Somalia - Multiple Indicator Cluster Survey - 2006

Publication date: 2006

1 Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Somalia, 2006 Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1 13 Under-five mortality rate 135 per thousand 2 14 Infant mortality rate 86 per thousand NUTRITION Nutritional status 6 4 Underweight prevalence 36 Percent 7 Stunting prevalence 38 Percent 8 Wasting prevalence 11 Percent Breastfeeding 45 Timely initiation of breastfeeding 26 Percent 15 Exclusive breastfeeding rate 13 Percent 16 Continued breastfeeding rate at 12-15 months at 20-23 months 50 35 Percent Percent 17 Timely complementary feeding rate 15 Percent 18 Frequency of complementary feeding 12 Percent 19 Adequately fed infants 11 Percent Salt iodization 41 Iodized salt consumption 1.2 Percent Vitamin A 42 Vitamin A supplementation (under-fives) 24 Percent 43 Vitamin A supplementation (post-partum mothers) 9 Percent Low birth weight 10 Infants weighed at birth 5 Percent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 26 Percent 26 Polio immunization coverage 35 Percent 27 DPT immunization coverage 12 Percent 28 15 Measles immunization coverage 19 Percent 31 Fully immunized children 5 Percent Tetanus toxoid 32 Neonatal tetanus protection 26 Percent Care of illness 33 Use of oral rehydration therapy (ORT) 21 Percent 34 Home management of diarrhoea 2 Percent 35 Received ORT or increased fluids, and continued feeding 7 Percent 23 Care seeking for suspected pneumonia 13 Percent 22 Antibiotic treatment of suspected pneumonia 32 Percent Solid fuel use 24 29 Solid fuels 100 Percent Malaria 36 Household availability of insecticide-treated nets (ITNs) 12 Percent 37 22 Under-fives sleeping under insecticide-treated nets 11 Percent 38 Under-fives sleeping under mosquito nets 18 Percent 39 22 Antimalarial treatment (under-fives) 3 Percent 40 Intermittent preventive malaria treatment (pregnant women) 1 Percent ENVIRONMENT Water and Sanitation 11 30 Use of improved drinking water sources 29 percent 13 Water treatment 22 percent 12 31 Use of improved sanitation facilities 37 percent 14 Disposal of child’s faeces 35 percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 15 percent S O M A L I A M I C S 2 0 0 6 R E P O R T 2 S O M A L I A M I C S 2 0 0 6 R E P O R T Topic MICS Indicator Number MDG Indicator Number Indicator Value Maternal and newborn health 20 Antenatal care 26 percent 44 Content of antenatal care: Blood test taken Blood pressure measured Urine Specimen taken Weight measured 14 21 9 22 percent percent percent percent 4 17 Skilled attendant at delivery 33 Percent 5 Institutional deliveries 9 percent Maternal mortality 3 16 Maternal mortality ratio 1044 per 100,000 Fertility Total Fertility Rate 6.7 rate CHILD DEVELOPMENT Child development 46 Support for learning 65 percent 47 Father’s support for learning 39 percent EDUCATION Education 52 Pre-school attendance 2 percent 54 Net intake rate in primary education 9 percent 55 6 Net primary school attendance rate 23 percent 56 Net secondary school attendance rate 7 percent 57 7 Children reaching grade five 92 percent 59 7b Primary completion rate 4 percent 61 9 Gender parity index: primary school secondary school 0.8 0.5 ratio ratio Literacy 60 8 Adult literacy rate 25 percent CHILD PROTECTION Birth registration 62 Birth registration 3 percent Child labour 71 Child labour 49 percent 72 Labourer students 44 percent 73 Student labourers 44 percent Early marriage and polygyny 67 Marriage before age 15 Marriage before age 18 8 46 percent percent 68 Young women aged 15-19 currently married/in union 25 percent 70 Polygyny 23 percent 69 Spousal age difference (10 years) Women age 15-19 Women age 20-24 31 30 percent percent Female genital mutilation/ cutting 66 Approval for FGM/C 65 percent 63 Prevalence of female genital mutilation/cutting (FGM/C) 98 percent 64 Prevalence of extreme form of FGM/C 77 percent 65 FGM/C prevalence among daughters 46 percent Domestic violence 100 Attitudes towards domestic violence 76 percent Orphaned children 75 Prevalence of orphans 10 percent 78 Children’s living arrangements 9 percent 77 20 School attendance of orphans versus non-orphans 0.9 ratio 79 Malnutrition among children orphaned and made vulnerable by HIV/AIDS 1.1 ratio HIV/AIDS HIV/AIDS knowledge and attitudes 82 19b Comprehensive knowledge about HIV prevention among young people 4 percent 89 Knowledge of mother- to-child transmission of HIV 38 percent 86 Attitude towards people with HIV/AIDS 5 percent 87 Women who know where to be tested for HIV 16 percent 88 Women who have been tested for HIV 3 percent 3 Table of Contents SuMMARy TAbLE Of fIndIngS . 1 TAbLE Of COnTEnTS . 3 LIST Of TAbLES . 5 LIST Of fIguRES . 7 LIST Of AbbREvIATIOnS . 8 ACknOwLEdgEMEnTS . 9 dISCLAIMER . 10 ExECuTIvE SuMMARy .11 MAP . 16 I. IntroductIon . 17 background . 17 Survey Objectives . 18 II. Sample and Survey methodology . 19 Sample design . 19 Questionnaires . 20 Training and fieldwork . 21 Climatic and Security Consideration . 21 data Processing . 21 III. Sample coverage and the characterIStIcS of houSeholdS and reSpondentS . 23 Sample Coverage. 23 Characteristics of Households . 23 Characteristics of Respondents . 24 Iv. chIld mortalIty . 27 Levels and Trends in Infant and Child Mortality . 27 differentials in Childhood Mortality . 28 v. nutrItIon . 31 nutritional Status . 31 breastfeeding . 33 Salt Iodization . 35 vitamin A Supplements . 35 Low birth weight . 36 vI. chIld health . 39 Immunization . 39 Tetanus Toxoid . 40 Oral Rehydration Treatment . 41 Care Seeking and Antibiotic Treatment of Pneumonia . 43 Solid fuel use . 44 Malaria . 44 Attitudes towards polio vaccination . 46 S O M A L I A M I C S 2 0 0 6 R E P O R T 4 vII. envIronment . 47 water and Sanitation . 47 water . 47 Sanitation . 49 Hygiene . 50 vIII. fertIlIty . 51 Current fertility . 51 fertility differentials . 52 fertility Trends. 52 IX. reproductIve health . 53 Contraception . 53 unmet need . 53 Antenatal Care . 54 Assistance at delivery . 55 Post natal Care . 56 Maternal Mortality . 56 X. chIld development . 57 XI. educatIon . 59 Pre-School Attendance and School Readiness . 59 Primary and Secondary School Participation . 59 Adult Literacy . 61 XII. chIld protectIon . 63 birth Registration . 63 Child Labour . 63 Early Marriage and Polygyny . 64 female genital Mutilation/Cutting . 65 domestic violence . 66 Orphaned Children . 67 XIII. hIv/aIdS . 69 knowledge of HIv Transmission . 69 knowledge of Mother-to-Child Transmission . 70 Attitudes toward people living with HIv . 71 knowledge of HIv Testing facilities . 71 tableS . 73 appendIX a. Sample deSIgn . 151 appendIX b. lISt of perSonnel Involved In the Survey . 155 appendIX c. eStImateS of SamplIng errorS . 161 appendIX d. data QualIty tableS . 169 appendIX e. mIcS IndIcatorS: numeratorS and denomInatorS . 179 appendIX f. QueStIonnaIreS . 185 S O M A L I A M I C S 2 0 0 6 R E P O R T 5 List of Tables Table HH.1: Results of household and individual interviews . 73 Table HH.2: Household age distribution by sex . 74 Table HH.3: Household composition . 75 Table HH.4: women’s background characteristics . 76 Table HH.5: Children’s background characteristics . 77 Table CM.1: Childhood mortality rates. 78 Table CM.2: Child mortality by sex and residence . 78 Table nu.1: Child malnourishment . 79 Table nu.2: Initial breastfeeding . 80 Table nu.3: breastfeeding. 81 Table nu.4: Adequately fed infants . 82 Table nu.5: Iodized salt consumption . 83 Table nu.6: Children’s vitamin A supplementation . 84 Table nu.7: Post-partum mothers’ vitamin A supplementation . 85 Table nu.8: Child size at birth . 86 Table CH.1: Vaccinations in first year of life . 87 Table CH.2: vaccinations by background characteristics . 88 Table CH.3: neonatal tetanus protection . 89 Table CH.4: Oral rehydration treatment . 90 Table CH.5: Home management of diarrhoea . 91 Table CH.6: Care seeking for suspected pneumonia . 92 Table CH.7: Antibiotic treatment of pneumonia. 93 Table CH.7A: knowledge of the two danger signs of pneumonia . 94 Table CH.9: Solid fuel use . 95 Table CH.10: Solid fuel use by type of stove or fire . 96 Table CH.11: Availability of insecticide treated nets . 97 Table CH.12: Children sleeping under bednets . 98 Table CH.13: Treatment of children with anti-malarial drugs . 99 Table CH.14: Intermittent preventive treatment for malaria≠– . 100 Table CH.14A: Pregnant women sleeping under bednets . 101 Table CH.15: knowledge of symptoms relating to malaria . 102 Table CH.16: knowledge and attitudes towards polio vaccination . 103 Table En.1: use of improved water sources . 104 Table En.2: Household water treatment . 105 Table En.2b: Household water treatment . 106 Table En.3: Time to source of water . 107 Table En.4: Person collecting water . 108 Table En.5: use of sanitary means of excreta disposal . 109 Table En.6: disposal of child’s faeces .110 Table En.7: use of improved water sources and improved sanitation .111 Table En.8: Handwashing .112 Table fE.1: Current fertility .113 Table fE.2: fertility by background characteristics .113 S O M A L I A M I C S 2 0 0 6 R E P O R T 6 S O M A L I A M I C S 2 0 0 6 R E P O R T Table fE.3: fertility Trends .114 Table RH.1: use of contraception .115 Table RH.2: unmet need for contraception . 116 Table RH.3: Antenatal care provider . 117 Table RH.4: Antenatal care content. 118 Table RH.4A: number of antenatal care visits . 119 Table RH.5: Assistance during delivery . 120 Table RH.5C: Postpartum medical problems . 121 Table RH.6: Maternal mortality ratio . 122 Table Cd.1: family support for learning . 123 Table Ed.1: Early childhood education . 124 Table Ed.2: Primary school entry . 125 Table Ed.3: Primary school net attendance ratio . 126 Table Ed.4: Secondary school net attendance ratio . 127 Table Ed.4w: Secondary school age children attending primary school . 128 Table Ed.5: Children reaching grade 5. 129 Table Ed.6: Primary school completion . 130 Table Ed.7: Education gender parity . 131 Table Ed.8: Adult literacy . 132 Table CP.1: birth registration . 133 Table CP.2: Child labour . 134 Table CP.3: Labourer students and student labourers . 135 Table CP.4: Early marriage and polygyny . 136 Table CP.5: Spousal age difference . 137 Table CP.6: female genital mutilation/cutting (fgM/C) . 138 Table CP.7: female genital mutilation/cutting (fgM/C) among daughters . 139 Table CP.7A: Age at circumcision among daughters . 140 Table CP.8: Attitudes toward domestic violence . 141 Table CP.10: Children’s living arrangements and orphanhood . 142 Table CP.11: School attendance of orphaned and vulnerable children . 143 Table CP.12: Malnutrition among orphans and vulnerable children . 144 Table HA.1: knowledge of preventing HIv transmission . 145 Table HA.2: Identifying misconceptions about HIv/AIdS . 146 Table HA.3: Comprehensive knowledge of HIv/AIdS transmission . 147 Table HA.4: knowledge of mother-to-child HIv transmission . 148 Table HA.5: Attitudes toward people living with HIv/AIdS . 149 Table HA.6: knowledge of a facility for HIv testing . 150 7 List of Figures figure HH.1: Age and sex distribution of household population . 24 figure CM.1: Trend in under-5 mortality rates . 28 figure CM.2 under-5 mortality rates for the 5 year period preceding the survey by background characteristics . 29 figure nu.1: Percentage of children under-5 who are undernourished . 32 figure nu.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth . 33 figure nu.3 Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group . 34 figure CH.1: Percentage of children 12-23 months who received immunisations by age 12 months . 40 figure CH.2 Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus . 41 figure CH.3 Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment . 42 figure CH.4 Percentage of children aged 0-59 with diarrhoea who received ORT or increased fluids, AND continued feeding . 43 Figure EN.1 Percentage distribution of household members by source of drinking water, . 48 Figure FE.1: Age-specific Fertility Rates by Urban-Rural Residence . 52 Figure CP.1: Percentage of ever-married women who believe a husband is justified in beating his wife in various circumstances . 67 figure HA.1 Percent of women who have comprehensive knowledge of HIv/AIdS transmission . 70 S O M A L I A M I C S 2 0 0 6 R E P O R T 8 List of Abbreviations AIdS .Acquired Immune Deficiency Syndrome bCg .bacillis-Cereus-geuerin (Tuberculosis) dPT .diphteria Pertussis Tetanus EPI .Expanded Programme on Immunization HIv .Human Immunodeficiency Virus Idd .Iodine Deficiency Disorders ITn .Insecticide Treated net Iud .Intrauterine device LAM .Lactational Amenorrhea Method Mdg .Millennium development goals MICS .Multiple Indicator Cluster Survey MoH .Ministry of Health nAR .net Attendance Rate ppm .Parts Per Million PAPfAM .Pan Arab Project for family Health SPSS .Statistical Package for Social Sciences TfR .Total fertility 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 wffC .world fit for Children wHO .world Health Organization S O M A L I A M I C S 2 0 0 6 R E P O R T 9 Acknowledgements The Somali 2006 Multiple Indicator Cluster Survey and Pan Arab Project for family Health was implemented by UNICEF Somalia as part of the global UNICEF MICS programme, in partnership with the League of Arab States. The survey was conducted with the support and endorsement of: Ministry of Planning and International Cooperation, Transitional Federal Government, · Somalia Ministry of National Planning and Coordination, Hargeisa, Somaliland· Ministry of Planning and International Cooperation, Garowe, Puntland· The field work was conducted by the following organizations: Central/Southern Somalia· women Care (Middle Shabelle)o Sean deveroux Human Rights Organisation (Lower Juba)o natural Resource Management and Information Centre (bakool)o African Rescue Committee (Middle Juba)o Samawada Rehabilitation and development Organisation (Lower Shabelle)o Community Care Centre (bay Region)o Community Research and development group (benadir Region)o Himilo Relief, Rehabilitation and Development Association (Gedo Region)o Hiran HIv/AIdS Prevention and Child Protection (Hiran Region)o unICEf Somalia (galgadud Region)o Somaliland· Training and Research groupo Puntland· Ministry of Planning and International Cooperationo The survey coordinator was Ms Rhiannon James. Managerial, training and field supervision support was provided by the following UNICEF staff: Marcus Betts, Ibrahim Shire, Asha Adam, Awil Bashir Ahmed, Gnanaruby Karunakaran, Catherine Kiraka, ‘Shafie’Adan Mohamed, Mohamed Dhaqane, Charles Nzuki, Sado Yusuf Ali, ‘Discipline’ Ahmed Moallim Mohamed, Mohamed Ahmed Yusuf, Deeqa Abdurahim Sharif, Fatuma Mohamed, Ahmed Osman and Abdulkadir dalib. Technical advice and support was provided by Dr Ahmed Monem (PAPFAM), Mona E Ahmed (PAPFAM), Attila Hancioglu (UNICEF), Ngagne Diakhate (UNICEF), Gareth Jones (UNICEF), Trevor Croft (UNICEF), KNS Nair (UNDP), Peter Wingfield Digby (UNDP) Denise Shepherd- Johnson (unICEf) and volker Huls (unICEf). Funding was provided by UNICEF, Global Fund against AIDS, TB and Malaria (Malaria component of Somalia grant). Additional funding for provision of technical assistance during data processing, training workshops, publication and dissemination was provided by PAPFAM, wHO and unfPA. S O M A L I A M I C S 2 0 0 6 R E P O R T 10 Disclaimer This Somali 2006 MICS covers all regions of Somalia. For the purposes of this survey, the analysis refers to the North West Zone, the North East Zone and Central South Zone according to prewar boundaries for Somaliland and Puntland and does not imply any recognition of administrative boundaries by the united nations or the League of Arab States. This will allow some comparison with the previous MICS surveys, and is consistent with the common approach adopted by the un Country Team Statistics working group. S O M A L I A M I C S 2 0 0 6 R E P O R T 11 Executive Summary The 2006 Multiple Indicator Cluster Survey (MICS) is a nationally representative survey of 5969 households, 6764 women age 15-49 and 6305 mother’s and caretakers of children age less than five. The primary purpose of the MICS is to provide policy makers and planners with reliable and detailed information needed to monitor the situation of women and children. Information on child mortality, nutrition, child health, child protection, water and sanitation, education, reproductive health, knowledge of HIV/AIDS and fertility is included. Child Mortality At current mortality levels, one in every twelve Somali children dies before reaching age · one, while one in every 7 does not survive to the fifth birthday. The highest levels of mortality are found in the Central South Zone. · Male children experience higher mortality than female children and the sex difference is · especially pronounced for infant mortality. Immunisation Twelve percent of children age 12 -23 months had been fully vaccinated at the time of · the survey. five percent received all their vaccinations before the age of one year.· Thirty percent of children age 12-23 months have received the BCG vaccination, and 29 · percent have been vaccinated against measles. Just under a quarter of children age 12-23 months have received the dPT1 vaccination; · only 14 percent however then go on to receive the third dose of dPT. Polio coverage is higher than dPT because of the efforts of the national immunisation · campaigns during which polio vaccinations are administered on a wide scale. Thirty- nine percent have received polio 3; nevertheless the dropout between the first and subsequent doses of polio is high. Thirty-six percent of children age 12-23 months, have not received any of the basic · vaccinations. diarrhea Nationally 21 percent of children under age five had diarrhea at some time in the two · weeks before the survey. Around one in five children who had diarrhea were treated with some kind of oral · rehydration therapy (ORT): 9 percent were treated with ORS (solution prepared from ORS packets); 9 percent were given recommended home fluids (RHF) prepared at home; and 7 percent were given pre-packaged ORS fluid. Just under 80 percent of children with diarrhea did not receive any type of treatment at all. · Acute respiratory Infection (ARI) Fifteen percent of children under age five showed symptoms of ARI in the two weeks · before the survey. Use of a health facility for the treatment of symptoms of ARI is low, with only 13 percent · of children taken to an appropriate health facility or provider. Thirty-two percent of children under age five who showed symptoms of ARI in the two · weeks before the survey received antibiotics. Just fifteen percent of mothers and caretakers identified that fast and difficult breathing · would be cause for taking their children immediately to a health facility. E X E C U T I V E S U M M A R Y S O M A L I A M I C S 2 0 0 6 R E P O R T 12 S O M A L I A M I C S 2 0 0 6 R E P O R T The risk of acute respiratory illness is increased by the near universal use of solid fuels · used for cooking in Somali households. Almost 100 percent of Somali households use solid fuels for cooking and just one in ten households have a hood or chimney above their open fire or stove. Mosquito nets One in five Somali households own at least one mosquito net, with 11 percent of households · owning a long lasting insecticide treated net (ITn). Eighteen percent of children under age 5 slept under a bed-net during the night prior to · the interview; with 11 percent of children sleeping under an ITn. nutrition The level of malnutrition is significant with at least one in three (36 percent) Somali · children under five years of age that are underweight, 38 percent stunted (short for their age) and 11 percent wasted (thin for their height). In general rural children and children of uneducated mothers are more likely to be · underweight, stunted or wasted than other children. breastfeeding Three out of five children are breastfed within one day of being born. · Among children age 12-15 months just half are still breastfed, this falls to 35 percent among · children age 20-23 months. Exclusive breastfeeding levels are very low, contrary to UNICEF/WHO recommendations, · only 9 percent of Somali children age 0-6 months are exclusively breastfed. Complementary foods are not introduced in a timely fashion for many children. At · 6-11 months, just 12 percent of children are receiving the recommended number of complementary feedings. Among children age 0-11 months, only one in ten children are considered appropriately · fed. water Twenty-nine percent of the Somali population has access to an improved source of drinking · water. A quarter of those living in the north East and Central South Zone have access to improved · sources, however access to improved water sources is above the national average in the north west Zone. One fifth of the Somali population uses an appropriate method to treat their water in the · household. People from households in urban areas and where the household head has had some form · of formal education are more likely to use an appropriate water treatment method than others. On average it takes one hour and twelve minutes to go to the source of drinking water, · get the water and then return. The time it takes to collect water is significantly longer for households in rural areas and households in the Central South Zone. In two thirds of households an adult women bears the responsibility for collecting water. · Sanitation Half of the Somali population is living without any type of toilet facilities. · Thirty-seven percent are using a facility with a sanitary means of excreta disposal. · Just over three quarters of Somalis living in urban areas are using a sanitary means of · excreta disposal compared to 13 percent of people living in rural areas. When it comes to disposing of child’s faeces, over a third of children age 0-2 months (35 · percent) have their stools disposed of in a safe way. 13 E X E C U T I V E S U M M A R Y One fifth of the Somali population is using both an improved source of drinking water · and a sanitary means of excreta disposal. Zonal differences are small but the difference between those living in urban and rural households is substantial. fertility The total fertility rate is 6.7 births per woman. · There are no substantial differences in fertility by zone or urban/rural residence; rural · women have on average just one more child than urban women by the end of their childbearing years. Contraception fifteen percent of married women age 15-49 are using a method of family planning.· One percent of women using a method of family planning are using a modern method. · The most commonly used modern method is the pill, although usage is extremely low. The most popular non modern method is the lactational amenorrhea method (LAM). · Antenatal care Twenty-six percent of mothers who had a live birth in the two years preceding the survey · received antenatal care from a doctor, nurse or trained midwife. Among women who received antenatal care: 14 percent had a blood test taken, 21 percent · had their blood pressure measured, 9 percent had a urine specimen and 22 percent had their weight measured. On average women receiving antenatal care would have 2 checkups. · Approximately seven in ten mothers did not receive any antenatal care; half of the women · not receiving antenatal care reported that they did not feel the need to see anyone. Assistance at delivery of births nine percent of births in the two years prior to the survey were delivered in a health · facility. A third of the births were delivered at home with the assistance of skilled health personnel, · that is, a doctor, nurse or midwife. fifty-one percent of births are attended by a traditional birth attendant (TbA). · Three percent of births were delivered without any type of assistance at all. · Maternal Mortality The maternal mortality ratio, which measures the obstetric risk associated with each live · birth is 1044 deaths per 100,000 live births. Education Early childhood education is rare in Somalia and is attended by just 2 percent of Somali · children age 3-5. Nine percent of children age 6, which is the primary school entry age, are currently · attending the first grade. Of all children of primary school age (6-13 years old), approximately 23 percent are attending · primary school. Seven percent of secondary school age children (14-18 years old) are attending secondary or · higher education. Just under one fifth (19 percent) of secondary school age children are still attending · primary school. data show that the primary school completion rate stands at just 4 percent.· For every 10 boys who attend primary school, there are 8 girls. The gender parity index · falls even more for secondary school education, with 5 girls attending for every 10 boys. S O M A L I A M I C S 2 0 0 6 R E P O R T 14 S O M A L I A M I C S 2 0 0 6 R E P O R T Literacy A quarter of Somali women age 15-24 are literate.· women living in urban areas are four and a half times more likely to be able to read than · women living in urban areas. birth Registration Three percent of children under 5 years old had their birth registered. Registration is highest · in the north west Zone. Orphans Around 10 percent of Somali children have lost either a mother or father.· One percent of Somali children have lost both parents. · Child Labour Almost half of all Somali children (49 percent) are involved in child labour activities. The · majority of child labour is centered around working for the family business or spending more than 28 hours a week on household chores. forty-four percent of those children engaged in child labour are also attending school. · Marriage Eight percent of women age 15-49 years were married by the time they were 15, the · proportion increases to 46 percent by the time women are 18. A quarter of Somali women age 15-19 are currently married. In thirty-one percent of these · marriages the husband is ten years older than the woman. Twenty-three percent of currently married women are married to men who are in a · polygamous union. Older women and women with no education are more likely to be in a polygamous union · than other woman. fgM/C Almost all (98 percent) of women age 15-49 have been circumcised. · Seventy-seven percent of women reported that they had experienced an extreme form of · FGM/C where their vagina had been sewn closed or flesh had been removed. Just less than half (46 percent) of women with at least one living daughter, have a daughter · who has experienced fgM/C. Sixty percent of daughters who have been circumcised have had the extreme form. · The majority of girls are circumcised between the ages of 5 and 9 years (79 percent).· Attitudes towards domestic violence Overall three quarters of ever married women age 15-49 believe that there are at least · some situations in which a husband is justified in beating his wife. Sixty-four percent of ever married women agree that a husband is justified in beating his · wife if his wife refuses to have sex with him. HIv/AIdS Sixty-five percent of women age 15-49 have heard of AIDS. · women are most aware that the chances of getting the AIdS virus can be reduced by · limiting sex to one uninfected partner (36 percent). knowledge of condoms and the role they can play in preventing the transmission of HIv is · low at 15 percent. Thirty-four percent of women know that a healthy-looking person can have the AIdS · virus. 15 E X E C U T I V E S U M M A R Y Many women erroneously believe that AIDS can be transmitted by supernatural means, · mosquito bites and by sharing food. A minority of women (4 percent) have comprehensive knowledge of HIv/AIdS · transmission, that is, they know that both condom use and limiting sex partners to one uninfected partner are HIv prevention methods; that a healthy-looking person can have HIV; and reject the two most common local misconceptions about HIV/AIDS – that AIDS can be transmitted by supernatural means and by mosquito bites. Half of women know that HIv can be transmitted by breastfeeding. · Approximately two fifths of women (38 percent) could identify all three ways of mother · to child transmission. women living in rural areas were more than twice as likely to know all three ways compared to women living in rural areas. Almost all women age 15-49 (95 percent) agreed with at least one discriminatory statement · towards people living with HIv/AIdS. Seventy-three percent of women said they would not buy food from a person living with · HIv/AIdS. Over half of the women (58 percent) said that they would care for a family member who · was sick with AIdS. Among the female population age 15-49, 16 percent know of a place to get tested for · HIv. Three percent of women reported that they had been tested for HIV at some time, and 73 · percent of these women had received the results of their test. S O M A L I A M I C S 2 0 0 6 R E P O R T 16 S O M A L I A M I C S 2 0 0 6 R E P O R T 17 I. Introduction background This report is based on the Somali Multiple Indicator Cluster Survey, conducted in 2005 by UNICEF as part of the global UNICEF MICS programme, with technical assistance from the PAPfAM project of the League of Arab States. The survey was conducted with the support and endorsement of: Ministry of Planning and International Cooperation, Transitional Federal Government, · Somalia Ministry of National Planning and Coordination, Hargeisa, Somaliland· Ministry of Planning and International Cooperation, Garowe, Puntland· The survey provides valuable information on the situation of children and women in Somalia and was based, in large part, on the need to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the united nations Special Session on Children in May 2002. both of these commitments build upon promises made by the international community at the 1990 world Summit for Children. 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 (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.” I N T R O D U C T I O N S O M A L I A M I C S 2 0 0 6 R E P O R T 18 This is in addition to the decisions issued by the League of Arab States and other related institutions and organizations with regard to the Arab framework for Arab child rights, the Cairo declaration towards an “Arab World Fit for Children”, and the second Arab plan for childhood (2004-2015) adopted by the Arab summits. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. unICEf was assigned a supporting role in this task (see table below). The Somali MICS (2006) follows the first Multiple Indicator Cluster Survey (MICS1) in 19951 and the second Multiple Indicator Cluster Survey (MICS2) in 1999 and was designed to provide a credible dataset at the national level in order to assess the situation of children and women in Somalia at the Mid-decade. The survey was also designed to be able to produce data at the level of zones; the North West Zone (Somaliland), the North East Zone (Puntland) and the Central South Zone of Somalia. The MICS findings will also provide data for monitoring progress (or establishing a baseline) for Somali specific goals (Reconstruction and Development Plan, UN Programmes, GFATM Malaria Programme, Five-Year Development Plans/ Poverty Reduction Strategies). The third Somali MICS includes many of the same questions and indicators as the 1999 MICS. However, since 1999, the survey methodology and in particular the sample design has undergone many improvements with more involvement from experts in this field. The sample size is also significantly larger. Therefore whilst the MICS should be used as a monitoring tool to identify national changes over time, this is difficult to do when there are wide divergences in sampling methodology between surveys. Therefore making direct comparisons between the 1999 and 2006 MICS has not been encouraged in this report. This final report presents the results of the indicators and topics covered in the survey. Survey objectives The 2006 Somali MICS has as its primary objectives: To provide up-to-date information for assessing the situation of children and women in · Somalia. To furnish data needed for monitoring progress toward goals established by the Millennium · Development Goals, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals, as a basis for future action; To contribute to the improvement of data and monitoring systems in Somalia and to · strengthen technical expertise in the design, implementation, and analysis of such systems. 1 Survey covered Somaliland only. S O M A L I A M I C S 2 0 0 6 R E P O R T 19 II. Sample and Survey Methodology Sample design The sample for the Somali Multiple Indicator Cluster Survey and Pan Arab Project for family Health (MICS/PAPfAM) was designed to provide estimates on a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for the three zones: North West Zone, North East Zone and Central South Zone. Zones were identified as the main sampling domains and the sample was selected in four stages. unlike most countries Somalia does not have well developed survey programmes through a national office of statistics or otherwise and has not had a census for more than 20 years. Thus with no predefined census enumeration areas, it was considered necessary to design a new sample frame using the most up- to-date sources of data available. The target sample size for the Somali MICS was calculated as 6000 households. within each zone a predetermined number of clusters were selected. In the north East and north west Zones 60 clusters were selected in each2. In the Central South Zone 130 clusters were selected making a total of 250 clusters with 24 households in each cluster. within each region of each zone districts were selected using probability proportional to size (pps); in total 57 districts, out of 114 districts in Somalia were selected. The number of clusters in each district was also allocated according to estimated population size of district.The proportion of urban to non-urban clusters was determined according to the estimated populations falling within each category within each district. The non-urban population includes both the settled population in rural areas as well as the nomadic population. within the selected districts permanent and temporary settlements were randomly selected also using probability proportional to size sampling3. In order to ensure than nomads were included in the sample, efforts were made to include temporary settlements near to known water points where nomads would most likely to be found. The third stage of sampling then involved the selection of the cluster(s) within the settlements. for settlements over the estimated size of 150 households some form of segmentation was necessary. Sketch maps were prepared to divide the settlements into roughly equal sizes of estimated households. Each segment was considered as an enumeration area making it possible to randomly select the required number of clusters. Once the final clusters had been identified, households were selected randomly using a modified expanded programme for immunisation (EPI) method. The sample was stratified by urban and non-urban and is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. 2 It should be noted that the decision to allocate an equal number of clusters to the two northern zones of the country was to avoid political disputes over population figures. The data was then reweighed to reflect population estimates during data analyses. 3 Lists of settlements were provided from the UNDP Settlement Survey (draft based on fieldwork 2005) and the most recent WHO Polio vaccination data (2006). S A M P L E A N D S U R V E Y M E T H O D O L O G Y S O M A L I A M I C S 2 0 0 6 R E P O R T 20 Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members, the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years; and 3) an under-5 questionnaire normally 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. Each questionnaire comprised several modules: The Household Questionnaire included the following: Household listingo Educationo water and Sanitationo Household characteristicso Child Labouro Insecticide Treated netso Maternal Mortalityo Salt Iodizationo The Questionnaire for Individual women included the following: Child Mortalityo birth Historyo Tetanus Toxoido Maternal and newborn Healtho Marriage/uniono Contraceptiono female genital Mutilationo HIv/AIdSo The Questionnaire for Children under five included the following: birth Registration and Early Learningo vitamin Ao breastfeedingo Care of Illnesso Malariao Immunizationo Anthropometryo The questionnaires are based on the MICS model questionnaire4 with some additional questions included to reflect PAPFAM’s interests as well as some country specific questions. From the MICS English version, the questionnaires were translated into Somali and were pre-tested in urban and rural areas in each zone during June and July 2006, efforts were made to ensure that nomadic households were included in the pre-testing. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Somali MICS questionnaires is provided in Appendix f. 4 The model MICS questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. S O M A L I A M I C S 2 0 0 6 R E P O R T 21 S A M P L E A N D S U R V E Y M E T H O D O L O G Y In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, and measured the weights and heights of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. training and fieldwork Training for the fieldwork was conducted for 16 days in July 2006. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent 2 days practicing the interviews in towns and villages near the training locations (Hargeisa, Garowe, Merca and Wajid). The data were collected by 20 teams; each team comprised 10 people which included 8 interviewers, one editor/measurer and a supervisor. fieldwork began in August 2006 and concluded in September 2006. In order to ensure that teams would have access to all clusters unICEf worked through local partners who had established reputations in the different regions and had experience of conducting surveys. The partners did not choose the interviewers until the final clusters had been selected, in this way partners were able to use personnel who resided in or had their origins from the different settlements and towns where clusters would occur. climatic and Security consideration The survey was conducted during the recovery period of an acute drought which had affected regions in the Central South Zone in 2005/2006. The data collection also occurred at a time of relative security allowing access to all selected districts. All but one of the selected clusters was accessed by the field teams. In Middle Juba it was not possible to access one cluster due to perceived insecurity just prior to visiting the cluster. Therefore another cluster with the same characteristics in the same district was randomly selected as an alternative. data collection was conducted in the dry season (August/September) which gave the advantage of having access to nomadic communities which settle near known water points. The disadvantage of conducting fieldwork at this time however was that many women and children in the populated northern cities of the north west and north East Zones had travelled south to stay with relatives in cooler climates. Therefore fewer women and children than expected were found in these areas. data processing Data were entered using the CSPro software. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS project and adapted to the Somali questionnaire were used throughout. data processing began simultaneously with data collection in September 2006 and was completed in October 2006. data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 14, and the model syntax and tabulation plans developed by unICEf for this purpose. PAPfAM also assisted in developing the syntax and tabulation for data relating to reproductive health. S O M A L I A M I C S 2 0 0 6 R E P O R T 22 S O M A L I A M I C S 2 0 0 6 R E P O R T 23 III. Sample Coverage and the Characteristics of Households and Respondents Sample coverage Of the 6000 households selected for the sample 5969 were successfully interviewed for a household response rate of 99.5 percent. In the interviewed households, 7277 women (age 15-49) were identified. Of these, 6764 were successfully interviewed, yielding a response rate of 93 percent. In addition, 6373 children under age five were listed in the household questionnaire. Of these, questionnaires were completed for 6305 which corresponds to a response rate of 98.9 percent. Overall response rates of 92.5 percent and 98.4 are calculated for the women’s and under-5’s interviews respectively (Table HH.1). Household response rates for the Somali MICS are almost 100 percent due to the method of the household selection. without a recent census or a household listing performed prior to data collection, household selection had to be performed around the same time that the interview would take place and quite often this occurred on the same day. Many households in Somalia are also temporary structures and therefore if the structure is present it would be unusual for it to be uninhabited. when response rates by zone are compared it appears that the response rate for women in the north west Zone was much lower (82.4 percent) than the national average. Survey teams reported that women, particularly in rural areas were too busy performing their daily chores to be interviewed for long periods. characteristics of households The age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 5,969 households successfully interviewed in the survey, 33,959 household members were listed. Of these, 16,988 were males, and 16,965 were females. The age structure of the household population is typical of a society with a very young population. The population pyramid has a wide base due to the large number of children less than 15 years of age. Children under 15 years of age comprise 49 percent of the population which is characteristic of a population with high fertility levels. Over half of the population (55 percent) is between the ages of 0 and 17. Forty seven percent of the population is in the age group 15 – 64 and about 3 percent are over 65 years of age. Collecting accurate information on age presents a particular challenge for Somalia. very few people have birth certificates or any form of identification and many people do not know the exact year they were born. Therefore some irregularities and data quality issues related to age are to be expected. Table dQ.1 in Appendix d presents ages in single year categories; the table shows high level of digit preference for ages ending in zero. In only 1 percent of cases was age unreported. S A M P LE C O V E R A G E A N D T H E C H A R A C T E R IS T IC S O F H O U S E H O LD S A N D R E S P O N D E N T S S O M A L I A M I C S 2 0 0 6 R E P O R T 24 S O M A L I A M I C S 2 0 0 6 R E P O R T figure hh.1: age and sex distribution of household population, Somalia, 2006 12 10 8 6 4 2 0 2 4 6 8 10 12 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Percent Males Females Table HH.3 provides basic background information on the households. Within households, the sex of the household head, zone, urban/rural status and number of household members are shown in the table. These background characteristics are also used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted numbers of households are equal, since sample weights were normalized (see Appendix A). The weighted number of households in the North East Zone is significantly lower than then unweighted observations due to over sampling in this zone. Households in Somalia are predominantly male headed with just under one in five households being headed by a female. Somali households are typically quite large; the average household size observed in the survey is 5.7 persons. Eight percent of households have 10 or more members. ninety-one percent of households have at least one child aged less than 18 years of age and 66 percent have at least one child aged less than 5 years. The majority of households (91 percent) have at least one woman of reproductive age. characteristics of respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, 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. 25 S O M A L I A M I C S 2 0 0 6 R E P O R T Table HH.4 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to zone, urban-rural areas, age, marital status, motherhood status, education5 and wealth index quintiles6. The weighted number of women in the North East region is significantly lower than then unweighted observations due to over sampling in this zone. More women reside in rural areas compared to urban areas (60 percent versus 40 percent) Due to high fertility and rapid population growth, the proportion of women in each 5 year age group declines as age increases with one in four surveyed women between the age of 15 -19. The majority of the surveyed women (65 percent) are married, a quarter of the women have never been married and 9 percent of women reported being widowed or divorced. Of the women who are married or had been formerly married, 91 percent had given birth. generally it appears that educational attainment among the surveyed women is very low. The majority of women had never received any kind of education (58 percent). Approximately the same number of women had received koranic education compared to primary education (16 percent versus 15 percent). Just under five percent of women had attended secondary or higher education and just under 4 percent had attended some form of non-standard curriculum. Table HH.5 presents some background characteristics of children under 5. These include distribution of children by several attributes: sex, zone and area of residence, age in months, mother’s or caretaker’s education and wealth. Just over half of the children in the survey were male (52 percent male versus 48 percent female). As with the surveyed women, the weighted number of children in the North East region is significantly lower than then unweighted observations and most of the children reside in rural areas compared to urban areas (64 percent versus 36 percent). The proportion of children in each yearly age group is approximately equal at around 20 percent in each year. Slightly fewer children however were observed in the age group 12-23 months. The educational attainment of the mothers and caretakers is generally very low. The majority of mothers and caretakers had not attended any form of education (62 percent). Mothers and caretakers are slightly more likely to have attended koranic school than any formal education (18 percent versus 16 percent). 5 Unless otherwise stated, “education” refers to highest educational level attended by the respondent throughout this report when it is used as a background variable. 6 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The assets used in these calculations were as follows: main source of drinking water, toilet facility, electricity, bed, radio, TV, mobile telephone, non mobile telephone, refrigerator, VCD/DVD, fan, satellite dish, watch, bicycle, animal cart, car/truck, clock, sewing machine, hectares of land and farm animals ). Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poor- est quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households bv wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. S A M P LE C O V E R A G E A N D T H E C H A R A C T E R IS T IC S O F H O U S E H O LD S A N D R E S P O N D E N T S 26 S O M A L I A M I C S 2 0 0 6 R E P O R T 27 IV. Child Mortality One of the overarching goals of the Millennium development goals (Mdgs) and the world fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction of under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. The mortality rates presented in this chapter are computed from information gathered from the birth history of the women’s Questionnaire. women in the age-group 15-49 were asked whether they had ever given birth, and if they had, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of their children in chronological order starting with the first child. Woman were asked whether a birth was single or multiple; the sex of the child; the date of birth (month and year); survival status; age of the child on the date of the interview if alive; and if not alive; the age at death of each live birth. Since the primary causes of childhood mortality change as children age, mostly biological factors to environmental factors, childhood mortality rates are expressed by age categories and are customarily defined as follows; Neonatal mortality (NN): the probability of dying within the first month of life· Postneonatal mortality (Pnn): the difference between infant and neonatal mortality· Infant mortality (· 1q0): the probability of dying between birth and the first birthday Child mortality (· 4q0): the probability of dying between exact ages one and five Under-five mortality (· 5q0): the probability of dying between birth and the fifth birthday The rates of childhood mortality are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one. levels and trends in Infant and child mortality Table CM.1 presents neonatal, post neonatal, infant, child and under-five mortality rates for the three recent five year periods before the survey. Neonatal mortality in the most recent period is 41 per 1000 live births. This rate is similar to post neonatal deaths (45 per 1000 live births) during the same period; that is, the risk of dying for any Somali child who survived the first month of life is similar as in the remaining 11 months of the first year of life. Thus just under 50 percent of infant deaths in Somalia occur during the first month of life. The infant mortality rate in the five years preceding the survey is 86 per 1,000 live births and under-five mortality is 135 deaths per 1,000 live births for the same period. This means that one in every 12 Somali children dies before reaching age one, while one in every 7 does not survive to the fifth birthday. Mortality trends can be examined in two ways: by comparing mortality rates for five year periods preceding a single survey and by comparing mortality estimates obtained from various surveys. However, these comparisons should be interpreted with caution because quality of data, time references and sample coverage varies. In particular, sampling errors associated with mortality estimates are large and should be taken into account when examining trends between surveys. C H I L D M O R T A L I T Y S O M A L I A M I C S 2 0 0 6 R E P O R T 28 Although not strictly comparable, the data from the 1999 MICS, using indirect measures of mortality7, reported infant mortality to be 134 per 1,000 live births and under five mortality as 224 per 1,000 live births in the same period. Figure CM.1 compares the trends in under five mortality rates from the two surveys. The most recent under five mortality estimate is about 40 percent lower than the estimate from 1999. However as can be seen from the graph, trend data from the 2006 survey for the same period show much lower mortality. Therefore, before it can be concluded that the most recent results indicate a significant reduction in mortality during the last 5 years, further qualification for any apparent decline, the extent of the decline as well as the determinants should be taken up in a more detailed and separate analysis. figure cm.1: trend in under-5 mortality rates, Somalia, 2006 differentials in childhood mortality Table CM.2 provides estimates of child mortality by sex, zone, urban rural residence, mother’s education and wealth for the five years preceding the survey. As to be expected male children experience higher mortality than female children. under-5 mortality rates are highest in the Central South Zone; in the North West Zones under 5 mortality is estimated at 113 per 1,000, rising to 122 per 1,000 in the North East and to 144 per 1,000 live births in the Central South Zone (figure CM.2). There appears to be very little difference with the risk of mortality between urban and rural residence. with respect to mother’s education and mortality the relationship is not consistent and the data shows an unexpected pattern suggesting that children born to mothers with no education, have a lower mortality risk than children born to mothers with any level of formal education. from table CM.2 it is apparent that infant and child survival is associated with wealth; infant mortality is consistently lower among children born to mothers in the richest 40 percent of households than those born to mothers in the poorest households. 7 The 1999 MICS did not include a birth history so mortality rates are based on an indirect estimation technique known as the Brass method. 0 50 100 150 200 250 1980 1985 1990 1995 2000 2005 MICS 1999 Indirect MICS 2006 Direct S O M A L I A M I C S 2 0 0 6 R E P O R T 29 C H I L D M O R T A L I T Y figure cm.2 under-5 mortality rates for the 5 year period preceding the survey by background characteristics, Somalia, 2006 S O M A L I A M I C S 2 0 0 6 R E P O R T 113 122 144 134 136 126 150 152 140 128 135 0 20 40 60 80 100 120 140 160 Zone North West North East Central South Area Urban Rural Mother's Education No education Koranic Primary + Wealth Quintiles Poorest 60 % Richest 40 % Country Per 1000 30 S O M A L I A M I C S 2 0 0 6 R E P O R T 31 S O M A L I A M I C S 2 0 0 6 R E P O R T V. Nutrition nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all children deaths worldwide. undernourished children are more likely to die from common childhood ailments, and those who survive, have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The world fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will 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 the wHO/CdC/nCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the survey was implemented. Each of the three nutritional status indicators 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. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In the MICS, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). findings in this section are based on the results of these measurements. Children who were not weighed and measured (approximately 7 percent of children) and those whose measurements are outside a plausible range are excluded from the analyses. In addition, a small number of children whose birth dates are not known are excluded. N U T R I T I O N 32 0 5 10 15 20 25 30 35 40 45 50 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) P er ce nt Underweight Stunted Wasted Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population. during the data analyses stage the Somali nutrition data underwent some additional data quality checks using the nutrisurvey software.8 The data quality checks highlighted certain problems such as a higher than normal level of rounding on height. While at the national level findings appear quite consistent, at the level of zones the results appear to show some unexpected patterns that require more understanding and analyses. Therefore table nu.1 is presented without the zonal estimates. At the time of publication unICEf has made plans to conduct substantial further analyses on the MICS nutrition data as well as on other sources of nutrition data collected in Somalia. Thirty-six percent of Somali children under the age of five are moderately underweight and 12 percent are classified as severely underweight (Table NU.1). Thirty eight percent of children are stunted or too short for their age and 11 percent are wasted or too thin for their height. Children living in rural areas are almost twice as likely to be moderately underweight than those living in urban areas (23 percent versus 43 percent). Those children whose mothers have primary or secondary education are less likely to be underweight and stunted compared to children of mothers with no education or koranic education. The age pattern shows that a higher percentage of children aged 12-23 months are wasted in comparison to children who are younger and older. This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. figure nu.1: percentage of children under-5 who are undernourished, Somalia, 2006 8 For more information on nutrisurvey software go to http://www.nutrisurvey.de/ (accessed on 20.07.07) S O M A L I A M I C S 2 0 0 6 R E P O R T 33 N U T R I T I O N S O M A L I A M I C S 2 0 0 6 R E P O R T breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The world fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to 2 years of age and beyond. wHO/unICEf have the following feeding recommendations: Exclusive breastfeeding for first six months• Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at 6 months• frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day • for 9-11 month olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators of recommended child feeding practices are as follows: Exclusive breastfeeding rate (< 6 months & < 4 months)• Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 & 20-23 months)• Timely initiation of breastfeeding (within 1 hour of birth)• frequency of complementary feeding (6-11 months)• Adequately fed infants (0-11 months)• Table nu.2 provides the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). Just over a quarter (26 percent) of women who had given birth in the 2 years preceding the survey started to breastfeed within one hour of birth. As presented in figure nu.2 this ranges from 39 percent in the north East Zone to 35 percent in the north west Zone and 21 percent in the Central South Zone. Sixty-one percent of Somali women begin breastfeeding within one day of the birth. women in urban areas are more likely to begin breastfeeding within one day of the birth compared to their rural counterparts. There is a positive relationship between education and breastfeeding; 71 percent of women with primary education began breastfeeding within one day of birth compared to 59 percent of women with no education. figure nu.2 percentage of mothers who started breastfeeding within one hour and within one day of birth, Somalia, 2006 70 74 55 67 57 61 35 39 21 27 26 26 0 10 20 30 40 50 60 70 80 North West North E ast C entral S outhern Urban R ural C ountry P er ce nt Within one day Within one hour 34 S O M A L I A M I C S 2 0 0 6 R E P O R T In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk and vitamins, mineral supplements, or medicine. The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Approximately 9 percent of children aged less than six months are exclusively breastfed, a level considerably lower than recommended. At age 6-9 months, 15 percent of children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 50 percent of children are still being breastfed and by age 20-23 months the percentage falls to 35 percent. girls were more likely to be exclusively breastfed than boys (14 percent versus 11 percent) and also have a higher rate for timely complementary feeding (11 percent versus 8 percent). Among children age 20-23 months boys were likely to be breastfed for longer than girls. figure nu.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is well below 10 percent. Only about 15 percent of children are receiving breast milk after 2 years. figure nu.3 Infant feeding patterns by age: percent distribution of children aged under 3 years by feeding pattern by age group, Somalia, 2006 The adequacy of infant feeding in children under 12 months is provided in Table nu.4. different criteria of adequate feeding are used depending on the age of the child. for infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 months are considered to be adequately fed if they are receiving breastmilk and complementary food at least two times per day, while infants aged 9-11 months are considered to be adequately fed if they are receiving breastmilk and eating complementary food at least three times a day. Just 9 percent of infants aged less than six months are exclusively breastfed; this figure ranges from 12 percent in the Central South Zone to 5 percent in the north west Zone and just 1 percent 0 10 20 30 40 50 60 70 80 90 100 0- 1 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 24 -2 5 26 -2 7 28 -2 9 30 -3 1 32 -3 3 34 -3 5 Age (in Months) P er ce nt Weaned (not breastfed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed 35 N U T R I T I O N S O M A L I A M I C S 2 0 0 6 R E P O R T in the north East Zone. Infants from the poorest households are more likely to be exclusively breastfed compared to infants from wealthier households. For infants age between 6-8 months, 10 percent received breast milk and complimentary food at least twice in the prior 24 hours to the survey. Fifteen percent of infants age 9 – 11 months were receiving breast milk and complimentary food at the 3 minimum number of recommended times per day. As a result of these feeding patterns, only 12 percent of children aged 6-11 months are being adequately fed. Adequate feeding among all infants (aged 0-11) drops to 11 percent with little variation among sex, urban rural residence and mother’s education. 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 international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In about 91 percent of households, salt used for cooking was tested for iodine content by using salt test kits to identify the presence of potassium iodate. Table nu.5 shows that in 7 percent of households there was no salt available. In just 1.2 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. use of iodized salt is extremely low across all zones; with the north west having the lowest rate at just 0.7 percent. vitamin a Supplements vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the un general Assembly’s Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted to all children between the ages of six to 59 months living in affected areas. Providing young children with two high- 36 S O M A L I A M I C S 2 0 0 6 R E P O R T dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother’s stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programmes, the definition of the indicator is the percent of children 6-59 months of age receiving at least one high dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, it is recommended that children aged 6-11 months be given one high dose vitamin A capsules and children aged 12-59 months given a vitamin A capsule every 6 months. In some parts of the country, Vitamin A capsules are linked to immunization services and programs and are given when the child has contact with these services after six months of age. It is also recommended that mothers take a vitamin A supplement within eight weeks of giving birth due to increased vitamin A requirements during pregnancy and lactation. Within the six months prior to the MICS, 24 percent of children aged 6-59 months received a high dose vitamin A supplement (Table nu.6). Approximately 7 percent did not receive the supplement in the last 6 months but did receive one prior to that time and 5 percent of children received a vitamin A supplement at some time in the past but their mother/caretaker was unable to specify when. vitamin A supplementation coverage is lowest in the north East Zone. The age pattern of vitamin A supplementation shows that supplementation in the last six months is around 18 percent among children aged 6-11 months, 23 percent among children 12-23 months and then above 25 percent in the older age groups. The mother’s level of education is also related to the likelihood of vitamin A supplementation. The percentage receiving a supplement in the last six months increases from 23 percent among children whose mothers have no education to 30 percent of those whose mothers have primary education and 36 percent among children of mothers with secondary or higher education. Of mothers who gave birth in the previous two years before the MICS, only about 9 percent received a vitamin A supplement within eight weeks of the birth (Table nu.7). This percentage is highest in the north west at 13 percent and lowest in the north East at 6 percent. vitamin A coverage is higher in urban areas compared to rural areas (15 percent versus 5 respectively) and also increases with the education of the mother. vitamin A coverage of mothers among the wealth quintiles increases from 5 percent in the poorest and second poorest quintiles to 19 percent in the richest wealth quintile. 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 (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, 37 N U T R I T I O N S O M A L I A M I C S 2 0 0 6 R E P O R T short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. As a result, 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 birth9 . Overall, only 5 percent of Somali children are weighed at birth. This is not surprising due to the large number of births that do not take place in a health facility. Among children born in the two years preceding the survey with a reported weight, five percent weighed less than 2500 grams. However a large proportion of reported weights were exactly 2500 grams and overall 11 percent of births were reported at weighing 2500 grams or less. A table showing these results along with background characteristics is not present in this report due to the small number of cases in each category with a reported birth weight. In the absence of reported birth weight a mother’s subjective assessment of the size of the baby may be useful. Seventeen percent of births were reported to be very small and 10 percent were reported as smaller than average (Table nu.8). births to mothers with no education are more likely to be reported as very small compared to mother’s who have received formal education. Almost a third of births (33 percent) in the Central South Zone are reported to be very small or smaller than average. 9 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 38 S O M A L I A M I C S 2 0 0 6 R E P O R T 39 VI. Child Health Immunization 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. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A world fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and a measles vaccination by the age of 12 months. Mothers were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. Overall, only 8 percent of mothers or caretakers were able to show the interviewers health cards for their children (CH.2). If the child did not have a card, the mother was asked to recall whether or not the child had received each of the vaccinations and, for DPT and Polio, how many times. The percentage of children aged 12 to 23 months who received each of the vaccinations is shown in CH.1. The denominator for the table comprises of children aged 12-23 months so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the bottom panel, only those who were vaccinated before their first birthday are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Approximately 26 percent of children aged 12-23 months received a bCg vaccination by the age of 12 months and the first dose of DPT was given to 20 percent of children. The percentage declines for subsequent doses of DPT to 17 percent for the second dose, and 12 percent for the third dose (Figure CH.1). Similarly, 52 percent of children had received Polio 1 by age 12 months and this declines to 35 percent by the third dose. It is not surprising to see that polio coverage is higher than dPT coverage due to the number of polio vaccination campaigns that have taken place since polio remerged in July 2005. The coverage for measles vaccine by 12 months is 19 percent; 29 percent of children under 2 years of age had received the measles vaccine but only 19 percent has received it by their first birthday. As a result, the percentage of children who had all eight recommended vaccinations by their first birthday is extremely low at only 5 percent. C H I L D H E A L T H S O M A L I A M I C S 2 0 0 6 R E P O R T 40 figure ch.1: percentage of children 12-23 months who received immunisations by age 12 months, Somalia 2006 Table CH.2 shows the vaccination coverage rates among children 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/ caretakers’ reports. For most vaccinations the coverage does not vary significantly between boys and girls other than when it comes to receiving all vaccinations where boys are at an advantage (14 percent versus 9 percent). for each vaccination children in urban areas are more likely to be vaccinated compared to their rural counterparts; 40 percent of urban children have receive the measles vaccination compared to 23 percent of children living in rural areas. vaccination coverage also increases with education of the mother; 45 percent of children born to mothers with primary education have received the bCg vaccination compared to 24 percent of children born to mothers with no education. tetanus toxoid One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1000 live births in every district. A world fit for Children goal was to eliminate maternal and neonatal tetanus by 2005. Prevention of maternal and neonatal tetanus is to assure all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during the pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met: Received at least two doses of tetanus toxoid vaccine, the last within the prior 3 years;· Received at least 3 doses, the last within the prior 5 years;· Received at least 4 doses, the last within 10 years;· Received at least 5 doses during lifetime.· 26 20 17 12 52 48 35 19 5 0 10 20 30 40 50 60 BC G DP T1 DP T2 DP T3 Po lio 1 Po lio 2 Po lio 3 M ea sle s Al l P er ce nt S O M A L I A M I C S 2 0 0 6 R E P O R T 41 C H I L D H E A L T H 17 21 30 49 13 20 27 47 56 9 12 21 36 54 26 0 10 20 30 40 50 60 Zones North West North East Central South Area Urban Rural Mother's Education No education Koranic Primary Secondary + Wealth Quintiles Poorest Second Middle Fourth Richest Country Percent 17 21 30 49 13 20 27 47 56 9 12 21 36 54 26 0 10 20 30 40 50 60 Zones North West North East Central South Area Urban Rural Mother's Education No education Koranic Primary Secondary + Wealth Quintiles Poorest Second Middle Fourth Richest Country Percent Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 12 months and the protection of women against neonatal tetanus by major background characteristics. Just 18 percent of women received two doses of the tetanus toxoid vaccination during their last pregnancy. A further 6 percent of women received two doses within the three years prior to the birth. Overall 26 percent of women are protected against tetanus. As shown in figure CH.2 women in urban areas are more than three times as likely to be protected against tetanus compared to women living in rural areas (49 percent versus 13 percent). More striking however are the differences among the wealth quintiles; women from the wealthiest households are six times as likely to be protected against neonatal tetanus compared to women from the poorest households (9 percent versus 54 percent). figure ch.2 percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus, Somalia, 2006 oral rehydration treatment Diarrhoea is the second 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. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half deaths due to diarrhoea among children under five by 2010 compared to 2000 (A world fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the world fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: Prevalence of diarrhoea· Oral rehydration therapy (ORT)· Home management of diarrhoea· (ORT or increased fluids) AND continued feeding· S O M A L I A M I C S 2 0 0 6 R E P O R T 42 S O M A L I A M I C S 2 0 0 6 R E P O R T In the MICS questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, 21 percent of under five children had diarrhoea in the two weeks preceding the survey (Table CH.4). diarrhoea prevalence was much higher in the Central South Zone at 25 percent compared to 13 percent in the north west and 11 percent in the north East Zone. The peak of diarrhoea prevalence occurs among children in their first and second year of life. Table CH.4 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. Seventy-nine percent of children who had diarrhoea in the two weeks preceding the survey did not receive any treatment. About 9 percent received fluids from ORS packets; 7 percent received pre-packaged ORS fluids, and 9 percent received recommended homemade fluids. Children of mothers with no education are less likely to receive oral rehydration treatment than other children. Approximately just one-fifth (21 percent) of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or RHF). figure ch.3 percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment, Somalia, 2006 Only 3 percent of under five children with diarrhoea in the last two weeks drank more than usual while 94 percent drank the same or less (Table CH.5). Twenty-eight percent ate somewhat less, same or more (continued feeding), but 71 percent ate much less or ate almost nothing. Combining the information in Table CH.5 with those in Table CH.4 on oral rehydration therapy, it is observed that 7 percent of children either received ORT or fluid intake was increased, and at the same time, feeding was continued, as is the recommendation. There are significant differences in the home management of diarrhoea by background characteristics. In the Central South, only 5 percent of children received ORT or increased fluids AND continued feeding, while the figure is 13 percent in the North East and 16 percent North west. 50 41 15 38 14 17 20 40 21 0 10 20 30 40 50 60 No rth W es t No rth E as t Ce ntr al So uth Ur ba n Ru ra l No ne Ko ra nic Pr im ar y + Co un try P er ce nt 43 C H I L D H E A L T H 16 13 5 9 6 6 6 13 7 0 5 10 15 20 Zones North West North East Central South Area Urban Rural Mother's Education No education Koranic Primary+ Country Percent figure ch.4 percentage of children aged 0-59 with diarrhoea who received ort or increased fluids, AND continued feeding, Somalia, 2006 care Seeking and antibiotic treatment of pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-5s with suspected pneumonia is a key intervention. A world fit for Children goal is to reduce by one- third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: Prevalence of suspected pneumonia· Care seeking for suspected pneumonia· Antibiotic treatment for suspected pneumonia· knowledge of the danger signs of pneumonia· Table CH.6 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Fifteen percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, only 13 percent were taken to an appropriate provider although this varied significantly with background characteristics. Male children were more likely to be taken to an appropriate provider than female children (14 percent versus 11 percent). The most common provider reported across all zones was a pharmacy which incidentally is not considered an appropriate provider. Table CH.7 presents the use of antibiotics for the treatment of suspected pneumonia in under-5s by sex, age, region, residence, age, and socioeconomic factors. In Somalia, 32 percent of under-5 children with suspected pneumonia had received an antibiotic during the two weeks prior to the S O M A L I A M I C S 2 0 0 6 R E P O R T 44 S O M A L I A M I C S 2 0 0 6 R E P O R T survey. There are noticeable differences between male and female children; 35 percent of male children received antibiotics compared to 29 of their female counterparts. The percentage was higher in urban areas at 49 percent, while the percentage declines to only 24 percent for children living in urban households. The table also shows that antibiotic treatment of suspected pneumonia is very low among the poorest households. The use of antibiotics rises with the education of the mother. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7A. Obviously, mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall just 15 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is diarrhoea followed closely by fever. Twenty eight percent of mothers identified fast breathing and 31 percent of mothers identified difficult breathing as symptoms which would cause them to immediately take their children to a health care provider. Interestingly mother’s knowledge of the danger signs of pneumonia did not increase with education and women in rural areas reported better knowledge of the danger signs than woman in urban areas. Solid fuel use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts, and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Overall, as is shown in Table CH.9, almost all households in Somalia are using solid fuels for cooking (99.6 percent). The table clearly shows that percentage is high due to the large levels of wood (63 percent) and charcoal (33 percent) use for cooking purposes. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. The type of stove used with a solid fuel is depicted in Table CH.10. Alarmingly 91 percent of households that use solid fuel cook on an open stove or fire with no chimney or hood. malaria Malaria is a leading cause of death of children under age five in Somalia. It also contributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of mosquito nets treated with insecticide (ITNs), can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti-malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. Also, children recovering from malaria should be given extra liquids and food and, for younger children, should continue breastfeeding. 45 C H I L D H E A L T H The MICS questionnaire incorporates questions on the use of bednets, both at household level and among children under five years of age, as well as anti-malarial treatment, and intermittent preventive therapy for malaria. As presented in Table CH. 11, in Somalia households with at least one insecticide treated net is 22 percent. Just over half of the mosquito nets (12 percent) used at household level were treated with insecticide and 10.5 percent were long lasting nets. Results indicate that 18 percent of children under the age of five slept under a mosquito net the night prior to the survey and 9 percent slept under a long lasting insecticide treated net (Table CH.12). ITN use among children under five years of age declines steadily with age but there were no significant gender disparities. In general children in the Central South Zone are less likely to sleep under mosquito nets than their northern counterparts. However, in terms of the type of net children in the Central South Zone are comparatively better off with 10 percent sleeping under a long lasting insecticide treated net compared to just over 7 percent in both the north west and north East Zones. Questions on the prevalence and treatment of fever were asked for all children under age five. In Somalia 22 percent of children under five were ill with fever in the two weeks prior to the MICS (Table CH.13). fever prevalence was considerably higher in the Central South Zone (27 percent) compared with Puntland (15 percent) and Somaliland (9 percent). Prevalence was also higher in rural areas compared to urban areas. fever prevalence was not as high among children whose mothers had primary or secondary education than among children of less educated mothers. wide differences in fever prevalence were also found between the rich and poor; the prevalence ranging from 27 to 13 percent between the poorest and richest groups. Mothers were asked to report all of the medicines given to a child to treat the fever, including medicine given at home and medicines given or prescribed at a health facility. “Appropriate” anti- malarial drugs include Chloroquine, SP/Fansidar, Artimisine combination drugs, Quinine and Amodiaquine. Overall, just 8 percent of children with fever in the last two weeks were treated with an “appropriate” anti-malarial drug and only 3 percent received the anti-malarial drugs within 24 hours of onset of symptoms. In Somalia, 5 percent of children with fever were given chloroquine, less than 1 percent received artemisinin combination therapy and less than 1 per cent received other appropriate anti-malarials. nine percent of children were given other types of medicines that are not anti-malarials, including anti-pyretics such as paracetemol, aspirin or ibuprofen. urban children and children from the richest households were more likely than rural children to be treated appropriately as were the children of mothers with primary or secondary education. A small difference was noted between boys and girls receiving appropriate anti-malarial drugs. Pregnant women living in places where malaria is highly prevalent are four times more likely than other adults to get malaria and twice as likely to die of the disease. Once infected, pregnant women risk anemia, premature delivery and stillbirth. Their babies are likely to be of low birth weight, which makes them unlikely to survive their first year of life. For this reason, steps are taken to protect pregnant women by distributing insecticide-treated mosquito nets and treatment during antenatal check-ups with drugs that prevent malaria infection (Intermittent preventive treatment or IPT). In the Somali MICS, women were asked of the medicines they had received in their last pregnancy during the 2 years preceding the survey. women are considered to have received intermittent preventive therapy if they have received at least 2 doses of SP/fansidar during the pregnancy. Intermittent preventive treatment for malaria in pregnant women who gave birth in the two years preceding the survey is presented in Table CH.14. Just six percent of women report taking medicine during pregnancy to prevent malaria, the most common type of medicine taken was chloroquine. S O M A L I A M I C S 2 0 0 6 R E P O R T 46 S O M A L I A M I C S 2 0 0 6 R E P O R T As in the case for children age under five, pregnant women are also a priority target group for use of insecticide treated nets. Table CH.14A shows the percentage of women who had given birth in the two years preceding the survey who had regularly slept under a mosquito net. Overall 17 percent of women reported that they had regularly slept under some type of bednet while they were pregnant. This ranged from 30 percent in the north East Zone to 23 percent in the north west Zone to just 13 percent in the Central South Zone. women from wealthier households are more likely to sleep under a bednet while pregnant than women from poorer households. In the Somalia MICS mothers and primary caretakers were also asked if they could recognise the signs and symptoms of malaria. As shown in Table CH.15 two thirds of respondents (66 percent) identified fever and sweats as a typical malaria symptom. The second most commonly reported symptom was vomiting and nausea (47 percent) and over a third of mother’s and caretakers identified headaches, chills/shivers and bitterness in the mouth as being symptoms. . attitudes towards polio vaccination negotiating protection against poliomyelitis is an ongoing issue for Somalia despite the repeated and widespread vaccination campaigns that occur on an annual basis. The Somali MICS included some questions in order to assess the proportion of mothers/caretakers who refuse polio vaccinations. A question was also included to determine who is the main decision maker when it comes to vaccinating children. The results are presented in Table CH.16. Encouragingly 82 percent of mothers/caretakers have heard of polio. when these mothers/ caretakers were asked if they agree with having their children receive the repeat vaccinations 86 percent reported they were in favour. Support of polio vaccinations was lowest in the north East Zone at 60 percent while in the Central South Zone support was at 91 percent and 83 percent in North West Zone. However despite the lack of complete support, 83 percent of mothers/ caretakers reported that they had never refused to vaccinate their child against Polio, 6 percent reported that they had refused on one occasion and 9 percent reported that they had refused several times. Refusing vaccinations also varied by zone, mothers/caretakers in the North East are much less likely to allow their child to receive a polio vaccination (35 percent) compared to the north west Zone (20 percent) and the Central South Zone (13 percent). In order to design awareness raising programmes for polio vaccination campaigns it is important to target the key decision makers in the household. Just under half of the mothers/caretakers interviewed (46 percent) reported that it is only the father who makes decisions about whether to vaccinate the children or not. Twenty-four percent reported that it is only the mother who makes the decisions while 21 percent reported that both the father and mother make decisions regarding child vaccinations. 47 VII. Environment Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The world fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in MICS are as follows : water use of improved drinking water sources• use of adequate water treatment method• Time to source of drinking water• Person collecting drinking water• Sanitation use of improved sanitation facilities• Sanitary disposal of child’s faeces• The distribution of the population by source of drinking water is shown in Table En.1 and figure En.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot), public tap/standpipe, tubewell/borehole, protected well, protected spring, rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as handwashing and cooking. Water Overall, 29 percent of the population is using an improved source of drinking water – 58 percent in urban areas. The situation in the Central South and north East is considerably worse than in the north west Zone; only 25 percent of the population in the Central South and north East Zones get their drinking water from an improved source. Those living in urban areas are five times more likely to have access to an improved source of drinking water compared to those living in rural areas. People living in households where the household head has attended secondary education are almost three times as likely to have access to an improved source of drinking water compared to households where the head has not received any education (62 percent versus 24 percent). As to be expected wealth is positively linked to improved water sources. E N V I R O N M E N T S O M A L I A M I C S 2 0 0 6 R E P O R T 48 The source of drinking water for the population varies by zone (Table En.1). In the north west 17 percent of the population uses drinking water that is piped into their dwelling or into their yard or plot. In the North East and the Central South Zone, 9 and 11 percent respectively use piped water. In the north west and north East the most important source of drinking water is a berkad; a berkad however is not considered an improved source. In the Central South Zone, the most common source of drinking water is surface water (28 percent) followed by unprotected wells (22 percent); both of these sources are deemed unsafe. figure en.1 percentage distribution of household members by source of drinking water, Somalia, 2006 use of in-house water treatment is presented in Table En.2. Households were asked if and how they treated water at home to make it safer to drink – boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, separately for all households, for households using improved and unimproved drinking water sources. Among the population using an improved drinking water source, 37 percent were also using an appropriate water treatment method. This compares to just 16 percent of the population who rely on an unimproved drinking water source. The most common method of water treatment appears to be adding bleach or chlorine to the water, 13 percent of the household population reported using this method. Households in urban areas were significantly more likely to use a water treatment method, 45 percent reported using an appropriate method compared to just 9 percent in rural areas. The higher the educational level of the household head the more likely the household is to use an appropriate method to treat the drinking water. The Somali MICS also asked household respondents whether they use a method to prevent contamination of water while it was being stored or when they were handling it. Thirty six percent of the household population reported that they did not do anything to prevent contamination of drinking water (Table En2b). forty one percent of households reported that they store water in a clean container with a cover. The amount of time it takes to obtain water is presented in Table En.3 and the person who usually collected the water in Table En.4. note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. Table EN.3 shows that for 15 percent of households, the drinking water source is on the premises. For just under a third of all households, it takes more than one hour to get to the water source and bring water. Excluding those households with water on the premises, the average time to and from the source of drinking water is 70 minutes. As to be expected there is a considerable Bali, 3% Tanker truck, 5% Cart with tank/ drum, 6% Berkad, 16% Unprotected spring, 2% Surface water, 19% Public tap/ stand- pipe, 8% Tubewell/ bore- hole, 2% Protected well, 4% Unprotected well, 18% Piped into yard/ plot, 3% Piped into dwelling, 12% S O M A L I A M I C S 2 0 0 6 R E P O R T 49 E N V I R O N M E N T time difference for collecting water between urban and rural households (38 minutes versus 82 minutes respectively). The time spent in the Central South Zone for collecting water is higher than the north west and north East (82 minutes versus 57 and 58 minutes respectively). As to be expected the time spent in collecting water decreases with wealth, however those living in the richest households still spend on average, 47 minutes to go and collect water. Household respondents were also asked to state how reliable their main source of water supply is. Just over a third of households almost never have problems with their water supply (34 percent). There is a positive relationship between education of household head and reliability of water supply; household heads with secondary education reported almost never having problems compared to 30 percent of households where the head has no education. Over a fifth of respondents in the poorest households (21 percent) reported that they had daily problems with their water supply and 36 percent of households in rural areas reported that their water supply was seasonal. Table EN.4 shows that for the majority of households, when the source of drinking water is not on the premises an adult female is usually the person who collects the water (66 percent). Adult men collect water in 26 percent of cases, while for the rest of the households, female or male children under age 15 collect water. Sanitation Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation facilities include: flush toilets connected to sewage systems, septic tanks or pit latrines, ventilated improved pit latrines and pit latrines with slabs. In Somalia just over 37 percent of the population is living in households using improved sanitary facilities (Table En.5). This percentage ranges from 78 percent in urban areas and 13 percent in rural areas. Residents of the Central South Zone are less likely than those in the north west and north East Zone to use improved facilities. More than half of the population in the Central South (58 percent) uses rivers, bush, fields, or has no facilities. There are also striking differences between the wealth quintiles, in the poorest and second poorest households less than 1 percent of the population are using sanitary facilities compared to 74 percent in the fourth richest quintile and 86 percent in the richest. Safe disposal of a child’s faeces is determined by whether the last stool by the child was disposed of by use of a toilet or rinsed into toilet or latrine. disposal of faeces of children 0-2 years of age is presented in Table EN.6. For thirty five percent of children aged 0-2 , stools are disposed of in a safe way. This varies considerable with zone ranging from 50 percent in the north west to 37 percent in the north East to 30 percent in the Central South. In urban areas stools are considerably more likely to be disposed of in a safe way compared to rural areas (75 percent versus 12 percent). An overview of the percentage of households with improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. One fifth of the Somali household population use both improved sources of drinking water and sanitary means of excreta disposal. There is a stark contrast between urban and rural populations; 47 percent of urban households use both improved sources of drinking water and sanitary means of excreta disposal compared to just 4 percent of rural households. There are also large differentails between wealth quintiles. S O M A L I A M I C S 2 0 0 6 R E P O R T 50 S O M A L I A M I C S 2 0 0 6 R E P O R T hygiene In Somalia unICEf has been engaged with promoting improved hygiene and environmental sanitation. One aspect of these efforts has been to promote positive behavioural change in hand-washing practices through extensive social mobilisation. The Somali MICS included a question in the household questionnaire to find out whether soap is being used in households for hand-washing and if so, in which situations. The results are presented in Table En.8. More than half of all the household respondents (55 percent) reported that soap in the household was used for washing hands in one or more of the given situations. This ranges from 84 percent in the north East to 77 percent in the north west and 41 percent in the Central South. Households in urban areas are more likely to have soap in the household for hand washing compared to rural areas (71 percent versus 46 percent respectively). The most common reason reported for using soap to wash hands was for after defecation (48 percent), followed by cleaning babies’ bottom (45 percent). Only 27 percent of the household respondents reported using soap to wash hands before cooking. 51 VIII. Fertility Population size may play a critical role in achieving the Mdgs. At both the household and national levels, larger families and rapidly growing populations obstruct development and prolong poverty. Children born into large, poor families face increased competition for limited resources, including food, clothing, health and education. At the national level, rapid population growth in poor countries stretches the demand for services, including health care and education, faster than the capacity to satisfy it. Monitoring levels of fertility is one of the three components of population dynamics needed to determine the future size and structure of the population. This chapter presents the 2006 MICS results on the levels and trends in fertility. The analysis is based on birth history information collected from women age 15-49 interviewed during the survey. Each eligible woman was asked a series of questions on the number of sons and daughters who were living with her, the number living elsewhere, and the number who had died, in order to obtain the total number of live births she had had in her lifetime. For each live birth, information was also collected on the name sex, age and survival status of the child. For dead children, age at death was recorded. Information from the birth history is then used to assess current levels and trends in fertility. current fertility Measures of current fertility are presented in Table fE.1 for the three year period preceding the survey, corresponding to the calendar period 2003-2006. A three-year period was chosen because it reflects the most current information, while also allowing the rates to be calculated on a sufficient number of cases so as not to compromise the statistical precision of the estimates. Two measures of current fertility are shown. Age-specific fertility rates (ASFRs), expressed as the number of births per thousand women in a specified age group, are calculated by dividing the number of live births to women in a specific age group by the number of woman-years lived in that age-group. The total fertility rate (TFR) is defined as the average number of babies born to a woman during her reproductive years if she were to pass through those years bearing children at the currently observed age-specific fertility rates. Table fE.1 shows the current fertility rates for Somalia as a whole and for urban and rural areas. The total fertility rate for Somalia is estimated at 6.7 births per woman. Such high fertility is a strong indication of the huge population growth that Somalia will experience. Childbearing begins early in Somalia as reflected by the overall age pattern of fertility shown in the ASFRs. Fertility is low among adolescents and increases to a peak of 306 births per 1,000 among woman age 25-29 and declines thereafter (Table fE.1). fertility rates are higher in rural areas than urban areas; the TfR in rural areas is above seven births (7.1) while the TfR in urban areas is 6 births per woman. Rural ASfRs are higher than urban ASfRs at the early ages (15-24) as well as the later ages (35-44) during the reproductive period.(figure fE.1). F E R T I L I T Y S O M A L I A M I C S 2 0 0 6 R E P O R T 52 S O M A L I A M I C S 2 0 0 6 R E P O R T Figure FE.1: Age-specific Fertility Rates by Urban-Rural Residence, Somalia, 2006 Fertility Differentials Table FE.2 present differentials in the total fertility rates over the 3 years preceding the survey by zone, residence, education and wealth quintiles. There are sizeable differentials in fertility among zones; the North West Zone has the lowest TFR at 5.9, followed by 6.2 in the North East Zone and is highest in the Central South Zone at 7.1. There are also noticeable differentials by education of the mother ranging from a low of 5.8 among women who have only received non standard curriculum education to a high of 7.0 among women who have not received any education at all. Women living in the poorest 60 percent of households experience a TFR of 7.0 while those living in the richest 40 percent of households experience a TFR of 6.2. Fertility Trends In addition to estimating levels and patterns of current fertility, retrospective data from birth histories can also be used to assess trends in fertility over time. Table FE.3 compares age-specific fertility for successive three-year periods preceding the survey. The numerators of the rates are classified by three-year segments of time preceding the survey and the mother’s age at the time of survey. Women 50 years and over were not interviewed in the survey, therefore rates for older age groups of women become progressively more truncated for periods more distant from the survey date. Table FE.3 shows an interesting pattern of fertility in Somalia over the last fifteen years. Fertility seems to have peaked during the 6-8 year period preceding the survey. Rates prior to this period appear to be lower in almost all age groups. The results indicate that fertility has been declining during the most recent periods. The decline is especially significant during the most recent two 3-year periods, where declines in excess of 15 percent are observed in all age groups. In light of the low contraceptive prevalence in Somalia, further understanding of these apparent fertility declines during the most recent period, along with the causes and modalities require further investigation. 0.0 25.0 50.0 75.0 100.0 125.0 150.0 175.0 200.0 225.0 250.0 275.0 300.0 325.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Group B ir th s p e r 1 ,0 0 0 w o m e n Urban Rural Total 53 IX. Reproductive Health contraception Appropriate family planning is important to the health of women and children by: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and 3) limiting the number of children. A world fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. The current level of contraceptive use is a measure of actual contraceptive use at the time of the survey. Currently married women were asked if they were using any method to space the number of births or to delay pregnancy. The current use of contraception was reported by just 15 percent of women (Table RH.1). Of the different family planning methods only 1 percent of currently married women reported using a modern method of contraception10. The single most popular method reported was the lactation amenorrhea method (LAM) which is used by 13 percent of married Somali women. both traditional and modern methods of contraceptive prevalence were highest in the north west (26 percent) compared to the north East (12 percent) and the Central South Zone (12 percent). In both the north west and the Central South Zone modern contraceptive use was particularly rare with less than one percent of married women reporting any use. In the north west Zone 3 percent of women reported using the pill. There did not appear to be any large differentials in contraceptive prevalence between married women of different age groups once women were over 20 years of age. Married women between ages 15 to 19 reported the lowest contraceptive prevalence use (7 percent). women’s education level may be associated with contraceptive prevalence. The percentage of women using any method of contraception rises from 14 percent among those with no education to 16 percent among women with primary education to 23 percent among women with secondary education or higher. unmet need unmet need11 for contraception refers to fecund women who are not using any method of contraception, but who wish to postpone the next birth or who wish to stop childbearing altogether. Unmet need is identified by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity, and fertility preferences. However it must be noted that due to the customisation of the Somali questionnaire it is not possible to use this data to make global comparisons. In the Somali MICS women who have an unmet need for spacing includes women who are currently married, believe they can still get pregnant and want to space their births. Pregnant women are also included if they want to have another birth at least two years later. women in unmet need for limiting are those women who are currently married and want to limit their births. This group includes women who are currently pregnant but do not want any more children and women who are not currently pregnant but do not want to have another child. 10 Known modern methods available In Somalia include the pill, IUD, injections, and condoms 11 Unmet need measurement in MICS is somewhat different than that used in other household surveys, such as the Demographic and Health Surveys (DHS). In DHS, more detailed information is collected on additional variables, such as postpartum amenhorrea, and sexual activity. Results from the two types of surveys are strictly not comparable. The Somali questionnaire was further modifies so comparisons with other MICS data should also be done with caution. R E P R O D U C T I V E H E A L T H S O M A L I A M I C S 2 0 0 6 R E P O R T 54 S O M A L I A M I C S 2 0 0 6 R E P O R T Total unmet need for contraception is simply the sum of unmet need for spacing and unmet need for limiting. Using information on contraception and unmet need, the percentage of demand for contraception satisfied is also estimated from the data. Percentage of demand for contraception satisfied is defined as the proportion of women currently married who are currently using contraception, of the total demand for contraception. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting), plus those who are currently using contraception. Table RH.2 shows the results of the survey on contraception, unmet need, and the demand for contraception satisfied. In Somalia the unmet need for contraception appears fairly low at 26 percent; the majority for this unmet need is for birth spacing (21 percent) as opposed to birth limiting (5 percent). It seems apparent therefore that Somali women want to have many children which results in a low unmet need for contraception. Of the unmet need, just thirty six percent of the demand is satisfied. The unmet need for contraception is highest in the north west Zone. There appears to be a positive relationship between unmet need and women’s age. Among women age 45 – 49 the unmet need is reported to be 42 percent as opposed to 21 percent among women age 15 -19. There are little differences between unmet need and other background variables such as urban rural residence, education and wealth. antenatal care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. better understanding of foetal growth and development and its relationship to the mother’s health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The prevention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women’s nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. wHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: blood pressure measurement· urine testing for bateriuria and proteinuria· blood testing to detect syphilis and severe anemia· weight/height measurement (optional)· The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding is presented in Table RH.3. In Somalia over two thirds of women (68 percent) 55 R E P R O D U C T I V E H E A L T H do not receive any form of antenatal care. In total 26 percent of women received antenatal care from skilled health personnel. This ranged from 32 percent in the north west to 26 percent in the north East and 24 percent in the Central South. women in urban areas are considerable more likely than women in rural areas to see receive antenatal care from skilled health personnel (46 percent versus 15 percent respectively). There is also a positive relationship between receiving antenatal care from a skilled provider and wealth; women in the richest households are 6 times as likely to receive skilled care than women from the poorest households. The types of services pregnant women received are shown in table RH.4. Among the women who received antenatal care at least once during their pregnancy, 14 percent had a blood test, 21 percent had their blood pressure measured, 9 percent had a urine specimen taken and 22 percent had their weight measured. The type of services received varies by zone. women in the north west Zone are considerably more likely to receive each type of service, for example in this zone 32 percent of women report having their blood pressure measured compared to 22 percent in the north East and 17 percent in the Central South. Mother’s education and wealth also appears to affect the type of services received during antenatal care visits; women with primary education were at least twice as likely to have each test performed compared to women with no education. Table RH.4A presents the number of antenatal care check-ups received by women who had given birth in the 2 years preceding the survey. Eighteen percent of women had between 2-3 antenatal care visits, eight percent had just one visit and 6 percent had over four visits. Overall, among the women who received antenatal care, the mean number of visits received was 2. assistance at delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A world fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress toward the Millennium development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. About a third of births (33 percent) occurring in the year prior to the survey were delivered by skilled personnel (Table RH.5). This percentage is highest in the north west Zone at 41 percent and lowest in the Central South at 30 percent. women in urban areas were considerably more likely than their rural counterparts to have delivered with the assistance of a skilled attendant (65 percent versus 15 percent). The more educated and more wealthy a woman is, the more likely she is to have delivered with the assistance of a skilled attendant, 73 percent of women with secondary education reported giving birth with the assistance of a skilled attendant compared to just 25 percent of women with no education. Just under a quarter of the births (24 percent) in the year prior to the survey were delivered with assistance by an auxiliary midwife. doctors assisted with the delivery of 7 percent of births and nurses assisted with just 2 percent. Overall, about 51 percent of births were delivered by traditional birth attendants. S O M A L I A M I C S 2 0 0 6 R E P O R T 56 S O M A L I A M I C S 2 0 0 6 R E P O R T post natal care The Somali MICS also included several questions to assess whether women in Somalia receive any postnatal care and whether women had experienced any postpartum complications after childbirth. Of women who had given birth in the two years preceding the survey 88 percent did not receive any postnatal care (Table RH.5a). Of the small number that did, around 6 percent visited a doctor and 4 percent visited an auxiliary/midwife. women were asked if they had experienced any of the following problems during the postpartum period: fever, problem controlling urine, urinary tract infection, mastitis, offensive discharge, tear or injury to the genital area, wound infection, haemorrhage or post delivery depression. Results are presented in Table RH.5b; the most commonly cited problem reported was fever (52 percent) followed by mastitis (41 percent). More than a quarter of women who had given birth in the 2 years preceding the survey reported experiencing haemorrhage, this ranged from 21 percent of women in urban areas to 30 percent in rural areas. maternal mortality The complications of pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. It is estimated worldwide that around 529,000 women die each year from maternal causes. And for every woman who dies, approximately 20 more suffer injuries, infection and disabilities in pregnancy or childbirth. This means that at least 10 million women a year incur this type of damage. The most common fatal complication is post-partum haemorrhage. Sepsis, complications of unsafe abortion, prolonged or obstructed labour and the hypertensive disorders of pregnancy, especially eclampsia, claim further lives. These complications, which can occur at any time during pregnancy and childbirth without forewarning, require prompt access to quality obstetric services equipped to provide lifesaving drugs, antibiotics and transfusions and to perform the caesarean sections and other surgical interventions that prevent deaths from obstructed labour, eclampsia and intractable haemorrhage. One MDG target is to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. Maternal mortality is defined as the death of a woman from pregnancy-related causes, when pregnant or within 42 days of termination of pregnancy. The maternal mortality ratio is the number of maternal deaths per 100,000 live births. In the MICS, the maternal mortality ratio is estimated by using indirect sisterhood method. To collect the information needed for the use of this estimation method, adult household members are asked a small number of questions regarding the survival of their sisters and the timing of death relative to pregnancy, childbirth and the postpartum period for deceased sisters. The information collected is then converted to lifetime risks of maternal death and ratios12. The Somali 2006 MICS results on maternal mortality are shown in Table RH.6. note that the estimates refer to a period approximately 10 to 12 years before the survey (1994-1996). The results are also presented only for the national total, since maternal mortality ratios generally have very large sampling errors. The level of maternal mortality in Somalia is extremely high. The maternal mortality ratio is estimated to be around 1044 per 100,000 live births (or alternatively 10 deaths per 1000 live births). 12 For more information on the indirect sisterhood method, see WHO and UNICEF, 1997. 57 X. Child Development It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, adult activities with children, presence of books in the home, for the child, and the conditions of care are important indicators of quality of home care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting, or drawing things. For over two-thirds (65 percent) of under-five children, an adult engaged in more than four activities that promote learning and school readiness during the 3 days preceding the survey (Table Cd.1). The average number of activities that adults engaged with children was 4. The table also indicates that the father’s involvement in such activities was somewhat limited. father’s involvement with one or more activities was 39 percent. Sixteen percent of children were living in a household without their fathers. There are no significant gender differentials in terms of adult activities with children or whether fathers engaged in activities more with male children than with female children. A slightly higher proportion of adults engaged in learning and school readiness activities with children in urban areas (67 percent) than in rural areas 63 percent). Stronger differentials by zone are observed: Adult engagement in activities with children was greatest in the north East Zone (79 percent) and lowest in the Central South Zone (62 percent). father’s involvement showed a similar pattern in terms of adults’ engagement in such activities. C H I L D D E V E L O P M E N T S O M A L I A M I C S 2 0 0 6 R E P O R T 58 S O M A L I A M I C S 2 0 0 6 R E P O R T 59 S O M A L I A M I C S 2 0 0 6 R E P O R T XI. Education pre-School attendance and School readiness Attendance to pre-school education in an organized learning or child education program is important for the readiness of children to school. One of the world fit for Children goals is the promotion of early childhood education. Extremely few Somalia children (2 percent) aged 36-59 months are attending pre-school (Table ED.1). With such a low numbers, background differentials should be compared with caution. Among children aged 36-59 months, attendance to pre-school is more prevalent in the richest households (6 percent) and among children born to mothers with secondary and non standard curriculum education. primary and Secondary School participation universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium development goals and A world Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. The indicators for primary and secondary school attendance include: net intake rate in primary education· net primary school attendance rate· net secondary school attendance rate· net primary school attendance rate of children of secondary school age· female to male education ratio (gPI)· The indicators of school progression include: Survival rate to grade five· Transition rate to secondary school· net primary completion rate· In 1990, prior to start of the civil war the Somali education system had four basic levels-preprimary, primary, secondary, and higher; however in the societal chaos that followed the fall of Said Barre in 1991, schools ceased to exist for all practical purposes. During the years following many Somali children and young people lost the chance to access any formal education. Slowly, and with the help of international assistance, there have now been substantial increases in the number of operational primary and secondary schools; however education and formal classroom learning opportunities are limited and still unavailable for a majority of children in Somalia. koranic schools remain the basic system of instruction in religion in Somalia. They provide Islamic education for children usually between the ages of 5-14, thereby filling a clear religious and social role in the country. Compared to other education sub-sectors, koranic schools teach the greatest number of students across the country and remain the only system available for nomadic children. Of children who are of primary school entry age (age 6) in Somalia, just 9 percent are attending the first grade of primary school (ED.2). There are large differentials by zone and urban-rural E D U C A T I O N 60 areas. In the North West Zone, for instance, the value reaches 22 percent, while it is 11 percent in the north East Zone and just 4 percent in the Central South Zone. Children’s participation in primary school is timelier in urban areas (16 percent) than in rural areas (5 percent). A positive correlation with mother’s education and socioeconomic status is observed; for children age 6 whose mothers have at least primary school education, 20 percent were attending the first grade. In rich households, the proportion is around 23 percent, while it is just under 2 percent among children living in the poorest households. Table Ed.3 provides the percentage of children of primary school age (6 to 13 years) who are attending primary or secondary school. Overall, 23 percent of children of primary school age in Somalia are attending primary school or secondary school. In urban areas, 41 percent of children attend school while in rural areas attendance is only 12 percent. School attendance in the Central South Zone is significantly lower than in the rest of the country at 13 percent. At the national level, just over a quarter of all boys of primary school age (25 percent) attend primary or secondary school, this drops to 21 percent for girls of the same age. The secondary school net attendance ratio is presented in Table Ed.4; the secondary school age in Somalia is between 14 and 17 years. Only 7 percent of children of secondary school age are attending secondary school. Of the remaining some are attending primary school but the majority are out of school (see below). The most striking differential is between urban and rural areas; in urban areas 14 percent of secondary school age children attend secondary school compared to just over 1 percent in rural areas. Once again a positive correlation with mother’s education and socioeconomic status is observed: 16 percent of secondary school age children with mothers educated to at least primary level attend secondary school compared to just 4 percent of children whose mothers have no education. The primary school net attendance ratio of children of secondary school age is presented in Table ED.4W. Just under one fifth (19 percent) of secondary school age children are attending primary school. The large number of secondary school age children attending primary school is probably due to the lack of educational opportunity these children had in the preceding years. There are significant differentials in all the background characteristics; 31 percent of secondary school age children in urban areas are attending primary school compared to 10 percent in rural areas. In the richest households, 36 percent of secondary school age children attend primary school compared to just 4 percent in the poorest households. The percentage of children entering first grade who eventually reach grade 5 is presented in Table Ed.5. However due to a low proportion of children in the sample who attend school the numbers in these categories are very small and therefore this table must be treated with caution. Of all children starting grade one, 92 percent will eventually reach grade five. When this data is compared to other school surveys completed in Somalia the figure is considered to be extremely optimistic13. notice that this number includes children that repeat grades and that eventually move up to reach grade five. The net primary school completion rate is presented in Table ED.6. At the time of the survey, only 4 percent of the children of primary completion age (13 years) were attending the last grade of primary education. This value should be distinguished from the gross primary completion ratio which includes children of any age attending the last grade of primary. 13 The UNICEF Primary School Survey 2006 estimates that just 56 percent of children entering grade one will eventually reach grade 5. S O M A L I A M I C S 2 0 0 6 R E P O R T 61 E D U C A T I O N S O M A L I A M I C S 2 0 0 6 R E P O R T The ratio of girls to boys attending primary and secondary education is provided in Table Ed.7. The table shows that gender parity for primary school is 0.8, i.e. for every 10 boys in school, there are only 8 girls, indicating the disadvantage for girls. The national gender parity indicator drops even further for secondary education to 0.5. The disadvantage of girls in secondary education is particularly pronounced in the north west Zone (0.3). In rural areas only 1 girl is are attending secondary school for every 10 boys. adult literacy One of the world fit for Children goals is to assure adult literacy. Adult literacy is also an Mdg indicator, relating to both men and women. In MICS, since only a women’s questionnaire was administered, the results are based only on females age 15-24. Literacy was assessed on the ability of women to read a short simple statement written in Af-Somali language. Table Ed.8 indicates that only a quarter of women in Somalia (25 percent) are literate and that literacy status varies greatly by place of residence. Forty five percent of women residing in urban areas are literate compared with only 10 percent of their rural counterparts indicating the lack of learning opportunities available for women in rural areas. The slightly higher level of literacy among women aged 15-19 (28 percent) compared to women aged 20-24 (22 percent) may suggest that the younger generation has had more opportunity for learning. There is a marked difference in literacy by women’s wealth status ranging from 2 percent in the lowest wealth quintile to 59 percent in the highest wealth quintile. Of women who stated that primary school was their highest level of education, just 72 percent were actually able to read the statement shown to them. Of women who had attended koranic school, just 10 percent were literate in Af-Somali. 62 S O M A L I A M I C S 2 0 0 6 R E P O R T 63 XII. Child Protection birth registration The International Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. birth registration is a fundamental means of securing these rights for children. However there is currently no formal mode of Somali birth registration therefore the figures for birth registration are unsurprisingly low. The births of just 3 percent of Somali children under the age of five years have been registered (Table CP.1). Children in the north west Zone are more likely to have their births registered (7 percent) compared to children in the north East Zone (3 percent) and Central South Zone (2 percent). Among those whose births are not registered the main reasons stated were not knowing where to register (33 percent), not knowing that the child should be registered (28 percent) and do not see the need to register the child (22 percent). child labour Article 32 of the Convention on the Rights of the Child states: “States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physical, mental, spiritual, moral or social development.” The World Fit for Children mentions nine strategies to combat child labour and the Mdgs call for the protection of children against exploitation. In the MICS questionnaire, a number of questions addressed the issue of child labour, that is, children 5-14 years of age involved in labour activities. A child is considered to be involved in child labour activities at the moment of the survey if during the week preceding the survey: Ages 5-11: at least one hour of economic work or 28 hours of domestic work per week. Ages 12-14: at least 14 hours of economic work or 28 hours of domestic work per week. This definition allows to differentiate child labour from child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labour since some children may be involved in hazardous labour activities for a number of hours that could be less than the numbers specified in the criteria explained before. Table CP.2 presents the results of child labour by the type of work. very few children appear to be engaged in work outside the household whether paid or unpaid (2.5 percent). Just under a quarter (24 percent) of children aged 5-14 perform more than 28 hours of household chores per week and almost one in four children aged 5-14 (37 percent) are working for the family business. Overall almost half (49 percent) of the children aged 5-14 in Somalia are engaged in child labour. females are more likely to be involved in child labour (54 percent) compared to their male counterparts (45 percent). Table CP.3 presents the percentage of children classified as student labourers or as labourer students. Student labourers are the children attending school that were involved in child labour activities at the moment of the surveys. More specifically, of the 49 percent of the children 5-14 years of age attending school, 44 percent are also involved in child labour activities. Out of the C H I L D P R O T E C T I O N S O M A L I A M I C S 2 0 0 6 R E P O R T 64 S O M A L I A M I C S 2 0 0 6 R E P O R T 49 percent of the children classified as child labourers, less than half are also attending school (44 percent). female children are more likely to be engaged in child labour than male children (54 percent versus 45 percent) and females who are attending school are more likely to be engaged in labour than their male student counterparts (51 percent versus 40 percent). early marriage and polygyny Marriage before the age of 18 is a reality for many young girls. According to unICEf’s worldwide estimates, over 60 million women aged 20-24 were married/in union before the age of 18. Factors that influence child marriage rates include: the state of the country’s civil registration system, which provides proof of age for children; the existence of an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws that condone the practice. In many parts of the world parents encourage the marriage of their daughters while they are still children in hopes that the marriage will benefit them both financially and socially, while also relieving financial burdens on the family. In actual fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to ‘free and full’ consent to a marriage is recognized in the Universal Declaration of Human Rights - with the recognition that consent cannot be ‘free and full’ when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. The Convention on the Elimination of all forms of discrimination against women mentions the right to protection from child marriage in article 16, which states: “The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.” While marriage is not considered directly in the Convention on the Rights of the Child, child marriage is linked to other rights - such as the right to express their views freely, the right to protection from all forms of abuse, and the right to be protected from harmful traditional practices - and is frequently addressed by the Committee on the Rights of the Child. Other international agreements related to child marriage are the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages and the African Charter on the Rights and welfare of the Child and the Protocol to the African Charter on Human and People’s Rights on the Rights of women in Africa. Child marriage was also identified by the Pan-African Forum against the Sexual Exploitation of Children as a type of commercial sexual exploitation of children. Young married girls are a unique, though often invisible, group. Required to perform heavy amounts of domestic work, under pressure to demonstrate fertility, and responsible for raising children while still children themselves, married girls and child mothers face constrained decision-making and reduced life choices. boys are also affected by child marriage but the issue impacts girls in far larger numbers and with more intensity. Cohabitation - when a couple lives together as if married - raises the same human rights concerns as marriage. where a girl lives with a man and takes on the role of caregiver for him, the assumption is often that she has become an adult woman, even if she has not yet reached the age of 18. Additional concerns due to the informality of the relationship - for example, inheritance, citizenship and social recognition - might make girls in informal unions vulnerable in different ways than those who are in formally recognized marriages. Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered as significant factors in determining a girl’s risk of becoming married while still a child. Women who married at younger ages were more likely to believe that it is sometimes acceptable for 65 C H I L D P R O T E C T I O N a husband to beat his wife and were more likely to experience domestic violence themselves. The age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the youngest of this cohort. There is evidence to suggest that girls who marry at young ages are more likely to marry older men which can put them at increased risk of HIv infection. Two of the indictors are to estimate the percentage of women married before 15 years of age and percentage married before 18 years of age. The percentage of women married at various ages is provided in Table CP.4. Marriage occurs relatively early in Somalia. Almost 8 percent of women between the ages of 15 to 49 married before they reached the age of 15 and a quarter of all women (25 percent) aged between 15 and 19 are married. women in the Central South Zone are more likely to get married before the age of 15 (10 percent) than women in the north west and north East (3 percent and 4 percent respectively). The number of women in a polygynous union is provided in Table CP.4. The data show that 23 percent of married women in Somalia are in polygynous unions. The percentage of women in polygynous unions tends to increase with age, from 13 percent among woman age 15 – 19 to 37 percent of women age 45 – 49. Women living in rural areas are slightly more likely to be in polygynous unions (24 percent) than women living in urban areas (21 percent). The difference between the zones is more pronounced with polygyny ranging from 17 percent in the north West Zone, to 24 percent in the Central South Zone and 26 percent in the North East Zone. There appears to be little difference in the percentage of polygynous unions across the different wealth quintiles. Another component is the spousal age difference with an indicator being the percentage of married/in union women with a difference of 10 or more years of age compared to their current spouse. Table CP.5 presents the results of the age difference between husbands and wives. Of the women aged 15-19 years 31 percent were married to a man 10 years older than themselves. There appears to be no marked differences between zone, urban and rural residence, education or wealth quintile. The spousal age difference also displayed the same pattern for women aged 20-24; 30 percent of this age group were married to men 10 or more years their senior. female genital mutilation/cutting female genital mutilation/cutting (fgM/C) is the partial or total removal of the female external genitalia or other injury to the female genital organs. fgM/C is always traumatic with immediate complications including excruciating pain, shock, urine retention, ulceration of the genitals and injury to adjacent tissue. Other complications include septicaemia, infertility, obstructed labour, and even death. In Somalia the procedure is generally carried out on girls between the ages of 4 and 14. It is often performed by traditional practitioners, including untrained village midwives, without anaesthesia, using knives, scissors, razor blades or even broken glass. The instruments are often not sterile and the ritual is very often performed in unsanitary conditions. In urban areas, some families use a doctor to perform the operation. fgM/C is a fundamental violation of human rights. In the absence of any perceived medical necessity, it subjects girls and women to health risks and has life-threatening consequences. Among those rights violated are the rights to the highest attainable standard of health and to S O M A L I A M I C S 2 0 0 6 R E P O R T 66 S O M A L I A M I C S 2 0 0 6 R E P O R T bodily integrity. Furthermore, it could be argued that girls (under 18) cannot be said to give informed consent to such a potentially damaging practice as fgM/C. In the MICS, a series of 16 questions were asked to determine knowledge of FGM/C, prevalence of FGM/C, and details of the type of FGM/C performed. Table CP.6 presents the prevalence of fgM/C among women and the type and extent of the procedure. It appears that in Somalia fgM/C is near universal at 98 percent. differences by background characteristics are small. Seventy nine percent of women reported that their vagina was sewn closed (infibulation) during circumcision which is the most severe form of fgM/C. Overall 77 percent of women age 15-49 have undergone an extreme form of fgM/C; however this varies by zone rising to 90 percent in both the north west and north East zone and falling to 70 percent in the Central South Zone. Table CP.6 also presents woman’s attitudes towards fgM/C. Just under two thirds of women (65 percent) believe that the practice should continue. Support for fgM/C varies with background characteristics. In the Central South where women are less likely to have received the most severe type of circumcision, 80 percent believe that the practice should be continued. In the North East Zone 53 percent support the continuation of circumcision and in the north west just a third of women (32 percent) support the practice. women in rural (72 percent) are more likely to support the practice of circumcision than women in urban areas (54 percent). The age of women does not appear to have a marked difference on whether the practice should be continued however the more educated the women the less likely she is to believe that the practice of circumcision should be continued. women in the poorest households are also more likely to support the practice of circumcision than women in the richest households (78 percent versus 47 percent). Table CP.7 presents the prevalence and extent of fgM/C performed on daughters of the respondents. Of the women reporting that they had a circumcised daughter, 60 percent reported that the daughter had received an extreme form of fgM/C. Overall 46 percent of women with one living daughter reported that their daughter had been circumcised. However it may be possible that many of the daughters of the women interviewed have not yet reached the age when fgM/C is likely to occur. The likelihood that a respondent’s daughter is circumcised varies directly with her age, rising from 4 percent among women age 20-24 to 91 percent among women age 45-49, indicating that there may have been a decline attitudes toward circumcision in recent years. There does not appear to be a wide variation between mother’s education or wealth and having a daughter circumcised. women were asked about the age at which the daughter had been circumcised. Table CP.7A presents the distribution of circumcised girls according to the age at circumcision. The majority of girls are circumcised between the ages of 5 - 9 (79 percent). In urban areas girls are more likely to be cut at 7 years old compared to any other age (22 percent). In the north west Zone more girls are circumcised at 8 years old (21 percent) which is slightly older than the other two zones where circumcision is more common around 6 and 7 years old. domestic violence A number of questions were asked of ever-married women age 15-49 years to assess their attitudes towards whether husbands are justified to hit or beat their wives/partners for a variety of scenarios. These questions were asked to have an indication of cultural beliefs that tend to be associated with the prevalence of violence against women by their husbands/partners. The main assumption here is that women that agree with the statements indicating that husbands/ partners are justified to beat their wives/partners under the situations described in reality tend to be abused by their own husbands/partners. The responses to these questions can be found in Table CP.8 and presented in figure CP.1. 67 C H I L D P R O T E C T I O N Figure CP.1: Percentage of ever-married women who believe a husband is justified in beating his wife in various circumstances, Somalia, 2006 53 56 52 64 29 76 0 10 20 30 40 50 60 70 80 When she goes out without telling him When she neglects the children When she argues with him When she refuses sex with him When she burns the food For any of these reasons P er ce n t Over three quarters of ever-married women age 15-49 believes that a husband is justified in beating his wife for at least one of the specified reasons. The most widely accepted reason for a husband to beat his wife is for when a wife to refuses to have sex with her husband (64 percent). The percentage of women who believe a husband is justified in beating his wife for at least one of the reasons is higher among women residing in rural areas, women with no education and women living in the poorest households. orphaned children Children who are orphaned may be at increased risk of neglect or exploitation if the parents are not available to assist them. Somali children may also have been left vulnerable or orphaned as a result of conflict and/or displacement. Monitoring the variations in different outcomes for orphans and vulnerable children and comparing them to their peers gives us a measure of how well communities and governments are responding to their needs. The frequency of children living with neither parent, mother only, and father only is presented in Table CP.10. Approximately 3 in 4 children in Somalia are living with both biological parents. nine percent of children are living in households with neither of their biological parents and 10 percent of children have lost either one or both of their biological parents. In Somalia just one percent of children are double orphans (both parents have died). One of the measures developed for the assessment of the status of orphaned and vulnerable children relative to their peers looks at the school attendance of children 10-14 for children who have lost both parents (double orphans) versus children whose parents are alive (and who live with at least one of these parents). If children whose parents have died do not have the same access to school as their peers, then families and schools are not ensuring that these children’s rights are being met. In Somalia among the children age 10-14 who have lost one biological parent, 30 per cent are currently attending school (Table CP.11); among children age 10-14 who have not lost a parent and who live with at least one parent, 30 percent are also attending school. This would suggest therefore that currently, due to the generally low school attendance within the country among all children, there is no large educational disadvantage between orphans to non-orphaned children. The prevalence of malnutrition among orphaned children under five years of age is presented in Table CP.12. Orphaned children appear to have slightly higher rates of malnutrition compared to non orphaned children. forty percent of orphaned children are underweight compared to 35 percent of non orphaned children. S O M A L I A M I C S 2 0 0 6 R E P O R T 68 S O M A L I A M I C S 2 0 0 6 R E P O R T 69 S O M A L I A M I C S 2 0 0 6 R E P O R T XIII. HIV/AIDS Knowledge of hIv transmission One of the most important prerequisites for reducing the rate of HIv infection is accurate knowledge of how HIv is transmitted and strategies for preventing transmission. Correct information is the first step toward raising awareness and giving young people the tools to protect themselves from infection. Misconceptions about HIv are common and can confuse young people and hinder prevention efforts. different regions are likely to have variations in misconceptions although some appear to be universal (for example that sharing food can transmit HIv or mosquito bites can transmit HIv). The un general Assembly Special Session on HIv/AIdS (ungASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIv. The indicators to measure this goal as well as the Mdg of reducing HIv infections by half include improving the level of knowledge of HIV and its prevention, and changing behaviours to prevent further spread of the disease. The HIv module was administered to women 15-49 years of age. One indicator which is both an Mdg and ungASS indicator is the percent of young women who have comprehensive and correct knowledge of HIv prevention and transmission. women were asked whether they knew of the three main ways of HIV transmission – having only one faithful uninfected partner, using a condom every time, and abstaining from sex. The results are presented in Table HA.1. In Somalia, 65 percent of the interviewed women have heard of AIDS. However, the percentage of women who know of all three main ways of preventing HIv transmission is extremely low at 5 percent. Thirty-six percent of women know of having one faithful uninfected sex partner, 15 percent know of using a condom every time, and 23 percent know of abstaining from sex as main ways of preventing HIv transmission. while 46 percent of women know at least one way, more than half of women (54 percent) do not know any of the three ways. Accurate knowledge of HIv transmission varies by zone; in the north west 12 percent of women could identify all 3 ways compared to 6 percent in the north East and just 3 percent in the Central South. women in urban areas are more likely to be able to identify the 3 main ways of preventing HIv compared to women from rural areas (9 percent versus 4 percent). There does not appear to be any difference in knowledge across age groups but there is a positive relationship with education. Seventy eight percent of women with secondary or higher education could identify at least one mode of prevention compared to 37 percent of women with no education. Table HA.2 presents the percent of women who can correctly identify misconceptions concerning HIV. The indicator is based on the two most common and relevant misconceptions in Somalia, that HIv can be transmitted by supernatural means and mosquito bites. The table also provides information on whether women know that HIv cannot be transmitted by sharing food. Of the interviewed women, just 13 percent reject the two most common misconceptions and know that a healthy-looking person can be infected. Thirty-nine percent of women know that HIv cannot be transmitted by sharing food, while 34 percent of women know that a healthy-looking person can be infected. Education and wealth are directly related to correct knowledge concerning common misconceptions. Among women, for example, a quarter of women with secondary school or higher education, reject the two most common misconceptions and know that a healthy-looking person can be infected compared to just 9 percent of women with no education. Interestingly H I V / A I D S 70 women who have attended a non standard curriculum form of schooling are the most likely of all women to identify common misconceptions about HIv/AIdS. Table HA.3 presents the percentage of women 15-49 years who know two ways of preventing HIv transmission. knowledge of HIv prevention methods is still very low although there are differences by residence. Overall, 11 per cent of women report knowing two prevention methods, knowledge is higher in urban areas than rural areas. The percentage of women who know two prevention methods increases with the woman’s education level. A key indicator used to measure countries’ responses to the HIv epidemic is the proportion of young people 15-24 years who know two methods of preventing HIv reject two misconceptions and know that a healthy looking person can have HIv. In Somalia just 4 percent of young women have comprehensive correct knowledge of HIv. The level of education and residence are highly associated with knowledge of HIv. figure ha.1 percent of women who have comprehensive knowledge of hIv/aIdS transmission, Somalia, 2006 Knowledge of mother-to-child transmission Knowledge of mother-to-child transmission (MTCT) of HIV is also an important first step for women to seek HIv testing when they are pregnant to avoid infection in the baby. women should know that HIv can be transmitted during pregnancy, delivery, and through breastfeeding. The level of knowledge among women age 15-49 years concerning mother-to-child transmission is presented in Table HA.4. Overall, 54 percent of women know that HIv can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 38 percent, while 11 percent of women did not know of any specific way. There are marked differences in MTCT knowledge among women by zone, residence, education and wealth. knowledge about mother-to-child transmission is highest among women living in urban areas and women living in the North West Zone. Knowledge levels are lowest among women with no education, are in the lowest wealth quintile and who live in the Central South Zone. 8 17 25 11 9 25 33 13 3 7 10 4 0 5 10 15 20 25 30 35 None Primary Secondary + Country P er ce nt Knows 2 ways to prevent HIV Identify 3 misconceptions Comprehensive knowledge S O M A L I A M I C S 2 0 0 6 R E P O R T 71 H I V / A I D S S O M A L I A M I C S 2 0 0 6 R E P O R T attitudes toward people living with hIv The indicators on attitudes toward people living with HIv measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the following four questions: 1) would care for family member sick with AIdS; 2) would buy fresh vegetables from a vendor who was HIv positive; 3) thinks that a female teacher who is HIv positive should be allowed to teach in school; and 4) would not want to keep HIv status of a family member a secret. Table HA.5 presents the attitudes of women towards people living with HIv/AIdS. women tend to express more positive attitude in response to the questions concerning behaviour towards HIv-infected relatives than to questions about shopkeepers or teachers. forty-two percent of women say that they would not care for a family member who was sick with AIdS. Sixty-four percent say that a teacher with HIv should not be able to work and 73 percent say that they would not buy food from a person with HIv or AIdS. The percentage expressing accepting attitudes on all four measures is low at just 5 percent among the women. Knowledge of hIv testing facilities Another important indicator is the knowledge of where to be tested for HIv and use of such services. Questions related to knowledge among women of a facility for HIv testing and whether they have ever been tested is presented in Table HA.6. Only 16 percent of women know where to be tested, the proportions of women who know where to be tested are higher for women in urban areas, women with secondary or higher education and those in the highest wealth quintile. Just 3 percent of the women have actually been tested, of these, a large proportion has been told the result (73 percent). S O M A L I A M I C S 2 0 0 6 R E P O R T List of References 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. Blanc, A. and Wardlaw, T. 2005. “Monitoring Low Birth Weight: An Evaluation of International Estimates and an Updated Estimation Procedure”. WHO Bulletin, 83 (3), 178-185. 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. UNICEF, 2006. Monitoring the Situation of Children and Women. Multiple Indicator Cluster Survey Manual, New York. UNICEF, 2006 Primary Education Survey, USSC Nairobi 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 WHO and UNICEF, 1997. The Sisterhood Method for Estimating Maternal Mortality. guidance notes for potential users, Geneva. www.Childinfo.org as accessed on 20.07.07 72 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Tables Table HH.1: Results of household and individual interviews Number of households, women, and children under 5 by results of the household, women’s and under-five’s interviews, and household, women’s and under-five’s response rates, Somalia, 2006 Residence Zone Urban Rural North West North East Central South Total Number of households Sampled 2232 3768 1440 1440 3120 6000 Occupied 2232 3768 1440 1440 3120 6000 Interviewed 2222 3747 1411 1440 3118 5969 Response rate 99.6 99.4 98.0 100.0 99.9 99.5 Number of women Eligible 3067 4210 1833 1702 3742 7277 Interviewed 2779 3985 1541 1638 3585 6764 Response rate 90.6 94.7 84.1 96.2 95.8 93.0 Overall response rate 90.2 94.1 82.4 96.2 95.7 92.5 Number of children under 5 Eligible 2356 4017 1232 1440 3701 6373 Mother/Caretaker interviewed 2317 3988 1204 1418 3683 6305 Response rate 98.3 99.3 97.7 98.5 99.5 98.9 Overall response rate 97.9 98.7 95.8 98.5 99.4 98.4 S O M A L I A M I C S 2 0 0 6 R E P O R T 73 S O M A L I A M I C S 2 0 0 6 R E P O R T Table HH.2: Household age distribution by sex Percent distribution of the household population by five-Year age groups and dependency age groups, and number of children aged 0-17 Years, by sex, Somalia, 2006 Males Females Total Number Percent Number Percent Number Percent Age 0-4 3379 20 3126 18 6506 19 5-9 2983 18 2843 17 5826 17 10-14 2220 13 2183 13 4404 13 15-19 1756 10 1863 11 3619 11 20-24 1172 7 1457 9 2629 8 25-29 887 5 1265 7 2153 6 30-34 787 5 875 5 1662 5 35-39 678 4 850 5 1527 4 40-44 776 5 630 4 1406 4 45-49 465 3 347 2 812 2 50-54 486 3 502 3 987 3 55-59 254 1 237 1 491 1 60-64 416 2 286 2 702 2 65-69 174 1 113 1 286 1 70+ 316 2 284 2 599 2 Missing/DK 240 1 103 1 349 1 Dependency age groups < 15 8582 51 8153 48 16735 49 15-64 7676 45 8312 49 15989 47 65 + 489 3 396 2 886 3 Missing/DK 240 1 103 1 349 1 Children aged 0-17 9668 57 9174 54 18842 55 Adults 18+/ Missing/ DK 7320 43 7791 46 15117 45 Total 16988 100 16965 100 33959 100 S O M A L I A M I C S 2 0 0 6 R E P O R T 74 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Table HH.3: Household composition Percent distribution of households by selected characteristics, Somalia, 2006 Number of households Weighted percent Weighted Unweighted Sex of household head Male 82.0 4894 4851 Female 18.0 1075 1118 Zone North West 24.4 1455 1411 North East 11.5 687 1440 Central South 64.1 3827 3118 Residence Urban 35.4 2113 2222 Rural 64.6 3856 3747 Number of household members 1 0.8 49 49 2-3 21.0 1252 1319 4-5 29.9 1787 1806 6-7 26.2 1565 1517 8-9 14.0 833 807 10+ 8.1 482 471 Total 100 5969 5969 At least one child aged < 18 Years 90.6 5969 5969 At least one child aged < 5 Years 65.8 5969 5969 At least one woman aged 15-49 Years 91.2 5969 5969 S O M A L I A M I C S 2 0 0 6 R E P O R T 75 S O M A L I A M I C S 2 0 0 6 R E P O R T Table HH.4: Women’s background characteristics Percent distribution of women aged 15-49 Years by background characteristics, Somalia, 2006 Number of women Weighted percent Weighted Unweighted Zone North West 25.5 1723 1541 North East 11.1 750 1638 Central Southern 63.4 4291 3585 Residence Urban 40.4 2735 2779 Rural 59.6 4029 3985 Age 15-19 25.2 1706 1695 20-24 20.0 1354 1374 25-29 17.5 1183 1193 30-34 12.1 822 816 35-39 11.8 798 799 40-44 8.6 580 572 45-49 4.7 320 315 Marital/Union status Currently married/in union 65.3 4417 4400 Formerly married/in union 9.3 630 642 Never married/in union 25.4 1717 1722 Motherhood status Ever gave birth 91.1 4597 4581 Never gave birth 8.9 450 461 Education None 58.3 3944 3862 Koranic 16.0 1082 1086 Primary 15.4 1040 1101 Secondary + 4.7 320 340 Non standard Curriculum 3.7 250 242 Don’t Know/Missing 1.9 128 133 Wealth index quintiles Poorest 18.0 1214 1119 Second 19.8 1337 1284 Middle 19.7 1334 1328 Fourth 20.3 1373 1450 Richest 22.3 1506 1583 Total 100 6764 6764 S O M A L I A M I C S 2 0 0 6 R E P O R T 76 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Table HH.5: Children’s background characteristics Percent distribution of children under five Years of age by background characteristics, Somalia, 2006 Number of under-5 children Weighted percent Weighted Unweighted Sex Male 51.9 3275 3270 Female 48.1 3030 3035 Zone North West 16.4 1032 1013 North East 13.9 879 1609 Central Southern 69.7 4394 3683 Residence Urban 35.7 2254 2317 Rural 64.3 4051 3988 Age < 6 months 10.8 681 687 6-11 months 10.2 646 653 12-23 months 17.2 1086 1096 24-35 months 20.0 1264 1243 36-47 months 20.7 1307 1317 48-59 months 21.0 1322 1309 Mother’s education None 62.2 3924 3838 Koranic 18.3 1151 1151 Primary 13.0 821 902 Secondary + 3.1 194 203 Non standard Curriculum 3.1 194 190 Don’t Know/Missing 0.3 21 21 Wealth index quintiles Poorest 20.1 1266 1160 Second 20.5 1294 1242 Middle 20.7 1304 1307 Fourth 20.7 1308 1406 Richest 18.0 1132 1190 Total 100 6305 6305 S O M A L I A M I C S 2 0 0 6 R E P O R T 77 S O M A L I A M I C S 2 0 0 6 R E P O R T Table CM.1: Childhood mortality rates Neonatal, post neonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Somalia 2006 Years preceding the survey Neonatal mortality (NN) Post neonatal mortality (PNN) Infant mortality (1q0) * Child mortality (4q0) Under five mortality (5q0)** 0-4 41 45 86 53 135 5-9 37 54 91 67 152 10-14 50 59 109 94 192 * MICS indicator 2; MDG indicator 14 ** MICS indicator 1; MDG indicator 13 Table CM.2: Child mortality by sex and residence Neonatal, postneonatal, infant, child, and under-five mortality rates for the five-year periods preceding the survey, by background characteristics Somalia 2006 Neonatal mortality (NN) Post neonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q0) Under five mortality (5q0)** Sex Male 43 48 91 53 139 Female 33 43 76 54 126 Zone North West 36 52 88 27 113 North East 35 45 80 46 122 Central South 44 43 87 63 144 Residence Urban 40 48 88 50 134 Rural 42 44 85 55 136 Total 41 45 86 53 135 S O M A L I A M I C S 2 0 0 6 R E P O R T 78 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Table NU.1: Child malnourishment Percentage of children aged 0-59 months who are severely or moderately malnourished, Somalia, 2006 Weight for age Height for age Weight for height Number of children aged 0-59 months % below % below % below % below % below % below % above - 2 SD* - 3 SD - 2 SD** - 3 SD - 2 SD*** - 3 SD + 2 SD Sex Male 36.7 11.4 37.7 20.9 11.7 2.5 2.8 2821 Female 34.3 11.7 38.0 20.0 10.1 1.9 3.6 2603 Residence Urban 22.8 6.0 27.8 12.5 6.7 1.1 2.4 1992 Rural 43.0 14.8 43.6 25.1 13.4 2.8 3.6 3432 Age < 6 months 6.6 1.1 9.5 2.8 6.4 1.1 6.5 531 6-11 months 18.0 5.2 18.8 6.4 12.6 2.6 4.5 588 12-23 months 37.3 12.9 37.9 19.4 15.7 4.7 3.9 928 24-35 months 45.1 18.7 46.9 27.4 10.4 1.7 1.6 1125 36-47 months 42.5 13.9 46.8 27.2 10.0 1.5 2.2 1127 48-59 months 40.5 9.2 43.0 23.4 9.8 1.6 2.8 1125 Mother’s education None 39.3 13.5 41.7 24.0 11.7 2.5 3.1 3343 Koranic 37.6 11.7 39.5 19.9 11.4 1.9 3.3 1011 Primary 22.1 5.7 24.3 10.1 8.0 1.5 2.8 717 Secondary + 14.5 3.7 20.6 7.5 7.4 1.4 5.0 170 Non standard curriculum 28.5 5.9 23.6 11.4 9.8 2.6 2.7 167 Wealth index quintiles Poorest 48.1 17.1 47.7 26.6 14.6 3.2 4.2 1064 Second 46.3 17.0 47.9 29.5 12.8 2.2 3.3 1120 Middle 40.3 13.8 42.4 24.9 13.2 2.8 2.7 1105 Fourth 26.0 6.3 28.8 12.2 9.2 2.3 3.2 1101 Richest 16.2 3.1 21.4 8.5 4.6 0.3 2.5 1034 Total 35.6 11.6 37.8 20.5 11.0 2.2 3.2 5424 * MICS indicator 6; MDG indicator 4 ** MICS indicator 7 *** MICS indicator 8 Total includes 16 children missing information on mother’s education who are not shown separately. Figures in parenthesis are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Zones are excluded from table (see text page 26)) S O M A L I A M I C S 2 0 0 6 R E P O R T 79 S O M A L I A M I C S 2 0 0 6 R E P O R T Table NU.2: Initial breastfeeding Percentage of women aged 15-49 years with a birth in the two years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, Somalia, 2006 Percentage who started breastfeeding within one hour of birth* Percentage who started breastfeeding within one day of birth** Number of women with a live birth in the two years preceding the survey Zone North West 35.1 69.8 496 North East 38.5 74.4 269 Central South 21.4 55.3 1560 Residence Urban 26.6 67.2 852 Rural 26.1 56.8 1472 Months since birth < 6 months 23.9 61.1 551 6-11 months 30.5 61.1 614 12-23 months 25.5 60.5 959 Mother’s education None 26.2 58.5 1460 Koranic 17.7 55.6 369 Primary 35.5 71.2 314 Secondary + 30.0 71.8 64 Non standard curriculum 24.9 71.6 75 Wealth index quintiles Poorest 23.5 49.6 435 Second 28.6 55.3 468 Middle 25.6 59.0 483 Fourth 24.3 66.0 508 Richest 29.7 73.0 430 Total 26.3 60.6 2325 * MICS indicator 45 ** Includes children who started breastfeeding within one hour of birth. Total includes 43 children missing information on mother’s education who are not shown separately. S O M A L I A M I C S 2 0 0 6 R E P O R T 80 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Ta bl e NU .3 : B re as tf ee di ng Pe rc en ta ge o f l ivi ng ch ild re n ac co rd in g to b re as tfe ed in g st at us a t e ac h ag e gr ou p, S om al ia , 2 00 6 Ch ild re n 0- 3 m on th s Ch ild re n 0- 5 m on th s Ch ild re n 6- 9 m on th s Ch ild re n 12 -1 5 m on th s Ch ild re n 20 -2 3 m on th s Pe rc en t ex clu siv el y br ea st fe d Nu m be r o f ch ild re n Pe rc en t ex clu siv el y br ea st fe d* Nu m be r o f ch ild re n Pe rc en t re ce ivi ng br ea st m ilk an d so lid / m us hy fo od ** Nu m be r o f ch ild re n Pe rc en t br ea st fe d* ** Nu m be r o f ch ild re n Pe rc en t br ea st fe d* ** Nu m be r o f ch ild re n Se x M al e 11 .2 23 8 7. 9 36 6 13 .5 23 9 49 .1 27 3 40 .1 98 Fe m al e 14 .4 20 0 10 .5 31 5 16 .6 25 4 51 .5 22 7 30 .1 86 Zo ne No rth W es t 7. 0 86 5. 1 13 7 24 .1 10 6 43 .1 11 3 17 .0 49 No rth E as t 1. 9 46 .3 1. 1 79 13 .2 59 38 .2 63 (2 0. 4) 18 Ce nt ra l S ou th 15 .9 30 5 11 .7 46 4 12 .5 32 7 55 .0 32 4 45 .5 11 7 Re si de nc e Ur ba n 9. 1 15 3 6. 8 23 8 21 .1 16 8 31 .9 17 8 26 .8 72 Ru ra l 14 .6 28 5 10 .4 44 3 12 .0 32 5 60 .4 32 2 40 .9 11 3 M ot he r’s e du ca tio n No ne 12 .7 28 2 9. 4 42 9 13 .1 33 2 53 .2 29 6 38 .5 11 4 Ko ra ni c 12 .4 82 8. 7 13 0 17 .7 69 52 .2 10 0 (3 6. 7) 27 Pr im ar y (1 7. 9) 47 11 .9 79 21 .8 63 41 .9 68 (3 0. 9) 28 Se co da ry (* ) 11 (* ) 18 (* ) 10 (* ) 18 (* ) 10 No n st an da rd cu rri cu lu m (* ) 15 (* ) 21 (* ) 18 (* ) 17 (* ) 4 W ea lth in de x qu in til es Po or es t 26 .1 75 17 .7 11 7 8. 8 96 71 .0 10 1 (4 6. 4) 30 Se co nd 18 .7 93 14 .2 14 7 11 .3 98 64 .5 10 5 (4 4. 3) 43 M id dl e 13 .4 93 8. 8 15 5 17 .7 10 6 52 .4 92 (4 5. 8) 37 Fo ur th 2. 9 10 2 1. 9 15 3 14 .8 12 4 36 .7 10 5 (2 2. 7) 40 Ri ch es t 4. 2 75 3. 7 10 9 25 .8 69 25 .5 97 (1 8. 6) 34 To ta l 12 .7 43 8 9. 1 68 1 15 .1 49 3 50 .2 50 0 35 .4 18 4 * M IC S in di ca to r 1 5 ** M IC S in di ca to r 1 7 ** * M IC S in di ca to r 1 6 To ta l i nc lu de s c hi ld re n m iss in g in fo rm at io n on m ot he r’s e du ca tio n w ho a re n ot sh ow n se pa ra te ly. Fig ur es in p ar en th es is ar e ba se d on 2 5- 49 u nw ei gh te d ca se s. An a st er isk in di ca te s t ha t a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s a nd h as b ee n su pp re ss ed . S O M A L I A M I C S 2 0 0 6 R E P O R T 81 S O M A L I A M I C S 2 0 0 6 R E P O R T Table NU.4: Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6-11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed, Somalia, 2006 Percent of infants 0-5 months exclusively breastfed 6-8 months who received breastmilk and complementary food at least 2 times in prior 24 hours 9-11 months who received breastmilk and complementary food at least 3 times in prior 24 hours 6-11 months who received breastmilk and complementary food at least the minimum recommended number of times per day* 0-11 months who were appropriately fed** Number of infants aged 0-11 months Sex Male 7.9 10.2 13.9 11.5 9.6 683 Female 10.5 10.2 16.4 12.4 11.5 644 Zone North West 5.1 18.9 18.8 18.9 12 277 North East 1.1 12.5 9.0 11.4 5.9 148 Central South 11.7 7.0 14.9 9.8 10.8 902 Residence Urban 6.8 12.8 17.2 14.3 10.4 460 Rural 10.4 8.8 14.2 10.7 10.5 867 Mother’s education None 9.2 9.8 16.2 11.9 10.5 893 Koranic 8.7 5.1 11 7.3 8.1 224 Primary or above 9.7 17 15.3 16.4 13.2 204 Wealth index quintiles Poorest 17.7 7.1 5.3 6.4 11.8 244 Second 14.2 9.9 14.7 11.4 13 270 Middle 8.8 10.5 19.4 13.4 10.9 291 Fourth 1.9 7.9 18.6 11.3 6.7 311 Richest 3.7 18.5 18.6 18.5 10.8 211 Total 9.1 10.2 15.2 11.9 10.5 1326 * MICS indicator 18 ** MICS indicator 19 Total includes children missing information on mother’s education who are not shown separately. S O M A L I A M I C S 2 0 0 6 R E P O R T 82 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Table NU.5: Iodized salt consumption Percentage of households consuming adequately iodized salt, Somalia, 2006 Percent of households in which salt was tested Number of households interviewed Percent of households with Number of households in which salt was tested or with no saltNo salt Salt test result < 15 PPM 15+ PPM* Total Zone North West 93.4 1454.9 4.7 94.6 0.7 100 1426 North East 92.9 686.6 5.8 93.0 1.2 100 677 Central South 89.9 3827.4 8.7 89.8 1.4 100 3772 Residence Urban 95.3 2112.8 3.4 94.8 1.8 100 2083 Rural 88.9 3856.2 9.6 89.5 0.9 100 3792 Wealth index quintiles Poorest 82.6 1155.3 16.0 82.4 1.6 100 1136 Second 89.6 1325.3 9.1 90.2 0.7 100 1307 Middle 91.5 1245.3 6.4 92.8 0.7 100 1218 Fourth 94.8 1204.1 3.7 94.9 1.5 100 1184 Richest 97.9 1039.0 1.2 97.0 1.8 100 1030 Total 91.1 5969 7.4 91.4 1.2 100 5875 * MICS indicator 41 Adequately iodized salt is defined as salt that contains at least 15 parts per million of iodine. S O M A L I A M I C S 2 0 0 6 R E P O R T 83 S O M A L I A M I C S 2 0 0 6 R E P O R T Table NU.6: Children’s vitamin A supplementation Percent distribution of children aged 6-59 months by whether they have received a high dose vitamin A supplement in the last 6 months, Somalia, 2006 Percent of children who received vitamin A: Not sure if received vitamin A Never received vitamin A Total Number of children aged 6-59 months Within last 6 months* Prior to last 6 months Not sure when Sex Male 24.9 6.4 5.6 1.1 61.9 100 2908 Female 23.5 6.7 5.2 0.5 64.0 100 2716 Zone North West 25.9 6.7 4.1 1.0 62.2 100 1107 North East 15.2 2.6 3.3 0.3 78.6 100 587 Central South 25.1 7.1 6.1 0.9 60.8 100 3930 Residence Urban 29.2 7.3 8.2 0.8 54.6 100 2016 Rural 21.5 6.2 3.9 0.9 67.6 100 3608 Age 6-11 months 18.0 2.0 2.2 0.7 77.2 100 646 12-23 months 22.8 4.4 4.4 0.7 67.7 100 1086 24-35 months 26.6 5.9 5.7 0.7 61.0 100 1264 36-47 months 25.2 8.5 5.9 0.7 59.7 100 1307 48-59 months 25.1 9.4 7.2 1.4 57.0 100 1322 Mother’s education None 22.8 6.0 4.4 0.9 65.8 100 3495 Koranic 22.5 6.9 7.0 0.6 62.9 100 1021 Primary 29.5 8.2 7.1 0.7 54.5 100 742 Secondary + 35.7 9.3 8.4 0.2 46.4 100 176 Non standard curriculum 27.0 6.7 6.3 1.8 58.2 100 173 Wealth index quintiles Poorest 17.9 5.5 3.8 0.5 72.3 100 1150 Second 24.2 5.8 3.1 0.8 66.0 100 1148 Middle 23.0 6.1 5.8 1.6 63.5 100 1149 Fourth 28.8 7.3 5.4 0.6 57.9 100 1155 Richest 27.5 8.3 9.6 0.7 53.9 100 1023 Total 24.2 6.6 5.4 0.8 62.9 100 5624 * MICS indicator 42 Total includes 17 children missing information on mother’s education who are not shown separately. Figures in parenthesis are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. S O M A L I A M I C S 2 0 0 6 R E P O R T 84 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Table NU.7: Post-partum mothers’ vitamin A supplementation Percentage of women aged 15-49 years with a live birth in the 2 years preceding the survey by whether they received a high dose vitamin A supplement before the infant was 8 weeks old, Somalia, 2006 Received vitamin A supplement* Not sure if received vitamin A Number of women aged 15-49 years Zone North West 13.1 2.8 496 North East 6.0 1.1 269 Central South 7.7 1.9 1560 Residence Urban 15.1 2.3 852 Rural 4.9 1.8 1472 Education None 6.9 2.0 1460 Koranic 7.3 2.8 369 Primary 16.4 1.2 314 Secondary + 23.4 3.8 64 Non standard curriculum 7.7 2.0 75 Wealth index quintiles Poorest 4.7 2.3 435 Second 4.7 1.8 468 Middle 5.1 1.5 483 Fourth 10.4 1.7 508 Richest 19.0 2.8 430 Total 8.7 2.0 2325 *MICS indicator 43 Total includes 43 women missing information on education who are not shown separately. S O M A L I A M I C S 2 0 0 6 R E P O R T 85 S O M A L I A M I C S 2 0 0 6 R E P O R T Table NU.8: Child size at birth Percentage of live births in the 2 years preceding the survey by mother’s estimate of baby size at birth, Somalia, 2006 Size of child at birth as estimated by the mother Weighed at birth* Very large Larger than average Average Smaller than average Very small Don’t know/ missing Total Number of births Zone North West 12.2 11.3 10.0 64.5 6.0 5.6 2.7 100 496 North East 2.7 6.3 3.9 70.4 6.8 11.3 1.2 100 269 Central South 2.4 5.1 3.3 53.7 11.7 20.9 5.2 100 1560 Residence Urban 10.2 9.6 6.3 53.4 9.0 19.1 2.6 100 852 Rural 1.3 4.8 4.0 60.6 10.5 15.0 5.2 100 1472 Mother’s education None 2.1 5.9 4.3 57.3 10.3 17.3 4.9 100 1460 Koranic 3.0 5.2 3.3 58.9 9.6 18.6 4.3 100 369 Primary 13.4 9.9 7.3 58.5 9.2 12.9 2.2 100 314 Secondary + 25.5 7.5 10.8 63.5 6.2 8.3 3.8 100 64 Non standard curriculum 7.6 12.5 10.0 48.8 12.9 15.2 0.6 100 75 Wealth index quintiles Poorest 1.4 5.8 3.8 52.8 14.1 14.1 9.2 100 435 Second 0.8 4.0 2.8 61.3 9.1 18.6 4.2 100 468 Middle 1.8 4.0 3.4 64.4 10.6 13.9 3.7 100 483 Fourth 3.2 8.4 5.4 60.2 8.6 14.3 3.0 100 508 Richest 16.4 10.7 8.9 49.6 7.4 22.2 1.2 100 430 Total 4.5 6.6 4.8 57.9 9.9 16.5 4.2 100 2325 ** MICS indicator 10 Total includes 43 children missing information on mother’s education who are not shown separately. S O M A L I A M I C S 2 0 0 6 R E P O R T 86 87 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Table CH.1: Vaccinations in first year of life Percentage of children aged 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, Somalia, 2006 Percentage of children who received: Number of children aged 12-23 monthsBCG* DPT1 DPT2 DPT3** Polio0 Polio1 Polio2 Polio3*** Measles**** All***** None Vaccinated at any time before the survey According to: Vaccination card 8 8.1 7.6 7.4 6.6 8 7.8 7.5 7.1 7.8 0 1086 Mother’s report 21.9 16.3 11.2 6.7 8.5 53.9 46.3 31.1 22.3 4 36.3 1086 Either 29.9 24.4 18.8 14.2 15.2 61.9 54.1 38.6 29.4 11.7 36.3 1086 Vaccinated by 12 months of age 25.7 20.4 16.6 12.2 15.2 51.5 47.7 34.8 18.9 4.8 37.3 1086 * MICS indicator 25 ** MICS indicator 27 *** MICS indicator 26 **** MICS indicator 28; MDG indicator 15 S O M A L I A M I C S 2 0 0 6 R E P O R T 87 S O M A L I A M I C S 2 0 0 6 R E P O R T Table CH.2: Vaccinations by background characteristics Percentage of children aged 12-23 months currently vaccinated against childhood diseases, Somalia, 2006 Percentage of children who received: Percent with health card Number of children aged 12-23 monthsBCG DPT1 DPT2 DPT3 Polio0 Polio1 Polio2 Polio3 Measles All None Sex Male 29.9 25.3 20.4 15.9 17.3 61.3 54.6 38.7 29.9 13.9 37.4 9.6 577 Female 29.9 23.4 16.9 12.3 12.7 62.7 53.4 38.5 28.8 9.3 35 6.3 510 Zone North West 36.7 25.3 11.1 4.8 16.4 72.2 60.3 35.1 33.2 3.3 24.6 1.3 253 North East 18.6 16 11.8 6.4 7.3 40.3 36.7 23.7 15.9 5.2 58.1 2.4 124 Central South 29.5 25.5 22.7 18.8 16.1 62.1 54.9 42.4 30.5 15.9 36.6 11.4 709 Residence Urban 47 42.3 34.3 26.4 27.7 75.4 70.1 53.8 40.4 21.9 23.1 15.1 410 Rural 19.6 13.6 9.4 6.8 7.6 53.9 44.6 29.6 23 5.7 44.2 3.8 677 Mother’s education None 23.5 18.6 13.9 10.6 12.5 58.1 48.9 34.2 23.8 8.8 39.9 6.3 635 Koranic 28.8 23 19 15.6 16.7 57 51.1 37.2 29 12.5 41.6 10.8 209 Primary 44.9 36.4 27 19.2 15.7 75.5 70.4 49.4 42 15.2 23.6 9.3 163 Secondary 63.2 58.9 45.6 24.7 41 83.8 75.1 56 48.4 19.4 14.6 5.3 41 Non Standard Curriculum 40.8 37.5 34.9 32.3 20.9 70.2 64.4 55.9 52.8 31.5 26.5 20.9 36 Wealth index quintiles Poorest 18.7 13.2 10.2 5.4 8.2 45 34.9 22.5 22.2 5.4 52.5 3 200 Second 14.5 11 6.5 6.5 5.9 53.4 43.7 26.6 18.9 4.5 45.9 3.7 216 Middle 27.9 20.7 16.5 14.6 15.8 61.2 54.9 43.1 27.4 13.1 36.9 11.1 217 Fourth 33.7 26.9 19.4 14.7 16.1 69.8 63.3 45 30.9 13.1 29.1 9.8 233 Richest 53.1 48.6 40.1 28.8 28.9 78.4 72.4 54.8 47.4 22.2 18.9 12 220 Total 29.9 24.4 18.8 14.2 15.2 61.9 54.1 38.6 29.4 11.7 36.3 8 1086 Total includes 2 children missing information on mother’s education who are not shown separately. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. S O M A L I A M I C S 2 0 0 6 R E P O R T 88 89 S O M A L I A M I C S 2 0 0 6 R E P O R T S O M A LI A M IC S 2 0 0 6 R E P O R T Table CH.3: Neonatal tetanus protection Percentage of mothers with a birth in the last 12 months protected against neonatal tetanus, Somalia, 2006 Percent of mothers with a birth in the last 12 months who: Number of mothers Received at least 2 doses during last pregnancy Received at least 2 doses, the last within prior 3 years Received at least 3 doses, last within prior 5 years Received at least 4 doses, last within prior 10 years Received at least 5 doses during lifetime Protected against tetanus* Zone North West 10.9 4.7 0.2 0.4 0.2 16.5 496 North East 14.8 5.7 0.3 0.3 0.2 21.3 269 Central South 20.5 6.4 1.4 1.7 0.3 30.2 1560 Residence Urban 33.0 11.0 1.9 2.3 0.4 48.5 852 Rural 9.0 3.0 0.5 0.6 0.2 13.4 1472 Mother’s Age 15-19 20.7 3.4 0.5 0.0 0.0 24.6 240 20-24 19.1 6.2 0.8 0.0 0.0 26.1 630 25-29 20.5 5.2 1.7 0.6 0.2 28.2 631 30-34 15.9 8.2 0.9 3.3 0.6 28.9 391 35-39 11.9 5.4 0.6 3.6 0.0 21.4 279 40 + 12.8 6.7 0.8 1.4 1.8 23.5 154 Mother’s education None 14.4 4.2 0.4 0.9 0.2 20.0 1460 Koranic 17.0 6.0 2.6 1.4 0.3 27.2 369 Primary 31.4 10.8 1.8 2.6 0.5 47.1 314 Secondary + 32.0 18.2 1.9 4.4 0.0 56.4 64 Non standard curriculum 23.5 12.6 2.3 0.0 1.8 40.1 75 Wealth index quintiles Poorest 7.4 1.1 0.0 0.0 0.0 8.6 435 Second 8.6 2.7 0.3 0.3 0.3 12.0 468 Middle 15.2 4.5 0.2 0.9 0.1 20.9 483 Fourth 23.0 9.2 1.5 2.2 0.2 36.1 508 Richest 35.3 12.0 3.0 2.8 0.8 53.9 430 Total 17.8 5.9 1.0 1.2 0.3 26.3 2325 * MICS indicator 32 Total includes 43 children missing information on mother’s education who are not shown separately. S O M A L I A M I C S 2 0 0 6 R E P O R T 89 90 S O M A L I A M I C S 2 0 0 6 R E P O R T Table CH.4: Oral rehydration treatment Percentage of children aged 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), Somalia, 2006 Had diarrhoea in last two weeks Number of children aged 0-59 months Children with diarrhoea who received: Number of children aged 0-59 months with diarrhoea Fluid from ORS packet Recommended homemade fluid Pre- packaged ORS fluid No treatment ORT Use Rate * Sex Male 22.5 3275 9.0 10.3 7.8 78.3 21.7 736 Female 19.7 3030

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