 53.6 33.0 2.8 1.2 .9 10.9 5.8 .9 2.5 .1 10.1 14.1 6.4 971 Primary 76.3 81.8 57.0 37.0 3.1 1.9 .0 14.4 8.4 .0 1.2 .4 6.1 13.2 5.3 193 Secondary 73.7 80.1 59.3 42.6 1.0 1.3 .9 9.4 6.1 .9 .9 .0 6.8 20.4 7.0 167 Wealth index quintiles Poorest 82.5 84.3 53.5 30.7 3.3 .9 1.4 9.7 4.1 .0 3.2 .0 9.6 14.9 8.4 306 Second 78.9 82.0 53.4 38.0 2.3 2.1 .4 11.1 4.8 1.3 1.1 .1 11.2 13.8 8.7 309 Middle 77.9 81.6 54.5 27.3 2.9 .7 .5 15.0 5.3 .9 2.9 .3 12.6 15.0 5.7 310 Fourth 83.3 90.7 57.6 42.2 1.2 1.0 .4 9.1 11.9 1.0 1.3 .1 4.5 15.7 3.5 232 Richest 75.7 83.9 56.2 39.9 3.3 2.0 1.2 10.5 6.2 .5 1.7 .5 4.5 14.4 3.2 174 Total 79.8 84.2 54.8 34.8 2.6 1.3 .8 11.2 6.2 .7 2.1 .2 9.1 14.8 6.3 1331 [1] MICS indicator 3.8 [*] Based on less than 25 unweighted cases and has been suppressed. 47 Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading global cause of death in children. The use of antibiotics to treat under-5s for suspected pneumonia is a key intervention to reduce pneumonia-associated child mortality. In the MICS4 survey, children with suspected pneumonia are defined as those who had an illness with a cough accompanied by rapid or difficult breathing within the two weeks prior to the survey and whose symptoms were NOT due to a problem in the chest or a blocked nose. The indicators measured in the MICS4 Survey that are related to care seeking behaviour of mothers for antibiotic treatment of pneumonia include the following:  Prevalence of suspected pneumonia  Care seeking for suspected pneumonia  Antibiotic treatment for suspected pneumonia  Knowledge of the danger signs of pneumonia 48 Table CH.7: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia Percentage of children age 0-59 months with suspected pneumonia in the last two weeks who were taken to a health provider and percentage of children who were given antibiotics, Sierra Leone, 2010 Had suspect ed pneum onia in the last two weeks Numb er of childre n age 0-59 month s Children with suspected pneumonia who were taken to: Any appropri ate provider [1] Percentage of children with suspected pneumonia who received antibiotics in the last two weeks [2] Number of children age 0-59 months with suspected pneumonia in the last two weeks Public sector: Governme nt hospital Public sector: Governme nt health center Public sector: Governme nt health post Public sector: Village health worker Public sector : Mobil e / Outre ach clinic Othe r publi c Private hospit al / clinic Private physicia n Private pharma cy Mobil e clinic Other privat e medic al Relativ e / Friend Shop Traditiona l practition er Oth er Sex Male 8.3 4288 7.8 40.8 13.0 6.6 .6 .0 3.6 .3 3.9 .6 .4 5.0 .8 1.6 .3 72.2 55.2 357 Female 9.1 4306 12.7 45.1 10.8 2.7 .4 .8 2.4 1.7 2.3 .9 .8 2.4 .4 .5 1.5 75.4 59.8 393 Missing * 4 * * * * * * * * * * * * * * * * * 2 Region East 12.7 2371 10.0 42.1 16.4 4.2 .8 .0 1.8 2.0 2.9 1.8 .0 4.3 1.1 2.2 .7 75.4 58.2 300 North 8.3 3218 8.0 48.3 11.8 4.2 .0 .0 2.0 .2 3.5 .2 .2 2.6 .5 .2 .0 74.6 60.1 266 South 6.8 2132 13.5 39.3 5.6 7.0 .4 .9 3.1 .0 1.5 .0 1.3 4.7 .0 .5 1.9 68.9 45.1 146 West 4.6 877 (17.2) (27.9) (.0) (.0) (1.8) (4.3) (17.8) (2.6) (6.2) (.0) (5.2) (1.8) (.0) (.0) (5.8) (73.0) (80.1) 40 District Kailahun 11.0 837 9.1 46.3 23.5 6.6 .0 .0 .0 1.2 6.6 5.8 .0 1.5 .4 2.4 2.2 83.6 71.4 92 Kenema 15.1 908 6.0 43.2 18.4 2.9 .8 .0 .0 3.6 1.6 .0 .0 3.8 2.1 2.1 .0 72.7 53.8 137 Kono 11.3 627 18.7 34.5 3.5 3.8 1.8 .0 7.8 .0 .8 .0 .0 8.7 .0 2.1 .0 70.2 49.7 71 Bombali 4.1 705 (19.9) (36.6) (22.9) (2.8) (.0) (.0) (2.0) (.0) (.0) (.0) (.0) (.0) (.0) (.0) (.0) (84.1) (83.8) 29 Kambia 10.1 460 (.0) (47.1) (29.8) (1.2) (.0) (.0) (1.3) (.0) (.0) (1.3) (1.2) (.0) (2.6) (.0) (.0) (80.8) (60.2) 46 Koinadugu 2.7 424 * * * * * * * * * * * * * * * * * 12 Port Loko 4.7 873 (6.9) (50.4) (12.0) (7.6) (.0) (.0) (.0) (1.2) (.9) (.0) (.0) (.0) (.0) (1.2) (.0) (78.2) (57.3) 41 Tonkolili 18.3 757 7.9 51.1 4.2 4.3 .0 .0 2.9 .0 6.2 .0 .0 5.0 .0 .0 .0 70.4 54.6 139 Bo 10.0 851 14.7 37.6 .0 5.1 .0 1.6 4.1 .0 1.4 .0 2.3 8.1 .0 .0 2.8 63.7 40.3 85 Bonthe 3.7 411 * * * * * * * * * * * * * * * * * 15 Moyamba 5.0 431 * * * * * * * * * * * * * * * * * 21 Pujehun 5.5 440 * * * * * * * * * * * * * * * * * 24 Western Rural 7.1 233 * * * * * * * * * * * * * * * * * 17 Western Urban 3.6 644 * * * * * * * * * * * * * * * * * 23 Area Urban 7.7 2359 16.0 29.3 12.1 3.7 2.0 .9 7.4 .6 2.8 .3 2.1 2.2 .2 .6 2.8 72.0 63.4 182 Rural 9.1 6240 8.5 47.3 11.7 4.8 .0 .2 1.6 1.2 3.1 .9 .1 4.1 .7 1.2 .3 74.3 55.6 569 Age 0-11 9.4 1824 12.7 44.4 15.5 4.6 .8 .0 4.1 3.2 1.4 .0 .7 1.4 .0 .3 .7 81.8 69.4 171 12-23 9.9 1502 11.8 41.9 9.8 3.2 .0 2.1 2.8 .2 3.6 2.3 .5 4.8 .2 1.0 1.8 71.8 59.0 149 24-35 9.1 1621 7.7 52.2 8.2 2.8 1.2 .0 4.2 1.1 2.3 1.7 1.0 1.7 .5 1.5 2.1 77.5 56.9 148 36-47 8.3 1970 7.7 40.6 13.4 3.7 .0 .0 1.7 .2 2.8 .0 .4 6.4 .9 .5 .0 67.4 46.5 163 48-59 6.9 1666 12.5 33.4 11.9 8.7 .5 .0 1.9 .0 6.0 .0 .5 2.9 .4 2.5 .0 68.4 56.1 115 DK/Missing * 16 * * * * * * * * * * * * * * * * * 6 Mother's educatio n None 9.1 6289 8.5 46.2 13.2 3.9 .5 .5 1.5 .7 3.2 .4 .8 3.0 .5 1.4 1.0 74.9 58.0 571 Primary 9.0 1133 13.9 35.5 9.6 8.5 .0 .0 4.5 3.7 2.6 .0 .0 4.6 .0 .0 1.6 72.3 57.6 102 Secondary 6.7 1176 19.0 29.2 4.6 3.8 .9 .0 11.7 .0 2.3 4.3 .0 6.6 2.2 .0 .0 67.3 53.5 79 Wealth index quintiles Poorest 8.8 1951 8.2 47.3 8.8 6.1 .0 .0 .0 1.5 2.6 1.5 .0 6.0 .2 2.6 .2 71.9 60.2 171 Second 10.2 1916 5.6 45.1 19.4 4.8 .3 .0 .9 .1 2.9 .0 .3 2.5 .0 1.5 .0 74.9 54.2 195 Middle 9.6 1783 11.5 40.8 13.1 6.6 .0 .8 3.7 .9 2.3 .0 .6 3.1 .2 .3 2.3 76.1 57.3 171 Fourth 9.1 1677 12.3 48.2 7.3 2.0 1.2 .0 4.0 1.7 4.4 2.2 1.5 3.5 2.4 .0 .8 76.0 55.0 153 Richest 4.9 1271 23.6 17.3 3.6 .0 2.2 2.8 13.2 1.2 3.3 .0 1.3 2.3 .0 .0 2.6 63.0 66.8 62 Total 8.7 8598 10.3 43.0 11.8 4.5 .5 .4 3.0 1.0 3.0 .8 .6 3.6 .6 1.0 .9 73.7 57.5 752 [1] MICS indicator 3.9 [2] MICS indicator 3.10 [*] Based on less than 25 unweighted cases and has been suppressed. 49 Table CH.7 presents the prevalence of suspected pneumonia and—if care was sought outside the home—the site of care. Nine 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, 74 percent were taken to an appropriate provider. The vast majority of children seen by an appropriate provider were seen at a government health facility. Children with suspected pneumonia were somewhat more likely to be seen by an appropriate provider if their mothers were uneducated, if they were from a younger age category, or if they were from households in the mid-level wealth quintiles. Table CH.7 also presents the use of antibiotics for the treatment of suspected pneumonia in under- 5s by sex, age, region, residence, age, and socioeconomic factors. In Sierra Leone, 58 percent of under-5 children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. The percentage was somewhat higher in urban areas and varies dramatically across regions; eighty percent of children with suspected pneumonia in the West were treated with antibiotics while only 45 percent of children in the south received this standard of care. The table also shows that treatment of suspected pneumonia with antibiotics varied modestly and inconsistently by household wealth level and was moderately higher among children whose mothers/caretakers had a primary education or were uneducated. The use of antibiotics decreases with the increasing age of the child. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.8. Mothers’ knowledge of danger signs is usually an important determinant of care-seeking behaviour. Overall, only eight percent of respondents could state both of the danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is “develops a fever” (stated by 85 percent of respondents). Nineteen percent of mothers identified fast breathing and 21 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. There is notable variation across regions regarding the percentage of mothers who correctly recognize the two danger signs of pneumonia, ranging from two percent in the east to thirteen percent in the south. There are no apparent associations between correct knowledge and other background variables. Table CH.8: Knowledge of the two danger signs of pneumonia Percentage of mothers and caretakers of children age 0-59 months by symptoms that would cause them to take the child immediately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, Sierra Leone, 2010 Percentage of mothers/caretakers who think that a child should be taken immediately to a health facility if the child: Mothers/ caretakers who recognize the two danger signs of pneumonia Number of mothers/ caretakers of children age 0-59 months Is not able to drink or breastfeed Become s sicker Develops a fever Has fast breathing Has difficulty breathing Has blood in stool Is drinking poorly Has other symptoms Region East 15.5 36.1 87.5 9.9 12.9 12.1 3.7 33.6 2.4 1647 North 17.9 45.3 81.6 22.2 24.0 18.6 4.0 25.8 7.9 2262 South 13.1 49.2 87.3 21.7 24.3 24.8 7.0 24.4 13.3 1471 West 20.7 50.9 81.9 24.7 25.6 20.6 10.6 18.7 11.6 677 Area Urban 15.2 44.4 84.7 18.3 21.6 20.4 7.0 29.8 7.6 1694 Rural 16.8 44.3 84.5 19.3 21.1 17.8 4.8 25.6 8.4 4364 Education None 16.0 45.3 84.2 19.2 22.1 18.6 5.0 25.1 8.3 4349 Primary 17.7 41.3 86.0 17.6 16.2 15.5 5.5 33.6 6.7 771 Secondary + 17.1 42.4 85.1 19.2 21.3 20.9 7.2 29.1 8.6 938 Wealth index quintiles Poorest 15.1 52.1 83.5 19.7 23.6 21.7 4.4 22.2 9.9 1352 Second 16.7 43.5 85.3 20.2 22.0 17.6 6.0 25.3 8.9 1298 Middle 18.9 41.1 85.0 18.4 20.2 16.6 4.3 28.5 7.1 1247 Fourth 15.3 39.7 85.8 18.2 17.8 17.5 4.6 30.8 6.2 1191 Richest 15.9 44.5 83.1 18.2 22.3 19.1 8.3 27.9 8.3 971 Total 16.4 44.4 84.6 19.0 21.2 18.5 5.4 26.8 8.1 6058 50 Discussion: Care-seeking and antibiotic treatment of pneumonia The MICS4 survey has documented higher rates of treatment of suspected pneumonia with antibiotics than were measured in previous surveys. Child health experts in Sierra Leone note that prior to the introduction of the Integrated Management of Childhood Illnesses (IMCI) program in Sierra Leone, children with fever were presumed to have malaria and were often prescribed anti- malarials and not examined carefully for ARI. The introduction of IMCI has led to more effective community-based treatment of child illnesses using a holistic approach. The success of this approach is reflected in the increased treatment rates of suspected pneumonia. Pilot efforts are underway in Sierra Leone to make the treatment of childhood illness at the community level more horizontal through cadres of community health volunteers (CHVs). This effort is currently emerging and the duties of some CHVs remain vertically oriented. The government has drafted a policy on the role of CHVs in the treatment of childhood illnesses that is to be validated in the near future. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels can lead to high levels of indoor smoke which contains a complex mix of health-damaging pollutants. Table CH.9: Solid fuel use Percent distribution of household members according to type of cooking fuel used by the household, and percentage of household members living in households using solid fuels for cooking, Sierra Leone, 2010 Percentage of household members who use: Use of solid fuel for cooking [1] Number of household members Petroleum products*** Charcoal Wood Others Total Region East 0 7.4 91.9 0.6 100 99.6 16922 North 0 3.6 96 0.4 100 99.8 24355 South 0.1 3.1 96.3 0.4 100 99.6 15865 West 0.7 69.8 27.7 1.7 100 97.6 9565 District Kailahun 0 1 98.7 0.4 100 99.6 5627 Kenema 0 8 91 0.9 100 99.5 6960 Kono 0.2 14.9 84.6 0.4 100 99.6 4336 Bombali 0 5 94.8 0.2 100 99.9 5511 Kambia 0 1.4 97.4 1.2 100 99.6 3208 Koinadugu 0.1 3.6 96 0.3 100 99.7 3365 Port Loko 0 6.1 93.8 0 100 100 6703 Tonkolili 0.1 0.4 99.1 0.2 100 99.7 5568 Bo 0.1 6.1 93.5 0.3 100 99.7 6477 Bonthe 0 0.7 99.3 0 100 100 2841 Moyamba 0 1.1 98.1 0.8 100 99.3 3175 Pujehun 0.4 1.3 97.5 0.8 100 99.2 3372 Western Rural 0.3 31.2 67.6 0.9 100 99.1 1982 Western Urban 0.9 79.9 17.3 1.8 100 97.3 7584 Area Urban 0.3 38.7 59.9 1.1 100 98.6 21153 Rural 0.1 2.5 97.1 0.4 100 99.7 45554 Education of household head None 0.1 7.9 91.5 0.5 100 99.6 44900 Primary 0 12.3 87 0.7 100 99.3 6093 Secondary + 0.4 32 66.6 0.8 100 98.7 15640 Missing/DK 0 26.2 73.8 0 100 100 75 Wealth index quintiles Poorest 0.1 0 99.8 0 100 99.9 13342 Second 0 0.4 99.2 0.4 100 99.8 13347 Middle 0.1 1.4 97.9 0.6 100 99.5 13338 Fourth 0.1 4.7 94.5 0.8 100 99.4 13343 Richest 0.6 63.4 34.8 1.2 100 98.2 13336 Total 0.2 14 85.3 0.6 100 99.4 66707 [1] MICS indicator 3.11 [***] Petroleum products include electricity, bio gas, kerosene, coal etc Others include Straw, agricultural crop, others and missing 51 The main problem with the use of solid fuels is that products of incomplete combustion—including CO, polyaromatic hydrocarbons, SO2, and other toxic elements—remain in the air indoors and are inhaled by all household members. 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 indicator that was measured in the MICS4 survey regarding the use of solid fuel is the proportion of the population using solid fuels as the primary source of energy for cooking. The use of solid fuel for cooking is universal (99 percent) across Sierra Leone. The population essentially uses two types of fuel for cooking: wood and charcoal. The only significant variation in solid fuel use is among the percentage of households that use charcoal for cooking versus wood. The use of charcoal is higher in urban areas as compared to rural areas and is much higher in the West than in other regions. Higher levels of use of charcoal are associated with higher levels of household wealth and higher education levels of the household head. Table CH.10: Solid fuel use by place of cooking Percent distribution of household members in households using solid fuels by place of cooking, Sierra Leone, 2010 Place of cooking: Number of household members in households using solid fuels for cooking In a separate room used as kitchen Elsewhere in the house In a separate building Outdoors Other Missing Total Region East 5.7 5.6 37.5 50.8 .2 .2 100.0 16851 North 6.2 9.2 42.3 41.7 .2 .4 100.0 24309 South 6.3 8.3 48.8 36.0 .4 .1 100.0 15797 West 16.2 5.3 23.4 54.3 .4 .4 100.0 9339 District Kailahun 1.8 2.8 46.8 48.3 .0 .3 100.0 5606 Kenema 6.0 6.6 42.3 44.8 .2 .1 100.0 6926 Kono 10.3 7.7 17.6 63.7 .5 .3 100.0 4319 Bombali 5.0 1.9 44.4 47.3 .4 .9 100.0 5506 Kambia 2.1 1.7 73.4 21.8 .0 .9 100.0 3195 Koinadugu 7.6 7.0 24.1 60.5 .3 .5 100.0 3356 Port Loko 5.4 13.6 39.0 42.0 .0 .0 100.0 6701 Tonkolili 9.9 16.9 37.1 35.9 .2 .0 100.0 5552 Bo 1.3 10.4 57.8 30.3 .2 .1 100.0 6460 Bonthe 2.4 3.7 43.4 50.2 .3 .0 100.0 2841 Moyamba 7.6 8.6 45.6 37.3 .9 .1 100.0 3151 Pujehun 18.2 7.9 38.9 33.8 .7 .5 100.0 3344 Western Rural 10.0 9.2 39.2 41.2 .5 .0 100.0 1963 Western Urban 17.9 4.3 19.2 57.8 .4 .5 100.0 7376 Area Urban 10.0 5.8 35.0 48.7 .3 .3 100.0 20865 Rural 6.4 8.3 42.2 42.5 .3 .3 100.0 45431 Education of household head None 6.4 7.9 40.3 44.8 .3 .3 100.0 44737 Primary 6.7 6.6 43.6 42.7 .3 .2 100.0 6051 Secondary + 11.0 6.7 37.6 44.0 .4 .3 100.0 15433 Missing/DK 14.3 3.9 36.7 45.2 .0 .0 100.0 75 Wealth index quintiles Poorest 5.7 12.2 31.3 50.2 .4 .3 100.0 13331 Second 5.3 7.9 37.2 49.1 .4 .2 100.0 13323 Middle 6.6 6.0 48.6 38.2 .2 .4 100.0 13277 Fourth 6.2 5.0 51.4 36.9 .3 .2 100.0 13267 Richest 14.0 6.4 31.1 47.8 .3 .4 100.0 13097 Total 7.5 7.5 39.9 44.4 .3 .3 100.0 66296 Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different types of stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while an open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. The places where Sierra Leoneans perform domestic cooking are depicted in Table CH.10. Eighty-four percent of households in Sierra Leone cook either in a separate building or outdoors. There is not much variation in this figure across the various background characteristics except in the West and among the richest wealth quintile, where there is a higher use of a separate room within the main house as a kitchen. 52 Malaria 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 mosquito nets treated with insecticide (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 extremely high fever or convulsions, should be taken to a health facility. Also, children recovering from malaria should be given extra liquids and food and, for younger children, should continue breastfeeding. Table CH.11: Household availability of insecticide treated nets and protection by a vector control methods Percentage of households with at least one mosquito net, percentage of households with at least one long-lasting treated net, percentage of households with at least one insecticide treated net (ITN) and percentage of households which either have at least one ITN or have received spraying through an indoor residual spraying (IRS) campaign in the last 12 months, Sierra Leone, 2010 Percentage of households with at least one mosquito net Percentage of households with at least one long-lasting treated net Percentage of households with at least one ITN [1] Percentage of households with at least one ITN or received IRS during the last 12 months [2] Number of households Region East 36.0 33.2 35.1 35.3 3072 North 40.9 37.3 38.5 38.7 3761 South 43.2 38.5 40.2 40.3 2760 West 26.1 24.7 25.0 33.7 1801 District Kailahun 38.0 36.4 37.5 37.5 991 Kenema 32.4 30.7 31.2 31.4 1287 Kono 39.3 33.4 38.5 38.7 793 Bombali 50.0 47.0 47.9 48.1 849 Kambia 45.7 37.9 41.8 42.3 411 Koinadugu 40.2 28.2 30.9 31.3 517 Port Loko 36.5 35.4 36.0 36.1 971 Tonkolili 36.0 35.6 35.6 35.8 1013 Bo 47.0 42.1 42.6 42.6 1100 Bonthe 42.6 37.1 41.2 41.2 466 Moyamba 38.5 33.8 35.5 35.8 569 Pujehun 41.4 37.6 39.6 39.6 625 Western Rural 30.7 27.5 28.7 29.2 355 Western Urban 24.9 24.0 24.2 34.9 1447 Area Urban 34.3 31.4 32.5 36.9 3608 Rural 39.4 36.0 37.5 37.6 7786 Education of household head None 35.7 32.4 33.9 34.5 7460 Primary 41.6 38.7 39.4 40.8 1056 Secondary + 42.1 38.5 39.8 43.8 2864 Missing/DK * * * * 14 Wealth index quintiles Poorest 30.6 27.5 28.9 28.9 2481 Second 37.3 33.9 35.2 35.5 2322 Middle 44.8 41.2 43.2 43.4 2180 Fourth 42.3 38.3 39.7 40.1 2088 Richest 35.4 33.0 33.6 40.3 2323 Total 37.8 34.5 35.9 37.4 11394 [1] MICS indicator 3.12, [2] MICS indicator 3.13 [*] Based on less than 25 unweighted cases and has been suppressed. The MICS4 questionnaire incorporates questions on the availability and use of bed nets, both at household level as well as among children under five years of age and pregnant women. Other questions address anti-malarial treatment, intermittent preventive therapy for malaria, and indoor residual spraying of households. It should be noted that the MICS4 survey was conducted just before a mass distribution of ITNs to every household in Sierra Leone that took place in December 2010. The results presented here are therefore perhaps best viewed as representing the situation with respect to ITN availability and use just prior to the distribution campaign. The MICS4 survey results indicate that 36 percent of households in Sierra Leone have at least one insecticide treated net (Table CH.11). Only 38 percent of households were found to have at least one mosquito net of any type, suggesting that most available nets are treated. The ownership of at least one ITN was positively associated with increasing education of the household head and rural location. The ITN ownership rate was especially low in the West as compared to other regions. 53 Table CH.12: Children sleeping under mosquito nets Percentage of children age 0-59 months who slept under a mosquito net during the previous night, by type of net, Sierra Leone, 2010 Percentage of children age 0-59 who stayed in the household the previous night Number of children age 0-59 months Percentage of children who: Slept under any mosquito net [1] Percentage of children who: Slept under an insecticide treated net [2] Number of children age 0-59 months who slept in the household the previous night Percentage of children who slept under an ITN living in households with at least one ITN Number of children age 0-59 living in households with at least one ITN Sex Male 98.7 4288 31.8 29.9 4234 69.6 1821 Female 98.3 4306 32.2 30.7 4235 70.6 1844 Missing * 4 * * 4 * 1 Region East 96.6 2371 30.0 29.1 2290 67.9 982 North 99.6 3218 32.4 30.8 3205 69.2 1427 South 98.8 2132 37.9 35.1 2106 75.1 984 West 99.4 877 21.4 20.2 872 64.2 274 District Kailahun 95.9 837 33.4 32.8 803 69.1 380 Kenema 96.0 908 26.1 25.1 871 67.8 322 Kono 98.3 627 31.1 30.1 616 66.4 279 Bombali 99.8 705 42.8 41.3 703 72.7 400 Kambia 99.9 460 31.0 27.0 459 62.3 199 Koinadugu 99.8 424 23.0 19.5 423 58.7 141 Port Loko 99.7 873 29.8 29.2 870 70.0 363 Tonkolili 99.0 757 31.8 31.6 749 72.9 324 Bo 97.8 851 41.2 37.9 832 73.6 428 Bonthe 99.2 411 33.1 31.8 407 78.8 165 Moyamba 99.5 431 33.0 30.8 428 73.7 179 Pujehun 99.5 440 40.7 37.2 438 76.5 213 Western Rural 99.7 233 24.6 23.2 232 76.8 70 Western Urban 99.3 644 20.2 19.1 640 59.9 204 Area Urban 98.9 2359 28.7 27.0 2334 67.5 933 Rural 98.4 6240 33.2 31.6 6139 71.0 2733 Age in months 0-11 98.3 1824 39.4 38.2 1792 77.8 878 12-23 98.9 1502 32.9 30.9 1486 73.6 624 24-35 98.9 1621 34.3 32.1 1603 74.6 690 36-47 98.6 1970 29.0 27.4 1943 65.8 809 48-59 98.0 1666 24.2 23.1 1632 57.3 656 DK/Missing * 16 * * 16 * 9 Mother's education None 98.6 6289 31.4 29.8 6199 70.0 2639 Primary 97.7 1133 32.8 31.7 1106 71.5 490 Secondary 99.2 1176 34.2 31.9 1167 69.3 537 Wealth index quintiles Poorest 98.5 1951 28.3 26.6 1921 74.2 689 Second 98.3 1916 29.8 27.8 1884 70.8 741 Middle 98.5 1783 37.0 35.7 1757 68.1 921 Fourth 98.3 1677 33.2 31.6 1648 67.3 772 Richest 99.3 1271 32.3 30.7 1262 71.3 543 Total 98.5 8598 32.0 30.3 8473 70.1 3666 [1] MICS indicator 3.14 [2] MICS indicator 3.15; MDG indicator 6.7 [*] Based on less than 25 unweighted cases and has been suppressed. Other MICS4 results indicate that 32 percent of children under the age of five slept under any mosquito net the night prior to the survey and 30 percent slept under an insecticide treated net (Table CH.12). Among households with at least one ITN, only seventy percent of children slept under an ITN. There were no significant gender disparities in ITN use among children under five. Availability of ITNs and the percentage of children who sleep under them are highest in the south and lowest in the West. The percentage of children who sleep under bed nets decreases with increasing age of child. Table CH.13 presents the proportion of pregnant women who slept under a mosquito net during the previous night. Twenty-eight percent of pregnant women slept under any mosquito net the night prior to the survey and an equivalent percentage slept under an insecticide treated net. Pregnant women’s patterns of use of bed nets were almost identical to those of children under five as described directly above; use was highest in the south and lowest in the West. Among households with at least one ITN, seventy-one percent of pregnant women slept under an ITN. 54 Table CH.13: Pregnant women sleeping under mosquito nets Percentage of pregnant women who slept under a mosquito net during the previous night, by type of net, Sierra Leone, 2010 Percentage of pregnant women who stayed in the household the previous night Number of pregnant women Percentage of pregnant women who: Slept under any mosquito net Percentage of pregnant women who slept under an insecticide treated net [1] Number of pregnant women who slept in the household the previous night Percentage of pregnant women who slept under an ITN, living in households with at least one ITN Number of pregnant women living in households with at least one ITN Region East 92.5 400 27.6 27.3 370 72.4 140 North 98.1 577 26.9 26.1 567 67.4 219 South 97.1 334 35.3 33.5 325 74.6 146 West 99.1 120 (19.2) (19.2) (119) (73.2) 31 District Kailahun 86.7 129 (21.7) (21.7) (112) (61.9) 39 Kenema 96.1 193 27.1 27.1 186 75.0 67 Kono 93.2 78 (37.9) (36.5) (72) (79.6) 33 Bombali 99.2 112 33.6 32.3 111 68.5 52 Kambia 99.2 58 * * * * 18 Koinadugu 97.8 63 (28.1) (27.2) (61) (60.3) 28 Port Loko 98.1 229 28.0 27.4 225 70.1 88 Tonkolili 96.7 115 (18.9) (18.9) (111) (64.2) 33 Bo 95.9 131 39.4 36.4 126 74.7 61 Bonthe 98.3 57 (43.5) (39.9) (56) (69.7) 32 Moyamba 97.8 59 * * * * 15 Pujehun 97.8 87 (32.8) (32.8) (85) (74.6) 37 Western Rural (99.8) 42 * * * * 9 Western Urban 98.8 77 * * * * 22 Area Urban 97.9 395 25.5 24.8 386 68.5 140 Rural 95.9 1037 29.5 28.6 994 71.9 396 Age 15-19 97.9 198 27.1 27.1 194 63.5 82 20-24 95.8 295 30.3 28.2 282 69.2 115 25-29 97.7 403 26.9 26.4 394 72.8 143 30-34 95.2 280 25.1 24.4 267 73.4 89 35-39 94.4 188 34.6 33.5 178 76.0 78 40-44 (100.0) 48 * * * * 21 45-49 * 19 * * * * 8 Education None 96.6 1039 27.0 26.3 1004 71.5 369 Primary 96.1 196 32.9 32.4 188 69.5 88 Secondary + 95.7 197 31.5 29.4 188 70.2 79 Wealth index quintiles Poorest 98.1 365 24.0 23.1 358 70.4 117 Second 96.7 308 31.0 31.0 298 73.9 125 Middle 94.9 323 33.1 32.2 306 77.4 127 Fourth 96.1 256 23.6 22.7 246 59.7 93 Richest 95.7 180 31.6 29.5 172 70.4 72 Total 96.4 1431 28.4 27.6 1380 71.0 536 [1] MICS indicator 3.19 [*] Based on less than 25 unweighted cases and has been suppressed. Questions on the prevalence and treatment of fever were asked for all children under age five. Almost two in five children under five (37 percent) were ill with fever in the two weeks prior to the survey (Table CH.14). Fever prevalence peaked at 40 percent among children aged 13-48 months. Fever is less common among children whose mothers have secondary or higher education than among children of less educated mothers. Fever prevalence varied significantly across regions, from 26 percent in the south to 44 percent in the north. Fever prevalence was somewhat lower among children living in households in the upper wealth quintile as compared to households in other quintiles. 55 Table CH.14: Anti-malarial treatment of children with anti-malarial drugs Percentage of children aged 0-59 months who had fever in the last two weeks who received anti-malarial drugs, Sierra Leone, 2010 Had a fever in last two weeks Number of children age 0-59 months Children with a fever in the last two weeks who were treated with: Number of children with fever in last two weeks Anti- malarials: SP / Fansidar Anti- malarials: Chloroquin e Anti-malarials: Armodiaquine Anti- malarials: Quinine Anti-malarials: Artemisinin based combinations Anti- malarials: Other Anti- malarial Anti- malarials: Any anti- malarial drug [1] Other medications: Paracetamol /Panadol/Ac etaminopha n Other medications : Aspirin Other medications : Ibuprofen Other medication s : Other Don't know Percentage who took an anti- malarial drug same or next day [2] Sex Male 37.0 4288 16.3 11.2 17.6 1.9 18.1 7.9 61.0 59.4 4.8 .3 17.9 1.7 50.5 1589 Female 36.7 4306 14.2 10.9 19.5 2.5 20.4 7.5 63.0 61.7 4.6 .3 14.7 1.4 50.1 1580 Missing * 4 * * * * * * * * * * * * * 3 Region East 39.2 2371 18.9 13.7 10.0 2.2 13.4 12.1 62.3 65.1 4.2 .0 18.8 .8 51.8 930 North 44.2 3218 12.1 10.6 23.8 2.5 24.2 3.1 62.6 61.3 6.5 .5 14.6 2.7 50.2 1423 South 26.4 2132 16.2 9.5 18.3 1.0 20.8 13.3 63.4 48.5 2.3 .3 17.1 .5 49.9 563 West 29.0 877 17.6 7.5 22.5 2.8 8.9 4.3 55.4 65.8 1.8 .0 14.8 .4 46.9 254 District Kailahun 34.4 837 30.7 10.9 10.2 3.2 7.4 15.7 70.6 64.3 6.0 .0 17.0 .3 64.1 287 Kenema 39.8 908 17.4 9.0 6.6 2.1 16.1 16.3 61.3 67.9 4.1 .0 26.9 .6 50.0 361 Kono 44.9 627 8.9 22.4 14.1 1.4 16.1 3.1 55.1 62.4 2.4 .0 10.3 1.4 41.5 281 Bombali 45.9 705 17.0 9.3 7.3 .5 12.3 2.2 44.0 71.0 17.6 .4 14.1 1.9 34.4 323 Kambia 48.0 460 3.7 11.8 29.9 1.9 37.7 3.7 64.3 60.6 1.0 .0 15.8 2.6 55.5 221 Koinadugu 29.9 424 20.0 18.7 12.3 3.1 8.3 11.6 62.1 52.3 1.6 .1 10.5 .0 49.8 127 Port Loko 39.1 873 15.6 7.1 48.4 1.7 10.0 .0 79.3 55.7 3.2 .2 14.3 .6 65.6 341 Tonkolili 54.3 757 7.3 11.4 16.7 5.0 43.1 3.4 62.4 61.6 5.0 1.2 15.9 6.0 47.0 411 Bo 28.2 851 8.6 8.4 13.0 .5 16.9 26.2 65.5 51.1 2.9 .5 15.2 .0 49.0 240 Bonthe 24.3 411 9.8 5.2 46.2 .6 27.6 4.9 66.3 53.9 1.5 .5 24.0 1.1 57.9 100 Moyamba 27.7 431 24.3 12.6 15.2 1.7 13.0 5.5 53.3 46.2 1.6 .0 22.4 .6 44.9 119 Pujehun 23.6 440 30.5 12.4 7.3 1.7 31.9 .8 67.1 39.8 2.7 .0 8.6 1.0 50.3 104 Western Rural 36.7 233 24.0 12.9 27.8 2.6 5.6 .1 59.9 72.1 1.8 .0 10.9 .8 54.3 85 Western Urban 26.2 644 14.4 4.8 19.8 2.9 10.6 6.5 53.1 62.6 1.7 .0 16.8 .3 43.2 169 Area Urban 32.5 2359 16.3 10.4 18.6 2.2 14.0 8.2 59.4 60.3 3.5 .2 15.4 1.6 45.9 766 Rural 38.5 6240 14.9 11.3 18.7 2.2 20.9 7.5 62.9 60.6 5.1 .3 16.6 1.5 51.8 2405 Age 0-11 28.2 1824 12.5 7.7 13.2 2.0 16.4 5.4 49.7 51.2 3.2 .0 8.8 2.9 41.6 514 12-23 40.3 1502 12.5 12.6 17.2 .8 21.6 9.8 64.2 60.7 6.7 .5 17.4 1.7 53.0 606 24-35 40.2 1621 20.6 9.9 20.1 2.7 19.1 8.0 65.9 64.2 5.0 .3 17.2 1.8 53.3 651 36-47 40.6 1970 13.6 13.5 20.1 2.4 18.8 8.2 64.1 62.9 4.3 .4 20.5 .8 50.3 801 48-59 35.3 1666 16.8 10.0 21.7 2.9 20.0 6.1 63.5 61.6 3.9 .3 15.3 1.2 52.3 589 DK/Missing * 16 * * * * * * * * * * * * * 11 Mother's education None 37.6 6289 15.3 10.5 19.7 2.2 19.0 7.0 61.6 60.0 4.9 .3 16.3 1.9 50.7 2362 Primary 39.8 1133 12.8 12.7 13.2 1.6 21.6 10.2 61.3 60.1 2.8 .0 15.9 1.2 47.4 451 Secondary 30.4 1176 17.9 12.6 18.5 2.5 17.9 9.0 65.8 64.8 6.0 .8 16.7 .2 51.4 358 Wealth index quintiles Poorest 34.2 1951 11.7 10.0 20.2 2.3 20.1 8.8 58.8 55.8 3.1 .6 15.4 2.3 47.2 668 Second 39.0 1916 14.1 10.7 18.2 2.1 21.0 7.5 62.7 59.1 3.7 .1 14.1 1.6 52.0 747 Middle 40.5 1783 19.0 11.1 15.9 1.7 19.2 8.0 63.1 61.3 6.6 .4 17.0 1.2 51.0 722 Fourth 38.8 1677 15.1 13.0 20.6 1.9 18.2 6.2 63.5 63.5 6.4 .2 18.0 1.8 52.4 651 Richest 30.2 1271 16.9 10.1 18.7 3.6 15.8 7.7 61.9 65.0 3.0 .0 18.0 .5 47.8 384 Total 36.9 8598 15.3 11.1 18.7 2.2 19.2 7.7 62.1 60.5 4.7 .3 16.3 1.6 50.3 3171 [1] MICS indicator 3.18; MDG indicator 6.8 [2] MICS indicator 3.17 [*] Based on less than 25 unweighted cases and has been suppressed. 56 Mothers / caretakers of children who had a fever in the two weeks prior to the survey were asked to report all of the medicines given to the child to treat the fever, including both medicines given at home and medicines given or prescribed at a health facility. Overall, 62 percent of children with fever in the last two weeks were treated with an anti-malarial drug and 50 percent received an anti- malarial drug within 24 hours of onset of symptoms. National policy in Sierra Leone is to treat severe malaria using Artemisinin Combination Therapy (ACT) and quinine and to use fansidar (SP) for intermittent preventive treatment (IPT). The use of chloroquine, armodiaquine alone and SP for active case treatment is not considered to be correct according to treatment guidelines in Sierra Leone. Among children with fever who were surveyed in MICS4, 11 percent were given chloroquine, 15 percent were given SP, 19 percent received ACT while another nineteen percent received armodiaquine. Sixty-one percent of children with fever were given paracetemol while 5 percent were given aspirin. Table CH.15: Malaria diagnostics usage Percentage of children age 0-59 months who had a fever in the last two weeks and who had a finger or heel stick for malaria testing, Sierra Leone, 2010 Had a finger or heel stick [1] Number of children age 0-59 months with fever in the last two weeks Sex Male 24.6 4288 Female 26.4 4306 Missing * 4 Region East 24.1 2371 North 23.0 3218 South 35.6 2132 West 22.3 877 District Kailahun 28.1 837 Kenema 21.1 908 Kono 24.0 627 Bombali 24.6 705 Kambia 41.2 460 Koinadugu 14.6 424 Port Loko 14.8 873 Tonkolili 21.4 757 Bo 46.3 851 Bonthe 19.6 411 Moyamba 14.3 431 Pujehun 50.8 440 Western Rural 18.6 233 Western Urban 24.2 644 Area Urban 27.6 2359 Rural 24.9 6240 Age in months 0-11 27.0 1824 12-23 24.4 1502 24-35 24.7 1621 36-47 27.8 1970 48-59 23.2 1666 DK/Missing * 16 Mother's education None 25.0 6289 Primary 25.1 1133 Secondary 29.8 1176 Wealth index quintiles Poorest 25.3 1951 Second 22.6 1916 Middle 27.4 1783 Fourth 25.4 1677 Richest 28.2 1271 Total 25.5 3171 [1] MICS indicator 3.16 [*] Based on less than 25 unweighted cases and has been suppressed. Overall, children with fever in the West are somewhat less likely than children in the other three regions to have received an anti-malarial drug (Table CH.14). Rural children are slightly more likely than urban children to be treated with an anti-malarial drug as are children above the age of 12 months. Little difference was noted between boys and girls with regards to treatment patterns. Table CH.15 describes the percentage of children aged 0-59 months who had a fever in the last two weeks and who had a finger or heel stick for malaria testing. Overall, 26 percent of children with a 57 fever in the last two weeks had a finger or heel stick. Testing for malaria was higher in the south (36 percent) than in other regions (22-24 percent). Differences in the percentage of children tested among the other background variables assessed in the MICS4 survey were relatively minor. 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 makes them less likely to survive their first year of life. For this reason, steps are taken to protect pregnant women and their newborns by distributing insecticide-treated mosquito nets and providing treatment during antenatal check-ups with drugs that prevent malaria infection (intermittent preventive treatment or IPT). In the MICS4 survey in Sierra Leone, women were asked about the preventive antimalarial treatment they had received during their last pregnancy in the 2 years preceding the survey. A woman is considered to have received IPT if she received at least 2 doses of SP/Fansidar during her pregnancy. Table CH.16: Intermittent preventive treatment for malaria Percentage of women aged 15-49 years who had a live birth during the two years preceding the survey and who received intermittent preventive treatment (IPT) for malaria during pregnancy at any antenatal care visit, Sierra Leone, 2010 Percentage of women who received antenatal care (ANC) Number of women who gave birth in the preceding two years Percentage of pregnant women who took: Women who had live birth in last 2 years and who received ANC Any medicine to prevent malaria at any ANC visit during pregnancy SP/Fansidar at least once SP/Fansidar two or more times [1] Region East 96.7 993 72.7 48.5 35.7 960 North 88.7 1230 84.6 64.6 44.8 1092 South 93.0 885 74.6 51.2 38.1 823 West 97.5 353 83.6 70.9 54.8 345 District Kailahun 94.9 330 73.0 47.3 36.4 313 Kenema 97.6 391 77.1 50.4 36.7 381 Kono 97.6 272 66.0 47.2 33.5 266 Bombali 97.3 269 86.7 73.3 41.0 261 Kambia 80.3 171 70.3 54.4 38.3 137 Koinadugu 85.9 129 83.6 75.3 64.9 111 Port Loko 78.8 360 83.5 76.7 54.3 284 Tonkolili 99.0 302 90.6 46.1 34.6 299 Bo 95.0 378 83.3 49.2 37.0 359 Bonthe 90.4 158 69.6 58.3 45.5 143 Moyamba 91.9 188 71.4 52.8 35.1 173 Pujehun 92.1 161 61.9 47.3 37.1 148 Western Rural 96.6 73 77.3 61.6 46.8 70 Western Urban 97.8 281 85.3 73.3 56.9 274 Area Urban 94.3 971 80.9 62.8 47.1 916 Rural 92.5 2491 77.4 54.7 39.2 2304 Education None 92.0 2348 77.2 56.3 40.8 2162 Primary 94.8 511 78.4 52.3 37.4 484 Secondary + 95.2 603 82.8 63.9 47.1 574 Wealth index quintiles Poorest 91.7 757 71.5 49.0 35.3 694 Second 93.1 750 77.5 56.2 39.8 698 Middle 91.2 765 79.2 56.2 40.1 697 Fourth 94.1 663 80.4 56.4 42.1 624 Richest 96.1 526 85.3 71.2 53.1 506 Total 93.0 3462 78.4 57.0 41.4 3220 [1] MICS indicator 3.20 Data that describe the IPT for malaria that was taken by pregnant women who gave birth in the two years preceding the survey are presented in Table CH.16. Overall, 78 percent of women took any medicine to prevent malaria during an ANC visit but only 41 percent of pregnant women took IPT. Provision of IPT was higher in the West (55 percent) than in other regions (36-45 percent). Pregnant women who live in urban areas, have secondary education or higher, and are from the highest wealth quintile were more likely to receive IPT than other women. 58 Discussion: Malaria As noted above, the MICS4 survey was conducted just prior to the mass distribution of (three) ITNs to every household in Sierra Leone. While the results presented above therefore do not reflect the post-campaign situation in Sierra Leone, they do hold some lessons for the ITN program. Experts who were consulted to interpret the MICS4 results feel that the ITN coverage levels reported above are reasonably good for the pre-campaign scenario. They noted, however, that the percentage of households with at least one ITN (36 percent) was higher than the percentage of children under 5 years who sleep under an ITN (30 percent). Given that ITNs were distributed to families with pregnant women and young children, this suggests that ITNs may have either been mis- targeted and/or are misused at the household level (by not prioritizing their use for children and pregnant women). Even among households with ITNs, only 70 percent of under-five children sleep under them, suggesting that ITNs are not being used appropriately in some households. While the percentage of children with fever who were treated with an appropriate anti-malarial was reasonably high (62 percent), only 19 percent of children were treated according to national guidelines by being provided Artemisinin Combination Therapy (ACT). There is significant use of other non-approved drugs to treat malaria. Improving the rate of correct treatment among children with fever remains an urgent and as yet unreached goal of the national malaria program in Sierra Leone. 59 VII. Water and Sanitation Safe drinking water and adequate sanitation are basic necessities for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, schistosomiasis and other pathogens that cause diarrhoea. Drinking water can also be tainted with chemical, physical and radiological contaminants that can have harmful effects on human health. In addition to its association with diseases, access to safe drinking water may be particularly important for women and children who bear the primary responsibility for obtaining and carrying water—tasks that can take a great deal of time due to the long distances and/or waiting times that are often required. Unsafe means of disposal of excreta and other waste also contribute to the transmission of diseases that lead to child morbidity and mortality. Access to adequate and improved means of basic sanitation is critical to maintain satisfactory levels of hygiene in households and communities and enable healthy practices related to sanitation. The relevant MDG goal is to achieve a fifty percent reduction in the proportion of people without sustainable access to safe drinking water and basic sanitation between 1990 and 2015. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators related to water and sanitation that is u

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