Sindh Multiple Indicator Cluster Survey 2014

Publication date: 2015

December 2015 P a g e | i Sindh Multiple Indicator Cluster Survey 2014 Final Report December 2015 P a g e | ii The Sindh Multiple Indicator Cluster Survey (MICS) was carried out in 2014 by Bureau of Statistics, Planning and Development Department, Government of Sindh in collaboration with Pakistan Council of Research in Water Resource (PCRWR) and Global Alliance for Improved Nutrition (GAIN), as part of the global MICS programme. Technical and financial support was provided by the United Nations Children’s Fund (UNICEF). The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The main objectives of the MICS Sindh are: a) establish a credible baseline for monitoring the socioeconomic status of districts and use for planning purpose b) empower districts with knowledge of current socioeconomic conditions c) build capacity of relevant government institutions through their active involvement in all phases of the survey and d) monitor progress through repeat surveys. Suggested citation: Sindh Bureau of Statistics and UNICEF. 2015. Sindh Multiple Indicator Cluster Survey 2014, Final Report. Karachi, Pakistan: Sindh Bureau of Statistics and UNICEF. P a g e | iii Message I am extremely pleased to present to the people of Sindh, Multiple Indicators Cluster Survey (MICS) 2014, the first ever survey successfully conducted by the Government of Sindh in accordance with the MICS global standards. This round of MICS has revealed some important improvements on key elements relating to the well-being of children and women. However, much still needs to be done to improve the quality of life for a vast majority of women and children in the Province. The MICS facilitates the collection of statistically sound and internationally comparable data essential for developing evidence-based policies and programmes and for monitoring progress towards global, national and provincial goals. By generating data on key indicators for children and women, this survey will help to shape policies for improvements in their lives. The Government of Sindh is committed to using the MICS for evidence based planning, monitoring and resource allocation down to the district-level, through an approach that is both responsible and practical and envisage the procedures that will lead to future progress. It will improve sustainable development in Sindh and will allow the Government to manage the effective delivery of basic services and to build and adapt as we learn over time. These commitments complement “World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs)”. It also provides the basis for Sustainable Development Goals, post 2015 agenda. In the end, I would like to compliment UNICEF for providing the technical support and the entire team of Bureau of Statistics, Planning & Development Department who have successfully conducted this survey and produced high-quality data on children and women of Sindh. SYED MURAD ALI SHAH Senior Minister Planning & Development Department Government of Sindh P a g e | iv P a g e | v Preface A diverse set of data is a pre-requisite for effective planning and governance. The Sindh Multiple Indicator Cluster Survey (MICS) is an important source of accurate and reliable data on a comprehensive set of socioeconomic indicators. The Survey was carried out in 2014 by Bureau of Statistics, Planning & Development Department, Government of Sindh in collaboration with Pakistan Council of Research in Water Resource (PCRWR), as part of the global MICS programme. Technical and financial support was provided by the United Nations Children’s Fund (UNICEF). The purpose of the survey is to provide statistically valid data for researchers, policy makers, planners, and individual’s vis-à-vis evidence based decision, program and policy making, in-depth analysis and future forecast regarding human development. MICS is a unique source of information in which more than 120 indicators are covered on the basis of the province, 5 divisions, 28 districts as well as area of residence and background. MICS also provides high-quality data on household’s characteristics, child mortality, nutrition, child health, reproductive health, ante-natal health checks, child development, education and literacy, water and sanitation, wealth quintiles and poverty status. The Government of Sindh is pleased to inform that MICS was one of the largest exercises, of its kind, in the history of Sindh, with a sample size of 19,360 households. This methodology has been successfully implemented in 108 countries for assessing progress towards major goals particularly affecting women and children, and to monitor progress towards the Millennium Development Goals (MDGs). I would like to convey my deep appreciation to the Bureau of Statistics team for conducting this survey and preparing this report, which I feel will provide the best avenue for planning & decision making in Sindh. I also acknowledge and appreciate technical support provided by UNICEF and PCRWR for making this survey a success. AJAZ ALI KHAN Additional Chief Secretary (Dev) Planning & Development Department Government of Sindh P a g e | vi P a g e | vii ACKNOWLEDGEMENTS The Sindh Multiple Indicator Cluster Survey (MICS) 2014 is the result of dedicated efforts of various departments and organizations. The survey was funded through the Sindh Annual Development Programme and UNICEF. The survey and its analysis was conducted by the Sindh Bureau of Statistics (BOS) with technical support from UNICEF Regional and Global MICS Team. Pakistan Bureau of Statistics was responsible for the sample design. Pakistan Council of Research on Water Resources (PCRWR) supported the survey in water quality component while Global Alliance for Improved Nutrition (GAIN) provided support on salt iodization in the survey. Each individual, department and organization involved in Sindh MICS, 2014 deserve recognition. The Additional Chief Secretary, Planning and Development (Head of the Provincial MICS Steering Committee) provided his immense support throughout the process. Mr. Ali Dino Gahoti, Director General Bureau of Statistics Sindh and his team deserve special appreciation for the timely completion of Sindh MICS, 2014. Significant contribution made by the members of the Steering Committee, Technical, Planning and Coordination groups is also acknowledged. The services of Mr. Shah Nawaz Jiskani, Survey Coordinator, in coordinating Sindh MICS, 2014 are highly commendable. The technical support provided by UNICEF at all stages of this Survey. UNICEF Sindh Field Office team, Pakistan Country Office, Regional Office for South Asia and Global MICS team, as well as UNICEF national and international consultants supported the Survey from the planning stage to the sample design, training, data collection, and the data processing phases to ensure the quality of the MICS Final Report. Contribution and support of Pakistan Bureau of Statistics in sample design and listing, Dr. Ghulam Murtaza, Research Officer, Pakistan Council of Research in Water Resources (PCRWR) testing and analysis of water quality testing and Global Allaince for Improved Nutrition (GAIN) for salt testing and analysis is duly acknowledged. Fieldwork was an enormous task especially regarding the secuirty situation in Karachi, very high temperature in upper Sindh areas from April to August and distant clusters in desert areas of Tharparkar and other districts. Without the dedication and hard work of the entire MICS team including divisional field managers, team supervisors, editors, measurers, enumerators and data processing staff at BOS Head Office, timely completion of the survey would not have been possible. All district functionaries and administrative departments provided valuable support through services of their staff and facilitation in field work. Communities, local leaders, households and survey respondents that devoted their time and resources need to be applauded for their confidence in sharing personal information and enriching this survey. The information provided remains in trust and will not be used for any purposes other than their own benefit and prosperity. P a g e | viii P a g e | ix SUMMARY TABLE OF SURVEY IMPLEMENTATION AND THE SURVEY POPULATION, SINDH, 2014 Survey implementation Sample frame - Updated - Household listing Census 1998 Urban Frame 2013 Rural Frame 2011 Jan-Jul 2014 Questionnaires Household Women (age 15-49) Children under five Vaccination records at health facilities 1 Water Quality Testing Interviewer training Jan-Feb 2014 Fieldwork Jan-Aug 2014 Survey sample Households - Sampled - Occupied - Interviewed - Response rate (Per cent) 19,360 18,018 17,014 94.4 Children under five - Eligible - Mothers/caretakers interviewed - Response rate (Per cent) 18,108 16,605 91.7 Women - Eligible for interviews - Interviewed - Response rate (Per cent) 29,898 26,647 89.1 Water Quality Testing 2 - Sampled - Occupied - Sample collected/tested - Response rate (Per cent) 1,936 1,845 1,758 95.3 Survey population Average household size 7.2 Percentage of population living in - Urban areas - Rural areas - Larkana - Sukkur - Hyderabad - Mirpurkhas - Karachi 52.4 47.6 13.5 17.3 22.4 10.0 36.8 Percentage of population under: - Age 5 - Age 18 13.6 44.2 Percentage of women age 15-49 years with at least one live birth in the last 2 years 22.9 Housing characteristics Household or personal assets Percentage of households with - Electricity - Finished floor - Finished roofing - Finished walls 91.4 60.9 72.4 76.8 Percentage of households that own - A television - A refrigerator - Agricultural land - Farm animals/livestock - Personal computer/Laptop 65.7 47.7 18.3 34.8 19.6 Mean number of persons per room used for sleeping 3.94 Percentage of households where at least a member has or owns a - Mobile phone - Car /Truck /Jeep /Van - Bank Account - Motorcycle / Scooter 87.5 8.2 29.7 39.2 1 The questionnaire for vaccination records at health facility was administered for all the children under-3 to reduce the memory recall errors and to obtain missing information in the vaccination cards at home. 2 Two households were randomly selected from each of the 968 clusters and samples of household drinking water were collected for water quality testing. P a g e | x SUMMARY TABLE OF FINDINGS3 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Sindh, 2014 CHILD MORTALITY Early childhood mortality* MICS Indicator Indicator Description Value 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 82 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 104 A*Indicator values are per 1,000 live births and rates refer to 2011.1. The East Model was assumed to approximate the age pattern of mortality in Sindh, Pakistan and calculations are based on the time since first birth version of the indirect children ever born/children surviving method. NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 42.0 17.0 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 48.0 24.4 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 15.4 3.6 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 1.0 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 95.6 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 20.7 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 28.9 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 56.0 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 76.7 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 48.9 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 21.3 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 53.4 3 See Appendix F for a detailed description of MICS indicators P a g e | xi 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 63.9 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 69.6 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the previous day 55.7 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 14.2 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children age 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 9.2 7.7 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 37.0 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodate 36.2 2.S1 Purchasing behavior for iodized salt Percentage of households who look/ask for salt with Handi logo or labeled as Iodized when purchasing salt 23.1 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 30.0 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 33.2 CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 76.3 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 60.3 3.3 3.5 3.6 Pentavalent (DPT+HepB+Hib) immunization coverage Percentage of children age 12-23 months who received the third dose of Pentavalent (DPT+HepB+Hib) vaccine by their first birthday 52.7 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 12-23 months who received measles vaccine by their first birthday 52.7 3.8 Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday 35.0 Tetanus toxoid 3.9 Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 54.1 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 28.4 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 69.2 P a g e | xii 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 11.6 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre-packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 41.0 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 12.9 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 75.4 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 32.9 Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 44.3 Malaria / Fever MICS Indicator Indicator Description Value - Children with fever Percentage of children under age 5 with fever in the last 2 weeks 42.8 3.16a 3.16b Household availability of insecticide-treated nets (ITNs) Percentage of households with (a) at least one ITN (b) at least one ITN for every two people 11.3 0.8 3.17a 3.17b Household vector control Percentage of households (a) with at least one ITN or that have been sprayed by IRS in the last 12 months (b) with at least one ITN for every two people or that have been sprayed by IRS in the last 12 months 12.5 2.4 3.18 MDG 6.7 Children under age 5 who slept under an ITN Percentage of children under age 5 who slept under an ITN the previous night 6.4 3.19 Population that slept under an ITN Percentage of household members who slept under an ITN the previous night 4.3 3.20 Care-seeking for fever Percentage of children under age 5 with fever in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 74.8 3.21 Malaria diagnostics usage Percentage of children under age 5 with fever in the last 2 weeks who had a finger or heel stick for malaria testing 4.4 3.22 MDG 6.8 Anti-malarial treatment of children under age 5 Percentage of children under age 5 with fever in the last 2 weeks who received any antimalarial treatment 1.6 3.23 Treatment with Artemisinin-based Combination Therapy (ACT) among children who received anti-malarial treatment Percentage of children under age 5 with fever in the last 2 weeks who received ACT (or other first-line treatment according to national policy) 15.9 3.24 Pregnant women who slept under an ITN Percentage of pregnant women who slept under an ITN the previous night 6.7 P a g e | xiii WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved A sources of drinking water 90.5 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 12.8 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 64.6 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 43.7 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 66.5 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 82.0 4.1 E. coli concentration in household drinking water Percentage of household members with E. coli concentration in household drinking water equal to or above 1 cfu/mL 38.8 4.S2 Arsenic concentration in household drinking water Percentage of household members using drinking water with over 10 ppb Arsenic concentration 3.0 AThe population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, compound, yard or plot, to neighbor, public tap/standpipe), tube well/borehole, protected well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for hand washing and cooking. REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate A for women age 15-49 years 4.0 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women age 15-19 years 56 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 10.0 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married who are using (or whose husband is using) a (modern or traditional) contraceptive method 29.0 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 21.7 A The age-specific fertility rate is defined as the number of live births to women in a specific age group during a specified period, divided by the average number of women in that age group during the same period, expressed per 1,000 women. The age-specific fertility rate for women age 15-19 years is also termed as the adolescent birth rate. The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. The TFR denotes the average number of children to which a woman will have given birth by the end of her reproductive years (by age 50) if current fertility rates prevailed. All fertility rates are calculated by using information on the date of last birth of each woman and are based on the one-year period (1-12 months) preceding the survey Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 79.7 41.1 P a g e | xiv 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 48.4 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 65.7 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 64.0 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 17.8 5.S1 Lady health worker visits Percentage of women age 15-49 years who were visited by lady health worker during the past three months 52.3 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 53.8 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 78.0 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 71.8 CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 17.8 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 39.8 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 3.8 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 10.4 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 6.7 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 62.3 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 17.6 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning 57.3 P a g e | xv LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young women Percentage of young women age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 52.3 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 86.2 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 21.7 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 45.2 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 37.0 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 88.6 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final grade of primary school) 49.0 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 90.9 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 0.86 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 0.81 CHILD PROTECTION Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 29.1 Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour 26.0 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 81.3 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of women age 15-49 years who were first married before age 15 9.3 8.5 Marriage before age 18 Percentage of women age 20-49 years who were first married before age 18 31.2 8.6 Young women age 15-19 years currently married Percentage of young women age 15-19 years who are married 16.3 8.7 Polygyny Percentage of women age 15-49 years who are in a polygyny 4.5 P a g e | xvi 8.8a 8.8b Spousal age difference Percentage of young women who are married and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years 12.4 14.8 Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of women age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food 49.0 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 1.9 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 5.5 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 0.5 HIV/AIDS HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of women age 15-49 years who have heard of AIDS 41.9 9.1 MDG 6.3 Knowledge about HIV prevention among young women Percentage of young women age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV 4 , and who reject major misconceptions about HIV transmission 5 2.2 9.2 Knowledge of mother-to- child transmission of HIV Percentage of women age 15-49 years who correctly identify all three means 6 of mother-to-child transmission of HIV 25.5 9.3 Accepting attitudes towards people living with HIV Percentage of women age 15-49 years expressing accepting attitudes on all four questions 7 toward people living with HIV 19.7 4 Using condoms and limiting sex to one faithful, uninfected partner 5 The two most common misconceptions about HIV transmission are included in the indicator calculation: i) Supernatural means and ii) Sharing food with someone with HIV. 6 Transmission during pregnancy, during delivery, and by breastfeeding 7 People (1) who think that a female teacher who is HIV-positive and is not sick should be allowed to continue teaching, (2) who would buy fresh vegetables from a shopkeeper or vendor who is HIV-positive, (3) who would not want to keep secret that a family member is HIV-positive, and (4) who would be willing to care for a family member with AIDS in own home P a g e | xvii ACCESS TO MASS MEDIA AND ICT Access to mass media MICS Indicator Indicator Description Value 10.1 Exposure to mass media Percentage of women age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 2.4 Use of information/communication technology 10.2 Use of computers Percentage of young women age 15-24 years who used a computer during the last 12 months 20.5 10.3 Use of internet Percentage of young women age 15-24 years who used the internet during the last 12 months 13.8 TOBACCO Tobacco use MICS Indicator Indicator Description Value 12.1 Tobacco use Percentage of women age 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month 10.0 12.2 Smoking before age 15 Percentage of women age 15-49 years who smoked a whole cigarette before age 15 0.9 HEPATITIS KNOWLEDGE MICS Indicator Indicator Description Value 13.S1 Knowledge about hepatitis B and C prevention among women Percentage of women age 15-49 with comprehensive knowledge about ways of transmission of Hepatitis B or C. 34.0 P a g e | xviii P a g e | xix TABLE OF CONTENTS Message . iii Preface . v Acknowledgements . vii Summary Table of Survey Implementation and the Survey Population, Sindh, 2014 . ix Summary Table of Findings. x Table of Contents . xix List of Tables . xxii List of Figures . xxvii List of Abbreviations . xxviii Executive Summary . xxix Map of Sindh (Division and district boundaries) . xxxi I. Introduction. 1 Survey Objectives . 2 II. Sample and Survey Methodology . 3 Sample Design . 3 Questionnaires . 3 Training and Fieldwork . 5 III. Sample Coverage and the Characteristics of Households and Respondents . 7 Sample Coverage . 7 Characteristics of Households . 8 Housing characteristics, asset ownership, and wealth quintiles . 14 IV. Child Mortality . 18 V. Nutrition . 22 Low Birth Weight . 22 Nutritional Status . 23 Breastfeeding and Infant and Young Child Feeding . 28 Salt Iodization . 39 VI. Child Health . 43 Vaccinations . 43 Neonatal Tetanus Protection . 47 Care of Illness . 48 Diarrhoea . 50 Acute Respiratory Infections . 59 Solid Fuel Use . 63 Malaria/Fever . 64 P a g e | xx VII. Water and Sanitation . 78 Use of Improved Water Sources . 78 Use of Improved Sanitation . 87 Handwashing . 94 Water Quality Testing . 97 VIII. Reproductive Health . 110 Fertility . 110 Contraception . 113 Antenatal Care . 119 Assistance at Delivery . 124 Place of Delivery . 126 Post-natal Health Checks . 128 Lady Health Worker Visits . 138 IX. Early Childhood Development . 140 Early Childhood Care and Education . 140 Quality of Care . 141 Developmental Status of Children . 146 X. Literacy and Education . 149 Literacy among Young Women . 149 School Readiness . 150 Primary and Secondary School Participation . 151 XI. Child Protection . 163 Birth Registration . 163 Child Labour . 165 Child Discipline . 172 Early Marriage and Polygyny . 176 Attitudes toward Domestic Violence . 182 Children’s Living Arrangements . 184 XII. HIV/AIDS . 187 Knowledge about HIV Transmission and Misconceptions about HIV . 187 XIII. Hepatitis B and C . 194 Knowledge about Hepatitis and Transmission . 194 XIV. Access to Mass Media and Use of Information/Communication Technology . 197 Access to Mass Media . 197 Use of Information/Communication Technology . 198 XV. Tobacco Use . 200 Tobacco Use . 200 P a g e | xxi Appendices: Appendix A. District Tables . 204 Appendix B. Sample Design . 307 Appendix C. List of Personnel Involved in the Survey . 311 Appendix D. Estimates of Sampling Errors . 316 Appendix E. Data Quality Tables . 391 Appendix F. MICS5 Indicators: Numerators and Denominators. 411 Appendix G. Questionnaires . 422 P a g e | xxii LIST OF TABLES Table HH.1: Results of household, women's and under-5 interviews . 7 Table HH.2: Household age distribution by sex . 8 Table HH.3: Household composition . 10 Table HH.4: Women's background characteristics . 11 Table HH.5: Under-5's background characteristics. 13 Table HH.6: Housing characteristics . 14 Table HH.7: Household and personal assets . 16 Table HH.8: Wealth quintiles . 17 Table CM.1: Children ever born, children surviving and proportion dead . 18 Table CM.2: Infant and under-5 mortality rates by time since first birth groups of women . 19 Table CM.3: Infant and under-5 mortality rates by background characteristics . 19 Table NU.1: Low birth weight infants . 23 Table NU.2: Nutritional status of children . 26 Table NU.3: Initial breastfeeding . 30 Table NU.4: Breastfeeding . 32 Table NU.5: Duration of breastfeeding. 34 Table NU.6: Age-appropriate breastfeeding . 35 Table NU.7: Introduction of solid, semi-solid, or soft foods . 36 Table NU.8: Infant and young child feeding (IYCF) practices . 37 Table NU.9: Bottle feeding . 38 Table NU.10: Iodized salt consumption . 39 Table NU11: Purchasing behaviour and packaging type for iodized salt . 41 Table CH.1: Vaccinations in the first years of life . 44 Table CH.2: Vaccinations by background characteristics . 46 Table CH.3: Neonatal tetanus protection . 48 Table CH.4: Reported disease episodes . 50 Table CH.5: Care-seeking during diarrhoea . 51 Table CH.6: Feeding practices during diarrhea . 52 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . 54 Table CH.8: Oral rehydration therapy with continued feeding and other treatments. 56 Table CH.9: Source of ORS and zinc . 58 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) . 60 Table CH.11: Knowledge of the two danger signs of pneumonia . 62 Table CH.12: Solid fuel use . 63 Table CH.13: Solid fuel use by place of cooking . 64 Table CH.14: Household availability of insecticide treated nets and protection by a vector control method . 66 Table CH.15: Access to an insecticide treated net (ITN) - number of household members . 67 Table CH.16: Access to an insecticide treated net (ITN) - background characteristics . 67 Table CH.17: Use of ITNs . 68 Table CH.18: Children sleeping under mosquito nets . 69 Table CH.19: Use of mosquito nets by the household population . 70 Table CH.20: Care-seeking during malaria . 72 Table CH.21: Treatment of children with fever . 73 Table CH.22: Diagnostics and anti-malarial treatment of children . 75 Table CH.23: Source of anti-malarial . 76 Table CH.24: Pregnant women sleeping under mosquito nets . 77 Table WS.1: Use of improved water sources . 80 Table WS.1a: Taste and colour/ transparency of drinking water . 83 Table WS.2: Household water treatment . 85 Table WS.3: Time to source of drinking water . 86 Table WS.4: Person collecting water . 87 Table WS.5: Types of sanitation facilities . 88 Table WS.6: Use and sharing of sanitation facilities . 90 Table WS.7: Drinking water and sanitation ladders . 91 P a g e | xxiii Table WS.8: Disposal of child's faeces . 93 Table WS.9: Water and soap at place for handwashing . 95 Table WS.10: Availability of soap or other cleansing agent . 96 Table WQ.1: Household water quality: arsenic . 98 Table WQ.2: Househod water quality: nitrate. 99 Table WQ.3: Household water quality: fluoride . 100 Table WQ.4: Household water quality: iron . 101 Table WQ.5: Household water quality: hardness . 102 Table WQ.6: Household water quality: Total dissolved solids (TDS) . 103 Table WQ.7: Household Water Quality: Bacterial contamination (E. coli) . 104 Table WQ.8: Drinking Water Source Quality: Bacterial contamination (E.coli) . 105 Table WQ.9: Household Water Quality: Bacterial contamination (Total Coliform) . 106 Table WQ.10: Water Source Quality: Bacterial contamination (Total Coliform) . 107 Table WQ.11: Household Water Quality: Bacterial contamination detected using the H2S test (Qualitative) . 108 Table WQ.12: Source Water Quality: Bacterial contamination detected using H2S test (Qualitative) . 109 Table RH.1: Fertility rates . 110 Table RH.2: Adolescent birth rate and total fertility rate . 111 Table RH.3: Early childbearing . 112 Table RH.4: Trends in early childbearing . 113 Table RH.5: Use of contraception . 115 Table RH.6: Unmet need for contraception . 118 Table RH.7: Antenatal care coverage . 120 Table RH.8: Number of antenatal care visits and timing of first visit . 121 Table RH.9: Content of antenatal care . 123 Table RH.10: Assistance during delivery and caesarian section . 125 Table RH.11: Place of delivery . 127 Table RH.12: Post-partum stay in health facility . 128 Table RH.12: Post-partum stay in health facility - continued . 129 Table RH.13: Post-natal health checks for newborns . 130 Table RH.14: Post-natal care visits for newborns within one week of birth . 132 Table RH.15: Post-natal health checks for mothers . 134 Table RH.16: Post-natal care visits for mothers within one week of birth . 135 Table RH.17: Post-natal health checks for mothers and newborns . 137 Table RH.18: Health care services provided by Lady health worker (LHW) . 139 Table CD.1: Early childhood education . 141 Table CD.2: Support for learning . 143 Table CD.3: Learning materials . 145 Table CD.4: Inadequate care . 146 Table CD.5: Early child development index . 148 Table ED.1: Literacy (young women) . 149 Table ED.2: School readiness . 150 Table ED.3: Primary school entry. 151 Table ED.4: Primary school attendance and out of school children . 153 Table ED.5: Secondary school attendance and out of school children . 155 Table ED.6: Children reaching last grade of Primary school . 156 Table ED.7: Primary school completion and transition to Secondary school . 158 Table ED.8: Education gender parity . 159 Table ED.9: Out of school gender parity . 160 Table ED.10: Type of school attended during school year (2013-2014) . 162 Table CP.1: Birth registration . 164 Table CP.2: Children's involvement in economic activities . 167 Table CP.3: Children's involvement in household chores . 169 Table CP.4: Child labour . 171 Table CP.5: Child discipline . 173 Table CP.6: Attitudes toward physical punishment . 175 Table CP.7: Early marriage and polygyny . 177 Table CP.8: Trends in early marriage . 179 P a g e | xxiv Table CP.9: Spousal age difference . 181 Table CP.13: Attitudes toward domestic violence . 183 Table CP.14: Children's living arrangements and orphanhood . 185 Table CP.15: Children with parents living abroad . 186 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission . 188 Table HA.2: Knowledge of mother-to-child HIV transmission . 190 Table HA.3: Accepting attitudes toward people living with HIV . 192 Table HE.1: Knowledge about Hepatitis B and C . 195 Table MT.1: Exposure to mass media . 198 Table MT.2: Use of computers and internet . 199 Table TA.1: Current and ever use of tobacco . 201 Table TA.2: Age at first use of cigarettes and frequency of use . 203 P a g e | xxv Appendices: Table SD.1: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Strata . 309 DQ.1: Age distribution of household population . 391 DQ.2: Age distribution of eligible and interviewed women . 393 DQ.4: Age distribution of children in household and under-5 questionnaires . 393 DQ.5: Birth date reporting: Household population . 394 DQ.6: Birth date and age reporting: Women . 395 DQ.8: Birth date and age reporting: Under-5s . 396 DQ.9: Birth date reporting: Children, adolescents and young people . 397 DQ.10: Birth date reporting: First and last births . 398 DQ.11: Completeness of reporting . 399 DQ.12: Completeness of information for anthropometric indicators: Underweight . 400 DQ.13: Completeness of information for anthropometric indicators: Stunting . 400 DQ.14: Completeness of information for anthropometric indicators: Wasting . 401 DQ.15: Heaping in anthropometric measurements . 402 DQ.16: Observation of birth certificates . 403 DQ.17: Observation of vaccination cards . 404 DQ.18: Observation of women's health cards . 405 DQ.19: Observation of bednets and places for handwashing . 406 DQ.20: Presence of mother in the household and the person interviewed for the under-5 questionnaire . 407 DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules . 408 DQ.22: School attendance by single age . 409 DQ.23: Sex ratio at birth among children ever born and living . 410 Table SE.1: Indicators selected for sampling error calculations. 317 Table SE.2: Sampling errors: Total sample . 319 Table SE.3: Sampling errors: Urban . 321 Table SE.4: Sampling errors: Rural . 323 Table SE.5: Sampling errors: Kashmore sample . 325 Table SE.6: Sampling errors: Jacobabad sample . 327 Table SE.7: Sampling errors: Kamber Shahdadkot sample. 329 Table SE.8: Sampling errors: Larkana sample . 331 Table SE.9: Sampling errors: Shikarpur sample . 333 Table SE.10: Sampling errors: Ghotki sample . 335 Table SE.11: Sampling errors: Sukkur sample . 337 Table SE.12: Sampling errors: Khairpur sample . 339 Table SE.13: Sampling errors: Naushahro Feroe sample . 341 Table SE.14: Sampling errors: Shaheed Benazirabad sample . 343 Table SE.15: Sampling errors: Dadu sample . 345 Table SE.16: Sampling errors: Jamshoro sample . 347 Table SE.17: Sampling errors: Hyderabad sample . 349 Table SE.18: Sampling errors: Matiari sample . 351 Table SE.19: Sampling errors: Tando Allahyar sample . 353 Table SE.20: Sampling errors: Tando Muhammad Khan sample . 355 Table SE.21: Sampling errors: Badin sample . 357 Table SE.22: Sampling errors: Sujawal sample . 359 Table SE.23: Sampling errors: Thatta sample . 361 Table SE.24: Sampling errors: Sanghar sample . 363 Table SE.25: Sampling errors: Mirpurkhas sample . 365 Table SE.26: Sampling errors: Umerkot sample . 367 Table SE.27: Sampling errors: Tharparkar sample . 369 Table SE.28: Sampling errors: Karachi Malir sample . 371 Table SE.29: Sampling errors: Karachi East sample . 373 Table SE.30: Sampling errors: Karachi Central sample . 375 P a g e | xxvi Table SE.31: Sampling errors: Karachi West sample . 377 Table SE.32: Sampling errors: Karachi South sample . 379 Table SE.33: Sampling errors: Larkana division sample . 381 Table SE.34: Sampling errors: Sukkur division sample . 383 Table SE.35: Sampling errors: Hyderabad division sample . 385 Table SE.36: Sampling errors: Mirpurkhas division sample . 387 Table SE.37: Sampling errors: Karachi division sample . 389 P a g e | xxvii LIST OF FIGURES Figure HH.1: Age and sex distribution of household population, Sindh, 2014 . 9 Figure HH.2: Distribution of wealth quintiles, urban, rural and total, Sindh, 2014 . 17 Figure CM.1: Under-5 mortality rates by division, mother’s education, wealth quintiles and area, Sindh, 2014 . 20 Figure CM.2: Trend in under-5 mortality rates, Sindh, 2014 . 21 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Sindh, 2014 . 27 Figure NU.2: Initiation of breastfeeding, Sindh, 2014 . 31 Figure NU.3: Infant feeding patterns by age, Sindh, 2014 . 33 Figure NU.4: Consumption of iodized salt, Sindh, 2014 . 40 Figure CH.1: Vaccinations by age 12 months, Sindh, 2014 . 45 Figure CH.2: Children under-5 with diarrhea who received ORS or recommended homemade liquids, Sindh,2014 . 53 Figure CH.3: Children under-5 with diarrhoea receiving oral rehydration therapy (ORT) and continued feeding, Sindh, 2014 . 57 Figure WS.1: Percent distribution of household members by source of drinking water, Sindh,2014 . 81 Figure WS.2: Percent distribution of household members by use and sharing of sanitation facilities, Sindh, 2014 . 89 Figure WS.3: Use of improved drinking water sources and improved sanitation facilities by household members, Sindh, 2014 . 92 Figure RH.1: Age-specific fertility rates by area, Sindh, 2014 . 111 Figure RH.2: Differentials in contraceptive use, Sindh, 2014 . 116 Figure RH.3: Person assisting at delivery, Sindh, 2014 . 126 Figure ED.1: Education indicators by sex, Sindh, 2014 . 161 Figure CP.1: Children under-5 whose births are registered, Sindh, 2014 . 165 Figure CP.2: Child disciplining methods, children age 1-14 years, Sindh, 2014 . 174 Figure CP.3: Early marriage among women, Sindh, 2014 . 180 Figure HA.1: Women with comprehensive knowledge of HIV transmission, Sindh, 2014 . 189 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS, Sindh, 2014 . 193 Figure TA.1: Ever and current smokers, Sindh, 2014 . 202 Appendix: Figure DQ.1: Number of household population by single ages . 392 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points . 402 P a g e | xxviii LIST OF ABBREVIATIONS ACT Artemisinin-based Combination Therapy AIDS Acquired Immune Deficiency Syndrome ANC Ante-natal Care ASFR Age Specific Fertility Rate APHA American Public Health Association ARI Acute Respiratory Illness AWWA American Water Works Association BCG Bacillis-Cereus-Geuerin (Tuberculosis) BHU basic health unit BOS Bureau of Statistics CBR Crude Birth Rate CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus ECDI Early Child Development Index E. Coli Escherichia coli EPI Expanded Programme on Immunization FGM/C Female genital mutilation/cutting GAIN Global Allaince for Improved Nutrition GPI Gender Parity Index GVAP Global Vaccine Action Plan HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders ITN Insecticide Treated Net IUD Intrauterine Device JMP Joint Monitoring Programme LHW Lady Health Worker LLIN Long Lasting Insecticide Net MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme MoH Ministry of Health NAR Net Attendance Rate ORS Oral Rehydration Salt ORT Oral Rehydration Treatment PCRWR Pakistan Council for Research in Water Resources PCV Pneumococcal Conjugate Vaccine PDHS Pakistan Demographic and Health Survey PNC Post-natal Care ppm Parts Per Million RHC Rural health Centre SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infections TFR Total Fertility Rate TDS Total Dissolved Solids U5MR Under Five Mortality Rate UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WEF Water Environment Federation WFFC World Fit for Children WFP World Food Programme WHO World Health Organization USI Universal Salt Iodization P a g e | xxix Executive Summary The Sindh Multiple Indicator Cluster Survey (MICS), 2014 was designed to provide estimates for more than 100 indicators on the situation of children and women for the province. It is one of the largest surveys in Sindh with a sample size of 19,360 households. The survey which was conducted from January to August, 2014 is part of the fifth global round of Multiple Indicator Clusters Surveys programme. The MICS Survey is a unique source of information which will serve as a baseline for researchers, policy makers, planners and individuals and provide evidence based data for decision making by program and policy makers. The survey was implemented by Sindh Bureau of Statistics in collaboration with UNICEF and Pakistan Council of Research in Water Resource (PCRWR) while Pakistan Bureau of Statistics provided the sampling frame. Key Findings report presents provincial level summary results and will be followed by final report containing division and district level disaggregated data. Main findings of the survey are: Early childhood mortality In recent years, the people of Sindh have experienced major emergencies as a result of two successive years (2010 and 2011) of record breaking rains and flooding. Children may have been disproportionately affected and Sindh MICS 2014 shows that Infant mortality rate is 82 deaths per 1,000 live births and the under-five mortality rate is 104 deaths per 1,000 live births. Nutritional status More than four out of ten children under the age of five in Sindh are underweight (42 percent) and 17 percent are classified as severely underweight. Almost half of children under five years (48 percent) are stunted or short for their age and one quarter (24 percent) children are severely stunted. The results also show that 15 percent of the children are wasted or thin for their height and only 1 percent of children are overweight or too heavy for their height. These indicators are also reflecting the crises situation of children under five year’s age and the Government of Sindh, taking notice of situation, has already launched a mega program for the nutrition support in the province. Child health Immunization is key to reducing child deaths from vaccine-preventable diseases. Overall, 35 percent of children age 12-23 months received all the recommended vaccinations by 12 months of age which reflects an improvement in last few years if compared to DHS 2012 findings of 29 percent for the same indicator. Similarly, an increase has been witnessed in measles vaccine coverage (53 percent) as compare to DHS 2012 (45 percent). Water and Sanitation Sindh MICS 2014 shows that 90 percent of the population has access to improved sources of drinking water which is a 10 percentage point increase in the last decade if compared to the Sindh MICS 2003 findings of same indicator (80 percent). The results also show that almost 65 percent of the population of Sindh is using improved sanitation facilities. The survey also presents findings from water quality testing. It is observed that 3 percent of households are using drinking water indicating Arsenic contamination while 39 percent of households are using drinking water indicating E.coli contamination in Sindh. P a g e | xxx Reproductive Health The total Fertility Rate in Sindh for the one year period before the survey was 4 children per woman which has reduced over the last decade from 5.3 children per woman as per findings of MICS 2003-4. The survey further shows that 29 percent of ever married women are using a contraceptive method and 25 percent are using a modern method. The most common contraceptive method is female sterilization which is currently used by 8.4 percent of ever married women. Maternal and newborn health The results indicate that almost 80 percent of ever married women receive antenatal care from a skilled provider which is almost 100 percent improvement in last decade as compared to the findings of MICS 2003-4 (42 percent). The prevalence of institutional deliveries is also considerably increased from 42 percent (DHS 2006-7) to 64 percent as reported in Sindh MICS 2014. Literacy and education More than half (52.3 percent) of young women age 15-24 are literate. Out of children of primary school age, 45.2 percent are currently attending primary education or higher with a modest improvement from 39 percent witnessed in MICS 2003-4. For every 100 boys attending primary school, 86 girls are also attending. This falls to 81 girls for every 100 boys attending secondary school. Child protection In Sindh, 29.1 percent of the births of children age under 5 are registered. 26 percent of children age 5-17 are involved in child labour. Eighty one percent of children age 1-14 years experienced psychological aggression or physical punishment as a way of discipline in the past month. Just over a third of children (35%) received a severe form of physical punishment. Early Marriages The survey shows that 16.3 percent young women age 15-19 years are currently married. However there seems to be a decline in the number of girls marrying before age 15. Data reflects that 17.5 percent of women in the 45-49 year age group married before the age of 15 compared with 4 percent of women in 15-19 year age group. The Government of Sindh has passed a law in 2014 to control early marriages in Sindh. Access to mass media and ICT Overall, 70.4 percent of women either watch television or read a newspaper or magazine or listen to the radio at least once a week which is a positive indicator for planners from the communication perspective. Among women age 15-24, almost 21 percent used a computer during in the one year period before the survey and 13.1 percent used a computer at least once a week during the past month. Further to that, 13.8 percent of young women used internet during the past year. Only 8.1 percent of young women used the social media (facebook, twitter, etc.), at least once a week during the last month. More than half of women in richest households used social media compared with less than 1 percent in poorest households. P a g e | xxxi MAP OF SINDH (DIVISION AND DISTRICT BOUNDARIES) P a g e | xxxii P a g e | 1 I. INTRODUCTION Background This report is based on the Sindh Multiple Indicator Cluster Survey (MICS), conducted in 2014 by the Sindh Bureau of Statistics in collaboration with Pakistan Council of Research in Water Resources (PCRWR), Global Alliance for Improved Nutrition (GAIN) with technical and financial support from UNICEF. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child- focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” The Sindh MICS results will be critically important for final MDG reporting in 2015, and are expected to form part of the baseline data for the post-2015 era. P a g e | 2 Sindh MICS is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health. Survey Objectives The 2014 Sindh MICS has as its primary objectives:  To provide up-to-date information for assessing the situation of children and women in Sindh, particularly at district level;  To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention;  To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action;  To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable;  To contribute to the generation of baseline data for the post-2015 agenda;  To validate data from other sources and the results of focused interventions. This final report presents the results of the indicators and topics covered in the survey. Provincial level results presented in this report were published earlier in October 2015 as part of the key findings report. The discussion for each chapter in this report is based on tables within the text that contain provincial and divisional level results. District level tables can be found in Appendix A of the report. The report is divided into 15 chapters, focusing on different aspects of the survey. The first three chapters explain about the survey objective, methodology (sample design, questionnaires, training and fieldwork) and sample coverage, characteristics of the households, asset ownership, and wealth quintiles. The remaining 12 chapters discuss the findings on child mortality, nutrition, child health, water and sanitation, reproductive health, early child development, literacy and education, child protection, HIV/AIDS knowledge, Hepatitis B and C, access to mass media and use of information/communication technology and tobacco use. P a g e | 3 II. SAMPLE AND SURVEY METHODOLOGY Sample Design The sample for the Sindh Multiple Indicator Cluster Survey was designed to provide estimates for a large number of indicators on the situation of children and women at provincial level, for urban and rural areas, for the five divisions namely Larkana, Sukkur, Hyderabad, Mirpurkhas and Karachi; and 28 districts. The districts within each division are administratively specified as follows: Larkana: Kashmore, Jacobabad, Kamber Shahdadkot, Larkana and Shikarpur Sukkur: Ghotki, Sukkur, Khairpur, Naushahro Feroze, and Shaheed Benazirabad Hyderabad: Dadu, Jamshoro, Hyderabad, Matiari, Tando Allahyar, Tando Muhammad Khan, Badin, Sujawal and Thatta Mirpurkhas: Sanghar, Mirpurkhas, Umerkot and Tharparkar Karachi: Karachi Malir, Karachi East, Karachi Central, Karachi West and Karachi South The urban and rural areas within each district were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas was selected systematically with probability proportional to size, for a total sample of 975 enumeration. After a household listing was carried out within the selected enumeration areas, a systematic sample of 20 households was selected in each EA, resulting in a total sample of 19,500 households for Sindh Province. Seven of the selected enumeration areas were not visited due to a law and order situation during the fieldwork period. The sample was stratified by district, urban and rural areas, and is not self-weighting. For reporting provincial, divisional and district level results, sample weights are used. A more detailed description of the sample design can be found in Appendix B, Sample Design. Questionnaires Five sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; 3) an under-5 questionnaire, administered to mothers (or caretakers) for all children under 5 living in the household; 4) a water quality testing questionnaire was used in selected households to record information on quality of household drinking water 5) a questionnaire form for vaccination records at health facility to obtain the vaccination record of all children age two years or less. The questionnaires included the following modules: The Household Questionnaire included the following modules: o List of Household Members o Education o Child Labour o Child Discipline o Household Characteristics o Insecticide Treated Nets o Indoor Residual Spraying P a g e | 4 o Water and Sanitation o Handwashing o Salt Iodization The Questionnaire for Individual Women was administered to all women age 15-49 years living in the households, and included the following modules: o Woman’s Background o Access to Mass Media and Use of Information/Communication Technology o Marriage o Fertility o Desire for Last Birth o Maternal and Newborn Health o Post-natal Health Checks o Illness Symptoms o Visit from Lady Health Worker8 o Contraception o Unmet Need o Attitudes Toward Domestic Violence o HIV/AIDS o Hepatitis9 o Tobacco Use The Questionnaire for children under-five was administered to mothers (or caretakers) of children under 5 years of age10 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age o Birth Registration o Early Childhood Development o Breastfeeding and Dietary Intake o Immunization o Care of Illness o Anthropometry The Questionnaire for Water Quality Testing was administered to two households per cluster. Details on the sampling procedure for selecting these households as well as the methodology used for water quality testing can be found in chapter seven of this report. Samples of drinking water were collected for testing of bacterial content in the household and from the household’s drinking 8 Visit from Lady Health Worker module is a survey specific module that includes questions on services provided by lady health workers. 9 Hepatitis module is a survey specific module on awareness and knowledge about Hepatitis. 10 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report. P a g e | 5 water source. Additional samples were collected for laboratory testing of the following parameters: Arsenic, Nitrate, Fluoride, Total Dissolved Solids, Iron and Hardness. For all children age 0-2 years with a completed Questionnaire for Children Under Five an additional form, the Questionnaire Form For Vaccination Records At Health Facility, was used to record vaccinations from the registers at health facilities. The questionnaires are based on the MICS5 model questionnaire11. From the MICS5 model English version, the questionnaires were customised and translated into Urdu and Sindhi and were pre- tested in three districts in clusters that were not selected for the survey during the month of September, 2013. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Sindh MICS questionnaires is provided in Appendix G. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, tested water quality, observed the place for hand washing, collected additional salt and water samples for quality testing in laboratory and measured the weights and heights of children age under 5 years. Details and findings of these observations and measurements are provided in the respective sections of the report. Training and Fieldwork Before training of enumerators, there was a Training of Trainers (ToT) and pretesting teams constituting of experienced survey staff. The training was conducted by a team of persons who had participated in the MICS5 Survey Design Workshop facilitated by the UNICEF MICS Global Team. During the training, subject matter specialists from Government line departments and UNICEF were invited as guest speakers for some modules. Due to the size of the survey and the large number of survey teams required, training for the fieldwork was conducted in three phases. The first phase started on 5th January, 2014, the second phase started on 17th February 2014, both phases lasted 21 days. The third phase which was from 16th April to 26th April, 2014 was conducted mostly to replace any drop out of survey personnel. Training in all phases included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Each training concluded with three days of field practice in different urban and rural locations, Sindhi and Urdu speaking areas, remote and nearby communities, inorder for the teams to gain practical field experience before deployment for actual field work. The data were collected by 34 teams; each was comprised of one supervisor, three female interviewers, one editor and one measurer. Fieldwork began in January 2014 and concluded in August 2014. During fieldwork, there were some challenges. Inaccessibility to some of the clusters required special arrangements to be made to reach the difficult to reach areas. Seven clusters in Karachi could not be accessed due to lack of law and order, poor geographical access and political disputes. Different strategies during field work were implemented to minimize refusal of interviews 11 The model MICS5 questionnaires can be found at http://mics.unicef.org/tools P a g e | 6 in Karachi. This included social mobilization which involved influential community and political leaders, engaging field teams from local communities, effective communication mechanisms and seeking support from local government. Senior citizens were also engaged to negogiate with head of households that were refusing to be interviewed which was found to be an effective strategy to increase response rates. In security compromised areas, support from local police was sought. Media also was used to increase awareness about the survey. In addition, leaflets were distributed to households a day prior to data collection. In two clusters (each in Dadu and Tando Muhammad Khan districts), data collection could not take place due to seasonal migration and internal conflict. Data collection was closely monitored throughout both in the field and at the central level. For example, the data processing team sent feedback to field staff on a daily basis based on enumeration errors observed during the data entry process and review of field check tables. Field teams also sent summary sheets of anthropometry measurements to the data processing team through mobile messaging service or email. Measurements were analyzed instantly using the Emergency Nutrition Assessment software. Any outlying measurement was flagged and this information was sent back to the field supervisor’s to instruct the measurements to be performed again. Data Processing Data were entered using the CSPro software, Version 5.0. The data were entered on 14 desktop computers and carried out by 14 data entry operators and 2 questionnaire administrators, 3 secondary editors and one data entry supervisor. For quality assurance purposes, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS programme and adapted to the Sindh MICS questionnaire were used throughout. Data processing began simultaneously with data collection in February 2014 and was completed in August 2014. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, Version IBM PAWS 18 (SPSS). Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. P a g e | 7 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Sample Coverage Of the 19,360 households selected for the sample, 18,018 were found to be occupied. Of these, 17,014 were successfully interviewed for a household response rate of 94.4 percent. Despite issues of security, law and order, field teams were extremely successful in achieving such a high response rate in the context of Sindh. In the interviewed households, 29,898 women (age 15-49 years) were identified. Of these, 26,647 were successfully interviewed, yielding a response rate of 89.1 percent within the interviewed households. There were 18,108 children under age five listed in the household questionnaires. Questionnaires were completed for 16,605 of these children, which corresponds to a response rate of 91.7 percent within interviewed households. Overall response rates of 84.2 percent and 86.6 percent are calculated for the individual interviews of women and under-5s, respectively (Table HH.1). Table HH.1: Results of household, women's and under-5 interviews Number of households, women and children under 5 by results of the household, women's and under-5's interviews household, women's and under-5's response rates, Sindh, 2014 Total Area Division Urban Rural Larkana Sukkur Hyderabad Mirpurkhas Karachi Households Sampled 19,360 9,600 9,760 3,160 3,520 5,740 2,560 4,380 Occupied 18,018 8,818 9,200 2,939 3,347 5,257 2,440 4,035 Interviewed 17,014 7,964 9,050 2,877 3,253 5,037 2,394 3,453 Household response rate 94.4 90.3 98.4 97.9 97.2 95.8 98.1 85.6 Women Eligible 29,898 14,365 15,533 4,842 6,378 8,953 3,754 5,971 Interviewed 26,647 12,404 14,243 4,448 5,857 8,069 3,413 4,860 Women's response rate 89.1 86.3 91.7 91.9 91.8 90.1 90.9 81.4 Women's overall response rate 84.2 78.0 90.2 89.9 89.3 86.4 89.2 69.7 Children under 5 Eligible 18,108 7,270 10,838 3,716 4,126 5,171 2,511 2,584 Mothers/caretakers interviewed 16,605 6,429 10,176 3,451 3,855 4,807 2,326 2,166 Under-5's response rate 91.7 88.4 93.9 92.9 93.4 93.0 92.6 83.8 Under-5's overall response rate 86.6 79.9 92.4 90.9 90.8 89.1 90.9 71.7 Response rates were higher in rural than urban areas. Across divisions, response rates were lowest in Karachi division, which is highly urban. Access to households in Karachi division was limited due to the security situation in Karachi and non-availability of eligible women at home at the time of the survey despite several follow-ups, resulting in low response rates for women and children under 5. It should be noted that in anticipation of low response rates in Karachi, a non-response rate of 15 percent was factored into the sample size calculation for the division compared with a 10 percent non-response rate for all other divisions. However despite all efforts to mitigate the non-response, it was not possible to collect data in seven clusters in Karachi as indicated in the previous chapter. P a g e | 8 Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 17,014 households successfully interviewed in the survey, 121,826 household members were listed. Of these, 62,690 were males, and 59,136 were females. Table HH.2: Household age distribution by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Sindh, 2014 Total Males Females Number Percent Number Percent Number Percent Total 121,826 100.0 62,690 100.0 59,136 100.0 Age 0-4 16,540 13.6 8,540 13.6 8,000 13.5 5-9 15,803 13.0 8,052 12.8 7,750 13.1 10-14 14,082 11.6 7,349 11.7 6,733 11.4 15-19 12,575 10.3 6,447 10.3 6,128 10.4 20-24 11,619 9.5 5,895 9.4 5,724 9.7 25-29 11,012 9.0 5,531 8.8 5,481 9.3 30-34 8,608 7.1 4,531 7.2 4,076 6.9 35-39 6,722 5.5 3,520 5.6 3,203 5.4 40-44 5,417 4.4 2,785 4.4 2,632 4.5 45-49 4,689 3.8 2,420 3.9 2,268 3.8 50-54 4,146 3.4 1,965 3.1 2,181 3.7 55-59 3,332 2.7 1,709 2.7 1,623 2.7 60-64 2,985 2.4 1,606 2.6 1,378 2.3 65-69 1,748 1.4 967 1.5 781 1.3 70-74 1,236 1.0 691 1.1 544 0.9 75-79 561 0.5 308 0.5 252 0.4 80-84 446 0.4 225 0.4 221 0.4 85+ 304 0.2 146 0.2 158 0.3 Dependency age groups 0-14 46,425 38.1 23,941 38.2 22,484 38.0 15-64 71,104 58.4 36,409 58.1 34,695 58.7 65+ 4,295 3.5 2,337 3.7 1,957 3.3 Child and adult populations Children age 0-17 years 53,889 44.2 27,765 44.3 26,124 44.2 Adults age 18+ years 67,935 55.8 34,923 55.7 33,012 55.8 Note: Total includes 2 male household members with missing age Table HH.2 shows that 38.1 percent of the population is under 15 years and 3.5 percent is age 65 or over, showing a high dependent population. Children age less than 18 constitute 44.2 percent of the population and 55.8 percent of the population is 18 years or older. Sindh has a youthful population as shown by the broad base of the population pyramid. P a g e | 9 Figure 1 Figure HH.1: Age and sex d istr ibut ion of household populat ion , S ind h, 2014 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49 and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provides background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.12 Table HH.3 provides basic background information on the households, including the sex of the household head, division, area, number of household members and education of household head. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted total number of households is equal, since sample weights were normalized10. The table also shows the weighted mean household size estimated by the survey. The data show that only 6.4 percent of the households are headed by females in Sindh. A majority of the households (55.9 percent) are in urban areas compared with 44.1 percent in rural areas. Most households (40.7 percent) are found in Karachi division, followed by Hyderabad (21.8 percent). Regarding household size, 48.8 percent of the households in Sindh have more than 6 members and 20.2 percent of the households have 10 members or more. The average household size is 7.2 members. More than a third of the household heads have only pre-school or no education. 12 See Appendix B: Sample Design, for more details on sample weights. 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Per cent Age Males Females Note: 2 household members with missing age are excluded P a g e | 10 Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Sindh, 2014 Weighted percent Number of households Weighted Unweighted Total 100.0 17,014 17,014 Sex of household head Male 93.6 15,919 16,219 Female 6.4 1,095 795 Division Larkana 12.5 2,122 2,877 Sukkur 14.5 2,470 3,253 Hyderabad 21.8 3,710 5,037 Mirpurkhas 10.5 1,788 2,394 Karachi 40.7 6,925 3,453 Area Urban 55.9 9,503 7,964 Rural 44.1 7,511 9,050 Number of household members 1 0.8 130 85 2 4.4 744 663 3 7.1 1,203 1,139 4 10.9 1,848 1,687 5 14.1 2,406 2,223 6 14.0 2,390 2,327 7 12.3 2,087 2,099 8 9.4 1,595 1,700 9 6.9 1,167 1,283 10+ 20.2 3,444 3,808 Education of household head None/Preschool 35.1 5,964 6,583 Primary 20.0 3,406 3,790 Middle 8.6 1,463 1,321 Secondary 14.3 2,426 2,096 Higher secondary 8.4 1,422 1,331 Higher 13.5 2,294 1,847 Missing/DK 0.3 39 46 Mean household size 7.2 17,014 17,014 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). 10 In addition to providing useful information on the background characteristics of women and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. P a g e | 11 Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Sindh, 2014 Weighted percent Number of women Weighted Unweighted Total 100.0 26,647 26,647 Division Larkana 12.0 3,204 4,448 Sukkur 16.4 4,375 5,857 Hyderabad 22.3 5,943 8,069 Mirpurkhas 9.1 2,433 3,413 Karachi 40.1 10,691 4,860 Area Urban 56.0 14,911 12,404 Rural 44.0 11,736 14,243 Age 15-19 20.9 5,572 5,739 20-24 18.8 4,998 5,053 25-29 17.9 4,762 4,847 30-34 14.0 3,736 3,696 35-39 11.4 3,037 2,922 40-44 9.3 2,468 2,387 45-49 7.8 2,073 2,003 Marital status Currently married 65.5 17,448 17,679 Widowed 2.1 564 557 Divorced 0.6 167 137 Separated 0.2 58 64 Never married 31.6 8,410 8,210 Motherhood and recent births Never gave birth 40.6 10,831 10,758 Ever gave birth 59.4 15,816 15,889 Gave birth in last two years 22.9 6,095 6,581 No birth in last two years 36.5 9,723 9,311 Education None/Preschool 45.1 12,017 14,566 Primary 14.5 3,863 4,175 Middle 9.0 2,390 1,929 Secondary 14.2 3,796 2,771 Higher secondary 9.0 2,408 1,779 Higher 7.8 2,084 1,328 Missing/DK 0.3 89 99 Wealth index quintile Poorest 17.2 4,576 5,892 Second 18.4 4,904 6,539 Middle 20.0 5,329 6,414 Fourth 22.8 6,083 4,370 Richest 21.6 5,754 3,432 P a g e | 12 Table HH.4 provides background characteristics of female respondents, age 15-49 years. The table includes information on the distribution of women according to division, area, age, marital status, motherhood status, births in last two years, education13, wealth index quintiles14, 15 of the household head. The results show that 56 percent of female respondents live in urban areas. At division level, the distribution of women by division shows that a high proportion of women live in Karachi (40.1 percent) and 22.3 percent live in Hyderabad. Reflecting the young population, the age distribution shows that 20.9 percent of the women are in the 15-19 age group and this declines to 7.8 percent in the 45-49 age group. The data further show that 65.5 percent of women are currently married and 31.6 percent have never been married. Forty five percent of the women have only pre-school or no education, while 7.8 percent have more than secondary education. Seventeen perrcent of women live in households in the poorest wealth quintile and 22.8 percent in the fourth quintile. In addition, 59.4 percent of the women have ever given birth. More than one in five women gave birth in the two years preceding the survey. Background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, division and area, age in months, respondent type, mother’s (or caretaker’s) education and wealth. 13 Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondent when it is used as a background variable. 14 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D. and Pritchett, L., 2001. “Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India”. Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro and Rutstein, S.O., 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. Calverton, Maryland: Macro International Inc. 15 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest household population”, which is used interchangeably with “women in the wealthiest survey population” and similar. P a g e | 13 Table HH.5 shows that 51.7 percent of children under 5 are male and 48.3 percent are female. There are more children (53.9 percent) living in rural areas than urban areas (46.1 percent). More than half of the children live in Karachi and Hyderabad divisions. The child’s natural mother was interviewed in almost all cases (98.8 percent). Fifty seven percent of children under 5 are born to mothers or taken care by a care taker who had either pre-school or no education at all. It is interesting to note that one quarter of the children live in households in the poorest wealth quintile and this proportion falls to one in seven (14.7 percent) in the richest quintile. Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Sindh, 2014 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 16,605 16,605 Sex Male 51.7 8,585 8,536 Female 48.3 8,020 8,069 Division Larkana 16.4 2,719 3,451 Sukkur 19.3 3,203 3,855 Hyderabad 22.7 3,775 4,807 Mirpurkhas 10.6 1,767 2,326 Karachi 31.0 5,140 2,166 Area Urban 46.1 7,651 6,429 Rural 53.9 8,954 10,176 Age 0-5 months 9.5 1,574 1,622 6-11 months 10.8 1,800 1,774 12-23 months 19.0 3,160 3,143 24-35 months 18.9 3,142 3,137 36-47 months 21.1 3,499 3,549 48-59 months 20.7 3,429 3,380 Respondent to the under-5 questionnaire Mother 98.8 16,407 16,400 Other primary caretaker 1.2 198 205 Mother’s education a None/Preschool 57.1 9,478 10,885 Primary 14.5 2,407 2,454 Middle 6.2 1,035 797 Secondary 10.8 1,789 1,222 Higher secondary 6.5 1,085 744 Higher 4.9 808 499 Missing/DK 0.0 4 4 Wealth index quintile Poorest 25.2 4,183 4,987 Second 22.4 3,722 4,604 Middle 20.6 3,414 3,718 Fourth 17.2 2,852 1,915 Richest 14.7 2,435 1,381 a In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. P a g e | 14 Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. Table HH.6 presents characteristics of housing, disaggregated by area and division, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. The majority of households in Sindh (91.4 percent) have access to electricity. The proportion is higher in urban areas (98.9 percent) than rural ares (82 percent). Nearly all households (99.2 percent) in Karachi division have electricity. In contrast 35 percent of households in Mirpurkhas division do not have access to electricity. Information collected on flooring for households shows that 60.9 percent of households have a finished floor. There is wide urban-rural variation in floor types as 86.6 percent of urban dwellings have finished floor and 71 percent of rural households have a natural floor. Most households also have finished roofing and exterior walls. Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and divisions, Sindh, 2014 Total Area Division Urban Rural Larkana Sukkur Hyderabad Mirpurkhas Karachi Electricity Yes 91.4 98.9 82.0 94.7 94.1 86.1 65.0 99.2 No 8.5 1.1 18.0 5.3 5.9 13.9 35.0 0.8 Flooring Natural floor 35.6 7.7 71.0 71.5 58.5 50.0 66.6 0.8 Rudimentary floor 0.4 0.6 0.1 0.1 0.2 0.1 0.1 0.8 Finished floor 60.9 86.6 28.3 28.4 41.3 49.3 32.9 91.2 Other 3.1 5.1 0.6 0.1 0.0 0.5 0.4 7.2 Roof Natural roofing 5.9 0.7 12.4 4.8 6.6 5.9 28.6 0.0 Rudimentary roofing 19.6 4.3 39.0 40.1 23.6 36.1 30.2 0.4 Finished roofing 72.4 92.6 46.9 54.0 67.4 57.0 39.4 96.6 Other 2.1 2.4 1.7 0.9 2.4 1.0 1.8 3.0 Exterior walls Natural walls 17.7 2.4 37.1 24.0 20.6 32.0 44.3 0.2 Rudimentary walls 3.3 0.5 6.7 3.7 7.4 6.9 1.6 0.1 Finished walls 76.8 96.7 51.6 71.8 70.1 60.3 37.6 99.6 Other 2.3 0.4 4.6 0.5 1.8 0.8 16.5 0.1 Rooms used for sleeping 1 33.8 26.9 42.6 52.1 37.9 32.3 43.0 25.3 2 38.7 41.1 35.6 33.2 36.4 39.2 34.7 42.0 3 or more 26.5 31.6 20.0 12.6 24.0 27.3 21.1 32.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 17,014 9,503 7,511 2,122 2,470 3,710 1,788 6,925 Mean number of persons per room used for sleeping 3.9 3.4 4.6 5.2 4.8 4.0 4.2 3.2 P a g e | 15 Overall, 33.8 percent of the households in Sindh use one room for sleeping and a further 38.7 percent use two rooms for sleeping. On average, there are 3.9 persons sleeping in a room at provincial level and increases to 5.2 persons per room in Larkana division. In rural households, there is one person more sleeping per room than in urban areas (4.6 persons and 3.4 persons). In Table HH.7, households are distributed according to ownership of assets by households and by individual household members. This also includes ownership of dwelling. Sixty nine percent of households own an iron while 65.7 percent own a television. Most households also own a washing machine (51.8 percent), a sewing or knitting machine (44.5 percent) and a water lifting pump (43.5 percent). Ownership of these assets is higher in urban than rural areas. For example, ownership of televisison is more than twice as high in urban than rural areas (85.5 percent compared with 40.6 percent). Only 8.4 percent of households in Sindh own a radio. The results further show that 19.6 percent of households own a computer or laptop and 11.5 percent of the household have access to internet. Only 1.2 percent of households have access to internet in their homes in rural areas compared with 19.7 percent in urban areas. Agricultural land ownership is slightly lower than the national estimate for Pakistan. Only 18.3 percent households own agricultural land and 34.8 percent of the households own a farm animal or livestock. This is lower than national level results from Pakistan DHS 2012-13 showing that30.8 percent of households own agricultural land and 46.1 percent of households own a farm animal or livestock. Information collected on ownership of assets by household members shows that 87.5 percent of households have at least one household member who owns a mobile phone; 54.1 percent own a watch. Motorcycle or scooter is the most common means of transportation as 39.2 percent of households in Sindh have a family member who has a motor cycle or scooter. Nearly one in three (29.7 percent) of the households in Sindh have at least one household member who has a bank account. The proportion is higher in urban areas (40.7 percent) than rural areas (15.7 percent). Table HH.7 further shows that, almost eight out of every ten dwellings (79.9 percent) are owned by a household member and 14.9 percent of dweiings are being rented. Ownership of dwelling is more common in rural than urban areas (92.3 percent and 70.1 percent respectively) while renting is more common in urban areas as expected. P a g e | 16 Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and divisions, Sindh, 2014 Total Area Division Urban Rural Larkana Sukkur Hyderabad Mirpurkhas Karachi Percentage of households that own a Radio 8.4 6.7 10.6 7.5 9.6 11.7 9.6 6.2 Television 65.7 85.5 40.6 49.6 59.6 54.7 31.4 87.5 Non-mobile telephone 8.5 14.4 1.1 1.9 3.6 2.7 2.4 17.0 Refrigerator 47.7 70.7 18.7 23.9 32.8 30.6 18.1 77.2 Freezer 6.2 9.1 2.6 3.0 4.3 3.3 1.5 10.7 Air conditioner 9.8 15.9 2.1 7.2 6.4 9.2 2.6 14.0 Air cooler 2.8 3.8 1.5 2.5 6.0 2.4 1.4 2.4 Washing machine 51.8 75.1 22.3 36.7 43.5 30.5 17.2 79.7 Sewing machine or knitting- machine 44.5 59.5 25.4 30.0 39.8 34.6 26.7 60.4 Personal computer /Laptop 19.6 32.3 3.6 5.9 8.2 12.1 5.4 35.6 Water lifting pump 43.5 61.8 20.3 25.9 36.4 33.1 22.6 62.4 Iron 69.0 88.8 43.9 51.4 65.7 52.9 35.8 92.7 Internet 11.5 19.7 1.2 2.5 3.8 5.8 2.3 22.5 Percentage of households that own Agricultural land 18.3 6.7 33.0 25.9 37.6 21.6 29.2 4.6 Farm animals/Livestock 34.8 11.1 64.7 49.1 60.8 44.0 69.9 7.0 Percentage of households where at least one member owns or has a Watch 54.1 62.8 43.0 42.6 41.4 49.1 56.1 64.3 Mobile telephone 87.5 94.7 78.5 82.3 83.1 82.0 77.7 96.3 Bicycle 11.1 9.9 12.7 15.3 20.3 8.1 7.2 9.2 Motorcycle or scooter 39.2 47.5 28.8 25.2 38.5 35.9 20.0 50.5 Animal-drawn cart 7.4 1.5 15.0 15.6 16.3 8.8 9.7 0.5 Car / Truck / Jeep / Van 8.2 12.2 3.1 2.0 4.3 4.6 3.1 14.7 Boat 0.3 0.1 0.4 0.2 0.5 0.2 0.2 0.2 Tractor/Agriculture machinery 1.6 0.6 2.8 2.5 4.1 2.0 1.4 0.3 Bank account 29.7 40.7 15.7 20.3 25.8 21.2 16.6 41.9 Ownership of dwelling Owned by a household member 79.9 70.1 92.3 87.6 90.5 90.1 88.5 65.9 Not owned 20.1 29.9 7.7 12.3 9.4 9.9 11.4 34.0 Rented 14.9 25.3 1.7 4.3 4.2 6.3 2.8 29.6 Other 5.2 4.6 6.0 8.0 5.2 3.5 8.6 4.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 17,014 9,503 7,511 2,122 2,470 3,710 1,788 6,925 P a g e | 17 Table HH.8 shows how the household populations in areas and divisions are distributed according to household wealth quintiles. The data show that 36.3 percent of the urban population is in the richest quintile compared with only 2.1 percent in rural areas. In contrast, 38.8 percent of the rural population falls in the poorest quintile compared with only 3 percent in urban areas. Karachi division which is highly urban has 41.8 percent of the population in the richest wealth quintile and less than 1 percent in the poorest quintile. In contrast, 53.2 percent of the population Mirpurkhas division is in the poorest wealth quintile compared with 4.5 percent of population in the richest quintile. Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintiles, according to area of residence and divisions , Sindh, 2014 Wealth index quintiles Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 121,826 Area Urban 3.0 6.0 20.8 34.0 36.3 100.0 63,848 Rural 38.8 35.4 19.1 4.6 2.1 100.0 57,978 Division Larkana 28.9 39.7 21.6 7.1 2.7 100.0 16,413 Sukkur 18.9 37.3 28.2 10.1 5.5 100.0 21,072 Hyderabad 33.0 25.8 18.3 10.1 12.8 100.0 27,335 Mirpurkhas 53.2 19.5 15.8 6.9 4.5 100.0 12,231 Karachi 0.2 1.2 17.7 39.1 41.8 100.0 44,776 Figure 2 Figure HH.2: D istr ibut ion of wealth quint i les , urban, rural and tota l , S indh, 2014 0 5 10 15 20 25 30 35 40 45 1 2 3 4 5 Wealth Index Quintiles P e rc e n t Total Urban Rural P a g e | 18 IV. CHILD MORTALITY One of the overarching goals of the Millennium Development Goals (MDGs) is the reduction of infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two- thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. The infant mortality rate is the probability of dying before the first birthday, while the under-five mortality rate is the probability of dying before the fifth birthday. In Sindh MICS, an indirect method, known as the Brass method16, was used. Robust estimates of the aforementioned indicators are produced by this indirect method, and are comparable with those obtained by applying direct methods. The data used by the indirect methods are: the mean number of children ever born for five-year time-since-first-birth groups of women age 15 to 49 years, and the proportion of these children who are dead, also for five-year time-since-first-birth groups of women (Table CM.1). The technique converts the proportions dead among children of women in each time-since-first-birth group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Pakistan, the East model life table was selected as most appropriate. Table CM.1: Children ever born, children surviving and proportion dead Mean and total numbers of children ever born, children surviving and proportion dead by time since first birth, Sindh, 2014 Children ever born Children surviving Proportion dead Number of women age 15-49 years Mean Total Mean Total Total 3.7587 53,610 3.3633 47,970 0.1052 14,263 Time since first birth 0-4 1.6343 6,343 1.5009 5,826 0.0816 3,881 5-9 3.2251 11,015 2.9190 9,969 0.0949 3,415 10-14 4.4958 12,570 4.0286 11,263 0.1039 2,796 15-19 5.3553 12,740 4.7653 11,337 0.1102 2,379 20-24 6.1088 10,942 5.3457 9,575 0.1249 1,791 Table CM.2 provides estimates of infant and under-five mortality rates derived from proportion dead among children of women in various time-since-first-birth groups from 0-4 to 20-24. This table provides estimates of infant and under-5 mortality rates for various points in time prior to the survey. These estimates are later used in Figure CM.2 to compare the trend indicated by these rates with those from other data sources. 16 United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division. United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN. International Union for the Scientific Study of Population, 2013. Tools for Demographic Estimation. Paris, UNFPA. P a g e | 19 Table CM.2: Infant and under-5 mortality rates by time since first birth groups of women Indirect estimates of infant and under-5 mortality rates by time since first birth of women, and reference dates for estimates, East model, Sindh, 2014 Reference date Infant mortality rate Under-5 mortality rate Time since first birth 0-4 2012.3 82.8 105.2 5-9 2009.9 81.4 103.1 10-14 2007.2 82.4 104.6 15-19 2004.1 83.2 105.8 20-24 2000.7 87.3 111.7 To obtain the most recent single estimates of the two indicators by background characteristics, estimates from time since first birth groups 0-4 and 5-9 are averaged and presented in Table CM.3. Table CM.3: Infant and under-5 mortality rates by background characteristics Indirect estimates of infant and under-five mortality rates by selected background characteristics, time since first birth version, East Model, Sindh, 2014 Infant mortality rate 1 Under-five mortality rate 2 Total 82 104 Sex Male 88 110 Female 76 98 Division Larkana 109 142 Sukkur 105 137 Hyderabad 85 109 Mirpurkhas 91 116 Karachi 52 62 Area Urban 57 69 Rural 106 139 Mother's education None/Preschool 106 139 Primary 83 105 Middle 51 61 Secondary 51 61 Higher secondary 34 39 Higher 35 40 Wealth index quintile Poorest 117 154 Second 98 128 Middle 86 110 Fourth 62 76 Richest 30 34 1 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 2 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate Rates refer to January 2011. The East Model was assumed to approximate the age pattern of mortality in Pakistan. The infant mortality rate for Sindh is estimated at 82 deaths per thousand live births, while the probability of dying under age 5 (U5MR) is around 104 per thousand live births. Probability of dying among males is higher than females. The infant mortality rate for males is 88 deaths per thousand P a g e | 20 live births compared with 76 deaths per thousand for females. At division level, under-5 mortality rates are lowest in Karachi division at 62 deaths per thousand live births and highest in Larkana division at 142 per thousand live births. There is also notable urban-rural variation with under-5 mortality rate with mortality in rural areas being twice as high in urban areas (139 and 69 deaths per thousand live births respectively. Infant mortality rate in rural areas is 106 deaths per thousand live births compared with 57 deaths per thousand live births. There are also differences in infant and under-5 mortality in terms of mother's educational levels and wealth. Under-5 mortality for children whose mothers have pre-school or no education is high (139 deaths per thousand live births) and the rates decline as the mother’s educational level increases. Infant mortality rate for children whose mothers have higher secondary education is much lower, approximately, a third of the infant mortality rate for children from mothers with pre-school or no education (106 versus 35 deaths per thousand live births). The probability of dying before age 5 for children in richest households is much lower (34 deaths per thousand live births) than in poorest households (154 deaths per thousand live births). Similarly, Infant mortality rate is 117 deaths per thousand live births in the poorest quintile compared with 30 deaths per thousand live births in the richest quintile. Figure 3 Figure CM.1: Under -5 mortal i t y rates by d iv is ion, mother ’s educat ion , wealth quint i les and area , S indh, 2014 area, Sindh, 2014 Figure CM.2 compares the findings of Sindh MICS with Pakistan Demographic and Health Survey (PDHS) 2012-13. The under-5 mortality rates from Sindh MICS that are used for the comparison are obtained from Table CM.2. The MICS estimates indicate a decline in mortality during 2000-2009 with a slight incline in last 4 years. The U5MR estimate (104 per thousand live births) from MICS, which is the most recent, is about12 percent higher than the estimate from PDHS conducted about a year before MICS (2012-13). It should be noted that the PDHS uses a direct method of mortality P a g e | 21 estimation. PDHS also depicts a declining mortality trend; however, MICS results are considerably higher than those indicated by PDHS 2012-13. Further qualification of these apparent declines and differences as well as its determinants should be taken up in a more detailed and separate analysis. Figure 4 Figure CM.2: Trend in under -5 mortal i ty rates , S indh, 2014 0 20 40 60 80 100 120 1996 2000 2004 2008 2012 Per 1,000 live births Year PDHS 2012-13 PDHS 2006-07 MICS 2003-04 MICS 2014 P a g e | 22 V. NUTRITION Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.17 17 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16 P a g e | 23 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Sindh, 2014 Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live- born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Total 7.8 16.5 68.0 6.6 1.1 100.0 30.0 33.2 6,095 Mother's age at birth Less than 20 years 8.3 21.4 62.1 7.6 0.7 100.0 32.4 27.1 551 20-34 years 7.7 15.7 69.0 6.5 1.1 100.0 29.6 35.0 4,809 35-49 years 8.1 17.9 66.5 6.4 1.1 100.0 30.7 25.9 735 Birth order 1 8.6 16.1 68.2 5.8 1.3 100.0 30.4 43.7 1,398 2-3 6.5 15.9 69.4 7.3 0.9 100.0 28.6 38.5 2,335 4-5 7.8 17.5 66.8 6.9 1.1 100.0 30.7 26.6 1,282 6+ 9.8 17.1 66.3 5.8 1.1 100.0 31.6 16.1 1,080 Division Larkana 7.5 20.7 67.8 2.7 1.3 100.0 32.3 8.1 1,004 Sukkur 11.0 17.8 63.6 6.6 1.0 100.0 32.4 18.0 1,186 Hyderabad 7.4 15.9 66.9 8.8 1.0 100.0 28.8 23.8 1,362 Mirpurkhas 11.8 15.5 62.4 9.2 1.0 100.0 31.3 14.9 658 Karachi 4.9 14.2 73.7 6.1 1.1 100.0 27.5 69.2 1,886 Area Urban 6.5 15.3 70.8 6.6 0.9 100.0 28.7 55.2 2,812 Rural 9.0 17.5 65.7 6.6 1.2 100.0 31.1 14.3 3,284 Mother’s educationa None/Preschool 8.9 18.0 65.4 6.7 1.0 100.0 31.2 14.1 3,368 Primary 8.5 17.4 66.9 6.4 0.9 100.0 30.7 35.5 926 Middle 6.5 14.3 72.7 5.9 0.6 100.0 28.0 51.8 393 Secondary 5.1 13.6 72.9 6.0 2.4 100.0 27.9 63.1 682 Higher secondary 6.7 10.7 75.9 5.4 1.2 100.0 26.8 76.7 405 Higher 3.0 12.9 74.9 9.2 0.0 100.0 24.6 88.6 303 Wealth index quintile Poorest 9.6 18.9 64.3 6.2 1.0 100.0 32.1 7.5 1,510 Second 8.9 18.4 66.4 5.2 1.0 100.0 31.7 11.3 1,355 Middle 8.3 16.2 66.2 8.2 1.0 100.0 30.0 31.8 1,260 Fourth 5.8 13.1 74.1 5.9 1.1 100.0 27.2 57.5 1,044 Richest 4.8 14.0 72.2 7.9 1.1 100.0 27.0 81.5 926 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth a Total includes 20 unweighted cases of children whose mother’s education information is missing Overall, 33.2 percent of births were weighed at birth and 30 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.1). There was some variation by division. Karachi division had the lowest proportion of low birth weight babies (27.5 percent) compared with Sukkur and Larkana (32.4 and 32.3 percent respectively). Mother’s education and household wealth have an inverse relationship with low infant birth weight. About one in four mothers with higher education had infants weighing less than 2500 grams at birth compared with 31.2 percent of infants born to mothers with pre-school or no education. Infants in poorest households seem more likely to have a low birth weight (32.1 percent) compared with 27 percent of the infants born into the richest households. Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Under nutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to P a g e | 24 malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards18. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height - can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight-for-height can be used to assess wasting and overweight status. Children whose weight-for- height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended19 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. Children whose full birth date (month and year) were not obtained, and children whose measurements are outside a plausible range are excluded from Table NU.2. Children are excluded 18 http://www.who.int/childgrowth/standards/technical_report 19 See MICS Supply Procurement Instructions here: http://mics.unicef.org/tools P a g e | 25 from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.12, DQ.13, and DQ.14 in Appendix E. The tables show that due to incomplete dates of birth, implausible measurements, and/or missing weight and/or height, 4.9 percent of children have been excluded from calculations of the weight-for-age indicator, 6.7 percent from the height-for-age indicator, and 5 percent for the weight-for-height indicator. Only 2 percent of children age below 6 months did not have their weight measured and the proportion is twice as high (4.7 percent) among children age 48-59 months. The same trend is observed for length or height measurement. P a g e | 26 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Sindh, 2014 Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z-Score (SD) Stunted Mean Z-Score (SD) Wasted Overweight Mean Z-Score (SD) Percent below Percent below Percent below Percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Total 42.0 17.0 -1.8 15,786 48.0 24.4 -1.9 15,501 15.4 3.6 1.0 -0.9 15,794 Sex Male 43.2 17.6 -1.8 8,181 48.3 25.0 -2.0 8,021 17.4 4.2 0.9 -1.0 8,161 Female 40.7 16.3 -1.8 7,605 47.6 23.8 -1.9 7,481 13.3 3.0 1.2 -0.8 7,633 Division Larkana 46.1 19.8 -2.0 2,558 59.2 33.6 -2.3 2,507 12.2 3.5 0.7 -0.8 2,554 Sukkur 42.3 17.8 -1.9 3,007 51.2 26.1 -2.1 2,973 13.5 3.4 0.5 -0.9 3,112 Hyderabad 50.7 22.8 -2.0 3,609 55.5 30.6 -2.2 3,512 19.4 4.9 2.0 -1.0 3,578 Mirpurkhas 58.6 28.4 -2.3 1,715 58.6 33.0 -2.3 1,680 25.0 6.6 0.7 -1.3 1,696 Karachi 27.5 6.7 -1.3 4,897 31.0 11.2 -1.3 4,829 12.0 1.9 0.9 -0.8 4,854 Area Urban 32.7 10.5 -1.5 7,282 37.2 15.5 -1.5 7,183 13.5 2.8 0.9 -0.9 7,222 Rural 50.0 22.6 -2.0 8,504 57.3 32.2 -2.3 8,318 17.0 4.3 1.1 -1.0 8,572 Age 0-5 months 36.2 16.1 -1.7 1,535 27.0 11.7 -1.2 1,520 22.2 8.3 1.3 -1.0 1,502 6-11 months 35.2 14.3 -1.6 1,753 28.9 11.4 -1.2 1,741 21.1 5.9 0.2 -1.1 1,745 12-17 months 41.0 16.6 -1.7 1,664 45.0 19.1 -1.8 1,638 21.8 6.8 1.0 -1.1 1,653 18-23 months 40.8 17.4 -1.8 1,367 49.8 25.1 -2.0 1,344 18.3 4.0 0.3 -1.0 1,353 24-35 months 46.4 19.9 -1.9 3,002 60.3 32.8 -2.4 2,929 12.9 3.3 1.0 -0.8 2,994 36-47 months 44.6 18.8 -1.9 3,291 55.8 31.6 -2.3 3,211 11.1 1.5 1.3 -0.8 3,315 48-59 months 42.7 14.3 -1.8 3,175 50.0 25.2 -2.0 3,119 11.3 1.0 1.3 -0.8 3,231 Mother’s education a None/Preschool 50.9 23.1 -2.1 9,002 58.5 32.9 -2.3 8,794 17.0 4.6 1.0 -1.0 9,062 Primary 40.2 13.5 -1.7 2,310 47.1 21.2 -1.9 2,265 15.2 2.8 0.9 -0.9 2,297 Middle 29.6 8.2 -1.5 993 35.4 12.8 -1.5 988 13.6 2.5 0.6 -0.9 991 Secondary 28.2 8.2 -1.4 1,694 31.7 11.4 -1.4 1,686 11.6 2.4 0.7 -0.9 1,683 Higher secondary 21.7 4.9 -1.1 1,037 21.9 6.4 -1.0 1,026 12.1 1.5 0.8 -0.8 1,024 Higher 15.7 2.9 -0.9 746 15.8 3.7 -0.7 738 11.8 1.8 3.0 -0.7 733 Wealth index quintile Poorest 60.4 29.7 -2.3 3,999 63.9 39.0 -2.5 3,887 21.7 6.2 1.0 -1.2 4,010 Second 47.5 20.7 -2.0 3,515 57.4 31.2 -2.3 3,454 14.9 3.8 1.1 -0.9 3,560 Middle 38.3 13.2 -1.7 3,246 47.6 22.4 -1.9 3,206 13.3 2.6 0.9 -0.8 3,260 Fourth 28.7 7.5 -1.4 2,714 33.9 11.5 -1.5 2,675 12.5 2.4 0.8 -0.9 2,691 Richest 22.6 5.7 -1.1 2,312 23.7 7.3 -1.1 2,281 11.3 2.0 1.3 -0.7 2,273 1 MICS indicator 2.1a and MDG indicator 1.8 - Underweight prevalence (moderate and severe) 2 MICS indicator 2.1b - Underweight prevalence (severe) 3 MICS indicator 2.2a - Stunting prevalence (moderate and severe) 4 MICS indicator 2.2b - Stunting prevalence (severe) 5 MICS indicator 2.3a - Wasting prevalence (moderate and severe) 6 MICS indicator 2.3b - Wasting prevalence (severe) 7 MICS indicator 2.4 - Overweight prevalence a Total includes 4 unweighted cases of mother’s education missing P a g e | 27 In Sindh, 42 percent of children under age five are are moderately or severely underweight and 17 percent are classified as severely underweight (Table NU.2). Almost half of children (48 percent) are moderately stunted or too short for their age and 15.4 percent are moderately wasted or too thin for their height. Only 1 percent of children are overweight or too heavy for their height. Children in Mirpurkhas division are more likely to be underweight (58.6 percent) than the children in other divisions. In contrast, the percentage stunted is highest in Larkana division (59 percent). All three anthopometric indicators are lowest in Karachi division. Comparison by area shows that half of the children in rural areas are underweight compared with 32.7 percent of children in urban areas. Stunting and wasting is also higher in rural areas (57.3 percent and 17.0 percent respectively). Those children whose mothers have secondary or higher education are the least likely to be underweight and stunted compared with children of mothers with pre-school or no education. Boys are slightly more likely to be underweight, stunted and wasted than girls. For example 17.4 percent of boys are wasted compared with 13.3 percent for girls. The age pattern shows that wasting peaks among children age under 6 months while underweight and stunting peaks among children age 24- 35 months (Figure NU.1). Mothers with more than higher secondary education are more likely to have children that are overweight. Figure 5 Figure NU.1: Under weight , s tunted, wast ed and over weight ch i ldren under age 5 (moderat e and sever e) , S indh, 2014 Underweight Stunted Wasted Overweight 0 10 20 30 40 50 60 70 0 12 24 36 48 60 P er c en t Age in months P a g e | 28 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life. 20 UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond. 21 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.22 A summary of key guiding principles23, 24 for feeding 6- 23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. The guiding principles for which proximate measures and indicators exist are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and (iii) appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Diet diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For diet diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).25 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds; 20 Bhuta Z. et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 21 WHO (2003). Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February 2003. 22 WHO (2003). Global Strategy for Infant and Young Child Feeding. 23 PAHO (2003). Guiding principles for complementary feeding of the breastfed child. 24 WHO (2005). Guiding principles for feeding non-breastfed children 6-24 months of age 25 WHO (2008). Indicators for assessing infant and young child feeding practices. Part 1: Definitions. P a g e | 29 (ii) food items form at least 4 food groups; and (iii) breastmilk or at least 2 milk feeds (for non-breastfed children). Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups 26 eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists na Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na 26 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. P a g e | 30 Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth, and within one day of birth, and percentage who received a prelacteal feed, Sindh, 2014 Percentage who were ever breastfed 1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live- born children in the last two years Within one hour of birth 2 Within one day of birth Total 95.6 20.7 68.9 49.0 6,095 Division Larkana 95.3 32.4 71.8 38.9 1,004 Sukkur 94.9 14.8 59.2 67.4 1,186 Hyderabad 95.6 27.3 76.5 34.8 1,362 Mirpurkhas 96.1 16.9 61.8 44.5 658 Karachi 96.0 14.7 70.4 54.7 1,886 Area Urban 95.4 17.3 69.0 53.1 2,812 Rural 95.8 23.6 68.8 45.5 3,284 Months since last birth 0-11 months 95.4 17.3 69.0 53.1 2,812 12-23 months 95.8 23.6 68.8 45.5 3,284 Assistance at delivery Skilled attendant 95.7 17.6 68.1 50.6 4,008 Traditional birth attendant 96.9 27.7 72.5 46.3 1,695 Other 96.8 23.7 66.6 48.3 355 No one/Missing (10.6) (2.1) (8.5) (4.6) 38 Place of delivery Home 96.9 26.8 71.8 46.9 2,130 Health facility Public 96.7 20.8 73.7 42.5 990 Private 95.3 16.5 65.9 53.4 2,911 Other/DK/Missing 48.8 5.0 32.5 22.2 64 Mother’s education None/Preschool 95.8 23.3 67.5 47.5 3,368 Primary 95.5 23.3 72.1 50.7 926 Middle 96.5 13.9 71.4 53.3 393 Secondary 93.3 12.7 67.2 53.1 682 Higher secondary 97.7 11.2 71.8 47.4 405 Higher 95.5 22.1 70.1 49.8 303 Wealth index quintile Poorest 96.6 25.3 68.9 42.3 1,510 Second 96.0 24.7 68.9 46.9 1,355 Middle 94.9 18.4 67.1 51.9 1,260 Fourth 94.3 14.0 68.1 52.8 1,044 Richest 95.9 17.9 72.1 54.9 926 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding a Total includes 20 unweighted cases of children whose mother’s education information is missing ( ) Figures that are based on 25–49 unweighted cases Table NU.3 is based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were P a g e | 31 first breastfed within one hour and one day of birth, and those who received a prelacteal feed.27 Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, 20.7 percent of babies are breastfed for the first time within one hour of birth, while 68.9 percent of new-borns in Sindh start breastfeeding within one day of birth. Nearly half (49 percent) of newborns receive prelacteal feed. The findings are presented in Figure NU.2 by division and area. In urban areas, mothers are less likely to initiate breastfeeding within one hour of birth than in rural areas. At division level, more children in Larkana are breastfed within the first hour of birth than the other divisions. Similarly, children delivered at home and those delivered with the assistance of a traditional birth attendant are more likely to be breastfed within one hour of being born. As shown in the table NU.3 there is a curvilinear relationship between first breastfeeding within one hour of birth and mother’s educational level. Twenty three percent of children born to mothers with pre-school or no education are breastfed within one hour of birth and this proportion drops for children whose mothers have secondary education but increases for mothers with higher education. Figure 6 Figure NU.2: In i t iat ion of breastfeeding, S indh, 2014 As seen in the Figure NU.2, percentage of children age 0-5 months that were breastfed within one day of birth is almost 60 percent or above across all divisions, urban rural areas and also at provincial level. Initiation of breastfeeding within one hour of birth varies from 15 percent to 32 percent across all divisions. 27 Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). 72 59 77 62 70 69 69 69 32 15 27 17 15 17 24 21 0 20 40 60 80 100 P er c en t Within one day Within one hour P a g e | 32 The set of Infant and Young Child Feeding indicators reported in tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to being interviewed. Data are subject to a number of limitations, some related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Sindh, 2014 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed 1 Percent predominantly breastfed 2 Number of children Percent breastfed (Continued breastfeeding at 1 year) 3 Number of children Percent breastfed (Continued breastfeeding at 2 years) 4 Number of children Total 28.9 56.0 1,574 76.7 1,128 48.9 852 Sex Male 29.3 54.3 871 77.5 581 46.4 432 Female 28.4 58.1 703 75.9 546 51.5 420 Division Larkana 27.9 53.5 289 80.1 228 55.8 126 Sukkur 19.1 49.2 335 77.8 205 50.3 145 Hyderabad 33.0 65.2 347 80.2 254 51.6 190 Mirpurkhas 42.4 75.5 182 80.9 138 49.7 87 Karachi 28.1 47.2 422 68.6 302 43.4 304 Area Urban 31.5 50.7 644 70.6 484 44.5 472 Rural 27.0 59.7 930 81.3 644 54.4 380 Mother’s education None/Preschool 25.4 59.2 930 77.8 680 53.0 463 Primary 34.5 55.5 234 73.0 163 53.2 127 Middle 36.4 65.1 121 (86.0) 55 (44.9) 53 Secondary 36.6 50.8 139 79.4 109 35.5 90 Higher secondary 24.3 28.7 87 64.4 80 49.5 58 Higher (34.4) (42.2) 63 (77.2) 42 31.4 61 Wealth index quintile Poorest 30.0 66.3 440 81.4 317 57.3 179 Second 23.4 54.3 389 82.9 255 57.1 177 Middle 28.5 61.3 302 70.2 213 47.2 183 Fourth 30.0 40.5 241 74.3 183 38.4 153 Richest 36.1 47.6 201 69.1 159 42.2 159 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.8 - Predominant breastfeeding under 6 months 3 MICS indicator 2.9 - Continued breastfeeding at 1 year 4 MICS indicator 2.10 - Continued breastfeeding at 2 years ( ) Figures that are based on 25–49 unweighted cases In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed (calculated from last 24 hours memory recall method); referring to infants age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. In Sindh, 28.9 percent of children less than six months age are exclusively breastfed. With 56 percent predominantly breastfed; plain water appears to be the main factor interrupting exclusive breastfeeding practices. By age 12-15 months, 76.7 percent of children are still breastfed and by age 20-23 months this falls to 48.9 percent of children. P a g e | 33 Exclusive breastfeeding for children age less than six months is slightly higher in urban areas than rural areas. In Sukkur division fewer children (19.1 percent) are exclusively breastfed compared with children in the other divisions. Predominant breastfeeding ranges from 47.2 percent in Karachi division to 75.5 percent in Mirpurkhas division. In rural Sindh, more than half of the children continue to breastfeed at the age of two and slightly more female than male children continue to breasfeed at that same age. Figure 7 Figure NU.3: Infant feeding patterns by age , S indh, 2014 Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest age of 0-1 months, the majority of children are receiving liquids or foods other than breast milk, with other milk, formula and plain water being provided. At age 4-5 months old, the percentage of children exclusively breastfed is only 16 percent. About 45 percent of children are receiving breast milk at age 22-23 months. Exclusively breastfed Breastfed and complimentary foods Weaned (not breastfed) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age in months Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk / formula Breastfed and complimentary foods Weaned (not breastfed) P a g e | 34 Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Sindh, 2014 Median duration (in months) of: Number of children age 0-35 months Any breastfeeding 1 Exclusive breastfeeding Predominant breastfeeding Median 21.3 0.7 3.3 9,677 Sex Male 21.0 0.9 3.2 4,999 Female 21.6 0.7 3.5 4,677 Division Larkana 21.9 0.7 3.2 1,591 Sukkur 21.4 0.6 2.4 1,893 Hyderabad 21.9 1.1 4.5 2,152 Mirpurkhas 21.4 2.0 5.6 1,041 Karachi 20.7 1.0 2.3 2,999 Area Urban 20.5 1.1 2.6 4,471 Rural 21.8 0.7 4.0 5,206 Mother’s education None/Preschool 21.8 0.7 4.0 5,360 Primary 21.5 1.5 3.1 1,513 Middle 21.2 1.9 4.4 621 Secondary 20.3 1.9 2.6 1,056 Higher secondary 19.8 0.5 0.6 649 Higher 16.9 1.9 2.2 475 Wealth index quintile Poorest 22.4 0.7 5.4 2,372 Second 22.0 0.6 3.3 2,165 Middle 20.6 1.2 3.6 2,038 Fourth 20.3 0.8 1.9 1,664 Richest 20.3 1.6 2.3 1,439 Mean 20.5 1.9 4.6 9,677 1 MICS indicator 2.11 - Duration of breastfeeding Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 21.3 months for any breastfeeding, less than 1 month for exclusive breastfeeding, and 3.3 months for predominant breastfeeding. The median duration of any breastfeeding among women with higher education is on average almost five months shorter than that of women with pre-school or no education. The median duration of predominant breastfeeding and any breastfeeding is longer in rural areas (4.0 months) compared with urban areas (2.6 months). Similarly, the median duration of exclusive breastfeeding is slightly higher in urban than rural areas (1.1 months and 0.7 months respectively). The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children age 6-23 months are considered to be appropriately fed if they are receiving breast milk and solid, semi-solid or soft food. As a result of feeding patterns, 61.1 percent of children age 6-23 months are being appropriately breastfed and age-appropriate breastfeeding among all children age 0-23 months drops to 53.4 percent. Proportion of children age 0-23 months, that are appropriately fed is higher in Mirpurkhas division (56.6 percent) compared with 48.7 percent in Sukkur division. Age appropriate feeding is also found to be slightly higher among girls than boys. P a g e | 35 Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Sindh, 2014 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 Total 28.9 1,574 61.1 4,960 53.4 6,534 Sex Male 29.3 871 59.0 2,521 51.3 3,392 Female 28.4 703 63.4 2,439 55.5 3,142 Division Larkana 27.9 289 61.2 808 52.4 1,097 Sukkur 19.1 335 59.3 932 48.7 1,267 Hyderabad 33.0 347 62.8 1,108 55.7 1,455 Mirpurkhas 42.4 182 61.6 523 56.6 704 Karachi 28.1 422 60.9 1,588 54.0 2,010 Area Urban 31.5 644 61.0 2,376 54.7 3,020 Rural 27.0 930 61.2 2,584 52.2 3,514 Mother’s education None/Preschool 25.4 930 61.8 2,689 52.5 3,619 Primary 34.5 234 58.9 784 53.3 1,018 Middle 36.4 121 64.0 304 56.1 425 Secondary 36.6 139 62.5 564 57.4 703 Higher secondary 24.3 87 59.1 357 52.3 444 Higher (34.4) 63 56.9 262 52.5 325 Wealth index quintile Poorest 30.0 440 61.5 1,177 53.0 1,617 Second 23.4 389 62.9 1,077 52.4 1,466 Middle 28.5 302 59.1 1,067 52.4 1,369 Fourth 30.0 241 60.2 853 53.5 1,095 Richest 36.1 201 61.8 786 56.5 987 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding a Total includes 2 unweighted case whose mother’s education is missing ( ) Figures that are based on 25–49 unweighted cases Table NU.7 shows that overall, 63.9 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day. Among currently breastfeeding infants, the corresponding percentage is 63 percent while it is 76.6 percent among infants currently not breastfeeding. Due to the the small age group represented by the indicator denominator, results in this table are only shown by province, child’s sex and urban- rural residence. Sixty nine percent of female infants receive solid, semi-solid, or soft foods compared with 58.5 percent of male infants. A higher proportion of infants living in urban areas (76.5 percent) receive solid, semi-solid, or soft foods as compared with infants living in rural areas (53.7 percent). Similar patterns are observed for breastfeeding and non-breastfeeding infants. P a g e | 36 In the following table NU.8, overall, more than half (55.7 percent) of the children age 6-23 months were receiving solid, semi-solid and soft foods the minimum number of times. A slightly higher proportion of female children (57 percent) were achieving the minimum meal frequency compared with male children (54.4 percent). The proportion of children receiving the minimum dietary diversity, or foods from at least 4 food groups, was much lower (14.2 percent) than that for minimum meal frequency, indicating the need to focus on improving diet diversity and nutrient intake among children. A higher proportion of older children age18-23 month old (24.9 percent) were achieving the minimum dietary diversity compared with only 2.7 percent of younger children (6-8 month old). The overall assessment using the indicator of minimum acceptable diet revealed that only 8.9 percent of children age 6-23 months were benefitting from a diet sufficient in both diversity and frequency. Children in urban areas, richest households and those whose mothers have higher education are most likely to receive as recommended the minimum meal frequency, minimum dietary diversity and minimum acceptable diet. Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Sindh, 2014 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 Total 63.0 938 76.6 67 63.9 1,006 Sex Male 57.2 460 73.0 43 58.5 503 Female 68.7 478 82.9 24 69.4 502 Area Urban 76.3 410 79.3 42 76.5 451 Rural 52.8 529 72.1 26 53.7 554 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods P a g e | 37 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Sindh, 2014 Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversity Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Total 10.8 48.5 9.3 3,655 25.3 78.3 7.7 69.6 1,162 14.2 55.7 8.9 4,960 Sex Male 10.1 46.9 8.6 1,838 26.5 76.8 8.8 72.6 610 14.1 54.4 8.7 2,521 Female 11.4 50.0 9.9 1,818 23.9 79.9 6.6 66.3 552 14.2 57.0 9.1 2,439 Age 6-8 months 2.3 44.3 1.7 938 10.1 83.4 0.0 83.7 51 2.7 46.3 1.6 1,006 9-11 months 5.5 37.6 5.4 674 9.0 88.4 3.0 92.7 91 5.7 43.7 5.1 795 12-17 months 13.3 51.1 11.1 1,259 23.4 78.9 7.6 75.1 431 15.9 58.2 10.2 1,731 18-23 months 21.4 58.5 18.7 784 30.4 75.9 9.2 60.8 590 24.9 66.0 14.6 1,429 Division Larkana 7.2 39.2 5.3 630 18.1 66.3 1.5 56.0 167 9.4 44.9 4.5 808 Sukkur 7.9 48.4 6.7 695 19.0 80.7 7.0 75.7 218 10.6 56.2 6.8 932 Hyderabad 9.3 43.4 7.1 848 24.1 66.1 4.7 61.5 228 12.5 48.2 6.6 1,108 Mirpurkhas 4.8 40.7 3.5 403 11.6 75.1 1.4 66.8 109 6.5 48.0 3.0 523 Karachi 18.1 60.7 17.0 1,081 35.1 88.7 13.7 76.5 440 22.4 68.8 16.1 1,588 Area Urban 15.2 55.5 13.6 1,642 31.3 83.1 11.2 71.7 653 19.5 63.3 12.9 2,376 Rural 7.2 42.7 5.7 2,014 17.5 72.1 3.3 66.8 509 9.2 48.7 5.2 2,584 Mother’s education d None/Preschool 7.4 44.5 6.0 2,062 17.7 72.2 3.6 60.9 560 9.5 50.4 5.5 2,689 Primary 7.3 46.5 6.6 578 22.8 76.9 5.2 68.6 179 10.9 53.7 6.2 784 Middle 14.7 53.4 12.5 228 22.2 83.2 7.1 78.8 72 16.3 60.5 11.2 304 Secondary 13.2 55.8 12.5 392 35.9 85.8 20.3 81.5 144 19.1 63.9 14.6 564 Higher secondary 22.3 55.1 19.2 238 32.7 91.6 10.8 82.3 108 25.6 66.5 16.6 357 Higher 39.5 71.7 34.3 156 51.0 85.9 14.7 82.3 100 43.5 77.2 26.6 262 Wealth index quintile Poorest 5.4 40.1 4.4 944 14.0 68.9 1.6 61.9 217 7.1 45.5 3.9 1,177 Second 7.9 44.5 6.0 843 13.7 69.6 2.0 59.4 210 9.0 49.5 5.2 1,077 Middle 8.3 47.9 6.9 749 20.8 77.2 5.9 66.3 271 11.4 55.7 6.6 1,067 Fourth 13.0 54.9 11.9 594 34.7 86.3 13.0 77.2 236 18.8 63.8 12.2 853 Richest 26.3 63.4 23.4 525 42.2 88.1 15.6 82.1 228 30.5 70.9 21.1 786 1 MICS indicator 2.17a - Minimum acceptable diet (breastfed) 2 MICS indicator 2.17b - Minimum acceptable diet (non-breastfed) 3 MICS indicator 2.14 - Milk feeding frequency for non-breastfed children 4 MICS indicator 2.16 - Minimum dietary diversity 5 MICS indicator 2.15 - Minimum meal frequency a Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. b Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times. c The minimum acceptable diet for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while for non-breastfed children it further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds. d Total includes 2 unweighted case of children whose mother’s education information is missing P a g e | 38 The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.9 shows that bottle- feeding is prevalent in Sindh as 37 percent of children age 0-23 months are fed using a bottle with a nipple. Among of children under 6 months, 30.4 percent are fed using a bottle with a nipple and this increases to 39.3 percent for older children age 6-11 months. There are slightly more male than female children that are bottle-fed. More than half (51.4 percent) of the children under two years are bottle fed in Karachi division compared with 14.4 percent in Mirpurkhas division. Children in urban areas are more likely (46.2 percent) to be fed with a bottle with a nipple compared with children in rural areas (29.2 percent). There exists a positive relationship between bottlefeeding of the child and the mother’s education as well as wealth status. Three in every ten children born to mother with no education are fed with a bottle with a nipple compared with six in ten children born to mothers with higher education. Similarly, the wealthier the household, the more likely the child is to be fed with a bottle with a nipple. Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Sindh, 2014 Percentage of children age 0-23 months fed with a bottle with a nipple 1 Number of children age 0-23 months Total 37.0 6,534 Sex Male 38.4 3,392 Female 35.6 3,142 Age 0-5 months 30.4 1,574 6-11 months 39.3 1,800 12-23 months 39.1 3,160 Division Larkana 35.3 1,097 Sukkur 43.1 1,267 Hyderabad 24.1 1,455 Mirpurkhas 14.4 704 Karachi 51.4 2,010 Area Urban 46.2 3,020 Rural 29.2 3,514 Mother’s education a None/Preschool 29.3 3,619 Primary 38.8 1,018 Middle 37.7 425 Secondary 50.4 703 Higher secondary 58.3 444 Higher 58.3 325 Wealth index quintile Poorest 20.7 1,617 Second 30.5 1,466 Middle 41.6 1,369 Fourth 47.0 1,095 Richest 56.1 987 1 MICS indicator 2.18 - Bottle feeding a Total has 2 unweighted case of children with mother’s education missing P a g e | 39 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). Government of Pakistan Nutrition Department with the assistance of Micronutrient Initiative and in collaboration with development partners which include WFP, UNICEF and GAIN is implementing a Universal Salt Iodization (USI) Project in selected 102 districts of Pakistan and the entire Sindh province. The project aims to ensure that all the edible salt produced or imported from other provinces is adequately iodized. In Sindh, the program started in 2006 covering four districts in Karachi division and was later expanded to the remaining districts in 2010. Furthermore, to ensure adequate availability and use of iodized salt, Sindh Government legistlated the “Sindh Compulsory Salt Iodization Act” in 2013. According to this act, the manufacturers, processors and importers of salt shall not process, store, sell uniodized salt neither sell any misbranded or mislabeled salt and any person who contravenes any of the provisions of this act shall be prosecuted by law. Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Sindh, 2014 Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM 1 Total 97.2 17,014 1.4 34.6 27.9 36.2 100.0 16,769 Division Larkana 98.1 2,122 0.9 54.5 24.6 20.0 100.0 2,101 Sukkur 98.4 2,470 0.9 47.5 18.5 33.2 100.0 2,452 Hyderabad 97.1 3,710 1.9 29.9 35.2 33.0 100.0 3,672 Mirpurkhas 98.1 1,788 1.2 48.7 24.0 26.1 100.0 1,775 Karachi 96.3 6,925 1.5 22.5 29.3 46.7 100.0 6,769 Area Urban 96.4 9,503 1.6 23.8 28.9 45.7 100.0 9,306 Rural 98.2 7,511 1.2 47.9 26.6 24.3 100.0 7,463 Wealth index quintile Poorest 97.6 3,607 1.8 53.4 26.2 18.6 100.0 3,583 Second 98.3 3,061 1.1 46.1 28.1 24.8 100.0 3,042 Middle 97.4 3,202 1.7 36.4 32.3 29.6 100.0 3,175 Fourth 96.6 3,609 1.5 24.1 31.9 42.5 100.0 3,537 Richest 96.2 3,535 0.9 13.8 21.1 64.2 100.0 3,431 1 MICS indicator 2.19 - Iodized salt consumption In 97.2 percent of households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate. Table NU.10 shows that in about 1 percent of households, there was no salt available. These households are included in the denominator of the indicator. In 36.2 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. In Karachi division, 46.7 percent of households use adequately iodized salt. More than 45 percent of urban households were found to be using adequately iodized salt as compared with 24.3 percent in rural areas. Similarly, use of adequately iodized salt is higher in richest households (64.2 percent) than poorest households (18.6 percent). The consumption of adequately iodized salt is graphically presented in Figure NU.4 together with the percentage of salt containing less the 15 ppm. Figure 8 P a g e | 40 Figure 8 Figure NU.4: Consumption of iodized sa lt , S indh, 2014 For futher quantitative testing of iodine content in salt, two households per cluster were selected to provide additional 50 grams of cooking salt for testing of iodine in a laboratory. Of the 1,770 households selected for laboratory iodine testing of salt, testing was done for 98 percent of the households. The iodine laboratory testing was conducted by the Quality Control Centre Karachi of the Pakistan Standards and Quality Control Authority of Government of Pakistan. Equipment known as I-Check was used for the analysis. Separate quantitative analysis is being done based on laboratory results. 45 52 68 50 76 75 51 45 53 62 74 85 64 2 0 3 3 3 3 2 6 4 7 4 6 2 4 1 9 2 5 3 0 4 2 6 4 3 6 0 20 40 60 80 100 P er c en t Any iodine 15+ PPM of iodine P a g e | 41 Table NU11: Purchasing behaviour and packaging type for iodized salt Percent distribution of households by purchasing behaviour and packaging of salt used to cook meals, Sindh, 2014 Percentage of households in which additional test for salt was done Purchasing behavior by whether household looks/asks for salt with a handi logo or salt labeled as iodised Packaging of the household salt Number of households selected for additional salt testing and with salt in the house Yes iodine logo/label sought No Missing/DK Total Sealed package Unsealed package/ loose salt Rock salt Missing/DK Total Total 94.2 23.1 68.5 8.4 100.0 68.1 17.1 10.0 4.8 100.0 1,748 Division Larkana 91.0 14.8 69.2 16.1 100.0 44.7 34.5 12.0 8.8 100.0 228 Sukkur 97.1 14.7 79.3 6.0 100.0 59.9 34.5 1.3 4.3 100.0 247 Hyderabad 92.4 11.9 78.9 9.2 100.0 68.1 15.3 10.9 5.7 100.0 383 Mirpurkhas 92.4 12.4 75.0 12.6 100.0 56.3 23.5 13.1 7.1 100.0 187 Karachi 95.6 37.7 57.0 5.3 100.0 81.6 4.6 11.2 2.6 100.0 703 Area Urban 94.1 31.8 61.3 6.9 100.0 77.0 11.0 8.2 3.7 100.0 974 Rural 94.2 12.1 77.5 10.4 100.0 56.8 24.8 12.2 6.2 100.0 775 Salt Packaging Sealed package 97.6 32.4 63.4 4.2 100.0 100.0 0.0 0.0 0.0 100.0 1,190 Unsealed package/ Loose salt 99.5 3.4 90.1 6.5 100.0 0.0 100.0 0.0 0.0 100.0 299 Rock salt 98.8 4.6 92.4 3.0 100.0 0.0 0.0 100.0 0.0 100.0 175 Missing/DK 17.2 0.0 12.9 87.1 100.0 na na na na na 84 Wealth index quintile Poorest 94.2 7.7 81.4 10.9 100.0 54.4 24.9 14.4 6.4 100.0 371 Second 93.0 10.6 77.7 11.8 100.0 57.3 28.6 8.0 6.1 100.0 321 Middle 94.5 19.5 72.5 8.0 100.0 62.8 22.2 9.3 5.7 100.0 346 Fourth 93.8 29.8 63.4 6.8 100.0 78.1 7.6 10.8 3.5 100.0 360 Richest 95.2 47.6 47.5 4.9 100.0 87.3 3.0 7.2 2.5 100.0 349 na :not applicable P a g e | 42 In the households selected for additional salt testing, other information was collected on whether the household looks for a particular logo on the salt packet indicating that salt is iodised. Table NU.11 presents findings on these additional questions. At provincial level, 23.1 percent of households reported that they look for salt with an iodine label or handi logo when buying salt. More households in urban areas (31.8 percent) reported that they look for iodine label or handi logo before purchasing salt as compared with 12.1 percent of households in rural areas. The survey results further show that households that buy packaged salt are more likely to look for an iodine label or handi label than households buying salt in an unsealed package (32.4 percent and 3.4 percent respectively). Almost half of the richest households (47.6 percent) reported that they look for iodine label or handi logo when purchasing salt compared with 7.7 percent of the poorest households. Sixty percent of households purchase salt in a sealed package for cooking while 17.1 percent purchase salt in unsealed package or purchase loose salt. The majority of the richest households (87.3 percent) purchase salt in a sealed package compared with 54.4 percent of the poorest households. P a g e | 43 VI. CHILD HEALTH Vaccinations The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still millions of children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT containing vaccine to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and a first dose of measles vaccination before a child’s first birthday (N.B., due to the epidemiology of disease in a country, the first dose of measles vaccine may be recommended at 12 months or later). The vaccination schedule followed by the Pakistan Expanded Program on Immunization (EPI) provides all the above mentioned vaccinations. This includes polio at birth, three doses of pentavalent vaccine comprising of antigens against diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenza type b (Hib), three doses of pneumococcal conjugate vaccine and one dose of measles during the first year of life followed by second dose of measles at the age of 12-15 months. Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the Sindh MICS are based on children age 12-23 months. Information on vaccination coverage was collected for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied vaccination information from the cards onto the MICS questionnaire. If no vaccination card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations, and for Polio, Penta and pneumococcal, how many doses were received. Information was also obtained from vaccination records at health facilities for all children through a separate questionnaire. The final vaccination coverage estimates are based on information obtained from the vaccination records at health facility, vaccination card or mother’s report of vaccinations received by the child. P a g e | 44 Table CH.1: Vaccinations in the first years of life Percentage of children age 12-23 months and 24-35 months vaccinated against vaccine preventable childhood diseases at any time before the survey and by their first birthday, Sindh, 2014 Children age 12-23 months: Children age 24-35 months: Vaccinated at any time before the survey according to: Vaccinated by 12 months of age a Vaccinated at any time before the survey according to: Vaccinated by 12 months of age Vaccination card or health facility records Mother's report Either Vaccination card or health facility records Mother's report Either Antigen BCG1 50.5 26.9 77.4 76.3 39.2 36.7 76.0 71.9 Polio At birth 45.9 28.2 74.1 73.4 33.4 38.1 71.5 69.2 1 48.8 28.9 77.8 76.0 37.2 40.5 77.7 72.1 2 46.2 25.6 71.8 69.9 34.9 36.0 71.0 64.3 3 2 42.3 21.2 63.5 60.3 32.3 30.6 62.9 55.3 Pentavalent 3 1 50.5 20.3 70.7 68.7 39.0 29.5 68.5 62.8 2 47.7 17.2 64.9 63.0 36.7 25.9 62.6 56.5 3 43.5 11.7 55.3 52.7 34.1 18.9 53.1 46.4 Pneumococcal 4 1 23.9 12.6 70.7 66.8 8.8 14.9 68.5 54.3 2 21.7 10.8 64.9 61.5 7.8 12.1 62.6 48.4 3 20.1 7.5 55.3 50.4 7.1 7.7 53.1 40.8 Measles 1 5 38.6 20.0 58.6 52.7 32.0 30.2 62.2 46.6 Measles 2 na na na na 20.3 1.0 21.3 19.5 Fully vaccinated 6,9 35.8 7.5 43.2 35.0 29.6 12.2 41.8 25.6 No vaccinations 0.1 19.4 19.5 19.6 0.0 20.2 20.2 20.2 Number of children 3,160 3,160 3,160 3,160 3,142 3,142 3,142 3,142 1 MICS indicator 3.1 - Tuberculosis immunization coverage 2 MICS indicator 3.2 - Polio immunization coverage 3 MICS indicator 3.3 - Pentavalent (Diphtheria, Pertussis and Tetanus, Hepatitis B and Hib) (PENTA) immunization coverage 4 MICS indicator 3.5 - Pneumococcal (PCV) immunization coverage 5 MICS indicator 3.4; MDG indicator 4.3 - Measles immunization coverage 6 MICS indicator 3.6 - Full immunization coverage a All MICS indicators refer to results in this column 9 Includes: BCG, Polio3, Penta3 and Measles 1 (MCV1) as per the vaccination schedule in Sindh The percentage of children age 12-23 months and 24-35 months who have received each of the specific vaccinations by source of information (vaccination records at health facilities or vaccination card and mother’s recall) is shown in Table CH.1 and Figure CH.1. The denominators for the table are comprised of children age 12-23 months and 24-35 months so that only children who are old enough to be fully vaccinated are counted. In the first three columns in each panel of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the vaccination records at health facilities or the mother’s report. In the last column in each panel, only those children who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards or records, the proportion of P a g e | 45 vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards or records. The results show that 76.3 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first dose of pentavalent vaccine was given to 68.7 percent. The percentage declines to 63 percent for the second dose of pentavalent vaccine, and 52.7 percent for the third dose. Similarly, 76 percent of children received Polio 1 by age 12 months and this declines to 60.3 percent by the third dose. The coverage for the first dose of measles vaccine by 12 months is lower than most of the other vaccines at 52.7 percent. As a result, the percentage of children who had all the recommended vaccinations by their first birthday is low at only 35 percent. The individual coverage figures for children age 24-35 months are generally lower to those age 12-23 months suggesting that immunization coverage has been on average improving in Sindh between 2011 and 2012. Figure 9 Figure CH.1: Vacc inat ions by age 12 months , S indh, 2014 Table CH.2 presents vaccination coverage estimates among children 12-23 and 24-35 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 the health facility records or vaccination cards or mothers’/caretakers’ reports. Health facility records or vaccination cards have been seen by the interviewer for only 52 percent of children age 12-23 months and 40 percent for older children age 24-35 months. P a g e | 46 Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against vaccine preventable childhood diseases, Sindh, 2014 Percentage of children age 12-23 months who received: P e rc e n ta g e w it h v a c c in a ti o n c a rd s e e n a n d v a c c in a ti o n r e c o rd s a t h e a lt h f a c ili ty N u m b e r o f c h ild re n a g e 1 2 -2 3 m o n th s Percentage of children age 24- 35 months who received: P e rc e n ta g e w it h v a c c in a ti o n c a rd s e e n N u m b e r o f c h ild re n a g e 2 4 -3 5 m o n th s B C G Polio Pentavalent Pneumococcal M e a s le s 1 F u ll a N o n e A t b ir th 1 2 3 1 2 3 1 2 3 M e a s le s (M C V 2 ) F u lla N o n e Total 77.4 74.1 77.8 71.8 63.5 70.7 64.9 55.3 36.6 32.4 27.6 58.6 43.2 19.5 52.0 3,160 21.3 41.8 20.2 40.0 3,142 Sex Male 79.0 75.0 78.6 72.5 63.6 71.9 65.5 55.8 38.5 34.3 28.9 58.9 43.1 18.3 53.5 1,622 21.7 42.6 20.1 40.8 1,607 Female 75.8 73.1 76.9 71.2 63.4 69.5 64.2 54.6 34.4 30.5 26.3 58.3 43.4 20.9 50.5 1,538 20.9 40.9 20.2 39.1 1,535 Division Larkana 65.3 64.6 65.3 59.8 49.1 52.2 45.9 37.3 29.3 24.9 20.1 38.7 25.6 31.6 36.9 544 8.8 24.2 34.5 24.5 494 Sukkur 76.2 72.9 74.8 66.3 54.2 68.1 60.0 46.8 45.2 37.0 28.1 52.4 33.7 21.7 47.1 577 20.0 36.2 22.3 43.7 626 Hyderabad 76.1 72.3 77.0 71.7 62.8 69.4 63.6 54.6 32.5 28.5 24.8 62.9 45.5 19.2 54.8 701 25.9 44.6 19.6 41.0 697 Mirpurkhas 79.8 70.6 85.0 79.3 74.3 73.4 67.2 57.3 42.4 38.2 31.7 71.1 47.4 12.7 57.1 346 25.5 43.2 16.4 46.2 336 Karachi 84.9 82.4 84.3 79.2 73.5 81.8 77.4 69.0 36.2 34.4 31.7 65.3 55.2 14.3 59.5 991 23.8 51.1 13.2 42.6 989 Area Urban 85.9 83.4 84.8 79.0 72.7 80.8 76.0 67.5 40.3 36.9 33.3 67.1 55.2 13.0 60.0 1,518 25.7 53.4 13.5 43.5 1,451 Rural 69.6 65.5 71.2 65.2 55.0 61.2 54.4 43.7 33.1 28.2 22.3 50.7 32.1 25.6 44.6 1,642 17.5 31.8 25.9 37.0 1,692 Mother’s education b None/Preschool 69.3 65.8 70.4 64.2 53.9 59.6 52.9 42.4 31.6 26.2 21.0 48.3 31.1 26.5 43.4 1,771 15.8 29.6 28.0 34.1 1,741 Primary 82.9 80.3 84.0 75.4 68.2 80.0 72.8 62.2 37.6 34.3 29.0 59.4 43.5 13.5 57.2 462 20.8 42.7 17.1 39.7 495 Middle 88.6 87.7 88.2 84.3 79.7 86.2 81.9 74.5 44.6 42.5 40.6 71.6 62.8 11.4 67.3 177 28.4 56.5 10.8 46.7 197 Secondary 88.2 83.2 86.7 79.4 75.1 82.8 77.2 70.3 39.1 38.0 32.6 72.1 60.3 10.7 60.4 348 29.6 63.3 8.0 51.8 353 Higher secondary 93.7 90.6 92.1 91.3 87.0 91.3 90.6 85.5 49.2 45.9 44.4 85.9 77.3 5.6 76.1 223 40.5 71.8 2.4 55.0 205 Higher 90.8 88.7 89.2 86.5 78.2 89.6 87.1 74.8 52.1 49.3 43.4 83.0 66.7 9.1 61.8 179 31.6 68.2 4.9 52.6 150 Wealth index quintile Poorest 61.3 56.5 64.2 58.6 49.7 51.3 44.4 34.6 28.7 23.1 18.2 43.6 24.7 31.6 37.3 780 13.0 23.9 31.9 29.9 755 Second 73.0 69.2 75.3 68.0 56.7 65.3 57.5 46.1 34.9 29.5 21.4 52.1 33.1 23.4 44.0 677 18.7 30.8 25.2 37.9 698 Middle 84.9 82.2 82.6 76.7 67.8 76.2 70.1 59.4 38.7 34.4 30.3 61.7 46.0 13.7 58.0 666 21.3 47.9 18.0 43.6 669 Fourth 84.6 82.2 83.9 77.5 72.1 82.7 76.3 68.5 38.5 36.2 33.5 65.7 56.4 14.2 61.8 541 23.2 50.6 11.2 42.4 569 Richest 90.8 88.5 89.2 85.1 79.2 87.2 86.4 78.7 45.8 43.9 40.2 78.7 68.0 9.0 67.3 496 36.9 67.8 7.3 51.8 451 a Includes: BCG, Polio3, Penta3 and Measles 1 as per the vaccination schedule in Sindh b Total includes 1 unweighted case of children whose mother’s education information missing P a g e | 47 Table CH.2 shows that 43.2 percent of children age 12-23 months received all the recommended vaccines according to the vaccination schedule in Sindh. More than half (55.2 percent) of children age 12-23 months are fully vaccinated in Karachi division compared with about one quarter (25.6 percent) of children in Larkana Division. There are no gender differentials in terms of full vaccination coverage. There are notable differences between urban and rural areas. Fifty five percent of children in urban areas are fully immunized compared with 32.1 percent of children in rural areas. Children from richest households and from more educated mothers are most likely to be vaccinated. For example, 68 percent of children in the richest wealth quintile are fully vaccinated compared with 24.7 percent in poorest quintile. Neonatal Tetanus Protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. Following on the 42nd and 44th World Health Assembly calls for elimination of neonatal tetanus, the global community continues to work to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births in every district by 2015. The strategy for preventing maternal and neonatal tetanus is to ensure that all pregnant women receive at least two doses of tetanus toxoid vaccine. If a woman has not received at least two doses of tetanus toxoid during a particular pregnancy, she (and her newborn) are also considered to be protected against tetanus if the woman:  Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years;  Received at least 3 doses, the last within the previous 5 years;  Received at least 4 doses, the last within the previous 10 years;  Received 5 or more doses anytime during her life. To assess the status of tetanus vaccination coverage in Sindh, women who had a live birth during the two years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth, and if so, how many.Wwomen who did not receive two or more tetanus toxoid vaccinations during this recent pregnancy were then asked about tetanus toxoid vaccinations they may have previously received. Interviewers also asked women to present their vaccination card on which dates of tetanus toxoid are recorded and referred to information from the cards when available. Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 2 years. More than half of women (54.1 percent) in Sindh who had a live birth in the two years before the survey are protected against tetanus. Furthermore, 47.4 percent of women received at least two doses of tetanus toxoid during the last pregnancy. Protection against tetanus is notably higher among women in Karachi division (68.8 percent) than the rest of the divisions. Educational attainment and household wealth are strongly correlated with protection against tetanus. For example, only 35.5 percent of women in the poorest wealth quintile are protected against tetanus compared with 73.7 percent of women in the richest wealth quintile. Similarly P a g e | 48 protection against tetanus is higher among women with higher education (83.3 percent) than those with only pre-school or no education (40.9 percent). Women in urban areas (66.4 percent) are also more likely to be protected against tetanus than their rural counterparts (43.6 percent). 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, Sindh, 2014 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 Total 47.4 5.3 0.7 0.5 0.2 54.1 6,095 Division Larkana 44.0 5.3 0.5 0.0 0.2 50.0 1,004 Sukkur 41.2 4.2 1.0 0.6 0.1 47.2 1,186 Hyderabad 41.2 5.9 0.6 0.5 0.3 48.4 1,362 Mirpurkhas 35.7 5.1 0.9 0.6 0.2 42.6 658 Karachi 61.8 5.7 0.7 0.6 0.0 68.8 1,886 Area Urban 58.5 6.2 0.8 0.6 0.3 66.4 2,812 Rural 38.0 4.6 0.7 0.4 0.0 43.6 3,284 Education a None/Preschool 35.4 4.5 0.5 0.4 0.1 40.9 3,368 Primary 54.2 5.0 1.6 0.9 0.0 61.8 926 Middle 64.1 6.6 1.0 0.5 0.0 72.2 393 Secondary 62.7 5.1 0.4 0.3 0.5 69.0 682 Higher secondary 70.1 9.7 0.9 0.7 0.0 81.4 405 Higher 73.4 8.8 0.6 0.4 0.1 83.3 303 Wealth index quintile Poorest 30.5 4.2 0.4 0.3 0.1 35.5 1,510 Second 39.4 5.0 0.7 0.5 0.0 45.6 1,355 Middle 51.6 4.4 1.2 0.4 0.3 57.9 1,260 Fourth 62.4 6.1 1.0 0.5 0.2 70.2 1,044 Richest 64.2 7.9 0.4 1.0 0.1 73.7 926 1 MICS indicator 3.9 - Neonatal tetanus protection a Total includes 20 unweighted case of women with education information missing Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading killers of children under 5. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable pneumonia and diarrhoea death by reducing mortality from pneumonia to 3 deaths per 1000 live births and mortality from diarrhoea to 1 death per 1000 live births by 2025. Malaria is also a major killer of children under 5, killing about 1200 children every day. The Global Malaria Action Plan (GMAP) aims to reduce malaria deaths to near zero by 2015 Table CH.4 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the two weeks preceding the survey. These results are not measures of true prevalence, and should not be used as such, but rather the period-prevalence of those illnesses over a two-week time window. P a g e | 49 The definition of a case of diarrhoea or fever, in this survey, was the mother’s or caretaker’s report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS survey, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. The timing of the survey and the location of the teams might thus considerably affect the results, which must consequently be interpreted with caution. For these reasons, although the period- prevalence over a two-week time window is reported, these data should not be used to assess the epidemiological characteristics of these diseases but rather to obtain denominators for the indicators related to use of health services and treatment. Overall, 28.4 percent of under five children were reported to have had diarrhoea in the two weeks preceding the survey, 12.9 percent symptoms of ARI, and 42.8 percent had an episode of fever (Table CH.4). At divisional level, there were more reports of all the three childhood illnesses for children in Sukkur compared with the other divisions. Differences are reported between urban and rural areas in the case of ARI (7.9 percent and 17.1 percent respectively). Diarrhoea, fever and ARI symptoms were less likely among children that are older, those whose mothers have higher education and in richest households. A lower proportion (15.6 percent) of children age 48-59 months reported to have had diarrhoea compared with 37.2 percent of children age 0-11 months. Only 5.7 percent of children in richest quintile were reported to have symptoms of ARI compared with 14.9 percent of children in the poorest quintile. P a g e | 50 Table CH.4: Reported disease episodes Percentage of children age 0-59 months for whom the mother/caretaker reported an episode of diarrhoea, fever, and/or symptoms of acute respiratory infection (ARI) in the last two weeks, Sindh, 2014 Percentage of children who in the last two weeks had: Number of children age 0-59 months An episode of diarrhoea Symptoms of ARI An episode of fever Total 28.4 12.9 42.8 16,605 Sex Male 28.7 14.1 44.2 8,585 Female 28.1 11.6 41.4 8,020 Division Larkana 22.3 15.1 37.9 2,719 Sukkur 32.1 26.6 52.4 3,203 Hyderabad 30.8 10.5 41.2 3,775 Mirpurkhas 28.5 8.9 38.4 1,767 Karachi 27.6 6.3 42.2 5,140 Area Urban 28.1 7.9 40.8 7,651 Rural 28.7 17.1 44.6 8,954 Age 0-11 months 37.2 16.6 50.3 3,375 12-23 months 39.2 14.5 49.7 3,160 24-35 months 30.2 11.8 44.5 3,142 36-47 months 21.1 12.3 37.1 3,499 48-59 months 15.6 9.3 33.4 3,429 Mother’s education a None/Preschool 29.2 15.2 43.6 9,478 Primary 31.8 13.4 46.8 2,407 Middle 26.9 9.2 40.4 1,035 Secondary 26.1 8.3 40.2 1,789 Higher secondary 24.6 7.9 37.5 1,085 Higher 21.9 5.1 38.1 808 Wealth index quintile Poorest 29.8 14.9 41.0 4,183 Second 28.8 18.1 46.3 3,722 Middle 28.6 13.7 45.8 3,414 Fourth 28.1 8.2 40.8 2,852 Richest 25.6 5.7 38.8 2,435 a Total includes 4 unweighted case of children whose mother’s education information missing Diarrhoea Diarrhoea is a leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. In addition, provision of zinc supplements has been shown to reduce the duration and severity of the illness as well as the risk of future episodes within the next two or three months. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. In the MICS, mothers or caretakers were asked whether their child under age five years had an episode of diarrhoea in the two weeks prior to the survey. In cases where mothers reported that the child had diarrhoea, a series of questions were asked about the treatment of the illness, including what the child had been given to drink and eat during the episode and whether this was more or less than what was usually given to the child. P a g e | 51 The overall period-prevalence of diarrhoea in children under 5 years of age is 28.4 percent (Table CH.4). The highest period-prevalence is seen among children age 12-23 months which grossly corresponds to the weaning period. Table CH.5 shows the percentage of children with diarrhoea in the two weeks preceding the survey for which advice or treatment was sought and where. Overall, a health facility or provider was seen in 69.2 percent of cases, mostly in the private sector (60.3 percent). Seeking diarrhoea treatment is more common for younger than older children. The results show that 72.8 percent of children age 0-11 months received treatment from a health facility compared with 62.6 percent of children age 48-59 months. Table CH.5: Care-seeking during diarrhoea Percentage of children age 0-59 months with diarrhoea in the last two weeks for whom advice or treatment was sought, by source of advice or treatment, Sindh, 2014 Percentage of children with diarrhoea for whom: Number of children age 0-59 months with diarrhoea in the last two weeks Advice or treatment was sought from: No advice or treatment sought Health facilities or providers Other source A health facility or provider 1, b Public Private Lady health worker a Total 12.1 60.3 0.2 3.1 69.2 26.3 4,720 Sex Male 12.1 60.8 0.1 2.8 69.3 26.1 2,465 Female 12.1 59.9 0.2 3.3 69.1 26.5 2,254 Division Larkana 7.7 66.2 0.0 3.5 72.2 23.6 607 Sukkur 12.0 58.1 0.3 2.8 65.1 30.0 1,028 Hyderabad 15.8 56.5 0.1 1.8 69.6 27.0 1,161 Mirpurkhas 16.3 55.9 0.1 6.4 68.0 23.6 504 Karachi 9.5 64.2 0.3 2.9 70.9 25.1 1,419 Area Urban 9.0 64.9 0.2 2.7 70.7 25.0 2,151 Rural 14.7 56.5 0.2 3.3 67.9 27.4 2,568 Age 0-11 months 11.1 64.6 0.3 2.6 72.8 23.3 1,257 12-23 months 11.6 63.4 0.0 2.3 71.7 24.9 1,239 24-35 months 12.5 60.2 0.2 2.7 69.6 26.2 950 36-47 months 12.6 54.6 0.1 4.6 63.0 30.2 738 48-59 months 14.4 51.6 0.4 4.2 62.6 31.3 537 Mother’s education None/Preschool 12.4 58.6 0.1 2.8 67.5 27.9 2,765 Primary 15.8 61.0 0.2 4.1 72.9 22.0 765 Middle 10.5 67.8 0.0 0.9 74.9 22.1 278 Secondary 10.6 61.6 0.2 3.9 68.9 27.2 467 Higher secondary 9.0 64.6 1.4 1.5 72.5 23.9 267 Higher 2.4 64.0 0.0 5.2 65.9 28.4 177 Wealth index quintile Poorest 15.9 55.5 0.2 2.8 67.7 27.8 1,245 Second 13.0 58.2 0.2 4.2 67.8 27.0 1,074 Middle 13.4 60.3 0.1 2.6 69.7 25.9 978 Fourth 10.5 63.6 0.5 2.5 71.2 23.9 800 Richest 2.9 69.6 0.0 3.0 71.3 25.8 623 1 MICS indicator 3.10 - Care-seeking for diarrhoea a Lady health worker is also included under public health provider as a survey specific category b Includes all public and private health facilities and providers, but excludes private pharmacy P a g e | 52 Table CH.6: Feeding practices during diarrhea Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Sindh, 2014 Drinking practices during diarrhoea Eating practices during diarrhoea Number of children age 0-59 months with diarrhoea in the last two weeks Child was given to drink: Total Child was given to eat: Total Much less Somewhat less About the same More Nothing Missing/ DK Much less Somewhat less About the same More Nothing Missing/ DK Total 15.1 35.2 39.2 6.8 3.1 0.5 100.0 16.5 37.9 32.3 2.2 10.8 0.4 100.0 4,720 Sex Male 14.5 34.8 38.9 7.9 3.4 0.5 100.0 16.4 38.6 31.7 2.7 10.1 0.5 100.0 2,465 Female 15.8 35.6 39.5 5.7 2.9 0.6 100.0 16.6 37.1 32.9 1.5 11.6 0.3 100.0 2,254 Division Larkana 18.1 31.7 35.0 9.8 4.3 1.1 100.0 19.6 33.5 30.9 1.8 12.8 1.4 100.0 607 Sukkur 13.4 31.4 43.5 9.3 2.3 0.1 100.0 15.4 34.8 34.3 2.3 13.1 0.1 100.0 1,028 Hyderabad 12.1 40.9 38.2 3.3 5.3 0.2 100.0 13.9 42.5 30.8 1.1 11.6 0.2 100.0 1,161 Mirpurkhas 24.9 43.0 28.0 2.4 1.7 0.0 100.0 25.4 44.3 25.8 2.6 1.8 0.0 100.0 504 Karachi 14.1 31.9 42.7 8.3 2.0 1.0 100.0 15.0 36.0 35.0 2.9 10.8 0.4 100.0 1,419 Area Urban 13.8 36.5 38.8 7.6 2.4 0.9 100.0 14.8 39.6 32.0 2.4 10.6 0.6 100.0 2,151 Rural 16.3 34.0 39.5 6.2 3.8 0.2 100.0 17.9 36.5 32.5 1.9 10.9 0.2 100.0 2,568 Age 0-11 months 14.6 31.7 44.5 6.8 2.1 0.2 100.0 11.5 27.9 30.6 1.2 28.2 0.6 100.0 1,257 12-23 months 17.4 36.0 39.1 5.8 1.5 0.2 100.0 18.6 38.8 32.6 2.3 7.6 0.2 100.0 1,239 24-35 months 14.4 37.5 38.2 5.9 3.4 0.6 100.0 19.2 40.9 34.1 2.5 3.0 0.2 100.0 950 36-47 months 10.9 40.0 35.1 8.3 4.8 1.0 100.0 14.9 47.9 30.6 3.1 2.8 0.7 100.0 738 48-59 months 18.2 30.7 34.3 8.9 6.5 1.3 100.0 20.8 40.5 34.4 2.2 2.1 0.0 100.0 537 Mother’s education None/Preschool 16.1 35.0 39.1 5.6 3.7 0.5 100.0 18.3 37.2 31.7 1.8 10.6 0.5 100.0 2,765 Primary 14.3 32.6 41.3 8.5 2.5 0.7 100.0 16.6 35.6 33.6 2.1 11.6 0.4 100.0 765 Middle 19.6 33.3 40.8 3.2 3.1 0.0 100.0 17.2 33.6 35.0 3.1 11.0 0.0 100.0 278 Secondary 11.6 38.2 39.5 8.2 2.5 0.0 100.0 14.5 40.2 34.6 2.6 8.1 0.0 100.0 467 Higher secondary 10.2 44.0 34.2 9.4 2.2 0.0 100.0 6.2 45.5 30.6 2.0 15.8 0.0 100.0 267 Higher 13.1 30.6 35.2 17.7 0.0 3.4 100.0 8.1 48.1 27.6 6.2 10.0 0.0 100.0 177 Wealth index quintile Poorest 19.1 35.0 36.1 6.0 3.5 0.3 100.0 20.3 37.9 30.7 2.1 8.5 0.4 100.0 1,245 Second 15.8 34.8 38.0 6.2 4.7 0.4 100.0 16.4 38.0 30.8 1.5 12.9 0.4 100.0 1,074 Middle 11.8 34.5 43.4 6.8 3.2 0.3 100.0 17.2 36.0 32.4 2.9 11.3 0.2 100.0 978 Fourth 12.8 34.8 41.9 7.3 2.1 1.0 100.0 12.3 38.2 35.2 2.0 11.8 0.5 100.0 800 Richest 14.3 37.7 37.1 9.1 0.8 1.0 100.0 13.4 40.3 34.0 2.3 9.6 0.4 100.0 623 P a g e | 53 Table CH.6 provides statistics on drinking and feeding practices during diarrhoea. For 6.8 percent of under-five children with diarrhoea, they were given more than usual to drink while 89.5 percent were given the same or less to drink. About 81 percent were given somewhat less, same or more (continued feeding) to eat, but 18.3 percent were given much less or almost nothing to eat. Eating and drinking patterns during diarrhoea varied by education of the mother. Children born to mothers with higher education are three times more likely (17.7 percent) to receive more liquid during diarrhoea episode as compared with children born to mothers with no education (5.6 percent). Table CH.7 shows the percentage of children receiving ORS, various types of recommended homemade fluids and zinc during the episode of diarrhoea. Since children may have been given more than one type of liquid, the percentages do not necessarily add to 100. The data show that 47.7 percent received fluids from ORS packets or pre-packaged ORS fluids and 18 percent received recommended homemade fluids. Additionally, 17.6 percent received zinc in one form or another. For 54.5 percent of children with diarrhoea, they received one or more of the recommended home treatments (i.e. were treated with ORS or any recommended homemade fluid). Furthermore, 11.6 percent received both ORS and zinc. Figure 10 Figure CH.2: Chi ldren under -5 with d iarrhea who received ORS or recommended homemade l iquids , S indh,2014 50 53 61 53 53 54 55 53 56 55 57 52 62 55 P er c e n t P a g e | 54 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration salts (ORS), recommended homemade fluids, and zinc, Sindh, 2014 Percentage of children with diarrhoea who received: Number of children age 0-59 months with diarrhoea in the last two weeks Oral rehydration salts (ORS) Recommended homemade fluid ORS or any recommended homemade fluid Zinc ORS and zinc 1 Fluid from packet Pre- packaged fluid Any ORS Tablet Syrup Any zinc Total 41.9 16.2 47.7 18.0 54.5 5.3 15.1 17.6 11.6 4,720 Sex Male 43.1 16.8 49.6 18.2 56.2 5.6 16.0 18.4 12.1 2,465 Female 40.5 15.5 45.6 17.7 52.8 5.0 14.2 16.7 11.0 2,254 Division Larkana 40.4 17.7 46.8 8.6 49.7 5.8 8.7 12.5 8.4 607 Sukkur 45.9 17.2 48.1 11.8 52.9 13.3 25.0 29.3 19.7 1,028 Hyderabad 43.0 15.1 50.1 29.6 61.0 3.9 9.7 11.8 7.9 1,161 Mirpurkhas 45.7 7.2 46.5 21.4 53.2 2.1 9.7 10.5 6.8 504 Karachi 37.2 18.8 46.4 15.7 53.1 1.6 17.2 18.5 11.8 1,419 Area Urban 38.0 20.2 47.4 15.0 53.7 3.1 15.4 17.4 11.1 2,151 Rural 45.1 12.8 48.0 20.5 55.2 7.2 14.9 17.7 12.0 2,568 Age 0-11 months 37.1 15.2 43.2 13.0 49.2 3.3 14.0 16.2 10.7 1,257 12-23 months 45.9 19.4 53.1 18.3 59.7 5.0 17.6 19.7 12.3 1,239 24-35 months 39.6 16.1 45.5 17.1 52.4 5.2 14.8 16.7 11.2 950 36-47 months 45.0 12.3 48.3 22.8 55.6 7.9 14.0 17.7 11.7 738 48-59 months 43.3 16.5 49.3 23.5 57.5 7.5 14.2 17.4 12.6 537 Mother’s education None/Preschool 42.9 12.9 46.5 18.6 53.4 6.4 13.2 16.0 10.9 2,765 Primary 43.6 17.2 50.1 18.0 56.2 5.5 13.2 15.9 10.6 765 Middle 40.4 19.4 47.1 16.3 54.6 2.2 17.2 18.7 12.0 278 Secondary 37.7 23.3 50.1 18.2 57.5 3.5 22.0 23.6 16.1 467 Higher secondary 34.3 25.7 46.4 11.5 52.1 0.9 19.6 20.2 9.2 267 Higher 42.5 24.6 53.6 19.7 61.7 3.5 25.7 27.3 17.6 177 Wealth index quintile Poorest 46.1 11.5 48.4 23.1 57.0 6.5 13.0 16.1 11.3 1,245 Second 42.6 13.4 45.8 18.0 52.6 7.5 13.9 17.4 10.3 1,074 Middle 39.7 17.7 48.0 13.2 52.3 5.4 12.9 15.0 10.2 978 Fourth 38.4 21.2 47.5 15.4 53.7 3.6 18.4 20.4 12.9 800 Richest 39.9 21.4 49.6 18.3 57.6 1.4 20.6 21.3 14.9 623 1 MICS indicator 3.11 - Diarrhoea treatment with oral rehydration salts (ORS) and zinc P a g e | 55 Table CH.8 provides the proportion of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and the percentage of children with diarrhoea who received other treatments. Overall, about half of children with diarrhoea received ORS or increased fluids, 56.7 percent received ORT (ORS or recommended homemade fluids or increased fluids). Combining the information in Table CH.6 with that of Table CH.7 on oral rehydration therapy, it is observed that 41 percent of children received ORT and, at the same time, feeding was continued, as is the recommendation. The results also show that more male children (43.6 percent) received ORT with continued feeding than female children (38 percent). Figure CH.3 shows that the practice of giving children with diarrhoea ORT with continued feeding is highest among mother’s with higher education. Table CH.8 also shows the percentage of children having had diarrhoea in the two weeks preceding the survey who were given various forms of treatment.Use of antibiotic pills or syrup in children with diarrhoea though not recommended, is reported in 5 percent of the children in Sindh.Use of antibiotics in children with diarrhoea is higher in Karachi division where 9.6 percent of children with diarrhoea were given an antibiotic pill or syrup and 5.5 percent received an antibiotic injection. Forteen percent of the children in Sindh who has diarrhoea in the last two weeks preceding the survey did not receive any treatment or drug. P a g e | 56 Table CH.8: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given oral rehydration therapy with continued feeding and percentage who were given other treatments, Sindh, 2014 Children with diarrhoea who were given: N o t g iv e n a n y tr e a tm e n t o r d ru g N u m b e r o f c h ild re n a g e 0 -5 9 m o n th s w it h d ia rr h o e a i n t h e l a s t tw o w e e k s Z in c O R S o r in c re a s e d fl u id s O R T ( O R S o r re c o m m e n d e d h o m e m a d e f lu id s o r in c re a s e d fl u id s ) O R T w it h c o n ti n u e d fe e d in g 1 Other treatments Pill or syrup Injection In tr a -v e n o u s H o m e re m e d y , h e rb a l m e d ic in e O th e r A n ti - b io ti c A n ti - m o ti lit y O th e r U n k n o w n A n ti - b io ti c N o n - a n ti b io ti c U n k n o w n Total 17.6 50.5 56.9 41.0 5.0 1.8 0.7 11.1 3.8 0.2 3.1 1.0 5.2 30.1 14.0 4,720 Sex Male 18.4 53.1 59.2 43.6 5.5 1.8 0.2 11.2 3.7 0.1 3.2 0.9 5.1 29.3 13.8 2,465 Female 16.7 47.5 54.3 38.0 4.4 1.8 1.2 11.0 3.9 0.2 3.1 1.0 5.2 30.8 14.3 2,254 Division Larkana 12.5 51.3 53.9 38.5 3.2 0.1 0.3 21.4 3.5 0.1 4.8 1.6 3.5 13.3 18.2 607 Sukkur 29.3 51.4 55.8 39.3 4.0 0.4 0.3 8.8 3.9 0.1 4.6 2.2 11.8 29.7 13.9 1,028 Hyderabad 11.8 51.4 61.7 46.0 2.2 3.5 0.0 13.7 1.6 0.3 3.8 0.7 5.9 29.8 10.3 1,161 Mirpurkhas 10.5 47.3 53.7 34.9 3.0 0.2 0.2 6.8 4.1 0.2 3.8 0.5 1.2 28.9 21.4 504 Karachi 18.5 49.7 56.1 41.3 9.6 2.6 1.8 7.8 5.5 0.1 0.6 0.2 1.9 38.1 12.7 1,419 Area Urban 17.4 50.5 56.7 42.0 7.2 2.3 1.0 9.7 3.8 0.2 2.1 0.6 2.9 39.7 12.2 2,151 Rural 17.7 50.4 57.1 40.1 3.2 1.4 0.4 12.3 3.7 0.2 4.0 1.3 7.1 22.0 15.6 2,568 Age 0-11 months 16.2 45.2 51.0 31.6 5.7 1.7 0.6 9.9 5.4 0.3 3.6 0.7 5.3 31.5 16.8 1,257 12-23 months 19.7 55.4 61.9 45.1 5.7 1.5 0.5 12.3 3.7 0.1 3.3 1.3 3.8 30.0 10.5 1,239 24-35 months 16.7 47.6 54.4 42.4 3.6 2.2 1.6 12.8 3.2 0.0 2.3 0.7 5.1 28.2 15.0 950 36-47 months 17.7 52.5 58.7 45.9 5.5 1.8 0.1 10.1 3.0 0.2 3.7 1.5 5.1 28.0 13.7 738 48-59 months 17.4 53.5 61.2 43.9 3.8 1.7 0.5 9.5 2.4 0.2 2.3 0.5 8.1 32.8 14.2 537 Mother’s education None/Preschool 16.0 49.2 55.5 39.0 3.2 1.1 0.3 12.6 3.5 0.1 4.0 1.3 6.0 24.6 16.2 2,765 Primary 15.9 51.8 57.5 39.8 7.9 2.7 2.2 10.2 3.8 0.3 3.0 0.5 4.4 32.3 11.6 765 Middle 18.7 48.8 56.3 39.6 9.3 1.4 0.9 8.5 5.8 0.0 0.9 0.9 4.5 39.1 13.9 278 Secondary 23.6 52.0 59.3 45.1 5.2 4.5 0.5 7.7 6.0 0.0 1.5 0.3 4.3 40.8 10.0 467 Higher secondary 20.2 51.2 57.0 46.3 9.2 0.8 0.7 10.6 2.2 0.6 0.6 0.7 1.3 43.0 9.9 267 Higher 27.3 62.1 70.2 59.0 7.1 3.1 0.0 6.5 1.4 0.0 0.2 0.3 5.0 43.1 7.2 177 Wealth index quintile Poorest 16.1 51.4 59.3 42.0 1.7 0.9 0.0 12.8 3.0 0.0 3.5 0.8 5.8 18.6 17.2 1,245 Second 17.4 48.0 54.4 38.1 3.5 0.9 0.2 14.1 3.5 0.2 5.5 1.9 8.7 24.4 15.2 1,074 Middle 15.0 50.3 54.4 37.6 4.3 3.1 1.1 12.4 4.3 0.4 3.4 1.0 4.7 33.4 13.5 978 Fourth 20.4 49.9 55.8 42.7 10.1 2.5 1.8 7.2 4.6 0.1 0.5 0.5 2.1 39.0 11.1 800 Richest 21.3 53.9 61.8 47.0 8.8 1.8 0.8 5.7 3.9 0.0 1.1 0.2 2.6 46.0 10.4 623 1 MICS indicator 3.12 - Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding P a g e | 57 Figure 11 Figure CH.3: Chi ldren under -5 with d iarrhoea receiv ing oral rehydrat ion therapy (ORT) and cont inued feeding , S indh, 2014 Table CH.9 provides information on the source of ORS and zinc for children who benefitted from these treatments. The main source of ORS is the private sector (86.1 percent); the same applies for zinc (84.1 percent). Children in urban areas are more likely to get ORS and zinc from private sources. 38 39 46 35 41 42 40 39 40 40 45 46 59 41 0 10 20 30 40 50 60 70 Regions Larkana Sukkur Hyderabad Mirpur Khas Karachi Area Urban Rural Mother's Education None/Preschool Primary Middle Secondary Higher Secondary Higher Sindh Percent P a g e | 58 Table CH.9: Source of ORS and zinc Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given ORS, and percentage given zinc, by the source of ORS and zinc, Sindh, 2014 Percentage of children who were given as treatment for diarrhoea: N u m b e r o f c h ild re n a g e 0 -5 9 m o n th s w it h d ia rr h o e a i n t h e l a s t tw o w e e k s Percentage of children for whom the source of ORS was: N u m b e r o f c h ild re n a g e 0 -5 9 m o n th s w h o w e re g iv e n O R S a s tr e a tm e n t fo r d ia rr h o e a i n t h e la s t tw o w e e k s Percentage of children for whom the source of zinc was: N u m b e r o f c h ild re n a g e 0 -5 9 m o n th s w h o w e re g iv e n z in c a s tr e a tm e n t fo r d ia rr h o e a i n t h e la s t tw o w e e k s Health facilities or providers O th e r s o u rc e D K /M is s in g A h e a lt h f a c ili ty o r p ro v id e rb Health facilities or providers O th e r s o u rc e D K /M is s in g A h e a lt h f a c ili ty o r p ro v id e rb O R S z in c P u b lic P ri v a te L a d y h e a lt h w o rk e ra P u b lic P ri v a te L a d y h e a lt h w o rk e ra Total 47.7 17.6 4,720 10.7 86.1 0.0 2.5 0.7 96.8 2,253 11.6 84.1 0.6 3.9 0.4 95.7 830 Sex Male 49.6 18.4 2,465 9.9 86.4 0.0 3.1 0.6 96.3 1,224 13.0 81.0 0.8 5.3 0.8 93.9 452 Female 45.6 16.7 2,254 11.8 85.7 0.1 1.8 0.7 97.5 1,029 9.9 87.9 0.4 2.1 0.0 97.9 377 Division Larkana 46.8 12.5 607 8.5 86.4 0.0 3.4 1.8 94.9 284 6.9 90.8 0.0 2.3 0.0 97.7 76 Sukkur 48.1 29.3 1,028 14.8 83.1 0.0 1.3 0.8 98.0 494 14.1 82.2 0.4 3.3 0.4 96.3 301 Hyderabad 50.1 11.8 1,161 15.4 80.9 0.0 3.3 0.4 96.3 581 13.9 80.5 0.0 4.8 0.8 94.4 137 Mirpurkhas 46.5 10.5 504 13.7 83.0 0.2 2.5 0.9 96.6 234 15.2 80.7 0.0 1.8 2.3 95.9 53 Karachi 46.4 18.5 1,419 3.5 93.9 0.0 2.3 0.3 97.4 658 8.1 87.0 1.4 4.9 0.0 95.1 262 Area Urban 47.4 17.4 2,151 5.5 91.2 0.0 2.6 0.7 96.7 1,020 8.6 86.9 1.0 4.4 0.0 95.6 374 Rural 48.0 17.7 2,568 15.1 81.8 0.0 2.4 0.7 96.9 1,233 14.0 81.8 0.3 3.4 0.8 95.8 455 Age 0-11 months 43.2 16.2 1,257 6.7 90.6 0.0 1.7 0.9 97.3 543 6.9 89.5 1.8 3.0 0.6 96.4 203 12-23 months 53.1 19.7 1,239 9.1 88.3 0.0 2.2 0.4 97.4 657 7.3 90.1 0.0 2.6 0.0 97.4 244 24-35 months 45.5 16.7 950 10.9 85.3 0.1 3.2 0.6 96.2 432 13.8 81.5 0.8 3.9 0.7 95.4 158 36-47 months 48.3 17.7 738 16.5 80.4 0.0 3.1 0.0 96.9 356 20.8 74.8 0.0 4.4 0.0 95.6 131 48-59 months 49.3 17.4 537 15.3 80.1 0.0 2.9 1.6 95.4 264 16.4 74.2 0.0 8.1 1.3 90.6 93 Mother’s education None/Preschool 46.5 16.0 2,765 13.7 83.4 0.0 1.9 0.9 97.2 1,285 14.7 80.7 0.0 3.8 0.8 95.4 444 Primary 50.1 15.9 765 9.1 88.5 0.0 2.0 0.4 97.6 384 7.3 90.8 0.0 1.9 0.0 98.1 122 Middle 47.1 18.7 278 4.6 94.9 0.0 0.5 0.0 99.5 131 (5.7) (88.1) (0.0) (6.2) (0.0) (93.8) 52 Secondary 50.1 23.6 467 6.8 89.1 0.1 4.2 0.0 95.8 234 9.2 90.8 1.2 0.0 0.0 100.0 110 Higher secondary 46.4 20.2 267 3.6 90.2 0.0 5.2 1.0 93.8 124 (7.4) (83.7) (6.7) (2.1) (0.0) (91.1) 54 Higher 53.6 27.3 177 4.5 87.6 0.0 7.7 0.3 92.1 95 (2.6) (80.1) (0.0) (17.3) (0.0) (82.7) 48 Wealth index quintile Poorest 48.4 16.1 1,245 17.2 80.4 0.0 1.8 0.6 97.6 603 17.4 77.7 0.0 3.8 1.2 95.1 200 Second 45.8 17.4 1,074 16.6 79.3 0.1 2.6 1.5 95.9 491 14.0 81.5 0.0 3.8 0.7 95.5 187 Middle 48.0 15.0 978 8.5 88.3 0.0 2.5 0.7 96.8 469 9.6 87.8 0.0 2.7 0.0 97.3 146 Fourth 47.5 20.4 800 2.6 96.3 0.1 1.0 0.1 98.9 380 8.4 90.2 2.2 1.4 0.0 98.6 163 Richest 49.6 21.3 623 2.2 92.1 0.0 5.6 0.1 94.3 309 5.6 86.0 1.0 8.4 0.0 91.6 132 a Lady health worker is also included under health provider as a survey specific category b Includes all public and private health facilities and providers ( ) Figures that are based on 25–49 unweighted cases P a g e | 59 Acute Respiratory Infections Symptoms of ARI are collected during the Sindh MICS to capture pneumonia disease, the leading cause of death in children under five. Once diagnosed, pneumonia is treated effectively with antibiotics. Studies have shown a limitation in the survey approach of measuring pneumonia because many of the suspected cases identified through surveys are in fact, not true pneumonia.28 While this limitation does not affect the level and patterns of care-seeking for suspected pneumonia, it limits the validity of the level of treatment of pneumonia with antibiotics, as reported through household surveys. The treatment indicator described in this report must therefore be taken with caution, keeping in mind that the accurate level is likely higher. Table CH.10 presents the percentage of children with symptoms of ARI in the two weeks preceding the survey for whom care was sought, by source of care and the percentage who received antibiotics. Overall, 75.4 percent of children age 0-59 months with symptoms of ARI were taken to a qualified provider. For most of the children (67 percent) with ARI symptoms in Sindh, advice or treatment was sought from a private source. Out of all children with ARI, 20.9 percent did not receive any treatment. At division level, seeking advice or treatment for ARI symptom in children from a qualified provider varied, being lowest (70.3 percent) in Sukkur division and highest (87.2 percent) in Karachi division. Treatment was sought mostly for children that are older, in urban areas and in the richest wealth quintile. Table CH.10 also presents the use of antibiotics for the treatment of children under 5 years with symptoms of ARI by sex, age, division, area, and socioeconomic factors. In Sindh, 32.9 percent of under- 5 children with symptoms of ARI received antibiotics during the two weeks prior to the survey. The percentage was slightly higher in urban than in rural areas. At division level, use of antibotics in children with ARI ranged from 18.6 percent in Mirpurkhas division to 41.5 percent in Hyderabad division. The table also shows that antibiotic treatment of ARI symptoms is lower among children in the poorest households. Table CH.10 also shows the point of treatment among children with symptoms of ARI who were treated with antibiotics. The treatment was received mostly from private health facilities (91.4 percent). 28 Campbell H, el Arifeen S, Hazir T, O’Kelly J, Bryce J, et al. (2013) Measuring Coverage in MNCH: Challenges in Monitoring the Proportion of Young Children with Pneumonia Who Receive Antibiotic Treatment. PLoS Med 10(5): e1001421. doi:10.1371/journal.pmed.1001421 P a g e | 60 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) Percentage of children age 0-59 months with symptoms of ARI in the last two weeks for whom advice or treatment was sought, by source of advice or treatment, and percentage of children with symptoms who were given antibiotics, Sindh, 2014 Percentage of children with symptoms of ARI for whom: P e rc e n ta g e o f c h ild re n w it h s y m p to m s o f A R I w h o w e re g iv e n a n ti b io ti c s i n t h e l a s t tw o w e e k s 2 N u m b e r o f c h ild re n a g e 0 -5 9 m o n th s w it h s y m p to m s o f A R I in th e l a s t tw o w e e k s Percentage of children with symptoms of ARI for whom the source of antibiotics was: N u m b e r o f c h ild re n w it h s y m p to m s o f A R I w h o w e re g iv e n a n ti b io ti c s i n t h e l a s t tw o w e e k s Advice or treatment was sought from: N o a d v ic e o r tr e a tm e n t s o u g h t Health facilities or providers O th e r s o u rc e A h e a lt h fa c ili ty o r p ro v id e r1 , b Health facilities or providers O th e r s o u rc e A h e a lt h f a c ili ty o r p ro v id e rc P u b lic P ri v a te L a d y h e a lt h w o rk e ra P u b lic P ri v a te L a d y h e a lt h w o rk e ra Total 12.5 67.0 0.0 1.9 75.4 20.9 32.9 2,139 6.3 91.4 0.0 1.4 97.7 703 Sex Male 11.9 68.4 0.0 1.8 76.1 20.3 33.9 1,207 4.5 93.0 0.0 1.6 97.5 410 Female 13.3 65.1 0.1 2.0 74.4 21.8 31.5 931 8.8 89.1 0.0 1.2 97.9 293 Division Larkana 8.0 69.3 0.0 1.2 75.7 22.2 40.5 411 5.0 90.9 0.0 4.1 95.9 167 Sukkur 12.0 64.9 0.0 1.8 70.3 24.4 26.9 853 5.3 92.2 0.0 0.5 97.5 229 Hyderabad 14.1 65.1 0.2 0.8 77.9 21.1 41.5 395 10.0 88.6 0.0 1.1 98.6 164 Mirpurkhas 10.5 65.9 0.0 7.9 71.1 19.2 18.6 156 (12.0) (83.9) (0.0) (0.0) (95.9) 29 Karachi 18.7 72.2 0.0 1.5 87.2 10.8 35.2 324 3.4 96.2 0.0 0.3 99.7 114 Area Urban 9.8 75.0 0.0 1.6 82.3 15.2 36.8 606 4.2 95.4 0.0 0.4 99.6 223 Rural 13.6 63.8 0.1 2.0 72.6 23.2 31.3 1,533 7.3 89.5 0.0 1.9 96.8 480 Age 0-11 months 11.4 73.5 0.0 2.3 80.5 16.3 33.6 562 5.6 92.2 0.0 0.4 97.8 189 12-23 months 12.5 66.6 0.0 1.3 74.9 21.2 36.4 457 4.1 93.7 0.0 1.3 97.7 167 24-35 months 13.7 64.4 0.0 2.0 74.3 21.8 29.2 371 6.5 92.3 0.0 1.1 98.9 108 36-47 months 12.4 66.9 0.0 1.3 75.8 21.5 32.9 431 7.2 88.6 0.0 3.3 95.8 142 48-59 months 13.3 58.8 0.3 2.6 67.4 27.2 30.6 318 9.9 88.8 0.0 1.3 98.7 97 Mother’s education None/Preschool 11.7 64.7 0.0 1.9 72.3 23.8 32.0 1,444 7.2 90.2 0.0 1.6 97.3 463 Primary 18.3 67.8 0.0 2.7 80.5 16.1 30.7 322 6.5 92.3 0.0 0.6 98.8 99 Middle 5.4 71.7 0.0 1.9 70.1 23.0 33.5 95 (0.0) (100.0) (0.0) (0.0) (100.0) 32 Secondary 18.4 66.9 0.6 1.5 83.2 14.7 33.1 149 (9.5) (90.5) (0.0) (0.0) (100.0) 49 Higher secondary 4.6 87.5 0.0 0.0 91.0 7.9 40.6 85 (0.0) (95.1) (0.0) (2.7) (95.1) 35 Higher (7.0) (86.7) (0.0) (0.0) (93.7) (6.3) (62.4) 41 (*) (*) (*) (*) (*) 26 Wealth index quintile Poorest 11.9 58.3 0.0 1.5 66.5 30.0 29.4 623 12.5 83.8 0.0 1.3 96.3 184 Second 12.8 66.9 0.0 2.2 74.7 21.3 33.4 674 4.1 93.0 0.0 2.6 97.1 226 Middle 16.7 67.6 0.2 2.4 78.4 16.4 34.6 467 6.8 92.0 0.0 0.9 98.7 162 Fourth 10.6 74.7 0.0 1.0 84.0 13.9 34.9 234 1.5 97.1 0.0 0.4 98.6 82 Richest 3.5 90.7 0.0 1.6 93.4 6.2 36.0 139 (0.0) (100.0) (0.0) (0.0) (100.0) 50 1 MICS indicator 3.13 - Care-seeking for children with acute respiratory infection (ARI) symptoms 2 MICS indicator 3.14 - Antibiotic treatment for children with ARI symptoms a Lady health worker is also included under public health provider as a survey specific category b Includes all public and private health facilities an

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