SUDAN Multiple Indicator Cluster Survey 2014

Publication date: 2014

MINISTRY OF CABINET CENTRAL BUREAU OF STATISTICS SUDAN Multiple Indicator Cluster Survey 2014 Final Report UNICEF-MICS Note that in Table RH.10, the MICS indicator 5.7 (also MDG Indicator 5.2) “Delivery assisted by any skilled attendant” is presented as 77.7 percent and the indicator value has been calculated by treating the category ‘certified midwife’ as ‘skilled birth attendant’. In previous Sudan MICS 2010 final report, this indicator value was shown as 72.5 percent while the corresponding category considered as ‘skilled birth attendant’ was labeled as ‘village midwife’. In Sudan, it is reported that the Certified Midwife/Village Midwife are trained and capacitated by the MoH and therefore considered as skilled to provide adequate assistance for birth delivery. Please also note the following changes (compared to the final report that was disseminated in March 2016): As a result of a problem noticed and then corrected in the dataset, education tables ED.2 to ED.9 have been reproduced. The updated tables are attached to the end of this report. The MICS indicator references in above mentioned updated education tables (except ED.2) have been removed and an additional table, Table ED.10 (ISCED), is attached to the end of this report with corrected MICS indicator values. This table is expected to be produced in survey reports when education systems do not follow the ISCED classification and where education tables (ED3-ED.9) therefore are produced according to national standards without any reference to the MICS indicators. The table is necessary in order to present easy access to indicators for global reporting. 23 May 2016 – MICS Team UNICEF-MICS Sticky Note Note that correction has been made in Table ED.10(ISCED), column "Secondary school (ISCED 2+3)". The Sudan Multiple Indicator Cluster Survey (MICS) was carried out in 2014 by the Central Bureau of Statistics (CBS) Sudan in collaboration with the Ministry of Health as part of the global MICS programme, round 5. Technical support was provided by the United Nations Children’s Fund (UNICEF) at national, regional and headquarter levels for quality assurance. A large partnership has been established for the conduct of MICS Sudan involving UNICEF, World Health Organization (WHO), United Nations Population Fund (UNFPA), World Food Program (WFP), and the Department for International Development (DfID) UK who provided financial support. The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The specific objectives of the survey is to: x Update information for assessing the situation of children and women in Sudan based on MICS5 modules and geographical coverage of the 18 States in Sudan. x Measure the trend towards achievement of the MDGs and the goals of a World Fit For Children Plan of Action and other internationally agreed upon indicators related to children and women. x Furnish data needed for the indicators as per the global review of the Millennium Development Goals. x Contribute to the improvement of data and monitoring systems in Sudan and to strengthen technical expertise, national capacity building in the design, implementation, and analysis of such systems. x Update Census indicators and provide solid evidence for decentralization (planning and measure of progress). x Provide key evidence for social sector programming and the Poverty Reduction Strategy Paper (PRSP) under development and accountabilities for sector strategic plans and UNDAF 2013-2016. Citation: Central Bureau of Statistics (CBS), UNICEF Sudan. 2016, Multiple Indicator Cluster Survey 2014 of Sudan, Final Report. Khartoum, Sudan: UNICEF and Central Bureau of Statistics (CBS), February 2016. iii Summary Table of Survey Implementation and the Survey Population, Sudan MICS, 2014 Survey implementation Sample frame - Household Listing Sudan Population Census 2008 July, 2014 Questionnaires Household Women (age 15-49) Children under five Interviewer training July, 2014 Fieldwork 10th September – 30th October 2014 Survey sample Households - Sampled - Occupied - Interviewed - Response rate (Percent) 18,000 17,142 16,801 98.0 Children under five - Eligible - Mothers/caretakers interviewed - Response rate (Percent) 14,751 14,081 95.5 Women - Eligible for interviews - Interviewed - Response rate (Percent) 20,327 18,302 90.0 Survey population Average household size 5.9 Percentage of population living in - Urban area - Rural area States - Northern - River Nile - Red Sea - Kassala - Gadarif - Khartoum - Gezira - White Nile - Sinnar - Blue Nile - North Kordofan - South Kordofan - West Kordofan - North Darfur - West Darfur - South Darfur - Central Darfur - East Darfur 29.8 70.2 2.5 4.0 3.1 4.3 5.1 13.8 15.6 5.2 3.9 3.9 6.7 2.8 6.0 7.4 3.3 7.6 1.8 3.0 Percentage of population under: - Age 5 - Age 18 15.2 50.6 Percentage of women age 15-49 years with at least one live birth in the last 2 years 30.7 iv Housing characteristics Household or personal assets Percentage of households with - Electricity - Finished floor - Finished roofing - Finished walls 44.9 14.0 25.0 28.1 Percentage of households that own - A television - A refrigerator - Agricultural land - Farm animals/livestock 39.6 25.9 39.5 51.0 Mean number of persons per room used for sleeping 3.2 Percentage of households where at least a member has or owns a - Mobile phone - Car or truck 73.8 6.4 Summary Table of Findings1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Sudan MICS, 2014 CHILD MORTALITY Early childhood mortalitya MICS Indicator Indicator Description Value 1.1 Neonatal mortality rate Probability of dying within the first month of life 33 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 52 1.3 Post-neonatal mortality rate Difference between infant and neonatal mortality rates 19 1.4 Child mortality rate Probability of dying between the first and the fifth birthdays 17 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 68 a Indicator values are per 1,000 live births and refer to the five-year period before the survey NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 33.0 12.0 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 38.2 18.2 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 16.3 4.5 1 See Appendix E for a detailed description of MICS indicators v NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 3.0 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 95.6 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last new-born to the breast within one hour of birth 68.7 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 55.4 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 80.8 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 89.4 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 48.8 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 21.2 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 63.1 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 61.2 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 57.5 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non- breastfed children) the minimum number of times or more during the previous day 40.7 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 28.0 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children age 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 25.0 37.0 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 7.3 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodide/iodate 7.6 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 32.3 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 16.3 vi CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 78.5 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 65.3 3.3 3.5 3.6 Pentavalanet DPT+HepB+Hib) immunization coverage Percentage of children age 12-23 months who received the third dose of Pentavalent (DPT+HepB+Hib) vaccine by their first birthday 63.9 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 12-23 months who received measles vaccine by their first birthday 60.9 3.8 Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday 42.8 Tetanus toxoid 3.9 Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 58.2 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 29.0 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 42.7 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 28.9 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre-packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 59.3 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 17.8 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 48.3 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 59.0 Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 58.2 vii WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 68.0 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 4.1 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 32.9 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 53.0 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 25.8 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 55.4 REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rateA for women age 15-49 years 5.2 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rateA for women age 15-19 years 87 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 21.5 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married who are using (or whose partner is using) a (modern or traditional) contraceptive method 12.2 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 26.6 A The age-specific fertility rate is defined as the number of live births to women in a specific age group during a specified period, divided by the average number of women in that age group during the same period, expressed per 1,000 women. The age-specific fertility rate for women age 15-19 years is also termed as the adolescent birth rate. The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. The TFR denotes the average number of children to which a woman will have given birth by the end of her reproductive years (by age 50) if current fertility rates prevailed. Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 79.1 50.7 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 62.8 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 77.5 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 27.7 viii 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 9.1 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 51.5 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 27.7 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 26.6 CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 22.3 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 1.5 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 45.5 LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young people Percentage of young people age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education (a) women 59.8 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 69.7 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 36.8 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 76.4 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 28.4 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 80.4 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final grade of primary school) 79.3 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 90.7 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 0.98 ix 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.07 CHILD PROTECTION Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 67.3 Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour 24.9 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 63.9 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of people age 15-49 years who were first married before age 15 (a) Women 11.9 8.5 Marriage before age 18 Percentage of people age 20-49 years who were first married before age 18 (a) Women 38.0 8.6 Young people age 15-19 years currently married Percentage of young people age 15-19 years who are married (a) Women 21.2 8.7 Polygyny Percentage of people age 15-49 years who are in a polygynous union (a) Women 21.7 8.8a 8.8b Spousal age difference Percentage of young women who are married and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years 7.9 23.0 Female genital mutilation/cutting 8.9 Approval for female genital mutilation/cutting (FGM/C) Percentage of women age 15-49 years who state that FGM/C should be continued 40.9 8.10 Prevalence of FGM/C among women Percentage of women age 15-49 years who report to have undergone any form of FGM/C 86.6 8.11 Prevalence of FGM/C among girls Percentage of daughters age 0-14 years who have undergone any form of FGM/C, as reported by mothers age 15-49 years 31.5 Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of people age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food (a) Women 34.0 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 3.4 x 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 5.3 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 1.8 HIV/AIDS AND SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of people age 15-49 years who have heard of AIDS (a) Women 74.8 9.1 MDG 6.3 Knowledge about HIV prevention among young people Percentage of young people age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission (a) Women 8.5 9.2 Knowledge of mother-to- child transmission of HIV Percentage of people age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV (a) Women 28.4 9.3 Accepting attitudes towards people living with HIV Percentage of people age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV (a) Women 7.9 HIV testing 9.4 People who know where to be tested for HIV Percentage of people age 15-49 years who state knowledge of a place to be tested for HIV (a) Women 17.0 9.5 People who have been tested for HIV and know the results Percentage of people age 15-49 years who have been tested for HIV in the last 12 months and who know their results (a) Women 1.6 9.6 Sexually active young people who have been tested for HIV and know the results Percentage of young people age 15-24 years who have had sex in the last 12 months, who have been tested for HIV in the last 12 months and who know their results (a) Women 1.2 9.7 HIV counselling during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 4.2 9.8 HIV testing during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 3.6 Orphans 9.16 MDG 6.4 Ratio of school attendance of orphans to school attendance of non-orphans Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents 0.82 xi Table of Contents SUMMARY TABLE OF SURVEY IMPLEMENTATION AND THE SURVEY POPULATION, SSSUDAN MICS, 2014 . III SUMMARY TABLE OF FINDINGS . IV LIST OF TABLES . XIV LIST OF FIGURES . XVIII LIST OF ABBREVIATIONS . XXIV FOREWORD . XXVI ACKNOWLEDGEMENTS . XXVII EXECUTIVE SUMMARY . XXVIII I. INTRODUCTION . 1 1.1 Background . 1 1.2 Survey Objectives . 2 II. SAMPLE AND SURVEY METHODOLOGY. 3 2.1 Sample Design . 3 2.2 Questionnaires . 3 2.3 Training . 4 2.4 Pre-test . 4 2.5 Field work . 4 2.6 Data Processing . 5 III. Sample Coverage and the Characteristics of Households and Respondents . 6 3.1 Sample Coverage. 6 3.2 Characteristics of Households . 8 3.3 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 11 3.4 Housing Characteristics, Asset Ownership, and Wealth Quintiles . 15 3.5 Household Assets . 18 IV. Child Mortality . 23 4.2. Status of Child Mortality at national level . 24 4.3 Geographic Disparity in Childhood Mortality . 25 4.4 Disparity in Childhood mortality by socioeconomic and demographic patterns . 28 4.5 Trend in Childhood mortality rate using different sources. 30 V. Nutrition . 33 5.1 Low Birth Weight . 33 5.2 Nutritional Status . 36 5.2.1 Overall Status of Child Malnutrition . 40 xii 5.2.2 Geographic Inequity in Child Malnutrition . 41 5.2.3 Disparity of Child Malnutrition by Wealth Index Quintile . 43 5.2.4 Disparity in Child Malnutrition by Mother’s Education . 44 5.2.5 Trends in Under-five Nutritional Status from 2006 to 2014 . 45 5.3 Breastfeeding and Infant and Young Child Feeding . 47 5.3.1 Initial Breastfeeding . 49 5.3.2 Young Child Feeding . 51 5.4 Salt Iodization . 64 5.5 Children’s Vitamin A supplementation . 67 VI. Child Health . 69 6.1 Vaccinations . 69 6.2 Neonatal Tetanus Protection . 76 6.3 Care of Illness . 78 6.3.1 Diarrhoea . 80 6.3.2 Acute Respiratory Infections . 95 6.3.3 Solid Fuel Use . 98 VII. WATER AND SANITATION . 103 7.1 Use of Improved Water Sources . 103 7.2 Use of Improved Sanitation . 113 7.3 Handwashing . 125 VIII. REPRODUCTIVE HEALTH . 130 8.1 Fertility . 130 8.2 Contraception . 136 8.3 Unmet Need . 140 8.4 Antenatal Care (ANC) . 142 8.5 Assistance at Delivery . 150 8.6 Place of Delivery . 153 8.7 Post-natal Health Checks . 155 IX. Child Development . 169 9.1 Early Childhood Care and Education . 169 9.2 Quality of Care . 171 X. Literacy and Education . 173 10.1 Literacy among Young Women . 173 10.2 School Readiness . 174 10.3 Primary and Secondary School Participation . 176 XI. Child Protection . 192 xiii 11.1 Birth Registration . 192 11.2 Child Labour . 194 11.3 Child Discipline . 200 11.4 Early Marriage and Polygamy . 206 11.5 Female Genital Mutilation/Cutting . 214 11.6 ATTITUDES TOWARD DOMESTIC VIOLENCE . 219 11.7 Children’s Living Arrangements . 221 XII. HIV/AIDS and Sexual Behaviour . 226 12.1 Knowledge about HIV Transmission and Misconceptions about HIV . 226 12.2 Accepting Attitudes toward People Living with HIV . 231 12.3 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care. 233 12.4 HIV Indicators for Young Women . 237 XIII: Household Food Security . 240 13.1 Household Food Consumption . 242 13.2 Food Coping Strategies . 248 Appendix A: Sample Design . 253 Sample Size and Sample Allocation . 253 Sampling Frame and Selection of Clusters. 255 Listing Activities . 255 Selection of Households . 255 Calculation of Sample Weights . 255 Appendix B: List of Personnel Involved in the Survey. 258 Appendix C: Estimates of Sampling Errors . 266 Appendix D: Data Quality Tables . 290 APPENDIX E: SUDAN MICS 2014INDICATORS: NUMERATORS AND DENOMINATORS . 311 Appendix F1: Household Questionnaire . 322 Appendix F2: Questionnaire for Individual Women . 349 Appendix F3: Questionnaire for Children Under-Five . 381 xiv List of Tables Table HH.1: Results of household, women's, and under-5 interviews . 7 Table HH.2: Age distribution of household population by sex . 8 Table HH.3: Household composition . 10 Table HH.4: Women's background characteristics . 12 Table HH.5: Under-5's background characteristics. 13 Table HH.6: Housing characteristics . 16 Table HH.7: Household and personal assets . 20 Table HH.8: Wealth quintiles . 22 Table CM.1: Early childhood mortality rates . 24 Table CM.2: Early childhood mortality rates by socioeconomic characteristics . 26 Table CM.3: Early childhood mortality rates by demographic characteristics. 29 Table NU.1: Low birth weight infants.……………………………….……………………………….36 Table NU.2: Nutritional status of children . 39 Table NU.3: Initial breastfeeding . 51 Table NU.4: Breastfeeding . 53 Table NU.5: Duration of breastfeeding . 56 Table NU.6: Age-appropriate breastfeeding . 58 Table NU.7: Introduction of solid, semi-solid, or soft foods . 60 Table NU.8: Infant and young child feeding (IYCF) practices . 61 Table NU.9: Bottle feeding . 64 Table NU.10: Iodized salt consumption . 67 Table NU.11: Children’s Vitamin A Supplementation . 68 Table CH.1: Vaccinations in the first years of life . 72 Table CH.2: Vaccinations by background characteristics . 75 Table CH.3: Neonatal tetanus protection . 78 Table CH.4: Reported disease episodes . 80 Table CH.5: Care-seeking during diarrhoea . 82 Table CH.6: Feeding practices during diarrhoea . 84 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . 87 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 90 Table CH.9: Source of ORS and zinc . 94 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) . 96 Table CH.11: Knowledge of the two danger signs of pneumonia . 98 Table CH.12: Solid fuel use . 100 Table CH.13: Solid fuel use by place of cooking . 102 Table WS.1: Use of improved water sources . 107 Table WS.2: Household water treatment . 109 Table WS.3: Time to source of drinking water . 111 Table WS.4: Person collecting water . 113 Table WS.5: Types of sanitation facilities . 116 Table WS.6: Use and sharing of sanitation facilities . 119 Table WS.7: Drinking water and sanitation ladders . 123 Table WS.8: Disposal of child's faeces . 125 xv Table WS.9: Water and soap at place for handwashing . 128 Table WS.10: Availability of soap or other cleansing agent . 130 Table RH.1: Fertility rates . 132 Table RH.2: Adolescent birth rate and total fertility rate . 134 Table RH.3: Early childbearing . 135 Table RH.4: Trends in early childbearing . 136 Table RH.5: Use of contraception . 138 Table RH.6: Unmet need for contraception . 142 Table RH.7: Antenatal care coverage . 145 Table RH.8: Number of antenatal care visits and timing of first visit . 148 Table RH.9: Content of antenatal care . 150 Table RH.10: Assistance during delivery and caesarean section . 153 Table RH.11: Place of delivery . 155 Table RH.12: Post-partum stay in health facility . 157 Table RH.13: Post-natal health checks for new-borns . 159 Table RH.14: Post-natal care visits for new-borns within one week of birth . 161 Table RH.15: Post-natal health checks for mothers . 164 Table RH.16: Post-natal care visits for mothers within one week of birth . 166 Table RH.17: Post-natal health checks for mothers and new-borns . 168 Table CD.1: Early childhood education. 171 Table CD.3: Learning materials . 172 Table ED.1: Literacy among young women . 174 Table ED.2: School readiness . 176 Table ED.3: Primary school entry . 177 Table ED.4: Primary school attendance and out of school children . 180 Table ED.5: Secondary school attendance and out of school children . 184 Table ED.6: Children reaching last grade of primary school . 185 Table ED.7: Primary school completion and transition to secondary school. 187 Table ED.8: Education gender parity . 188 Table ED.9: Out of school gender parity . 190 Table CP.1: Birth registration . 193 Table CP.2: Children's involvement in economic activities . 197 Table CP.3: Children's involvement in household chores . 198 Table CP.4: Child labour . 200 Table CP.5: Child discipline . 204 Table CP.6: Attitudes toward physical punishment . 206 Table CP.7: Early marriage and polygyny among women . 210 Table CP.8: Trends in early marriage among women . 212 Table CP.9: Spousal age difference . 214 Table CP.10: Female genital mutilation/cutting (FGM/C) among women . 215 Table CP.11: Female genital mutilation/cutting (FGM/C) among girls . 217 Table CP.12: Approval of female genital mutilation/cutting (FGM/C) . 219 Table CP.13: Attitudes toward domestic violence among women . 221 Table CP.14: Children's living arrangements and orphanhood . 223 Table CP.15: Children with parents living abroad . 225 xvi Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission among women . 227 Table HA.2: Knowledge of mother-to-child HIV transmission among women . 231 Table HA.3: Accepting attitudes toward people living with HIV among women . 232 Table HA.4: Knowledge of a place for HIV testing among women . 235 Table HA.5: HIV counselling and testing during antenatal care . 237 Table HA.7: Key HIV and AIDS indicators among young women………….………………………………….239 Table HA.9: School attendance of orphans and non-orphans.…………….…………………………………240 Table HFS.1: Proportion of households with poor, borderline and acceptable food consumption. . 243 Table HFS.2: Proportion of househlds who employ food coping strategies . 250 Appendices: Table SD.1: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Strata . 255 Table SE1: Indicators selected for sampling error calculations . 269 Table SE2: Sampling errors: Total Sample - Sudan . 270 Table SE3: Sampling errors: Urban . 271 Table SE4: Sampling errors: Rural . 272 Table SE5: Sampling errors: Northern state . 273 Table SE6: Sampling errors: River Nile state. 274 Table SE7: Sampling errors: Red Sea state . 275 Table SE8: Sampling errors: Kasala state . 276 Table SE9: Sampling errors: Gadarif state . 277 Table SE10: Sampling errors: Kharoum state . 278 Table SE11: Sampling errors: Gizera state . 279 Table SE12: Sampling errors: White Nile state . 280 Table SE13: Sampling errors: Sinnar state . 281 Table SE14: Sampling errors: Blue Nile state . 282 Table SE15: Sampling errors: North Kordofan state . 283 Table SE16: Sampling errors: South Kordofan state . 284 Table SE17: Sampling errors: West Kordofan state . 285 Table SE18: Sampling errors: North Darfur state . 286 Table SE19: Sampling errors: West Darfur state . 287 Table SE20: Sampling errors: South Darfur state . 288 Table SE21: Sampling errors: Central Darfur state . 289 Table SE22: Sampling errors: East Darfur state . 290 Table DQ.1: Age distribution of household population . 291 Table DQ.2: Age distribution of eligible and interviewed women . 294 Table DQ.4: Age distribution of children in household and under-5 questionnaires . 294 Table DQ.5: Birth date reporting: Household population . 295 Table DQ.6: Birth date and age reporting: Women . 296 Table DQ.8: Birth date and age reporting: Under-5s . 297 Table DQ.9: Birth date reporting: Children, adolescents and young people . 298 Table DQ.10: Birth date reporting: First and last births. 299 xvii Table DQ.11: Completeness of reporting . 299 Table DQ.12: Completeness of information for anthropometric indicators: Underweight . 300 Table DQ.13: Completeness of information for anthropometric indicators: Stunting . 301 Table DQ.14: Completeness of information for anthropometric indicators: Wasting . 301 Table DQ.15: Heaping in anthropometric measurements . 302 Table DQ.16: Observation of birth certificates . 303 Table DQ.17: Observation of vaccination cards . 304 Table DQ.18: Observation of women's health cards . 305 Table DQ.20: Respondent to the under-5 questionnaire . 306 Table DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules . 306 Table DQ.22: School attendance by single age . 307 Table DQ.23: Sex ratio at birth among children ever born and living . 309 Table DQ.24: Births by periods preceding the survey . 309 Table DQ.25: Reporting of age at death in days . 310 Table DQ.26: Reporting of age at death in months . 311 xviii List of Figures Figure HH.1: Age and sex distribution of household population . 9 Figure CM.1: Early childhood mortality rates …………………………………….………………………………………25 Figure CM.2: Under-5 mortality rates by state, . 27 Figure CM.2a: Under-5 mortality rates by geographich area . 28 Figure CM.2b: Under-5 mortality rates by sex of child and wealth quintile . 28 Figure CM.2c: Under-5 mortality rates by mother’s education . 29 Figure CM.3: Trend in under-5 mortality rates. 31 Figure CM.3a: Trend in under-5 mortality rates by sex of child and wealth quintile as estimated at SHHS 2010 and MICS 2014 . 33 Figure NU.1a: Underweight, stunted and wasted children under-five years………. . 41 Figure NU.1: Under-five children underweight (moderate and severe) by state . 42 Figure NU.1b: Under-five children stunted (moderate and severe) by state . 43 Figure NU.1c: Under-five children wasted (moderate and severe) by state . 44 Figure NU.1d: Under-five children underweight, stunted or wasted by household wealth quintile . 45 Figure NU.1e: Trend in percentage of children under-5 underweight, stunted and wasted (moderate and severe) from SHHS 2006, SHHS, 2010 and MICS . 46 Figure NU.1f: Trend in inequality of poorest and riches under5 children underweight, stunted or wated in Sudan from SHHS 2010 to MICS 2014 . 47 Figure NU.1g: Trend in under-5 children stunted (moderate and severe) from SHHS 2010 to MICS 2014. 48 Figure NU.2: Initiation of breastfeeding . 50 Figure NU.3: Exclusive breastfeeding . 54 Figure NU.4: Infant feeding patterns by age . 55 Figure NU.5: Consumption of iodized salt . 66 Figure NU.6: Percentage of children who received Vitamin A in last six months . 69 Figure CH.1: Vaccinations by age 12 months (measles by 24 months) . 73 Figure CH.1a: Measles vaccination coverage by states: Children age 12-23 months and 24-35 months currently vaccinated against measles………………………………….……………………74 Figure CH.2: Children under-5 with diarrhoea who received ORS or recommended homemade liquids . 89 Figure CH.3: Children under-5 with diarrhoea receiving oral rehydration therapy (ORT) and continued feeding . 92 Figure CH.3a: Sources of ORS and zinc . 93 Figure WS.1: Household members access to drinking water by source . 105 Figure WS.1a: Household members with access to improved water sources by State . 106 Figure WS.1b: Household members with access to improved water sources by urban/rural and wealth index quintile . 106 Figure WS.2a: Households using Improved sanitation facility. 115 Figure WS.2: Household members by use and sharing of sanitation facilities . 121 Figure WS.2b: Household members practicing open defecation by urban and rural residence xix and by state………………………………………………………………………………….…………………….121 Figure WS.3: Household members using improved sanitation, by wealth . 124 Figure RH.1: Age-specific fertility rates by area . 133 Figure RH.2: Differentials in contraceptive use . 140 Figure RH.3a: Antenatal care service providers . 146 Figure RH.3b: Women age 15-49 years with a live birth in the last two years who made 4 or more antenatal care visits, by state, area and mother’s education . 147 Figure RH.3: Person assisting at delivery . 152 Figure ED.1a: Children of primary school age attending primary (adjusted net attendance ratio) for boys and girls by state and by urban/rural area . 179 Figure ED.1b: Children of secondary school age attending secondary school (adjusted net attendance ratio) for boys and girls by state and by urban/rural area . 183 Figure ED.1c: Girls out of school in primary and secondary by wealth index quintiles . 190 Figure ED.1: Education indicators by sex . 192 Figure CP.1: Children under age five whose births are registered . 195 Figure CP.2a: Children age 1-14 years experiencing any violent discipline method by sex, state and rural/urban disaggregation . 203 Figure CP.2: Child disciplining methods, children age 1-14 years . 205 igure CP.3a: Women age 20-49 years who first married or entered a maritial union before their 18th birthday.………………………………………………………………………………………….….209 Figure CP.3: Early marriage before ages 15 and 18 by age group of women 15-49 years . 213 Figure CP.3b: Women age 15-49 years and girls age 0-14 years by FGM/C status and by education of the woman or mother of the child . 218 Figure HA.1: Women age 15-49 years who have comprehensive knowledge of HIV transmission . 230 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS . 234 Figure HFS.1: Household food consumption score by states . 244 Figure HFS.2a: Household food consumption, by urban and rural (part one) ….………….………245 Figure HFS.2b: Household food consumption, by urban and rural (part two) . 246 Figure HFS.3a: Number of days foods are consumed (part one)….…….……….….……….…….247 Figure HFS.3b: Number of days foods are consumed (part two).……….……………….……….248 Figure HFS.3c: Number of days foods are consumed (part three) . 248 Figure HFS.3d: Number of days foods are consumed (part four) . 249 Figure HFS.4a: Food coping strategies (part one) . 251 Figure HFS.4b: Food coping strategies (part two) . 251 Figure HFS.4c: Food coping strategies (part three) . 252 Figure HFS.4d: Food coping strategies (part four) . 253 Appendix: Figure DQ.1: Number of household population by single ages . 293 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points. 302 xxiv List of Abbreviations AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ARI Acute Respiratory Infection BCG Bacillis-Calmette-Geuerin (Tuberculosis) CBS Central Bureau of Statistics CPR Contraceptive Prevalence Rate CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DHS Demographic and Health Survey DPT Diphtheria Pertussis Tetanus EPI Expanded Programme on Immunization FGM/C Female Genital Mutilation/Cutting FMoH Federal Ministry of Health FP Family Planning GPI Gender Parity Index HB Hepatitis B HIB Haemophilus Influenza type B HIV Human Immunodeficiency Virus ICPD International Conference on Population and Development IDD Iodine Deficiency Disorders IGME Inter-Agency Group on Mortality Estimation IMR Infant Mortality Rate ITN Insecticide Treated Net IUD Intrauterine Device JICA Japan International Cooperation Agency JMP Joint Monitoring Programme LAM Lactational Amenorrhea Method MD Millennium Declaration MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS4 Multiple Indicator Cluster Survey Round 4 MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme MMR Measles, Mumps, and Rubella NAR Net Attendance Rate NCCW National Council for Child Welfare NIDs National Immunisation Days NMR Neonatal Mortality Rate ORT Oral Rehydration Treatment PAPFAM Pan Arab Project for Family Health PRSP Poverty Reduction Strategy Paper RH Reproductive Health SHHS Sudan Household Health Survey SHHS2 Sudan Household Health Survey - Second Round xxv SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infections TBA Traditional Birth Attendant TT Tetanus Toxoid USMR Under 5 Mortality Rate UNAIDS United Nations Programme on HIV/ AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children's Fund USAID United States Agency for International Development Vit. A Vitamin A WFFC World Fit for Children WFP World Food Programme WHO World Health Organization xxvi Foreword The Government of Sudan represented by the Ministry of Cabinet Affairs and UNICEF Representative in Sudan are pleased to launch this Multiple Indicator Cluster Survey (2014) Final Report for Sudan. This report of statistically sound and internationally comparable data source provides a credible evidence for informing policies and programmes, and for monitoring Sudan’s progress toward national development plan and the Sustainable Development Goals (SDGs). Under the leadership of the Director General of the Central Bureau of Statistics (CBS), a steering committee comprising of representatives from national and international institutions that contribute to the goals of the survey worked tirelessly for the past year to present a coherent and nationally validated information related to nutrition, education, child health, maternal health, HIV/AIDS, water and sanitation and child protection. The availability of accurate and current nationwide data provided by MICS 2014 represents a key assest for Sudan after the separation of South Sudan in 2011. We are grateful for the role played by a wide range of partnerships during the implementation of this survey with special reference to the Government of Sudan including all relevant line ministries, states, and local authorities. We are also grateful for the technical and financial support provided by UNICEF, WFP, UNFPA, WHO and DFID for this exercise. In the light of the above we encourage all policy makers, humanitarian and development partners, academic institutions, and indeed the people of Sudan to make effective use of this report to plan, monitor and evaluate relevant goals and objectives addressing the survival, development and protection rights of children in the country. Signed on 03rd March 2016, by: xxvii Acknowledgements The fourth Sudan Multiple Indicator Cluster Survey (MICS5), was conducted from August to December 2014 at national level covering asll eighteen states. The MICS was designed to collect information on a variety of socioeconomic and health indicators required to inform the planning, implementation and monitoring of national policies and programmes for the enhancement of the welfare of women and children. The MICS plays a critical role in informing national policies such as the Sudan Strategic Plan (2012-2016); and the sector strategic plans of health, education, and water and sanitation. It also serves as an instrument to measure progress towards the achievement of national and international committements for children and women wellbeing (MDG2015, SDG 2030). The Central Bureau of Statistics (CBS) wishes to express sincere gratitude to the various institutions and individuals who worked tirelessly to make the survey a success. Their commitment and dedication to this exercise ensured quality information for data analysis and report writing.This survey was made possible through financial and technical support from the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World Food Programme (WFP), the Department for International Development (DFID). In addition, the expertise provided by various consultants (at global, regional and national levels) in the areas of sampling, training, fieldwork, data processing and report writing, and input from various stakeholders who participated in MICS workshops cannot be overemphasized. CBS is very grateful to the technical guidance, capacity building and quality assurance guaranteed by UNICEF’s experts in Sudan’s Office, Regional Office and HQ during all steps of the MICS design and implementation. This survey would not have been possible without the sustained commitment of the Survey Management Team (SMT), field and data entry and processing personnel, and patience and cooperation of respondents. CBS is thankfull to the team of Analyst and Report writers who have been devoted in the completion of statistical and demographic data analysis and writing of 13 Chapters. CBS would like to acknowledge the following institutions who were members of the MICS Steering and Technical Committees for their invaluable contributions towards the accomplishment of the survey: x Director General Central Bureau of Statistics Chairperson x Survey Technical Coordinator Reporter x Under Secretary, Federal Ministry of Health Member x Under Secretary Ministry of Education Member x Under Secretary Ministry of Welfare and S. Security Member x Under Secretary, Ministry of Environment and Public Member x UNICEF Representative Member x UNFPA Representative Member x WHO Representative Member x WFP Representative Member x Secretary General of National population Council Member xxviii Executive Summary This Sudan Multiple Indicator Cluster Survey (MICS5) is a nationally representative survey of households, women, and children with fieldwork conducted from August to November 2014. The survey was conducted by the central bureau of statistics (CBS) in collaboration with the ministries of health, welfare, general education, national environment, and national water cooperation. The survey provides statistically sound and internationally comparable data essential for developing evidence- based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). Interviews were successfully completed in 15,801 households drawn from a sample 18,000 households all 18 states of Sudan with an overall response rate of 98 percent. The main results from the survey are summarized below. Child Mortality Child mortality was measured in this survey through a methodology that produced retrospective estimates (for the year 2012) of the infant mortality rate (IMR) and under-five mortality rate (U5MR). The survey estimated the IMR as 52 per 1000 live births and the U5MR as 68 per 1000 live births indicating that 76.5 percent of under-five deaths are infant deaths. Findings reveal that there is inequality of probabilities of dying between urban and rural areas: under- five mortality and infant mortality rates are respectively 56.5 and 11.8 deaths for 1,000 live births in urban area, 72.8 and 19.3 in rural area. Also the risk of dying of under-five children before the five birthday widely varies among states with East Darfur (111.7/1,000 live births) the highest and Northern state (29.9/1,000 live births) the lowest. There is also disparity in child mortality in Sudan by wealth index quintile: U5MR is estimated at 84/1,000 live births and 39/1,000 live births for the poorest and richest quintile respectively. Nutrition The survey indicated that there is high prevalence of child malnutrition is high in Sudan: one-third (33 percent) of under-five children are underweight, nearly two in five (38.2 percent) children under-five years are stunted (too short for their age), and one in six (16.3 percent) children is wasted (too thin for their height). The prevalence of underweight is 23.2 percent in urban area as compared to 37.1 percent in rural area; there is a very wide gap in child stunting between rural areas (43 percent) and urban areas (27.1 percent). Breastfeeding There is a high breastfeeding practice in Sudan with approximately 96 percent of children ever breastfed. However only 69 percent of the babies are breastfed for the first time within one hour of birth, 28 percent of newborns are given pre-lacteal feeds birth. Fifty-five (55.4 percent) of children 0- 5 months are exclusively breastfed, nearly 90 percent aged 12-15 months are having continued breastfeeding at year of age and nearly half (48.8 percent) of the children aged 20-23 months are receiving continued breastfeeding at 2 years of age. xxix Salt Iodization Sudan does not have a national law on salt iodization and as a consequence only 7.6 percent of households have adequately iodized salt (which contains 15 parts per million ppm or more of iodine). Use of adequately iodized salt is lowest in States of West Kordofan (2.9 percent), Blue Nile (3.1 percent), Red Sea (3.2 percent) and Khartoum (3.3 percent) and relatively highest use is recorded in East Darfur (18.1 percent), Central Darfur (14.8 percent) and Sinnar (15.6 percent). There is no difference of iodized salt consumption between the richest (8.8 percent) and poorest households (8.0 percent). Vitamin A Supplementation There is high coverage of vitamin A supplementation in Sudan; 78 percent of children under five years receive Vitamin A during the last 6 months preceding the survey. The coverage of Vitamin A varies by State, age of children, mother’s education and wealth index quintile. Low Birth Weight Weight at birth is an excellent indicator of both a mother's health and nutritional status and also a newborn's chances for survival, growth, long-term health and psychosocial development. The Sudan’s 2014 MICS states that 16.3 percent of births were weighed at birth. Approximately 32.3 percent of infants born during the last two years were estimated to weigh less than 2,500 grams at birth. The prevalence of low birth weight varies by urban 27.9 percent and rural area 33.9 percent and by mother’s education from 33.7 percent among children for whose mothers are not educated to 23.7 percent for children whose mothers have higher level of education The highest prevalence of low birth weight was observed in states of North Darfur (47.5 percent), East Darfur (46.9percent), North Kordofan (41.4percent) and West Kordofan (36percent) in comparison to the low prevalence observed in states of River Nile (17.2 percent), Khartoum (22.2 percent), Gadarif (23.9 percent) and Blue Nile (25.7 percent). Child Health Immunization Approximately 78.5 percent of children age 12-23 months received a BCG vaccination by the age of 12 by their first birthday. About sixty-four (63.9 percent) of the children received the third dose of Pentavalent (DPT+HepB+Hib). Similarly, 65.3 percent by the third dose of Polio vaccination, 58.9 percent for the first dose of measles vaccine by 12-23 months by 12 months of age. Overall, the percentage of children who had all the recommended vaccinations by their first birthday is low at only 42.8 percent. Tetanus Toxoid Thirty-two (32.1 percent) of surveyed women aged 15-49 years who gave birth during the year prior to the MICS5 survey received at least two doses of tetanus toxoid (TT) vaccine during their pregnancy and 58.2 percent of the women were protected against neonatal tetanus due to previous TT vaccinations. The data also showed a higher percentage of women aged 15-49 years in urban areas with a live birth in the last two years prior to the survey were protected against neonatal tetanus (65.9 percent) than their counterparts in rural areas (55.4 percent). xxx Oral Rehydration Treatment Approximately 34 percent of the children age 0-59 months with diarrhoea received ORS or increased fluids. Nearly sixty (59.3 percent) of children received ORT with continued feeding as recommended. There are notable differences in ORT and continued feeding during diarrhoea among the states ranging from percent 16.9 percent in River Nile State to 31.3 percent in West Kordofam. Care Seeking and Antibiotic Treatment of Pneumonia Approximately half (48.3 percent) of children age 0-59 months with symptoms of ARI were taken to a qualified provider. While 59 percent of the children received antibiotics during the two weeks prior to the survey. The percentage was considerably higher in urban than in rural areas, and ranged from 49 percent in South Darfur state to 78 percent in River Nile state. Antibiotic treatment of ARI symptoms is low among the poorest households and among children whose mothers/caretakers have less than secondary education. Only about five (4.5 percent) of the children with symptoms of ARI received treatment from community health workers. Mothers’ knowledge of danger signs is an important determinant of care-seeking behaviour. In the Sudan MICS 2014, 26.9 percent of women knew at least one of the two danger signs of pneumonia – fast and/or difficult breathing. The most commonly identified symptom for taking a child to a health facility is fever accounting for more than 80 percent of respondents. About 11.7 percent and 20.9 percent of mothers identified fast breathing and difficult breathing respectively as symptoms for taking children immediately to a health care provider. Solid Fuel Use Overall, more than 58.2 percent of the household population in Sudan of use solid fuels for cooking, consisting mainly of wood (40.7 percent). Use of solid fuels is low in urban areas (40.7 percent), but high in rural areas, used by two-thirds (66 percent) of household members. Very big difference between the states as use of solid fuels ranges from 99.9 percent in Central Darfur and to 13.3 percent in River Nile State Water and Sanitation The MICS5 estimates of the Sudan population’s access to improved sources of drinking water (68 percent). Overall, more than two-fifths (41.4 percent) of the household members used drinking water that was piped into their dwelling or into their compound, yard or plot or into public tap/standpipe. Nearly 41 percent of the population are living in households using improved sanitation facilities. Access to improved sanitation facilities widely varies between urban areas (39.3 percent) as compared with 28.2 percent rural areas. About 30 percent of the households in Sudan practiced open defecation (no facility, bush field). Use of open defecation as a method faecal disposal ranged from 1.7 percent in Khartoum State to 44.9 percent in Kassala State. Overall 28 percent of the households in Sudan have access to both improved sources of drinking water and improved sources of sanitation. This figure greatly varies among households along the wealth index status ladder; 3 percent in households in the poorest quintile compared to 75 percent in households in the richest quintile xxxi Reproductive Health Fertility The Total Fertility Rate (FTR) for the three years preceding the MICS5 survey is 5.2 births per woman. Fertility is considerably higher in rural areas (5.6 births per woman) than in the urban areas (4.4 births per woman). The urban-rural difference in fertility is most pronounced for women in the 20-24 age group: 167 births per 1,000 women in urban areas versus 225 births per 1,000 women in rural areas. The overall age pattern of fertility, as reflected in the ASFRs, indicates that childbearing begins early. Fertility is low among adolescents, increases to a peak of 259 births per 1,000 among women age 25-29 Contraception Current use of contraception in Sudan MICS5 was reported as 12.2 percent of women currently married 2 . The most popular method was the pill which is used by about one in ten married women in Sudan (9.0 percent). Almost 87.8 percent of the married women reported that they are not using any form of contraception. The survey results show that contraceptive prevalence ranges from 2.9 percent in Central Darfur to 26.5 percent in Khartoum State. About 20.1 percent of married women in urban and 9.0 percent in rural areas use a method of contraception. Women’s level of education is strongly associated with contraceptive prevalence; prevalence rising from 4.4 percent among those with no education to 13.3 percent among those with primary education, and to 21 percent and 27.6 percent among those with secondary and higher education respectively. About 27 percent of women 15-49 years reported for unmet need in the Sudan MICS5. Antenatal Care Overall, the proportion of women who received ANC from any skilled provider (i.e., a doctor, nurse, or midwife) was 79.1 percent while those women who did not receive ANC was 19.9 percent. There exists rural-urban differentials in favour of women who received antenatal care in urban areas (90.8 percent) compared to women in rural areas (74.9 percent). There was also significant differences among the states for women who received ANC from any provider; ranging from 61.8 percent of women in South Darfur state to 97.1 percent of the women in Khartoum state. Assistance at Delivery About 80 percent of births in Sudan that occurred in the two years preceding the MICS 2014 survey were delivered by the assistance of skilled personnel. This percentage is higher in urban areas with 92.9 percent of the deliveries by skilled personnel than 71.9 percent in rural areas. Deliveries by skilled personnel varied widely in the States ranging from 37.5 percent in Central Darfur state 99 percent in Northern State. Also delivery by skilled personnel is found to be strongly influenced by the level of education; assistance by skilled delivery attendant for women with no education was 58.5 percent, while among 2 All references to “married women” in this chapter include women in marital union as well. xxxii those with primary education it was 86.7 percent, and among women with secondary and higher education levels it was 95.7 percent and 97.6 percent respectively. More than half of the births (55 percent) in the two years preceding the MICS survey were delivered with the assistance of a certified midwife. Medical doctors assisted with the delivery of 19.2 percent of births and the births delivered by assistance of Traditional Birth Attendants (TBAs) with is 18 percent. Place of Delivery Slightly more than a quarter (27.7 percent) of births in Sudan are delivered in a health facility; of which 26.1 percent occur in public sector facilities while only 1.6 percent of the deliveries occur in private sector facilities. The MICS results also indicate that 71.3 percent of the deliveries takes place at home. Women in urban areas (45.2 percent) are more than twice as likely to deliver in a health facility as their rural counterparts (21.5 percent). Women with higher levels of educational attainment are more likely to deliver in a health facility than women with less education or no education. Specifically; 11.5 percent of women who had delivered in a health facility no education compared to 25.8 percent of the women with primary education, to 49.8 percent of the women with secondary education, and to 75.5 percent of the women with higher level of education. Post-natal checks Overall, 51.5 percent of women who gave birth in a health facility stay 12 hours or more in the facility after delivery. Across the country, the percentage of women who stay 12 hours or more varies from 29.3 percent in Central Darfur to 73.2 percent in White Nile State. The survey results indicated small difference between proportions of those delivering in public and private facilities and who stay 12 hours or more in the facility. Child Development About 22.3 percent of children aged 36-59 months are attending an organised early childhood education programme in Sudan. Urban-rural and statestate differentials are notable – the figure is as high as 44.6 percent in urban areas, compared to 13.9 percent in rural areas. Among children aged 36-59 months, attendance to early childhood education programmes is more prevalent in Khartoum state (44.3 percent), and lowest in the West Kordofan (4.3 percent). There are also significant differences among children living in different socioeconomic backgrounds; 59.4 percent of children living in the richest (20 percent) households attend such programmes, while the figure drops to 6.9 percent among children in the poorest households. Literacy and Education Adult Literacy The MICS5 indicates that about six out of ten ( 59.8 percent) young women in Sudan are literate and that literacy status varies greatly by area (79.8 percent in urban areas and 50 percent in rural areas). Of women who stated that primary school was their highest level of education, just 43.7 percent were actually able to read a simple statement shown to them. xxxiii The proportion of women who were literate was higher at 63.4 percent among women aged 15-19 years than that among women age 20-24 years (55.6 percent).The proportion of literate women (aged 15-24 years) also varied by their household wealth. The proportion of literate women was much higher among those belonging to households in the richest quintile (92.2 percent) than those belonging to households in the poorest quintile (31.2 percent). Pre-School Attendance and School Readiness Approximately seventy (69.7) percent of children who are currently attending the first grade of primary school were attending pre-school the previous year with varying proportion of children in first grade in urban areas (81.0 percent) had attended pre-school the previous year compared to 64.7 percent among children living in rural areas. State differentials are also very significant; first graders in Khartoum state have attended pre-school nearly 3 times as likely (87 percent) as their counterparts in Central Darfur State (30.5 percent). Socioeconomic status appears to have a positive correlation with school readiness – while the indicator is only 50.6 percent among the poorest households, it increases to 86.9 percent among children living in the richest households. Primary and Secondary School Participation Less than forty (36.8) percent children who are of primary school entry age in Sudan are attending the first grade of primary school. Sex differentials do not exist; however, significant differentials are present by state and urban-rural areas. In Northern state, for instance, percentage of children entering grade one is 73.6 percent, while those entering at grade one in Western Kordofan state is 13.4 percent. Those entering grade one in urban areas (56.6 percent) is nearly twice as those in rural areas (29.5 percent). A positive correlation with socioeconomic status is observed for children aged 6 who were attending the first grade. In richest households, the proportion is around 77.6 percent, while it is 14.5 percent among children living in the poorest households. Over three-fourths (76.4 percent) of children of primary school age are attending school while only (28.4 percent) of the children of secondary school age are attending secondary school. Child Protection Birth Registration The births of 67.3 percent of children under five years in Sudan have been registered; 23.4 percent of the registration certificates have been seen by the interviewers, 26.4 percent have not been seen by the interviewers, and 17.5 were reported to have no birth certificate. Children in Central Darfur State (30.9 percent) were the least to have their births registered than children in other states with Northern states (98.3 percent) registering the highest number of children under five at birth. While only 37.0 percent of the children in the poorest households were registered, nearly all children (97.9 percent) of under five children who belong to richest households were registered. Overall, only 49.8 of the children possess a birth certificate. Child Labour According to the definition of “child labour” that was used in MICS5, a child aged 5-11 years was considered to be involved in child labour activities if s/he, during the week preceding the survey, performed at least one hour of economic work or 28 hours or more of domestic work per week. For a child aged 12-14 years the cut-off points to be considered a “child labourer” were at least 14 hours of economic work or 28 hours or more of domestic work per week. xxxiv While 41.2 percent of children age 12-14 are engaged in some forms of economic activities, 9 percent are performing such tasks for fourteen or more hours. The involvement in economic activities change with age: 21 percent of children aged 5-11 years is engaged in economic activities, compared to 39.1 percent of children aged 12-14 years, and 41.2 percent of children aged 15-17 years. It is also clear from the MICS5 results that engagement in economic activities increases with movement from wealthiest to poorest households. For instance, among children aged 5 – 11 years engaged in economic activity, 9.2 percent of them belong to the wealthiest households while 35.0 percent of them fall in the poorest category. The involvement in economic activities by children varies by State ranging from 4.9 percent in Khartoum to 46.8 percent in South Darfur Child Discipline In MICS 2014 for Sudan, 63.9 percent of children age 1-14 years was subjected to at least one form of psychological or physical punishment by household members during the past month prior to the survey. Generally, the households employed a combination of violent disciplinary practices, reflecting caregivers’ motivation to control children’s behaviour by any means possible. While 52.8 percent of children experienced psychological aggression, about 47.7 percent experienced physical punishment. The most severe forms of physical punishment (hitting the child on the head, ears or face or hitting the child hard and repeatedly) are overall less common: 13.6 percent of children were subjected to severe punishment. Overall, 52.8 percent of children in the aged group 1-14 years experienced psychological aggression in the month preceding the survey. River Nile state was reported of having the highest proportion (69.6 percent) and Central Darfur state (12.6 percent) the lowest of the children aged 1-14 years who experienced psychological aggression. Early Marriage and Polygyny Early marriage, polygyny, and large spousal age differences are common in Sudan. About 21.2 percent of young women age 15-19 years are currently married. This proportion is significantly different between young women in urban areas (11.2 percent) and those in rural areas (26.0 percent). Wide variations between states are also observed; for example in Khartoum state it is 12 percent, while it is 29.9 percent in Blue Nile state. It is strongly related to the level of education, for example, 27.5 percent for women with primary education compared to only 2.4 percent for those with higher education. The percentage of women in a polygynous union is also provided in Table CP.7. Among all women age 15- 49 years who are in union, 21.7 percent are in polygynous unions. Polygynous unions are more common among rural women 23.6 percent compared to 16.9 percent for urban women. Polygynous relationships are more prevalent among older women age 45-49 years 30.8 percent compared to only 7.7 percent among younger women age 15-19 years. Among currently married women age 20-24 years, about (41.8 percent) are married to a man who is older by ten years or more. For currently married women age 15-19 years, the corresponding figure is (39.5 percent). Female Genital Mutilation/Cutting The practice of female genital mutilation /cutting (FGM/C) is highly prevalent in Sudan. Approximately 87 percent of women aged 15-49 years had had some form of female genital mutilation. The percentages rise from 76.8 percent for women without formal education to 91.8 percent for women with higher education. The practice appears more common in rural areas, the highest percentage is in North Darfur state (97.6 percent) and lowest for Central Darfur state (45.4 percent). Surprisingly the practice is highly prevalent among women in wealthy households with population in the richest and xxxv fourth richest quintiles recording 90.0 percent and 91.6 percent respectively. The prevalence of FGM is higher among older women 45-49 years with a percentage of 91.8 percent compared to 81.7 percent for women in the 15-19 years age group. Domestic Violence Women aged 15-49 years were asked whether husbands are justified in hitting or beating their wives or partners according to five different scenarios. Researchers have found that women who agree that their partners are justified in beating them tend to themselves be victims of domestic violence. Overall, 34 percent of women in the survey feel that a husband is justified in hitting or beating his wife in at least one of the five situations (If she goes out without telling him, If she neglects the children, If she argues with him, If she refuses sex with him, and If she burns the food). Women who justify a husband’s violence, in most cases agree and justify violence in instances when a wife neglects the children (24.2 percent), or if she demonstrates her autonomy, demonstrated by going out without telling her husband or arguing with him (19.5 percent). Nearly one-fifth (18.2 percent) of women believe that wife-beating is justified if the wife refuses to have sex with the husband. Justification in any of the five situations is more common among those living in poorest households, less educated, and also currently married women. Among the states, East Darfur with 77.4 percent of women approve wife beating reported the highest while River Nile with 9.6 percent reported the lowest. HIV/AIDS and Orphanhood Knowledge of HIV Transmission and Utilization of HIV Testing Services In Sudan, about three-quarters (74.8 percent) of the women age 15-49 years have heard of HIV and AIDS. However, the percentage of those who know of both main ways of preventing HIV transmission – having only one faithful uninfected partner and using a condom every time – is only about one in ten (8.9 percent). About sixty (59.8 percent) of the women know of having one faithful uninfected sex partner and 26.7 percent know of using a condom every time as main ways of preventing HIV transmission. Correct identification of misconceptions about HIV is based on the two most common and relevant misconceptions in the survey, that HIV can be transmitted by sharing food with someone with HIV (50.5 percent) and by mosquito bites (53.1 percent). Overall, 19.2 percent of the respondents reject the two most common misconceptions and know that a healthy-looking person can be HIV-positive. People who have comprehensive knowledge about HIV prevention include those who know of the two main ways of HIV prevention (having only one faithful uninfected partner and using a condom every time), who know that a healthy looking person can be HIV-positive, and who reject the two most common misconceptions. Comprehensive knowledge of HIV prevention methods and transmission is fairly low although there are differences by area; 6.9 percent and 13.1 percent in rural and urban areas respectively. Comprehensive knowledge about HIV transmission greatly varies with women’s education (48.3 percent) in women with higher level of education compared to women with no education (2.1 percent) and with wealth index level of the household; (20.4 percent) in the richest quintile compared with (2.1 percent) in the poorest quintile of the households. xxxvi Seventeen percent of women know a place where to be tested, while 5.2 percent, have actually been tested, fewer, 4.3 percent of the women, know the result of their most recent test. A very small proportion has been tested within the last 12 months prior to the survey (1.9 percent), while a somewhat smaller proportion has been tested within the last 12 months and know the result (1.6 percent). Orphanhood Less than one (0.3 percent) of children age 10-14 years in Sudan are orphans. Of these, 66.1 percent are attending school, as compared with a 80.2 percent attendance amongst non-orphan children of the same age group who are living with at least one parent. This results in an orphans to non-orphans school attendance ratio of 0.82 which suggests that orphans are not disadvantaged in relation to non- orphans. The ratio is 0.71 for girls and 1.0 for boys. The ratio is 0.92 for children in urban areas compared to 0.78 for children in rural areas. Household Food Security Data was collected on two important proxy measures of household food security: the household food consumption score (FCS) and the coping strategies that households use when they don’t have enough food or money to buy food. The food consumption groups can be described as follows: x Poor food consumption: Households that are consuming only cereals and vegetables every day and never or very seldom are consuming protein rich food such as meat and dairy. x Borderline food consumption: Households that are consuming cereals and vegetables every day, accompanied by oil and pulses a few times a week. x Acceptable food consumption: Households that are consuming cereals and vegetables every day, frequently accompanied by oil and pulses and occasionally meat and dairy. Overall, 81 percent of the households were having acceptable food consumption score. There is wide variation of food security among the states with North Darfur state having the poorest food consumption score of 16 percent 1 I. Introduction 1.1 Background This report is based on the Sudan Multiple Indicator Cluster Survey (MICS5), conducted in 2014 fieldwork August-November by the central bureau of statistics (CBS), ministry of health, ministry welfare, ministry of general education, national environment, national water cooperation The survey provides statistically sound and internationally comparable data essential for developing evidence- based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the statelevel and assess progress towards the goals and targets of the present Plan of Action at the national, state and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” 2 The MICS 2014 results will be critically important for final MDG reporting in 2015, and are expected to form part of the baseline data for the post-2015 era. MICS 2014 is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health. This final report presents the results of the indicators and topics covered in the survey. 1.2 Survey Objectives The Sudan MICS 2014 has as its primary objectives: x Measure the trend towards achievement of the MDGs and the goals of a World Fit for Children Plan of Action and other internationally agreed upon indicators related to children and women. x Furnish data needed for the indicators as per the global review of the Millennium Development Goals. x Contribute to the improvement of data and monitoring systems in Sudan and to strengthen technical expertise, national capacity building in the design, implementation, and analysis of such systems. x Update Census indicators and provide solid evidence for decentralization (planning and measure of progress). x Provide key evidence for social sector programming and the Poverty Reduction Strategy Paper (PRSP) under development and accountabilities for sector strategic plans and UNDAF 2013-2016. x To provide up-to-date information for assessing the situation of children and women in Sudan x To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention; x To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable; x To contribute to the generation of baseline data for the post-2015 agenda; In 2014, the population of Sudan was estimated at 36.2 million based on the 2008 population census. About 8 percent of the population (2.7 million) are nomads and pastoralists. The population of Sudan is growing very rapidly—2.5 percent annually—with an average fertility rate of 5.5. The average household size is 6.4 persons. Life Expectancy at birth is estimated at 54 years. Overall, Sudan is experiencing a major demographic shift to an increasingly young, urbanized population. There are 15 million children below the age of 18 years and 4.5 million below the age of five years. In some states, children under the age of 16 years constitute 52 percent of the population. Agriculture and livestock are essential to Sudan’s economic diversification (away from oil) and could contribute to medium-term macroeconomic stability. While these sectors presently contribute approximately 35 percent of gross domestic product (GDP), they could contribute significantly more with greater investment and better governance. Sudan now recognizes the need for greater attention to agriculture and livestock, as reflected in its Interim Poverty Reduction Strategy and the five- year program for economic reform. 3 II. Sample and Survey Methodology 2.1 Sample Design The sample for Round Five of the Sudan Multiple Indicator Cluster Survey (MICS5) was designed to provide estimates for a large number of indicators that describe the situation of children and women at the national level, in urban and rural areas, and in the 18 States of Sudan. In order to produce State- level estimates of moderate precision, a minimum of 40 enumeration areas (EAs) were selected in each State, resulting in a sample that was not self-weighting. The urban and rural areas within each state were identified as the main sampling strata and the sample was selected in two stages. In the first stage, within each stratum, a specified number of EAs were selected systematically with probability proportional to size. In the second stage, after a household listing was carried out within the selected enumeration areas, a systematic sample of 25 households was drawn in each selected EA. All of the selected EAs were visited during the fieldwork period. The sample was thus stratified by state and then by urban / rural areas. For reporting national and state-level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. 2.2 Questionnaires Three types of questionnaires were used in the survey: 1) a household questionnaire 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, administered to mothers or caretakers of all children under 5 years living in the household. The questionnaires included the following: 9 Household Questionnaire, including the following modules: 1. Household Information Panel 2. List of Household Members 3. Education 4. Child Labour 5. Child Discipline 6. Water and Sanitation 7. Hand washing 8. Salt Iodization 9. Food Consumption & Sources3 10. Coping Strategies3 9 Individual Women questionnaire, including the following modules: 1. Woman’s Information Panel 2. Woman’s Background 3. Fertility/Birth History 4. Desire for Last Birth 5. Maternal and New-born Health 6. Post-Natal Health Checks 7. Contraception 8. Unmet Need 9. Female Genital Mutilation/Cutting 10. Attitudes toward Domestic Violence 11. HIV/AIDS 3 Survey-specific module 4 12. Mid Upper Arm Circumference(Muac)4 13. Haemoglobin Testing (Anaemia)4 9 Children under Five questionnaire, administered to mothers or caretakers of children under- five years of age5 living in the households. The questionnaire included the following modules: 1. Under Five Child Information Panel 2. Age 3. Birth Registration 4. Early Childhood Development 5. Breastfeeding and Dietary Intake 6. Immunization 7. Care Of Illness 8. Anthropometry 9. Haemoglobin Testing (Anaemia)4 2.3 Training Training of Trainers (TOT) was conducted in Khartoum during the period 24th May 2014 – 5th June 2014. The training was facilitated by three HH survey consultants (Housni Elarabi, Manar Abdel- Rahman and Achraf Mrabet). 18 State directors, 18 National Supervisor, 54 team supervisor and 18 measurers from Ministry of Health attended the TOT. Training of interviewers and measurers was conducted in the States the period 8th -17th July 2014. 2.4 Pre-test Pre-test conducted in Khartoum states covering two clusters urban/ rural with one day workshop convened for questionnaire finalization. The exercise was to test the language, the clarity of questions, coding, skipping, the translation, test areas of senility and the overall do-ability within the country context and specifics. 2.5 Field work The field work wasapplied by central bureau of statistics and states ministries of health. Overall, there are 54 teams for the 18 States. Each team consist of 6 members: 3 female interviewers, one supervisor, one editor and one measures. Therefore, the total field staff are 54 teams 6 members for each team. Each State is supported with the State CBS director and the National state supervisor. The table below outlines the schedule of the start and completion dates of the field work in the States: Completion date of data collection Starting Date of data collection State 2014/10/30 10/9/2014 Northern 1. 28/10/2014 10/9/2014 River Nile 2. 28/10/2014 10/9/2014 Red Sea 3. 01/11/2014 13/9/2014 Kassala 4. 01/11/2014 13/9/2014 Gadarif 5. 27/10/2014 11/9/2014 Gezira 6. 28/09/2014 11/8/2014 Khartoum 7. 31/10/2014 16/9/2014 White Nile 8. 06/11/2014 18/9/2014 Sinnar 9. 05/11/2014 18/9/2014 Blue Nile 10. 27/10/2014 17/9/2014 North Kordofan 11. 4 Survey specific module 5 Completion date of data collection Starting Date of data collection State 30/10/2014 12/9/2014 South Kordofan 12. 27/10/2014 16/9/2014 West Kordofan 13. 20/10/2014 01/9/2014 North Darfur 14. 29/10/2014 09/9/2014 East Darfur 15. 05/11/2014 08/9/2014 Central Darfur 16. 30/10/2014 11/9/2014 West Darfur 17. 30/10/2014 01/9/2014 South Darfur 18. 2.6 Data Processing Data were entered into the computers using the Census and Surveys Processing System (CSPro) software package, Version 5.0. The data were entered on 32 desktop computers by 40 data entry operators and 9 data entry supervisors. For quality assurance purposes, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS programme and adapted to the Sudan questionnaires were used throughout. Data of entry started 14th of September and was completed in 27th of November 2014. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software, Version 21. Model syntax and tabulation plans developed by the Global MICS team were customized and used for this purpose. 6 III. Sample Coverage and the Characteristics of Households and Respondents 3.1 Sample Coverage Of the 18,000 households selected in the sample, 17,142 were found to be occupied. Of these, 16,801 were successfully interviewed for a household response rate of 98 percent. In the interviewed households, 20,327 women (age 15-49 years) were identified. Of these, 18,302 were successfully interviewed, yielding a response rate of 90 percent. In addition to the women, 14,751 children under the age of five years were listed in the household questionnaires. Questionnaires were completed for 14,081 of these children, corresponding to Under-5s response rate of 95.5 percent within the interviewed households. The highest response rate at state level for households was in south Darfur at 99.3 percent, while the lowest response rate was in West Kordofan at 93.4 percent. Response rate was slightly higher in rural areas at 98.5 percent than in urban areas at 96.8 percent. The highest response rate among eligible women 15-49 years was 96.6 percent in Giezera State while the lowest response rate of 78.1 percent was in North Durfur. Similarly, the highest respond rate among eligible children under-5’s was recorded for Giezera was 96.9 percent and the lowest response rate was also in North Darfur at 87.9 percent (Table HH.1). 7 Table HH.1: Results of household, women's, and under-5 interviews Number of households, women, and children under 5 by results of the household, women's, and under-5's interviews, and household, women's and under-5's response rates, Sudan MICS, 2014 Background Charactristics Total Area State Urban Rural North- ern River Nile Red Sea Kassala Gadarif K/toum Gezira White Nile Sinnar Blue Nile North Kordo- fan South Kordo- fan West Kordo- fan North Darfur West Darfur South Darfur Central Darfur East Darfur Households Sampled 18,000 5,275 12,725 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Occupied 17,142 4,984 12,158 963 938 946 932 966 945 992 925 969 961 960 971 934 943 925 953 963 956 Interviewed 16,801 4825 11,976 957 928 928 899 947 921 988 912 955 954 928 961 872 914 904 946 955 932 response rate 98.0 96.8 98.5 99.4 98.9 98.1 96.5 98.0 97.5 99.6 98.6 98.6 99.3 96.7 99.0 93.4 96.9 97.7 99.3 99.2 97.5 Women Eligible 20,327 6,692 13,635 1,191 1,115 969 1,036 1,110 1,274 1,395 1,074 1,158 1,181 1,096 1,264 969 1,153 1,035 1,176 988 1,143 Interviewed 18,302 5,979 12,323 1,083 1,027 826 946 1,012 1,171 1,347 1,027 1,057 1,079 949 1,171 863 901 918 1,065 878 982 Response rate 90.0 89.3 90.4 90.9 92.1 85.2 91.3 91.2 91.9 96.6 95.6 91.3 91.4 86.6 92.6 89.1 78.1 88.7 90.6 88.9 85.9 Overall response rate 88.2 86.5 89.0 90.4 91.1 83.6 88.1 89.4 89.6 96.2 94.3 90.0 90.7 83.7 91.7 83.1 75.7 86.7 89.9 88.1 83.8 Children under 5 Eligible 14,751 3,998 10,753 559 600 443 681 881 717 822 785 859 1,052 799 1,120 763 976 860 1,017 875 942 Mothers/ caretakers interviewed 14,081 3,811 10,270 532 565 404 655 858 699 800 754 814 1,006 750 1,092 741 885 843 975 837 871 Response rate 95.5 95.3 95.5 95.2 94.2 91.2 96.2 97.4 97.5 97.3 96.1 94.8 95.6 93.9 97.5 97.1 90.7 98.0 95.9 95.7 92.5 Overall response rate 93.6 92.3 94.1 94.6 93.2 89.5 92.8 95.5 95.0 96.9 94.7 93.4 94.9 90.7 96.5 90.7 87.9 95.8 95.2 94.9 90.1 8 3.2 Characteristics of Households The weighted stratified 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 16,801 households successfully interviewed in the survey, 98,883 household members were listed. Of these, 49,286 were males, 49,577 were females and 21 of them were of unknown gender. Table HH.2: Age distribution of household population by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Sudan MICS, 2014 Background charateristics Total Males Females Missing Number Percent Number Percent Number Percent Number Percent Sudan 98,883 100.0 49,286 100.0 49,577 100.0 21 (100.0) Age 0-4 15,050 15.2 7611 15.4 7,439 15.0 0 * 5-9 16,071 16.3 8,036 16.3 8,035 16.2 0 * 10-14 13,447 13.6 6,540 13.3 6,905 13.9 1 * 15-19 9,161 9.3 4,711 9.6 4,451 9.0 0 * 20-24 7,134 7.2 3,463 7.0 3,670 7.4 1 * 25-29 6,690 6.8 2,925 5.9 3,765 7.6 0 * 30-34 5,519 5.6 2,665 5.4 2,854 5.8 0 * 35-39 5,418 5.5 2,598 5.3 2,820 5.7 0 * 40-44 3,877 3.9 2,065 4.2 1,812 3.7 0 * 45-49 3,315 3.4 1,789 3.6 1,526 3.1 0 * 50-54 4,112 4.2 1,641 3.3 2,471 5.0 0 * 55-59 2,462 2.5 1,356 2.8 1,106 2.2 0 * 60-64 2,166 2.2 1,274 2.6 892 1.8 0 * 65-69 1,350 1.4 808 1.6 542 1.1 0 * 70-74 1,455 1.5 851 1.7 604 1.2 0 * 75-79 659 0.7 404 0.8 256 0.5 0 * 80-84 523 0.5 299 0.6 224 0.5 0 * 85+ 421 0.4 229 0.5 192 0.4 0 * Missing/DK 53 0.1 24 * 12 * 17 * Dependency age groups 0-14 44,568 45.1 22,187 45.0 22,380 45.1 1 * 15-64 49,855 50.4 24,485 49.7 25,368 51.2 2 * 65+ 4,408 4.5 2,590 5.3 1,817 3.7 0 * Missing/DK 53 0.1 24 * 12 * 17 * Children and adult populations Children age 0-17 years 50,054 50.6 25,074 50.9 24,979 50.4 1 * Adults age 18+ years 48,777 49.3 24,188 49.1 24,586 49.6 2 * Missing/DK 53 0.1 24 * 12 * 17 * [*] Based on less than 25 unweighted cases and percentages have been suppressed. ( ) Figures that are based on 25-49 unweighted cases 9 Children aged 0-17 years comprise 47.73 percent of the MICS4 survey population, indicating the young nature of the population in Sierra Leone. Comparing the age distribution of MICS5 (table HH.2 ) with result from household survey 2010 no significant differences are observed for example the percentage of population aged 0-14 was 45.1 percent in MICS5 as compared to 45.6 percent for household survey 2010, percentage of population 15-64 was 50.4 percent and 50.5 percent respectively while population 65 + was 4.5 percent in MICS5 compare with 3.9 percent in 2010 household survey, comparing children aged 0-17 the percentage was 50.6 percent in MICS5 comparing with 50.8 percent in the 2010 Household Health survey the adult population 18+was 49.3 percent in MICS 5 and 49.1 percent in the 2010 Household Health survey. Data from Table HH.2 are used to create the population pyramid in Figure HH.1. Examination of this figure reveals that the population pyramid is as the same as expected; it took bell shape. Except for the female population in the age group 50-54 compared to the neighbouring age groups where there was an over representation which could have been related to interviewers bias to reduce number of eligible women in the data collection. Figure HH.1: Age and sex distribution of household population, Sudan MICS, 2014 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15- 49, male respondents 15-49, and children under-5. Both unweight and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in this report 10 8 6 4 2 0 2 4 6 8 10 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Per cent Age Males Females Note: # household members with missing age and/or sex are 10 and provide background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.5 Table HH.3 provides basic background information on the households, including the sex of the household head, State, area, number of household members, and education of household head6 shown in the table. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. 1. Select the cell or cells whose contents you want aligned. 2. Click repeatedly on the tab stop marker at the left edge of the ruler, stopping when you see the symbol for a decimal tab. 3. Click on the ruler above the selected cells, at the location where you want the numbers aligned. Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics Sudan MICS, 2014 Background characteristics Weighted percent Number of households Weighted Unweighted Sudan 100.0 16,801 16,801 Sex of household head Male 85.8 14,414 14,513 Female 14.2 2,387 2,288 State Northern 2.5 423 957 River Nile 4.0 666 928 Red Sea 3.1 519 928 Kassala 4.3 722 899 Gadarif 5.1 858 947 Khartoum 13.8 2,317 921 Gezira 15.6 2,629 988 White Nile 5.2 874 912 Sinnar 3.9 661 955 Blue Nile 3.9 656 954 North Kordofan 6.7 1,125 928 South Kordofan 2.8 462 961 West Kordofan 6.0 1,003 872 North Darfur 7.4 1,243 914 West Darfur 3.3 553 904 South Darfur 7.6 1,282 946 Central Darfur 1.8 299 955 East Darfur 3.0 508 932 Area Urban 29.8 5,000 4,825 Rural 70.2 11,801 11,976 5 See Appendix A: Sample Design, for more details on sample weights. 6 This was determined by asking the questions used for the construction of the background variables; typical questions asked in MICS surveys are mother tongue, ethnic background and/or religion. 11 Number of household members 1 1.6 268 314 2 7.8 1,303 1,394 3 10.6 1,773 1,867 4 13.3 2,236 2,288 5 14.5 2,443 2,447 6 14.0 2,359 2,347 7 12.5 2,108 2,030 8 9.7 1,624 1,573 9 7.1 1,190 1,095 10+ 8.9 1,498 1,446 Education of household head None 46.4 7,799 8,418 Primary 28.2 4,730 4,452 Secondary 18.7 3,137 2,885 Higher 6.0 1,013 915 Missing/DK 0.7 122 131 The weighted and unweighted Sudan number of households are equal, since sample weights were normalized.5 The table also shows the weighted mean household size estimated by the survey. The head of household in the survey was predominantly male in 85.8 percent of surveyed household members. The most populated States in the survey were Gezira, 15.6 percent and Khartoum, 13.8 percent respectively. Approximately one-third of the population was urbanized (29.8percent) while 70.2 percent were Rural. 3.3 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 TableHH.4 and Table HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under 5 years of age. In both tables, the Sudan numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized).5 In addition to providing useful information on the background characteristics of women, and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Mean household size 5.9 16,801 16,801 12 Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Sudan MICS 2014 Background characteristics Weighted percent Number of women Weighted Unweighted Sudan 100.0 18,302 18,302 State Northern 2.5 457 1,083 River Nile 3.8 701 1,027 Red Sea 2.7 493 826 Kassala 4.1 747 946 Gadarif 4.8 879 1,012 Khartoum 15.4 2,821 1,171 Gezira 17.4 3,176 1,347 White Nile 4.9 889 1,027 Sinnar 3.8 698 1,057 Blue Nile 4.0 729 1,079 North Kordofan 6.4 1,173 949 South Kordofan 2.9 525 1,171 West Kordofan 5.3 965 863 North Darfur 7.2 1,317 901 West Darfur 3.0 555 918 South Darfur 7.4 1,363 1,065 Central Darfur 1.5 272 878 East Darfur 3.0 542 982 Area Urban 32.9 6,029 5,979 Rural 67.1 12,273 12,323 Age 15-19 20.3 3,709 3,655 20-24 17.3 3,162 3,150 25-29 18.4 3,359 3,415 30-34 14.0 2,558 2,593 35-39 13.9 2,542 2,527 40-44 8.9 1,633 1,639 45-49 7.3 1,339 1,323 Marital status Currently married 64.8 11,867 12,023 Widowed 1.5 278 286 Divorced 3.1 564 588 Separated 0.2 45 45 Never married 30.3 5,547 5,359 Missing * 1 1 Motherhood and recent births Never gave birth 37.1 6,798 6,601 Ever gave birth 62.9 11,504 11,701 13 Background characteristics Weighted percent Number of women Weighted Unweighted Gave birth in last two years 30.7 5,622 5,684 No birth in last two years 32.2 5,895 6,024 Education None 31.9 5,843 6,462 Primary 33.5 6,128 5,988 Secondary 23.8 4,361 4,132 Higher 10.7 1,965 1,715 Missing/DK * 5 5 Wealth index quintile Poorest 17.7 3,246 3,345 Second 18.5 3,380 4,074 Middle 19.9 3,646 3,929 Fourth 20.5 3,759 3,363 Richest 23.3 4,271 3,591 [*] Based on less than 25 unweighted cases and percentages have been suppressed. Sixty-five percent of sampled women are married and 63 percent have given birth to at least one child. Thirty-two percent of MICS5 respondents are uneducated while 34 and 24 percent have completed primary and secondary education respectively. The large differences between weighted and unweighted numbers for state are due to the oversampling of smaller states as described in Chapter Two. We observe that there is a significant variation between weight and un-weighted in number of women especially by state level also in HHs 2010 the same variation Some background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, State and area, age, mother’s or caretaker’s education**, and wealth of household head. 49.2 percent of the children represented in the MICS5 survey are female. Only 16 percent of children live in households in the wealthiest quintile while 23 percent of children live in households in the least wealthy quintile. Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Sudan MICS, 2014 Background characteristics Weighted percent Number of children Weighted Unweighted Sudan 100.0 14,081 14,081 Sex Male 50.8 7,157 7,190 Female 49.2 6,924 6,891 State Northern 1.7 236 532 14 Background characteristics Weighted percent Number of children Weighted Unweighted River Nile 2.8 393 565 Red Sea 1.7 244 404 Kassala 3.5 498 655 Gadarif 5.4 765 858 Khartoum 12.3 1,736 699 Gezira 15.3 2,149 800 White Nile 5.0 711 754 Sinnar 3.9 555 814 Blue Nile 4.9 691 1,006 North Kordofan 6.4 907 750 South Kordofan 3.8 529 1,092 West Kordofan 6.3 893 741 North Darfur 8.6 1,211 885 West Darfur 3.5 487 843 South Darfur 9.4 1,326 975 Central Darfur 1.8 254 837 East Darfur 3.5 495 871 Area Urban 27.4 3,862 3,811 Rural 72.6 10,219 10,270 Age 0-5 months 10.8 1,516 1,543 6-11 months 10.3 1,448 1,423 12-23 months 19.0 2,672 2,641 24-35 months 18.6 2,618 2,647 36-47 months 23.2 3,268 3,217 48-59 months 18.2 2,559 2,610 Respondent to the under-5 questionnaire Mother 98.5 13,810 13,810 Other primary caretaker 1.5 213 214 Mother’s education** None 42.6 5,994 6,587 Primary 35.1 4,936 4,666 Secondary 15.3 2,152 2,018 Higher 7.0 982 794 Missing/DK * 17 16 Wealth index quintile Poorest 22.6 3,188 3,248 Second 21.4 3,015 3,734 Middle 21.0 2,956 3,088 Fourth 19.1 2,684 2,212 Richest 15.9 2,238 1,799 15 Background characteristics Weighted percent Number of children Weighted Unweighted [*] Based on less than 25 unweighted cases and percentages have been suppressed. ** In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. 3.4 Housing Characteristics, Asset Ownership, and Wealth Quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. HH.6 presents characteristics of housing, disaggregated by area and state, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. Only about 45 percent of the households in Sudan have access to electricity. Availability of electricity widely varies among the States: while 94.4 percent of the households in the Northern State has of access to electricity, less than 20 percent of the Darfur and Kordofan States have access to electricity. North Darfur has the least percentage, 8.7 access to electricity. Seventy-six percent of households with access to electricity are in urban areas Main shelter materials in Sudan are made of natural floors, natural roofing and natural walls. About 30 percent of the houses have single rooms for sleeping, 42 percent of the houses have 2 rooms for sleeping, and 28 percent of them have 3 or more rooms for sleeping. The mean number of persons per room used for sleeping is 3.23. 16 Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and states, Sudan MICS, 2014 Background characteristic s Sudan Area State Urba n Rural North ern River Nile Red Sea Kass ala Gadari f Khart oum Gezira Whit e Nile Sinna r Blue Nile North Kordo fan South Kordo- fan West Kordo- fan N. Darfu r West Darfu r Sout h Darfu r Centr al Darfu r East Darfu r Electricity Yes 44.9 76.3 31.7 94.4 79.1 39.6 38.0 39.5 81.6 72.9 40.1 57.9 48.6 17.7 19.6 12.0 8.7 15.5 19.9 11.4 11.0 No 55.0 23.6 68.3 5.6 20.7 60.4 62.0 60.4 18.4 27.0 59.8 41.9 51.4 82.3 80.4 87.9 91.3 84.5 80.1 88.5 89.0 Missing 0.0 0.1 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.1 0.1 0.3 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.0 Flooring Natural floor 85.4 68.9 92.4 64.4 80.6 74.7 91.5 96.0 62.6 77.5 90.6 86.4 92.2 96.4 93.1 95.5 94.8 96.0 97.9 95.3 94.6 Rudimentary floor 0.1 0.2 0.0 0.0 0.0 0.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.3 0.2 0.0 0.3 0.2 0.0 0.0 Finished floor 14.0 30.2 7.2 35.4 19.2 22.5 7.9 2.9 36.9 22.3 9.2 13.2 7.8 2.6 6.2 4.0 4.4 2.7 1.3 4.0 4.7 Other 0.3 0.3 0.2 0.2 0.1 1.7 0.0 0.4 0.3 0.2 0.0 0.1 0.0 0.4 0.1 0.0 0.4 0.1 0.3 0.0 0.3 Missing/DK 0.3 0.4 0.2 0.0 0.0 0.4 0.6 0.8 0.1 0.0 0.2 0.3 0.1 0.5 0.3 0.3 0.3 0.9 0.3 0.7 0.3 Roof Natural roofing 38.7 14.2 49.1 20.1 7.2 5.3 53.2 84.8 1.5 5.6 1.7 16.1 30.4 63.3 35.3 77.8 87.2 69.7 72.1 80.7 84.7 Rudimentary roofing 34.7 34.3 34.8 61.0 84.2 28.7 30.2 2.6 49.5 76.6 77.7 46.7 4.0 10.6 6.2 9.6 1.7 6.9 9.0 5.9 0.7 Finished roofing 25.0 50.5 14.2 18.7 8.1 50.8 11.7 12.6 48.4 17.1 20.5 36.7 62.9 25.1 54.4 12.4 10.4 21.7 18.1 11.5 5.8 Other 1.6 1.0 1.9 0.2 0.5 15.1 4.5 0.1 0.6 0.6 0.1 0.1 2.7 0.8 4.2 0.1 0.7 1.6 0.7 1.9 8.8 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.1 0.3 0.0 0.0 0.0 0.0 0.3 0.0 0.2 0.0 0.1 0.0 0.0 0.0 0.1 0.0 Exterior walls Natural walls 60.6 36.3 70.8 63.6 65.2 34.1 79.9 64.0 36.8 43.7 80.1 53.2 30.2 79.4 36.3 85.4 81.3 68.3 75.4 72.0 83.8 Rudimentary walls 4.9 7.5 3.8 11.4 8.8 13.9 6.7 1.5 4.7 5.0 1.6 2.0 1.5 4.4 4.8 3.4 5.9 3.8 6.7 7.8 .3 Finished walls 28.1 50.8 18.5 24.9 25.8 42.7 11.2 2.3 56.7 51.2 17.9 43.4 20.2 10.0 39.7 7.0 7.9 19.7 17.7 18.7 6.1 Other 6.3 5.3 6.8 0.1 0.1 9.2 1.6 32.2 1.8 0.2 0.4 1.1 48.0 6.1 19.1 4.1 4.7 8.0 0.3 1.5 9.8 Missing/DK 0.1 0.0 0.1 0.0 0.0 0.0 0.6 0.0 0.0 0.0 0.0 0.3 0.1 0.1 0.0 0.1 0.2 0.2 0.0 0.1 0.0 17 Background characteristic s Sudan Area State Urba n Rural North ern River Nile Red Sea Kass ala Gadari f Khart oum Gezira Whit e Nile Sinna r Blue Nile North Kordo fan South Kordo- fan West Kordo- fan N. Darfu r West Darfu r Sout h Darfu r Centr al Darfu r East Darfu r Rooms used for sleeping 1 29.7 22.3 32.8 17.6 23.6 52.4 36.4 24.7 22.1 25.7 21.0 34.1 33.6 29.4 37.0 29.0 33.5 35.2 34.9 34.9 46.5 2 41.8 40.5 42.3 49.8 48.1 28.9 35.9 49.4 38.1 41.5 46.8 42.4 48.4 42.7 37.5 43.5 44.0 42.9 38.2 39.7 37.7 3 or more 28.2 36.5 24.6 32.6 28.0 18.6 27.1 25.6 39.4 32.7 31.4 23.3 17.9 27.2 25.6 26.2 22.5 20.9 26.3 24.8 15.9 Missing/DK 0.4 0.6 0.3 0.0 0.3 0.1 0.6 0.3 0.3 0.1 0.8 0.1 0.1 0.7 0.0 1.3 0.1 1.0 0.5 0.6 0.0 Sudan 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 16,801 5,000 11,801 423 666 519 722 858 2,317 2,629 874 661 656 1,125 462 1,003 1,243 553 1,282 299 508 Mean number of persons per room used for sleeping 3.23 3.06 3.30 2.61 2.94 3.28 3.35 3.13 2.98 3.26 2.87 3.22 3.56 3.11 3.87 3.17 3.58 3.13 3.38 3.16 4.00 18 3.5 Household Assets MICS5 2014 collected information on households, ownership of selected assets that are in themselves believed to have a strong association with poverty levels. Some of these can be used to measure household welfare when combined with other indicators to generate wealth index. Information was collected on household ownership of television , radio as a measure of access to mass media ; non – mobile phone telephones as an indicator of access to an efficient means of communication ; refrigerators as indication of capacity for hygienic storage of foods; digital receiver flat TV screen ,internet ,computer and washing machine. Information was also collected from households with regard to ownership of the following: means of transportation (bicycle, motorcycle, animal-drawn cart, car or truck, boat with motor), smart mobile, laptop, Thira mobile and bank account. Table HH.7 shows the percentage distribution of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and states. Access to non-mobile phones was the least at 1.8 percent while approximately 40 percent of the households have access to Television. About 74 percent of households had a least a household member possessing a mobile telephone with Northern, Khartoun, Blue Nile, Gezira, and River Nile having access at 96.6, 91.3, 87.5, 87.3, and 84.6 percent respectively. Central Darfur had the least access to mobile phones at 47.3 percent. Almost all the mobile phones are likely to be owned by urban households 87.3 percent own mobile phone compared to 68.1 percent ownership in rural areas. Access to Internet and computer were minimal at 3.8 and 3.7 percent respectively. Table HH.7 shows that 35.2 percent of the households own a radio; urban households are more likely than rural households to own television 71.1 percent compared with 26.3 percent respectively. Overall, 25.9 percent of all households own a refrigerator and as expected, urban households are more likely than rural households to own a refrigerator 50.1 percent compared with 15.7 percent respectively. Access to Agricultural land and Farm animals/livestock was highest in rural households at 51 and 64 percent respectively. Such access unfavourably compares to urban households at 12 and 20 percent respectively. With regard to access to transport, table HH.7 shows that access to car or truck transportation was 6.4 percent of households ranging from 4.4 percent in rural households to 11.0 percent in urban households. In contrast access to animal drawn transportation was 17.9 percent of rural households compared to 8.1 percent in urban households. Most of the people surveyed did not own personal bank accounts. Ownership of personal bank account was 2.4 percent in rural households and 11.1 percent in urban households. Ownership of personal bank account was highest in Khartoun and Northern States respectively at 12.6 and 9.6 19 percent and lowest in Central Darfur and West Kordofan/North Darfur at 1.0 and 1.6 percent respectively. Most of the dwellings were owned by a household member. The highest ownership was in households in North Darfur at 94.4 percent, West Kordofan at 93.5 percent, North Kordofan at 92.2 percent, Blue Nile at 92.2 percent, South Kordofan at 91.3 percent, and White Nile at 91.0 percent. 20 Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and states, Sudan MICS, 2014 Background characteristics Sudan Area State Urban Rural Northern River Nile Red Sea Kassala Gadarif Khartoum Gezira White Nile Sinnar Blue Nile North Kordofan South Kordofan West Kordofan North Darfur West Darfur South Darfur Central Darfur East Darfur Percentage of households that own a Radio 35.2 41.5 32.6 30.5 37.1 27.7 21.2 30.5 42.3 35.1 41.2 36.5 44.0 41.9 47.0 29.4 30.7 20.9 37.5 22.2 31.7 Television 39.6 71.1 26.3 86.0 75.3 41.2 29.0 28.8 77.0 60.5 42.0 41.5 30.4 17.4 20.2 12.4 7.6 13.8 18.2 8.0 12.5 Non-mobile phone 1.8 3.6 1.1 2.6 3.3 2.7 2.7 0.9 3.1 2.1 1.6 2.7 1.0 1.2 1.0 1.5 0.8 1.1 0.6 1.3 1.2 Refrigerator 25.9 50.1 15.7 75.7 63.1 26.7 17.8 11.0 63.2 39.8 25.1 23.1 8.7 7.7 5.0 3.5 2.7 4.5 5.9 1.8 5.9 Digital receiver 33.8 62.5 21.6 81.8 71.0 36.3 24.3 20.3 71.6 52.8 32.6 37.4 22.8 10.1 13.6 3.8 5.5 10.6 14.1 3.9 10.7 Flat TV Screen 2.3 5.7 .9 3.6 2.3 2.1 2.0 0.8 7.1 2.8 2.2 1.7 1.1 0.6 0.3 0.3 0.8 1.7 1.6 0.6 0.2 Internet 3.8 10.2 1.1 3.3 2.3 6.8 1.7 1.8 16.4 2.7 1.1 5.7 0.2 1.0 0.6 0.3 0.4 0.5 1.6 0.9 0.2 Computer 3.7 8.9 1.4 5.8 5.0 4.6 2.9 0.9 12.0 4.2 1.6 3.4 0.8 1.2 1.4 .7 1.4 1.2 1.4 1.0 0.6 Wash Machine 11.1 22.5 6.2 43.6 31.7 15.4 7.8 2.8 30.8 15.5 5.8 7.1 2.7 2.6 0.6 0.8 0.6 0.8 0.6 1.3 0.8 Percentage of households that own Agricultural land 39.5 12.0 51.1 31.3 22.7 30.3 28.0 43.4 7.0 24.0 30.2 42.7 48.0 55.6 52.0 43.2 83.4 69.4 63.3 48.8 55.7 Farm animals/ Livestock 51.0 20.3 64.0 65.1 51.9 44.0 44.9 51.0 13.8 45.4 54.8 51.7 62.9 62.3 52.7 55.1 83.1 54.4 66.5 54.2 71.7 Percentage of households where at least one member owns or has a Mobile telephone 73.8 87.3 68.1 96.4 84.6 58.9 54.9 72.1 91.3 87.3 69.4 74.7 87.5 66.5 73.0 66.1 60.6 57.9 59.2 47.3 60.0 Bicycle 13.3 17.8 11.4 12.0 12.4 5.5 14.8 10.0 13.9 18.4 10.0 22.5 30.8 2.9 35.5 13.1 3.5 5.6 11.8 21.7 4.3 Motorcycle or scooter 4.4 6.6 3.5 2.5 4.4 2.9 6.1 3.5 4.2 2.8 2.3 6.2 15.8 1.1 10.4 7.0 1.1 3.4 7.0 6.2 1.9 Animal-drawn cart 15.0 8.1 17.9 16.4 11.8 1.9 9.0 16.3 5.6 14.8 24.3 21.7 14.2 16.5 24.1 28.0 4.5 8.2 19.8 16.4 39.1 Car or truck 6.4 11.0 4.4 12.7 10.8 6.1 6.0 3.1 16.4 7.8 6.0 6.2 4.1 4.2 1.4 0.7 1.4 1.9 2.6 0.8 2.4 Boat with motor 0.5 0.3 0.6 1.0 1.4 0.5 0.2 0.0 0.1 0.3 4.8 0.6 0.2 0.2 0.2 0.0 0.0 0.1 0.2 0.6 0.0 21 Background characteristics Sudan Area State Urban Rural Northern River Nile Red Sea Kassala Gadarif Khartoum Gezira White Nile Sinnar Blue Nile North Kordofan South Kordofan West Kordofan North Darfur West Darfur South Darfur Central Darfur East Darfur Raksha 1.3 3.4 .4 2.0 2.8 2.7 0.1 0.5 3.6 1.0 1.8 1.6 0.5 0.2 1.3 0.3 0.0 0.2 1.4 0.8 0.1 Smart Mobile 8.9 17.8 5.1 33.4 15.3 10.3 12.4 2.9 22.1 9.8 11.0 6.7 2.9 2.8 2.5 1.0 1.5 1.8 3.1 6.1 2.7 Labtop/Tablet 3.8 9.4 1.4 7.2 4.8 4.4 2.0 .9 11.9 4.4 2.2 3.6 2.0 1.4 1.0 .4 1.0 2.2 2.3 1.4 1.2 Thria mobile 0.4 0.5 0.3 0.3 0.3 0.3 0.4 0.2 0.0 0.2 3.4 0.7 0.2 0.2 0.3 0.0 0.0 0.6 0.3 0.1 0.4 Bank account 5.0 11.1 2.4 9.6 4.4 8.2 2.1 4.5 12.6 4.9 2.3 5.4 5.6 1.7 4.3 1.6 1.6 3.3 3.4 1.0 2.9 Ownership of dwelling Owned by a household member 85.5 67.3 93.3 75.5 84.4 81.4 91.1 89.1 69.3 87.2 91.0 82.6 92.2 92.2 91.3 93.5 94.4 85.8 83.5 83.2 86.3 Not owned 14.4 32.5 6.7 24.5 15.4 18.5 8.8 10.9 30.7 12.8 8.8 17.1 7.8 7.7 8.6 6.2 5.5 14.2 16.5 16.7 13.7 Rented 7.0 19.1 1.9 6.3 6.2 9.0 4.9 3.1 21.4 3.8 5.0 3.1 4.0 3.0 4.5 4.5 1.7 6.0 9.2 6.5 4.2 Other 7.4 13.4 4.8 18.3 9.2 9.6 3.9 7.8 9.4 9.0 3.7 14.0 3.8 4.6 4.1 1.7 3.7 8.2 7.3 10.2 9.5 Missing/DK 0.1 0.1 0.0 0.0 0.2 0.1 0.1 0.0 0.0 0.0 0.2 0.3 0.0 0.1 0.1 0.2 0.2 0.0 0.0 0.1 0.0 Number of households 16,801 5,000 11,801 423 666 519 722 858 2,317 2,629 874 661 656 1,125 462 1,003 1,243 553 1,282 299 508 [*] Based on less than 25 unweighted cases and has been suppressed. 22 Table HH.8 shows how the household populations in Areas and States are distributed according to household wealth quintiles. Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintiles, according to area of residence and states, Sudan MICS, 2014 Background characteristics Wealth index quintile Sudan Number of household members Poorest Second Middle Fourth Richest Sudan 20.0 20.0 20.0 20.0 20.0 100.0 98,883 Area Urban 2.8 7.2 21.0 26.9 42.0 100.0 30,476 Rural 27.7 25.7 19.6 16.9 10.2 100.0 68,407 State Northern 0.0 0.8 10.5 39.3 49.5 100.0 2,181 River Nile 3.6 1.9 10.4 38.3 45.8 100.0 3,715 Red Sea 9.1 22.5 26 21.2 21.3 100.0 2,489 Kassala 19.5 28.4 25.3 13.6 13.1 100.0 4,117 Gadarif 16.7 35.5 30.7 12.8 4.3 100.0 5,005 Khartoum 0.2 2.8 12.5 26.0 58.4 100.0 13,830 Gezira 0.6 4.7 21.3 44.5 28.8 100.0 16,270 White Nile 2.0 22.5 38.3 21.3 15.9 100.0 5,016 Sinnar 1.2 21.2 36.7 21.8 19.1 100.0 3,763 Blue Nile 2.3 26.4 45.5 18.5 7.3 100.0 4,094 North Kordofan 37.4 28.1 21.3 8.1 5.1 100.0 6,359 South Kordofan 9.9 51.0 28.4 8.5 2.2 100.0 2,983 West Kordofan 41.6 40.9 14 2.9 0.6 100.0 5,745 North Darfur 59.9 26.8 8.0 2.8 2.5 100.0 7,776 West Darfur 40.5 30.0 13.7 11.0 4.8 100.0 3,023 South Darfur 52.0 22.3 14.8 7.9 2.9 100.0 7,712 Central Darfur 32.1 49.5 12.7 4.0 1.7 100.0 1,646 East Darfur 60.8 26.0 5.9 3.4 3.9 100.0 3,158 23 IV. Child Mortality 4.1 Introduction One of the overarching goals of the Millennium Development Goals (MDGs) 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. The Goal of the Sudan Health Sector Strategic Plan (HSSP 2012-2016) was to “improve health status and outcomes, especially for poor, underserved, disadvantaged and vulnerable populations” expecting the reduction of under-five mortality rate from 83 thousands life births estimated by SHHS 2010 to 53 thousands life births and the reduction of infant mortality rate from 57 to 43 at the end of the health strategic plan in 2016. This national commitment is part of the Government’s National Development Plan 2012-2016 compatible with the 25-year National Strategic Plan for Health (2003-2027) and the National Health Policy (2007). Monitoring progress towards those global and national goals is an important but difficult objective. MICS 2014 offers an opportunity to generate accurate evidence on the status of child survival in Sudan at national level and by state following the separation of the South Sudan with Sudan in 2011 which resulted to structural economic challenges of limited fiscal space (the loose of 65percent of oil revenue) for capital investment on social sector. The persistent humanitarian responses to vulnerable population affected by natural disasters, conflicts and displacements represent also major challenges for development results. The gap of human resources capacities and health financing, the limited geographic coverage of PHC (11.3 percent of population don’t have access to health services within 5km), the financial barriers of use of health services by poorest families because of the requirement of users fees and the prevailing social norms and behaviours issues represent major bottlenecks for the acceleration of progress to achieve MDG4 and MDG5 in Sudan as mentioned in 2012 by the SHSS 2012-2016. Despite those challenges and bottlenecks, it is important to recognise that in Sudan health infrastructures and skilled manpower are in place and efforts have been made to operationalize strategies and innovative high impact interventions as agreed within HSSP and the Health Sector COMPACT in a very large partnerships of Government, Donors, Civil Society, Local Authorities with engagement of communities and family participation. Mortality rates presented in this chapter are calculated from information collected in the birth histories of the Women’s Questionnaires. All interviewed women were asked whether they had ever given birth, and if yes, 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 live births of children in chronological order starting with the firstborn. Women were asked whether births were single or multiple, the sex of the children, the date of birth (month and year), and survival status. Further, for children still alive, they were asked the current age of the child and, if not alive, the age at death. Childhood mortality rates are expressed by conventional age categories and are defined as follows: • Neonatal mortality (NN): probability of dying within the first month of life • Post-neonatal mortality (PNN): difference between infant and neonatal mortality rates • Infant mortality (1q0): probability of dying between birth and the first birthday 24 • Child mortality (4q1): probability of dying between the first and the fifth birthdays • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday Rates 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, and post-neonatal mortality, which is the difference between infant and neonatal mortality rates. 4.2. Status of Child Mortality at national level Table CM.1 and Figure CM.1 present neonatal, post-neonatal, infant, child, and under-five mortality rates for the three most recent five-year periods before the survey. In Sudan, the under-five mortality is estimated by MICS 2014 at 68 deaths per 1,000 live births for the period of five years preceding the survey (2010-2014) and the infant mortality rate is 52 per 1,000 live births for the same period indicating that 76.5 percent of under-five deaths are infant deaths. Neonatal mortality in the most recent 5-year period is estimated at 33 per 1,000 live births, while the post-neonatal mortality rate is estimated at 19 per 1,000 live births. Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, infant, child and under-five mortality rates for five year periods preceding the survey, Sudan MICS, 2014 Years preceding the survey Neonatal mortality rate (1) Post neonatal mortality(2) Infant mortality(3) Child mortality (4) Under five mortality(5) 0-4 32.6 19.4 52.0 17.3 68.4 5-9 28.2 19.7 47.9 23.0 69.8 10-14 28.3 26.5 54.9 32.1 85.2 1MICS indicator 1.1 – Neonatal mortality 2 MICS indicator 1.3 – Post neonatal mortality rate 3 MICS indicator 1.2 – MDG indicator 4.2 – infant mortality rate 4 MICS indicator 1.4 – Child Mortality Rate 5 MICS indicator 1.5 - MDG indicator 4.1 – Under-five mortality rate Post neonatal mortality rates are computed as the difference between the infant and neonatal mortality rate The birth history method enables to calculate early child mortality rates for different years preceding the survey. The table and figure also show a declining trend at the national level, during the last 15 years, with under-five mortality at 85 per 1,000 live births during the 10-14 year period preceding the survey, and 69.8 per 1,000 live births during the most recent 5-year period, roughly referring to the years indicate period. A similar pattern is observed in all other indicators. However, there has been stagnation of neonatal mortality rate during the period 10-14 years (28.3) and 5-9 years (28.2) preceding the MICS 2014. 25 F i g u r e C M . 1 : E a r l y c h i l d h o o d m o r t a l i t y r a t e s , S u d a n M I C S , 2 0 1 4 4.3 Geographic Disparity in Childhood Mortality Tables CM.2 and figure CM.2 provide estimates of child mortality by area and by states. Findings reveal that there is inequality of probabilities of dying between urban and rural areas: under-five mortality and infant mortality rates are respectively 56.5 and 11.8 deaths for 1,000 live births in urban area, 72.8 and 19.3 in rural area. The risk of dying of under-five children before the five birthday is very high in the states of East Darfur (111.7), South Kordofan (95.4), West Darfur (91.4), North Darfur (90.3); however the lowest under- five mortality rates are measured in Northern (29.9), River Nile (35.1), North Kordofan (41.9) and Khartoum (49.8) states. Figure CM.2 provides a graphical presentation of these differences. 28 27 55 32 85 28 20 48 23 70 33 19 52 17 68 Neonatal mortality rate Post-neonatal mortality rate Infant mortality rate Child mortality rate Under-five mortality rate Years preceding the survey Note: Indicator values are per 1,000 live births 10-14 5-9 0-4 26 Table CM.2: Early Childhood Mortality Neonatal, post-neonatal, infant, child and under-five mortality rates for five year periods preceding the survey by Area and State, Sudan MICS, 2014 Geographic area Neonatal mortality1 Post neonatal mortality2 Infant mortality3 Child mortality4 Under five mortality5 Sudan 32.6 19.4 52.0 17.3 68.4 Area Urban 30.3 14.8 45.1 11.8 56.5 Rural 33.4 21.1 54.5 19.3 72.8 State Northern 23.0 6.9 30.0 0.0 29.9 River Nile 25.8 2.3 28.1 7.2 35.1 Red Sea 18.6 25.6 44.2 17.9 61.3 Kassala 47.2 15.0 62.1 19.7 80.5 Gadarif 32.6 20.8 53.4 24.6 76.7 Khartoum 30.5 14.6 45.1 4.9 49.8 Gezira 26.2 15.2 41.4 12.6 53.5 White Nile 30.3 16.5 46.8 20.0 65.8 Sinnar 18.0 16.1 34.1 18.1 51.6 Blue Nile 26.0 20.8 46.8 38.9 83.9 North Kordofan 23.0 12.7 35.6 6.5 41.9 South Kordofan 32.5 37.6 70.2 27.1 95.4 West Kordofan 43.4 24.8 68.2 15.0 82.1 North Darfur 43.9 24.6 68.5 23.4 90.3 West Darfur 39.2 32.0 71.2 21.8 91.4 South Darfur 35.2 17.5 52.6 20.4 71.9 Central Darfur 24.7 19.8 44.5 34.4 77.4 East Darfur 51.8 36.7 88.5 25.5 111.7 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate 27 Graph below reveals the 3.7 times gap of equity in child survival between Northern state (the lowest U5MR of 30 deaths per 1,000 live births) and East Darfur (the highest under-five mortality rate of 111.7 deaths for 1,000 live births). F i g u r e C M . 2 : U n d e r f i v e M o r t a l i t y R a t e s b y S t a t e , S u d a n M I C S , 2 0 1 4 The gap of equity of child survival between urban and rural area is high in Sudan as indicated below. 0 20 40 60 80 100 120 Northern River Nile North Kordofan Khartoum Sinnar Gezira Red Sea White Nile Sudan South Darfur Gadarif Central Darfur Kassala West Kordofan Blue Nile North Darfur West Darfur South Kordofan East Darfur 29.9 35.1 41.9 49.8 51.6 53.5 61.3 65.8 68.0 71.9 76.7 77.4 80.5 82.1 83.9 90.3 91.4 95.4 111.7 28 Figure CM.2a: Underfive Mortality Rates by geographic area, Sudan MICS, 2014 4.4 Disparity in Childhood mortality by socioeconomic and demographic patterns Tables CM.2b and figures CM.2c-CM.2d provide estimates of child mortality by socioeconomic and demographic characteristics. There is difference between the probabilities of dying among boys (78.7) and girls (57.6). Inequity for child survival is very high in Sudan: children living in poorest families are double times at risk of dying before their firth birthday (U5MR of 84.2) in comparison to children from richest household (U5MR of 39.4). There is also differences in mortality in terms of mothers’ education, age-group, birth order and interval of birth as indicated in figures and tables below. Figure CM.2b: Under Five Mortality Rates by sex of child and wealth quintile, Sudan MICS, 2014 56.5 72.8 68 0 10 20 30 40 50 60 70 80 Urban Rural Sudan 84.2 79.9 67.7 59.6 39.4 78.7 57.6 68 0 10 20 30 40 50 60 70 80 90 Poorest Second Middle Fourth Richest Boys Girls Sudan 29 Figure CM.2c: Underfive mortality rates by mother's education, Sudan MICS, 2014 Table CM.3: Early Childhood Mortality Neonatal, post-neonatal, infant, child and under-five mortality rates for five year periods, preceding the survey by demographic characteristics, Sudan MICS, 2014 Background characteristics Neonatal mortality Post neonatal mortality Infant mortality Child mortality Under five mortality Sudan 32.6 19.4 52.0 17.3 68.4 Sex of child Boys 38.4 21.1 59.4 20.5 78.7 Girls 26.5 17.7 44.2 14.1 57.6 Birth order 1 37.9 10.2 48.0 12.5 60.0 2-3 22.8 20.5 43.3 14.8 57.5 4-6 28.3 19.6 47.9 18.9 65.9 7+ 53.4 25.8 79.2 24.4 101.7 Previous birth interval < 2 years 52.7 30.2 82.9 27.1 107.8 2 years 23.8 19.8 43.7 18.4 61.3 3 years 13.7 11.6 25.3 7.3 32.4 4+ years 30.5 15.8 46.3 8.7 54.6 Mother’s education None 34.6 20.6 55.3 24.6 78.4 Primary 32.5 20.7 53.2 14.5 66.9 Secondary 35.0 13.0 48.0 6.1 53.8 Higher 14.6 20.2 34.8 3.8 38.4 Wealth index quintile Poorest 41.1 23.8 64.9 20.6 84.2 Second 36.0 24.3 60.3 20.9 79.9 Middle 31.2 19.2 50.3 18.2 67.7 Fourth 25.0 17.7 42.7 17.7 59.6 78.4 66.9 53.8 38.4 68.4 0 10 20 30 40 50 60 70 80 90 None Primary Secondary Higher Sudan 30 Richest 25.7 8.2 33.9 5.7 39.4 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates (*) Rates based on fewer than 250 unweighted exposed persons ( ) Rates based on 250 to 499 unweighted exposed persons 4.5 Trend in Childhood mortality rate using different sources As part of an effort to recap the overall evolution of child mortality measurement done in Sudan, this section presents data related to the estimation of under-five mortality as officially approved and published within national household survey full report completed in Sudan since 2000. In addition, reference to the estimation performed by the United Nations inter agency estimation group (IGME) is also presented in the graph for information. This trend analysis will cover the evolution of under-five mortality at national level, by state and by wealth quintile. Those data must be considered with caution taking into account the difference of sampling, the variance of indicator, method used and variation of geographic area (variation from 15 states in 2010 to 18 states in 2014). Despite, the limitations of different surveys in statistical view, those recap of estimation from previous surveys provide an indication of potential evolution of the situation of child survival in Sudan (decrease or increase by state and wealth quintile). 4.5.1 Trend at national level Figure CM.3 compares the findings of MICS 2014 on under-5 mortality rates with those from other data sources like SHHS 2010, SHSS 2006 and SHSS 2000. The MICS estimates indicate a decline in mortality during the last 20 years. Further secondary data analysis will provide explanation related to probable factors determinants of the acceleration or not of decline of U5MR during the two periods (1995-2006 and 2006-2014). 31 F i g u r e C M . 3 : Trends in Under-Five Mortality and Infant Mortality in Sudan as estimated by SHHS 2000, SHHS 2006, SHHS2 2010 and MICS 2014 4.5.3 Trend by wealth index quintile from SHHS 2010 and MICS 2014 data sources Figure CM.3a below seems to indicate that the reduction of under-five mortality during the last five years greatest among the middle wealth quintile than the poorest and richest quintiles. 104 102 83 68 68 71 60 52 0 20 40 60 80 100 120 1995-2000 2001-2005 2006-2010 2010-2014 U5MR-All MICS InfMR-All MICS 32 Figure CM.3a: Trend in Under Five Mortality Rates by sex of child and wealth quintile in Sudan, SHHS 2010 and Sudan MICS, 2014 86 97 95 77 42 89 76 83 84.2 79.9 67.7 59.6 39.4 78.7 57.6 68 0 20 40 60 80 100 120 Poorest Second Middle Fourth Richest Boys Girls Sudan U5MR SHHS 2010 U5MR MICS 2014 33 V. Nutrition Sudan has been committed to the 2015 Millennium Development Goals aiming to eradicate the extreme poverty and hunger. The reduction of child malnutrition is one of the goals of Sudan’s National Health Sector Strategic Plan (NHSSP) 2012-2016 which intended to reduce the prevalence of moderate malnutrition (underweight) from 32 percent to 16 percent. According to the Ministry of Health’s annual statistical reports, pneumonia, malaria, diarrhoea and malnutrition are the major causes of under-five illness and hospital admission. With reference to the global evidence of studies conducted by the World Bank (2010) and Horton and Steckel (2013) which estimated that investing in nutrition can increase a country’s GDP by at least 3 percent annually, the Investment in Nutrition Case Document developed for Sudan in 2014 has estimated that investing in nutrition can increase Sudan’s 2013 GDP by US$66.55 billions, equaling to a gain of US$2 billion per annum. Sudan has a National Nutrition Policy which supports many of the interventions that are considered to be high impact and evidence based. Within the SHSSP 2012-2016, efforts have been made by Government and Donors in order to strengthen institutional capacity of coordination and management of nutrition services at federal, state and periphery levels and to increase financial investment for addressing the prevention and treatment of acute malnutrition: the coverage of health-based services for treatment of severe acute malnutrition has reached 28 percent in 2014 and government has allocated in 2015 a Sudan amount of US$ 8 million for therapeutic foods. MICS 2014 offers an opportunity to assess the status of child malnutrition in Sudan vis-à-vis MDG 2015 and the NHSSP 2012-2016 targets and to provide baseline evidence-based prioritization of child malnutrition within the full Poverty Reduction Strategic Paper in process, the development of a national multi-sector nutrition strategy and better targeting and investment of humanitarian responses to reduce child acute malnutrition. This chapter presents findings related to low birth weight, nutritional status of children under-five years, breastfeeding and Infant and Young Child Feeding, the use of salt iodization at household level, and the coverage of child’s Vitamin A supplementation. 5.1 Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished during pregnancy face a greatly increased risk of dying during their early stages of life up to five years of age. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also have a risk of lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In developing countries, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have the most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a 34 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 pregnant mother becomes infected Cigarette smoking during pregnancy is a leading cause of low birth weight. In addition, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of new-borns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. The percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s own assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.7 Sudan’s 2014 MICS report states that 16.3 percent of births were weighed at birth. Approximately 32.3 percent of infants born during the last two years were estimated to weigh less than 2,500 grams at birth (Table NU.1). The prevalence of low birth weight varies by urban 27.9 percent and rural area 33.9 percent and by mother’s education from 33.7 percent among children for whose mothers are not educated to 23.7 percent for children whose mothers have higher level of education. The highest prevalence of low birth weight was observed in states of North Darfur (47.5 percent), East Darfur (46.9 percent), North Kordofan (41.4 percent) and West Kordofan (36 percent) in comparison to the low prevalence observed in states of River Nile (17.2 percent), Khartoum (22.2 percent), Gadarif (23.9 percent) and Blue Nile (25.7 percent). There is inequality of the prevalence of low birth weight among children in the wealth index quintiles of the population; 39 percent among children living in the poorest household to 22.2 percent for children of richest household category. 7 For a detailed description of the methodology, see Boerma, JT et al. 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization 74(2): 209-16. 35 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Sudan MICS, 2014 Background Characteristics Percent distribution of births by mother's assessment of size at birth Sudan Percentage of live births: Number of last live- born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams [1] Weighed at birth [2] Sudan 18.6 15.2 51.5 12.9 1.8 100.0 32.3 16.3 5,622 Mother's age at birth Less than 20 years 19.7 20.2 47.2 11.3 1.5 100.0 36.2 11.6 640 20-34 years 18.8 14.9 51.5 13.1 1.8 100.0 32.2 16.4 4,001 35-49 years 17.4 13.3 54.0 13.4 1.8 100.0 30.3 19.2 981 Birth order 1 16.6 16.8 53.7 11.7 1.1 100.0 31.9 21.9 910 2-3 16.2 14.8 54.0 13.0 2.0 100.0 30.5 19.3 1,669 4-5 18.8 16.1 51.0 12.2 1.9 100.0 33.1 13.5 1,428 6+ 22.1 14.0 48.0 14.1 1.8 100.0 33.8 12.7 1,614 State Northern 16.3 9.0 67.9 5.8 1.1 100.0 27.1 27.3 92 River Nile 2.7 7.5 81.2 8.6 .0 100.0 17.2 26.5 151 Red Sea 15.4 9.1 53.0 6.2 16.2 100.0 29.3 26.2 92 Kassala 16.2 7.8 62.3 12.4 1.3 100.0 26.0 13.7 199 Gadarif 9.0 11.6 70.9 7.8 0.6 100.0 23.9 7.2 307 Khartoum 7.8 10.5 69.5 11.4 0.8 100.0 22.2 56.3 684 Gezira 13.3 19.5 60.8 6.0 0.3 100.0 31.6 15.2 852 White Nile 24.6 13.4 50.0 8.7 3.3 100.0 35.6 13.6 273 Sinnar 18.2 15.4 55.6 9.9 0.9 100.0 32.1 13.1 226 Blue Nile 15.2 9.9 43.9 30.9 0.1 100.0 25.7 12.4 287 North Kordofan 23.8 23.9 36.5 13.2 2.5 100.0 41.4 10.9 352 South Kordofan 20.4 14.0 51.2 12.1 2.2 100.0 32.9 7.9 194 West Kordofan 26.6 12.9 48.2 10.8 1.5 100.0 36.0 4.3 341 North Darfur 29.5 26.9 34.6 6.0 3.0 100.0 47.5 5.3 525 West Darfur 14.4 17.3 37.0 27.0 4.2 100.0 30.7 12.7 179 South Darfur 26.6 11.2 37.1 23.2 1.9 100.0 34.5 5.1 556 Central Darfur 11.2 11.8 42.9 33.3 0.9 100.0 24.3 5.7 99 East Darfur 38.8 17.5 21.6 19.4 2.6 100.0 46.9 4.2 211 Area Urban 15.2 11.7 56.4 14.6 2.1 100.0 27.9 33.6 1,488 Rural 19.9 16.5 49.7 12.3 1.7 100.0 33.9 10.1 4,134 Mother’s education None 20.2 15.8 46.4 15.2 2.4 100.0 33.7 5.8 2,247 Primary 19.4 16.9 50.0 12.5 1.2 100.0 33.8 13.2 2,022 Secondary 16.6 12.9 58.6 10.0 2.0 100.0 29.7 31.3 942 Higher 10.9 9.5 69.9 8.9 0.8 100.0 23.7 54.7 410 Wealth index quintile 36 Background Characteristics Percent distribution of births by mother's assessment of size at birth Sudan Percentage of live births: Number of last live- born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams [1] Weighed at birth [2] Poorest 25.3 19.2 39.2 14.7 1.7 100.0 39.0 3.7 1,251 Second 22.7 15.3 44.9 14.7 2.4 100.0 35.1 7.4 1,232 Middle 17.7 14.7 52.8 13.0 1.8 100.0 31.4 10.9 1,192 Fourth 15.2 16.0 55.9 11.5 1.5 100.0 30.6 21.0 1,096 Richest 8.9 9.0 71.3 9.5 1.3 100.0 22.2 49.3 851 [1] MICS indicator 2.20 - Low-birthweight infants [2] MICS indicator 2.21 - Infants weighed at birth 5.2 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 child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards8. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height - can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. 8 http://www.who.int/childgrowth/standards/technical_report 37 Weight-for-height can be used to assess wasting and overweight status. Children whose weight-for- height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended9 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. Regarding the quality of nutrition’s indicators, children whose full birth date (month and year) were not obtained and children whose measurements are outside a plausible range are excluded from Table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.12, DQ.13, and DQ.14 in Appendix D. The tables show that due to incomplete dates of birth, implausible measurements, missing weight and/or height and possible particular situation in Sudan, 19.3 percent of children have been excluded from calculations of the weight-for-age indicator, 21.8 percent from the height-for-age indicator, and 11.9 percent for the weight-for-height indicator. 9 See MICS Supply Procurement Instructions: http://www.childinfo.org/mics5_planning.html 38 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Sudan MICS, 2014 Background characteristics Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent above - 2 SD [1] - 3 SD [2] - 2 SD [3] - 3 SD [4] - 2 SD [5] - 3 SD [6] + 2 SD [7] Sudan 33.0 12.0 -1.5 11,713 38.2 18.2 -1.6 11,333 16.3 4.5 3.0 -.8 12,550 Sex Male 34.6 12.8 -1.5 5,975 40.3 20.5 -1.6 5,778 16.9 5.1 3.2 -.9 6,375 Female 31.5 11.2 -1.4 5,737 36.1 15.8 -1.5 5,556 15.7 3.8 2.8 -.8 6,175 State Northern 21.9 4.5 -1.1 214 22.6 7.2 -1.1 208 11.4 2.6 2.7 -.7 206 River Nile 32.2 11.0 -1.5 338 29.5 12.1 -1.2 336 20.1 6.1 2.0 -1.0 346 Red Sea 33.6 15.9 -1.6 182 45.4 27.1 -1.9 178 14.0 2.3 4.1 -.6 184 Kassala 42.0 15.5 -1.7 409 48.8 25.7 -1.8 400 18.5 5.1 1.7 -1.0 414 Gadarif 37.7 15.5 -1.6 666 46.0 24.3 -1.9 658 15.4 5.4 4.6 -.7 698 Khartoum 23.2 6.4 -1.2 1,603 21.9 8.4 -1.0 1,593 14.5 3.8 .5 -.8 1,632 Gezira 32.4 12.3 -1.3 2,084 41.6 21.1 -1.7 2,046 14.0 3.7 8.5 -.5 2,050 White Nile 29.8 11.1 -1.4 572 36.6 17.4 -1.5 562 14.4 3.5 2.2 -.7 622 Sinnar 36.4 14.6 -1.6 471 38.1 17.9 -1.5 465 16.0 4.5 1.6 -1.0 477 Blue Nile 35.3 10.7 -1.5 668 46.7 22.6 -1.9 656 11.1 2.7 2.2 -.6 666 North Kordofan 32.4 11.5 -1.5 752 40.8 17.5 -1.7 731 14.8 4.5 2.5 -.8 764 South Kordofan 34.8 14.5 -1.6 431 40.6 23.7 -1.6 413 16.3 3.8 2.6 -.8 452 West Kordofan 38.7 14.8 -1.5 388 42.5 22.4 -1.5 383 18.7 5.1 1.5 -1.0 781 North Darfur 44.9 16.9 -1.9 861 45.9 21.6 -1.8 759 27.9 8.6 .9 -1.4 959 West Darfur 29.4 9.9 -1.3 223 35.2 13.7 -1.2 218 19.1 6.7 4.7 -0.9 455 South Darfur 29.4 9.9 -1.4 1,231 34.2 12.8 -1.4 1,120 15.9 3.5 .3 -1.0 1,164 Central Darfur 41.0 18.5 -1.6 163 47.5 25.5 -1.8 156 17.8 4.3 5.9 -0.7 221 East Darfur 40.2 16.6 -1.7 457 46.6 24.7 -1.8 452 15.3 4.2 .9 -0.9 460 Area Urban 23.2 7.6 -1.2 3,405 27.1 10.8 -1.2 3,327 13.4 3.6 2.5 -0.7 3,494 39 Background characteristics Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent above - 2 SD [1] - 3 SD [2] - 2 SD [3] - 3 SD [4] - 2 SD [5] - 3 SD [6] + 2 SD [7] Rural 37.1 13.8 -1.6 8,308 42.9 21.2 -1.7 8,006 17.4 4.8 3.2 -0.9 9,056 Age 0-5 months 12.4 4.3 -0.5 1,296 12.2 5.3 -0.3 1,100 12.2 4.1 7.2 -0.3 1,158 6-11 months 24.1 9.1 -1.1 1,308 18.6 6.4 -0.8 1,274 18.3 6.1 3.3 -0.8 1,319 12-17 months 34.8 12.7 -1.4 1,290 36.1 14.8 -1.4 1,274 22.6 6.6 2.4 -1.1 1,361 18-23 months 36.3 15.1 -1.7 1,034 46.0 23.5 -1.9 1,014 19.5 5.2 0.9 -0.9 1,083 24-35 months 39.4 16.6 -1.8 2,216 49.8 25.2 -2.0 2,166 17.1 4.9 2.3 -0.9 2,391 36-47 months 37.9 13.3 -1.6 2,555 47.2 23.9 -1.9 2,519 13.2 3.0 3.0 -0.8 2,928 48-59 months 36.2 10.2 -1.6 2,014 38.8 17.5 -1.7 1,987 15.2 3.7 2.7 -0.9 2,310 Mother's education None 40.8 17.2 -1.7 4,683 46.8 24.3 -1.9 4,504 18.1 5.2 2.0 -1.0 5,278 Primary 32.3 11.1 -1.4 4,179 37.8 17.1 -1.5 4,055 16.3 4.5 3.4 -0.8 4,430 Secondary 23.8 5.4 -1.1 1,930 27.6 10.1 -1.2 1,883 13.5 2.9 4.1 -0.7 1,934 Higher 16.8 3.7 -0.9 907 19.7 9.2 -1.0 877 12.1 3.2 4.5 -0.5 891 Missing/DK * * -1.0 14 * * -0.9 13 * * * -1.0 16 Wealth index quintile Poorest 39.5 14.9 -1.7 2,277 44.0 22.2 -1.8 2,127 20.1 5.7 1.4 -1.1 2,720 Second 39.8 16.4 -1.7 2,321 47.3 23.9 -1.8 2,235 17.8 4.9 2.0 -0.9 2,657 Middle 35.4 13.6 -1.6 2,548 43.6 20.9 -1.7 2,481 15.4 5.3 3.4 -0.8 2,641 Fourth 31.1 9.9 -1.4 2,493 33.8 14.9 -1.4 2,462 15.4 3.3 3.8 -0.7 2,482 Richest 17.8 4.6 -1.0 2,072 21.1 8.4 -1.0 2,027 11.7 2.6 4.8 -0.6 2,050 1 MICS indicator 2.1a and MDG indicator 1.8 - Underweight prevalence (moderate and severe) 2 MICS indicator 2.1b - Underweight prevalence (severe) 3 MICS indicator 2.2a - Stunting prevalence (moderate and severe) 4 MICS indicator 2.2b - Stunting prevalence (severe) 5 MICS indicator 2.3a - Wasting prevalence (moderate and severe) 6 MICS indicator 2.3b - Wasting prevalence (severe) 7 MICS indicator 2.4 - Overweight prevalence 40 5.2.1 Overall Status of Child Malnutrition In Sudan, as indicated by the graph below, the overall prevalence of child malnutrition is high: one- third (33 percent) of under-five children are underweight, approximately two in five children (38.2 percent) under-five years are stunted (too short for their age), and one in six (16.3 percent) children is wasted (too thin for their height). Figure NU.1a: Percentage of underweight, stunted and wasted children under-five years in Sudan MICS, 2014 With regard to gender variation in undernutrition, boys were reported to be slightly more underweight, stunted, and wasted than girls. The age pattern shows that a higher percentage of children in the age group 12-23 months are undernourished according to all three indices in comparison to children who are in the younger and older age groups (Figure NU.1b). This pattern is expected and is related to the age group at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. 33 38.2 16.3 12 18.2 4.5 0 5 10 15 20 25 30 35 40 45 Underweight Stunting Wasting Moderate & Severe (-2SD) Severe (-3SD) 41 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Sudan MICS, 2014 5.2.2 Geographic Inequity in Child Malnutrition Table NU.2 shows that children living in the rural area are the most affected by child malnutrition. The prevalence of underweight is 23.2 percent in urban area in comparison to 37.1 percent in rural area; 17.4 percent of children living in rural area are affected by acute malnutrition in comparison to 13.4 percent for urban area. The gap is very high regarding child stunting between rural area (43 percent) and urban area (27.1 percent). In Sudan, children are mostly affected by malnutrition in the states affected by conflicts and displacements of populations; Darfur and Kordofan, and in Kassala state as indicated below: x Very high prevalence of child underweight in the states of North Darfur (44.9 percent), Central Darfur (41.0 percent), East Darfur (40.2 percent), West Kordofan (38.7 percent) and Kassala (42.0 percent) in comparison to the lowest prevalence in Northern (21.9 percent), Khartoum (23.2 percent) and White Nile (29.8 percent). x High stunting prevalence among children in the states of Kassala (48.8 percent), Blue Nile (46.7 percent), Central Darfur (47.5 percent), North Darfur (45.9 percent) and East Darfur (46.6 percent). x Severe wasting prevalence, children are likely to be affected in the states of North Darfur (8.6 percent), West Darfur (6.7 percent), Central Darfur (4.3 percent) and Kassala (5.1 percent). Underweight Stunted Wasted Overweight 0 10 20 30 40 50 60 0 12 24 36 48 60 P E R C E N T AGE IN MONTHS 42 Figure NU.1b: Percentage of underfive children stunted (moderate and severe) by State, Sudan MICS, 2014 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 Khartoum Northern River Nile South Darfor West Darfor White Nile Sinnar Sudan South Kordofan North Kordofan Gezira West Kordofan Red Sea North Darfor Gadarif East Darfor Blue Nile Central Darfor Kassala 21.9 22.6 29.5 34.2 35.2 36.6 38.1 38.2 40.6 40.8 41.6 42.5 45.4 45.9 46.0 46.6 46.7 47.5 48.8 43 Figure NU.1.c: Percentage of underfive children wasted (moderate and severe acute malnutrition) by State, Sudan MICS, 2014 5.2.3 Disparity of Child Malnutrition by Wealth Index Quintile Figure NU.1d below shows the disparity in child malnutrition by household poverty conditions measured through the wealth index calculated using household assets. The prevalence of underweight, stunting and wasting is highest among children living in poorest household respectively 39.5 percent, 44.0 percent and 20.1 percent in comparison to low prevalence of malnutrition among children living in the richest household respectively 17.8 percent, 21.1percent and 11.7percent. 0.0 5.0 10.0 15.0 20.0 25.0 30.0 Blue Nile Northern Red Sea Gezira White Nile Khartoum North Kordofan East Darfor Gadarif South Darfor Sinnar South Kordofan Sudan Central Darfor Kassala West Kordofan West Darfor River Nile North Darfor 11.1 11.4 14.0 14.0 14.4 14.5 14.8 15.3 15.4 15.9 16.0 16.3 16.3 17.8 18.5 18.7 19.1 20.1 27.9 44 Figure NU.1d: Percentage of children under five years underweight, stunted or wasted by household wealth quintile, Sudan MICS, 2014 5.2.4 Disparity in Child Malnutrition by Mother’s Education Children whose mothers have secondary or higher education are the least likely to be underweight and stunted compared to children of mothers with no education as indicated by table NU.2. 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 Underweight Stunting Wasting 39.5 44.0 20.1 17.8 21.1 11.7 Poorest Second Middle Fourth Richest 45 5.2.5 Trends in Under-five Nutritional Status from 2006 to 2014 Since 2006, the nutritional status of children in Sudan remains as very challenging issues for child survival. Using the same WHO standard reference, the figure NU1.f below indicates that there has not been any change in the prevalence of acute malnutrition. The prevalence is still over the WHO emergency threshold of 15 percent. The percentage of underweight children remains also high at the same level of approximately one-third of under-five children as estimated by all three national surveys; SHHS 2006, SHHS 2010 and MICS 2014. The prevalence of stunting has increased from 32.5 percent in 2006 to 35 percent in 2010 and to 38.2 percent in 2014. With reference to the literature, gap of knowledge of mothers of child malnutrition, the gap of capacities of health facilities, the low effective use of health services due to limited geographic access and financial barriers (poverty issue and health policy of cost recovery), low coverage of use of improved sanitation facilities (33 percent), the high prevalence of diarrhoea among children (29percent) and the continuous influx of displaced populations and refugees represent key determinant factors for increased child malnutrition in Sudan. Figure NU.1e: Trend in percentage of children underfive years that are underweight, stunted and wasted (moderate and severe), SHHS 2006, SHHS 2010 and Sudan MICS 2014 In view of equity, figure NU.1g below shows that there is an important increase of stunting (from 15 percent in 2010 to 21.1) among children living in richest household conditions in comparison to low increase affecting poorest children. However, regarding the acute malnutrition, there has been a tendency of increase of prevalence of wasting among poorest children in comparison to a decrease trend for children living in richest family conditions. 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Underweight Stunting Wasting 31.0 32.5 14.8 32.2 35.0 16.4 33.0 38.2 16.3 SHHS 2006 SHHS 2010 MICS 2014 46 Figure NU.1f: Trend in inequality of Poorest and Richest under five children underweight, stunted or wasted, SHHS 2010 and Sudan MICS, 2014 Figure NU.1g below indicates that the prevalence of stunting has increased in the states of Darfur, Kordofan, Blue Nile and Gadarif. However, the prevalence of stunting has decreased in River Nile, Read Sea, Sinnar and Northern. The prevalence of acute malnutrition has increased in Darfur from 24.4 percent in 2010 to 28 percent in 2014. 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 18.8 12.7 42.1 15.0 40.0 16.5 20.1 11.7 44.0 21.1 39.5 17.8 SHHS 2010 MICS 2014 47 Figure NU.1g: Trend in Stunted Children underfive years (moderate and severe) from SHHS 2010 to Sudan MICS 2014 5.3 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards, leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.10 10 Bhuta, Z. et al. 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 0.0 10.0 20.0 30.0 40.0 50.0 60.0 Khartoum Northern River Nile South Darfor West Darfor White Nile Sinnar Sudan South Kordofan North Kordofan Gezira West Kordofan Red Sea North Darfor Gadarif East Darfor Blue Nile Central Darfor Kassala SHHS 2010 MICS 2014 48 UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond.11 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.12 A summary of key guiding principles13, 14 for feeding 6-23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. The guiding principles for which proximate measures and indicators exist are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and (iii) appropriate nutrient content of food Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Dietary diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For dietary diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).15 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds; (ii) food items form at least 4 food groups; and (iii) breastmilk or at least 2 milk feeds (for non-breastfed children). Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups16 eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists na 11 WHO. 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February, 2003. 12 WHO. 2003. Global Strategy for Infant and Young Child Feeding. 13 PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. 14 WHO. 2005. Guiding principles for feeding non-breastfed children 6-24 months of age. 15 WHO. 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. 16 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. 49 Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na 5.3.1 Initial Breastfeeding Table NU.3 is based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.17 In Sudan, 95.6 percent of children ever breastfed. Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 68.7 percent of babies are breastfed for the first time within one hour of birth, while 87.2 percent of new-borns in Sudan start breastfeeding within one day of birth. The findings are presented in Figure NU.2 by state and area. The relative low percentage of initial breastfed children within one hour is observed in Central Darfur (48.6percent) and South Darfur (51.0percent). Figure NU.2: Initiation of breastfeeding, Sudan MICS, 2014 17 Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). 93 93 84 86 95 92 92 90 88 90 76 83 73 87 89 83 88 87 89 86 87 37 74 74 77 90 74 69 75 68 70 63 76 60 77 68 51 49 66 71 68 69 0 20 40 60 80 100 P er c en t Within one day Within one hour 50 Table NU.3 shows that early breastfeeding of children by mothers within one hour of birth represents a universal practice of mothers in Sudan irrespective of their socio-economic status, education level, location of delivery or assistance at delivery by skilled health worker. Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth, and within one day of birth, and percentage who received a pre-lacteal feed, Sudan MICS, 2014 Background characteristics Percentage who were ever breastfed [1] Percentage who were first breastfed: Percentage who received a pre- lacteal feed Number of last live-born children in the last two years Within one hour of birth [2] Within one day of birth Sudan 95.6 68.7 87.2 28.3 5,622 State Northern 99.2 36.7 93.1 44.2 92 River Nile 97.3 74.1 93.5 43.6 151 Red Sea 87.3 74.2 84.4 16.9 92 Kassala 94.9 76.6 85.5 19.5 199 Gadarif 96.8 90.2 94.6 25.7 307 Khartoum 96.9 73.7 91.9 35.9 684 Gezira 95.2 68.8 91.8 35.2 852 White Nile 97.4 74.6 89.9 42.1 273 Sinnar 97.9 68.0 87.7 32.6 226 Blue Nile 98.8 70.1 90.2 25.1 287 North Kordofan 96.9 62.8 76.0 38.6 352 South Kordofan 96.2 75.7 82.8 30.7 194 West Kordofan 88.6 59.9 72.7 11.8 341 North Darfur 95.9 77.2 86.9 10.2 525 West Darfur 93.4 68.3 89.1 3.6 179 South Darfur 95.2 51.0 82.7 28.8 556 Central Darfur 95.8 48.6 87.6 14.9 99 East Darfur 95.7 65.5 86.8 33.9 211 Area Urban 96.0 71.0 89.1 30.1 1,488 Rural 95.5 67.9 86.5 27.6 4,134 Months since last birth 0-11 months 95.5 68.9 86.2 27.0 3,001 12-23 months 95.8 68.5 88.3 29.7 2,620 Assistance at delivery Skilled attendant 96.4 70.2 88.8 28.4 4,370 Traditional birth attendant/Daya habil 96.2 65.8 84.2 26.8 1,014 Other 93.7 67.4 84.9 28.7 144 No one/Missing 57.9 33.2 48.9 35.7 94 Place of delivery Home 96.4 71.5 87.8 26.3 4,006 Health facility: Public 96.3 63.4 88.1 34.0 1,468 Health facility: Private 96.7 65.1 86.6 37.1 91 Other/Missing 22.9 16.7 18.6 1.6 57 Mother's education None 95.5 68.0 85.1 27.7 2,247 51 Background characteristics Percentage who were ever breastfed [1] Percentage who were first breastfed: Percentage who received a pre- lacteal feed Number of last live-born children in the last two years Within one hour of birth [2] Within one day of birth Primary 95.9 67.5 87.3 29.4 2,022 Secondary 94.9 73.1 89.8 25.4 942 Higher 97.3 68.8 92.0 32.5 410 Wealth index quintile Poorest 94.4 62.1 81.2 23.9 1,251 Second 95.5 69.8 86.1 22.3 1,232 Middle 97.5 73.1 89.6 30.4 1,192 Fourth 94.6 68.2 89.5 34.3 1,096 Richest 96.4 71.3 91.1 32.5 851 [1] MICS indicator 2.5 - Children ever breastfed [2] MICS indicator 2.6 - Early initiation of breastfeeding 5.3.2 Young Child Feeding The set of Infant and Young Child Feeding indicators reported in tables NU.4 through NU.8 are based on the mother’s report of children’s consumption of food and fluids during the day or night prior to being interviewed. Data are subject to a number of limitations, some related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. In Table NU.4, breastfeeding status is presented for both exclusively breastfed and predominantly breastfed. Exclusively breastfed refers to children age less than 6 months who received only breast milk (and vitamins, mineral supplements, or medicine), distinguished by the predominantly breastfed allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. In Sudan, overall 55.4 percent of children age less than six months are exclusively breastfed with limited disparity between girls (54.3 percent) and boys (56.7 percent) and between urban (53.1 percent) and rural area (56.3 percent). With 80.8 percent predominantly breastfed, it is evident that water-based liquids are displacing feeding of breastmilk to the greatest degree. 52 Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Sudan MICS, 2014 Background characteristics Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed [1] Percent pre- dominantly breastfed [2] Number of children Percent breastfed (Continued breastfeeding at 1 year) [3] Number of children Percent breastfed (Continued breastfeeding at 2 years) [4] Number of children Sudan 55.4 80.8 1,516 89.4 1,019 48.8 799 Sex Male 56.7 80.4 735 88.5 496 50.7 425 Female 54.3 81.2 781 90.1 523 46.6 375 State Northern (34.7) (79.5) 21 (93.7) 19 (48.6) 13 River Nile (38.2) (81.0) 39 (95.7) 32 (74.6) 17 Red Sea * * 17 * 14 * 21 Kassala 61.3 79.5 56 (74.9) 27 (39.8) 23 Gadarif 67.3 86.7 96 85.2 51 (37.7) 38 Khartoum 55.9 81.0 160 98.7 146 49.1 133 Gezira 50.0 83.0 226 87.7 142 52.1 154 White Nile 59.4 84.3 74 94.2 56 (58.7) 31 Sinnar 43.1 83.3 58 91.0 37 (42.1) 30 Blue Nile 54.9 90.4 70 92.1 56 40.5 48 North Kordofan 69.6 87.4 92 (92.7) 56 (36.6) 57 South kordofan 51.3 71.2 56 87.2 31 61.9 25 West Kordofan 43.5 64.2 126 83.9 68 (65.6) 35 North Darfur 75.6 90.3 121 87.0 96 (43.7) 42 West Darfur 57.0 66.7 50 82.7 25 (40.8) 22 South Darfur 50.4 84.7 155 83.4 108 41.9 79 Central Darfur 44.5 65.4 34 84.9 23 * 7 East Darfur 60.3 75.8 65 89.0 35 (54.0) 23 Area Urban 53.1 78.9 399 90.4 253 46.7 260 Rural 56.3 81.5 1,117 89.0 767 49.8 539 Mother's education None 51.6 80.0 648 85.2 447 55.2 265 Primary 57.2 81.4 581 90.6 322 42.5 302 Secondary 61.3 87.2 193 95.2 183 54.2 154 Higher 59.2 69.8 92 95.0 68 41.0 78 Missing/DK * * 1 * 0 * 0 Wealth index quintile Poorest 58.4 81.8 364 84.7 231 45.7 124 Second 55.9 77.9 350 90.5 226 49.0 158 Middle 52.4 85.2 332 91.6 229 55.2 163 Fourth 53.4 84.1 274 86.7 179 48.2 212 Richest 57.0 72.1 196 94.5 155 44.7 142 [1] MICS indicator 2.7 - Exclusive breastfeeding under 6 months [2] MICS indicator 2.8 - Predominant breastfeeding under 6 months [3] MICS indicator 2.9 - Continued breastfeeding at 1 year [4] MICS indicator 2.10 - Continued breastfeeding at 2 years ( ) Figures that are based on 25-49 unweighted cases; (*) Figures that are based on fewer than 25 unweighted cases 53 Figure NU.3: Exclusive Breastfeeding (per cent), Sudan MICS, 2014 Figure NU.4 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, with local soup named “Salega/Maraga” being of highest prevalence, even at the early age of 0-1 months. At age 4-5 months old, the percentage of children exclusively breastfed is below 20 percent. Only about 0.7 percent of children are receiving breast milk at age 2 years. 75.6 69.6 67.3 61.3 60.3 59.4 57 55.9 54.9 51.3 50.4 50 43.5 43.1 53.1 56.3 55.4 0 10 20 30 40 50 60 70 80 North Darfor North Kordofan Gadarif Kassala East Darfor White Nile West Darfor Khartoum Blue Nile South Kordofan South Darfor Gezira West Kordofan Sinnar Urban Rural Sudan 54 Figure NU.4: Infant feeding patterns by age, Sudan MICS, 2014 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 36 months, the median duration is 21.2 months for any breastfeeding, 3.1 months for exclusive breastfeeding, and 5.8 months for predominant breastfeeding. There is no significant difference of duration of breastfeeding by geographic area, mother’s education and wealth index quintile. However specific cases of very low duration of exclusive breastfeeding of children is observed in Northern and West Kordofan (0.7 months), River Nile (1.4 months) and Central Darfur (1.9 months). Exclusively breastfed Breastfed and complementary foods Weaned (not breastfed) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age in months Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk / formula Breastfed and complementary foods Weaned (not breastfed) 55 Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Sudan MICS, 2014 Background characteristics Median duration (in months) of Number of children age 0-35 months Any breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Median 21.2 3.1 5.8 8,254 Sex Male 21.3 3.1 5.7 4,200 Female 21.0 3.0 6.0 4,054 State Northern 21.2 .7 4.6 141 River Nile 23.4 1.4 6.1 224 Red Sea 23.5 3.1 4.8 145 Kassala 21.1 4.1 7.1 298 Gadarif 20.1 4.4 6.2 470 Khartoum 21.5 2.9 5.3 1,015 Gezira 21.5 2.5 5.4 1,257 White Nile 21.7 3.2 5.8 435 Sinnar 20.0 2.1 5.4 333 Blue Nile 20.1 3.1 6.7 422 North Kordofan 20.0 4.3 6.0 501 South Kordofan 21.7 2.6 5.8 302 West Kordofan 22.4 .7 5.3 499 North Darfur 20.5 4.8 6.2 682 West Darfur 20.9 4.5 7.0 276 South Darfur 20.7 2.5 6.7 823 Central Darfur 21.5 1.9 6.8 141 East Darfur 21.6 3.5 5.5 288 Area Urban 21.0 2.8 5.6 2,268 Rural 21.2 3.2 5.9 5,986 Mother's education None 21.4 2.7 6.6 3,358 Primary 20.8 3.2 5.8 2,971 Secondary 21.7 3.3 5.1 1,308 Higher 19.9 3.4 4.2 607 Wealth index quintile Poorest 21.0 3.4 6.7 1,794 Second 21.4 3.2 6.0 1,784 Middle 21.5 2.8 6.0 1,773 Fourth 21.1 2.8 5.7 1,608 Richest 20.9 3.2 4.5 1,295 Mean 21.0 3.8 6.4 8,254 [1] MICS indicator 2.11 - Duration of breastfeeding 56 The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children age 6-23 months are considered to be appropriately fed if they are receiving breastmilk and solid, semi-solid or soft food. Overall 66.0 percent of children age 6-23 months are being appropriately breastfed. Among children age 0-23 months, 63.1 percent are age-appropriate breastfeeding. There is disparity of appropriately breastfeeding practices of children aged 0-23 months by state: low level of practice is observed in Central (50.9 percent) andWest Darfur (51.2 percent), South Darfur (57.9 percent) and in West Kordofan (54.6 percent). Children from mothers of secondary or high education level and those living in richest households are the most appropriately breastfed in comparison to other groups. 57 Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Sudan MICS, 2014 Background characteristics Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed [1] Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed [2] Number of children Sudan 55.4 1,516 66.0 4,120 63.1 5,636 Sex Male 56.7 735 66.4 2,118 63.9 2,853 Female 54.3 781 65.4 2,002 62.3 2,782 State Northern (34.7) 21 83.0 74 72.4 95 River Nile 38.2 39 82.7 109 71.0 148 Red Sea (54.8) 17 69.2 72 66.4 89 Kassala 61.3 56 39.4 134 45.8 190 Gadarif 67.3 96 65.4 213 66.0 309 Khartoum 55.9 160 71.1 534 67.6 694 Gezira 50.0 226 70.9 689 65.8 915 White Nile 59.4 74 72.4 210 69.0 284 Sinnar 43.1 58 63.1 169 58.0 227 Blue Nile 54.9 70 68.3 218 65.1 288 North Kordofan 69.6 92 64.0 253 65.5 345 South Kordofan 51.3 56 65.7 132 61.4 189 West Kordofan 43.5 126 60.4 245 54.6 371 North Darfur 75.6 121 65.5 342 68.1 463 West Darfur 57.0 50 49.0 131 51.2 180 South Darfur 50.4 155 60.9 392 57.9 547 Central Darfur 44.5 34 54.1 67 50.9 101 East Darfur 60.3 65 65.0 136 63.5 202 Area 58 Background characteristics Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed [1] Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed [2] Number of children Urban 53.1 399 68.7 1,104 64.6 1,503 Rural 56.3 1,117 64.9 3,016 62.6 4,133 Mother's education None 51.6 648 60.6 1,577 57.9 2,225 Primary 57.2 581 66.0 1,478 63.5 2,059 Secondary 61.3 193 74.9 734 72.1 927 Higher 59.2 92 72.0 329 69.2 421 Missing/DK * 1 * 1 * 2 Wealth index quintile Poorest 58.4 364 59.6 848 59.2 1,212 Second 55.9 350 62.7 876 60.7 1,225 Middle 52.4 332 66.2 867 62.4 1,199 Fourth 53.4 274 68.0 867 64.5 1,142 Richest 57.0 196 75.5 661 71.3 858 [1] MICS indicator 2.7 - Exclusive breastfeeding under 6 months [2] MICS indicator 2.12 - Age-appropriate breastfeeding ( ) Figures that are based on 25-49 unweighted cases [*] Based on less than 25 unweighted cases and has been suppressed. 59 Overall, 61.2 percent of infant’s age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day (Table NU.7). Among currently breastfeeding infants this percentage is 61.1 percent while it is 63.4 percent among infants currently not breastfeeding. The practice of introduction of solid, semi-solid and soft foods to children aged of 6-8 months currently breastfeeding, varies by sex of children (62.4 percent for boys and 59.7 percent for girls) and by urban (67.9percent) and rural (58.9 percent). Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Sudan MICS, 2014 Background characteristics Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods [1] Number of children age 6-8 months Sudan 61.1 798 * 19 61.2 817 Sex Male 62.4 427 * 9 62.0 436 Female 59.7 371 * 10 60.2 381 Area Urban 67.9 192 * 5 68.1 198 Rural 58.9 605 * 14 59.0 619 [1] MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods [*] Based on less than 25 unweighted cases and has been suppressed. Table NU.8 in next page indicates that more than one-fourth of the children age 6-23 months (40.7 percent) were receiving solid, semi-solid and soft foods the minimum number of times. There is no difference of practices for boys (40.7 percent) and girls (40.7 percent) in achieving the minimum meal frequency. The proportion of children receiving the minimum dietary diversity, or foods from at least 4 food groups (28.0 percent), was much lower than that for minimum meal frequency (40.7 percent), indicating the need to focus on improving diet quality and nutrient intake among this vulnerable group. A slightly higher proportion of older (18-23 month, old) children (37.2 percent) were achieving the minimum dietary diversity compared to younger (6-8 month old) children (9.2 percent). The overall assessment using the indicator of minimum acceptable diet revealed that only 15.1 percent of children were benefitting from a diet sufficient in both diversity and frequency. A very few percentage of children are benefiting from a diet sufficient in both diversity and frequency in the states of Kassala (3.4 percent), South Darfur (6.0 percent), North Darfur (6.6 percent), Central Darfur (6.9 percent) and North Kordofan (9.0 percent). These figures unfavourably compare to the high percentages of diet sufficiency in both diversity and frequency in Northern (48.4 percent), River Nile (29.4 percent) and Sinnar (21.5 percent) states. Children from uneducated mothers/caretakers are less covered (10.8 percent) than children from higher educated mothers (30.1 percent). Children of poorest household are less benefiting from a diet sufficient in both diversity and frequency (6.4 percent) in comparison to children living in richest household conditions (29.6 percent). 60 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Sudan MICS, 2014 Background characteristics Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [1], [c] Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [2], [c] At least 2 milk feeds [3] Minimum dietary diversity [4], [a] Minimum meal frequency [5], [b] Minimum acceptable diet [c] Sudan 25.0 37.0 15.0 3,325 42.0 57.7 15.3 57.5 718 28.0 40.7 15.1 4,120 Sex Male 25.2 36.9 15.2 1,722 42.7 59.3 15.8 58.6 353 28.1 40.7 15.3 2,118 Female 24.9 37.1 14.8 1,603 41.3 56.1 14.7 56.5 365 27.9 40.7 14.8 2,002 Age 6-8 months 8.9 38.8 6.6 798 * * * * 12 9.2 38.7 6.6 817 9-11 months 25.8 34.5 15.1 589 (38.2) (48.3) (13.3) (46.3) 36 26.3 35.3 15.0 631 12-17 months 31.6 37.3 18.1 1,271 33.0 61.1 12.6 64.7 190 31.8 40.4 17.4 1,486 18-23 months 31.2 36.5 19.1 667 46.1 57.8 16.7 56.1 480 37.2 45.4 18.1 1,186 State Northern 63.3 72.8 49.8 62 (76.1) (72.2) (41.1) (56.7) 12 65.4 72.7 48.4 74 River Nile 41.5 52.1 27.8 100 * * * * 9 44.5 52.8 29.4 109 Red Sea 36.1 27.1 12.8 64 * * * * 8 36.7 30.3 13.2 72 Kassala 5.4 12.4 .3 100 (30.4) (52.1) (14.5) (72.6) 28 11.6 21.0 3.4 134 Gadarif 29.2 40.2 20.0 166 (43.7) (57.2) (19.6) (58.8) 45 32.3 43.9 19.9 213 Khartoum 39.9 26.4 12.1 435 (65.7) (51.1) (20.3) (69.2) 88 44.0 30.6 13.5 534 Gezira 23.5 50.1 19.4 559 (45.7) (68.2) (11.8) (51.8) 117 27.7 53.2 18.1 689 White Nile 31.3 39.0 19.4 178 (60.7) (72.6) (23.6) (79.0) 29 36.0 43.8 20.0 210 Sinnar 26.5 50.8 24.3 133 43.1 68.1 10.2 50.5 33 29.8 54.2 21.5 169 Blue Nile 34.4 43.6 22.3 176 71.0 61.5 21.4 59.0 41 41.7 47.0 22.1 218 61 Background characteristics Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [1], [c] Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [2], [c] At least 2 milk feeds [3] Minimum dietary diversity [4], [a] Minimum meal frequency [5], [b] Minimum acceptable diet [c] North Kordofan 16.1 37.7 10.4 201 (24.1) (37.3) (2.4) (37.1) 42 17.8 37.6 9.0 253 South Kordofan 21.4 40.5 13.6 109 34.6 59.2 15.3 42.9 22 23.5 43.6 13.9 132 West Kordofan 27.9 37.0 20.6 197 (21.0) (52.6) (12.6) (69.8) 42 26.1 39.8 19.2 245 North Darfur 7.4 30.5 6.1 266 15.0 47.4 8.5 40.4 69 8.8 34.0 6.6 342 West Darfur 22.0 25.3 12.3 107 59.3 (55.6) (25.9) (64.6) 23 28.4 30.7 14.7 131 South Darfur 13.8 22.1 4.3 309 28.0 61.5 13.2 65.2 75 16.5 29.8 6.0 392 Central Darfur 11.9 29.7 5.7 52 (25.7) (30.4) (13.2) (34.8) 10 13.8 29.8 6.9 67 East Darfur 14.1 38.8 9.0 112 (27.7) (65.8) (11.0) (47.7) 23 16.3 43.5 9.3 136 Area Urban 36.1 34.9 16.5 877 58.8 59.4 26.7 65.0 201 40.1 39.5 18.4 1,104 Rural 21.1 37.8 14.5 2,448 35.5 57.0 10.8 54.6 517 23.6 41.1 13.9 3,016 Mother's education None 16.2 31.3 10.7 1,276 27.1 55.2 11.4 57.8 271 18.4 35.5 10.8 1,577 Primary 20.4 37.5 11.0 1,186 41.3 57.4 14.7 50.0 266 24.1 41.2 11.7 1,478 Secondary 42.2 44.0 24.8 608 65.7 60.4 21.6 67.2 114 45.2 46.6 24.3 734 Higher 49.9 46.4 32.0 254 (65.7) (64.5) (22.6) (69.4) 66 53.2 50.2 30.1 329 Missing/DK * * * 0 * * * * 1 * * * 1 Wealth index quintile Poorest 10.7 28.8 6.6 680 12.4 55.5 5.4 57.3 154 11.0 33.8 6.4 848 Second 17.4 31.6 11.5 712 27.5 46.5 9.3 48.3 144 18.9 34.1 11.1 876 Middle 23.2 40.3 13.9 703 49.6 56.0 16.1 57.4 153 28.2 43.1 14.3 867 Fourth 27.6 41.3 17.2 688 52.2 68.1 17.8 58.3 159 32.3 46.3 17.3 867 62 Background characteristics Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [1], [c] Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [2], [c] At least 2 milk feeds [3] Minimum dietary diversity [4], [a] Minimum meal frequency [5], [b] Minimum acceptable diet [c] Richest 52.1 44.8 29.0 541 78.3 63.0 32.6 69.4 107 56.1 47.8 29.6 661 [1] MICS indicator 2.17a - Minimum acceptable diet (breastfed) [2] MICS indicator 2.17b - Minimum acceptable diet (non-breastfed) [3] MICS indicator 2.14 - Milk feeding frequency for non-breastfed children [4] MICS indicator 2.16 - Minimum dietary diversity [5] MICS indicator 2.15 - Minimum meal frequency [a] Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables [b] Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times [c] The minimum acceptable diet for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while it for non-breastfed children further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds ( ) Figures that are based on 25-49 unweighted cases [*] Based on less than 25 unweighted cases and has been suppressed. 63 The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of appropriate hygiene practices during preparation. Table NU.9 shows that 7.3 percent of infants Sudan are bottle fed. About 7.4 percent of children under 6 months are fed using a bottle with a nipple. Bottle-feeding of children is very prevalent in Red Sea (20.7 percent), Northern (16.7 percent) and Central Darfur (16.2 percent) states of Sudan. This practice is more common in urban areas, among richest households and in households with higher educated mothers. Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Sudan MICS, 2014 Background characteristics Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months: Sudan 7.3 5,636 Sex Male 6.9 2,853 Female 7.8 2,782 Age 0-5 months 7.4 1,516 6-11 months 9.0 1,448 12-23 months 6.4 2,672 State Northern 16.7 95 River Nile 10.3 148 Red Sea 20.7 89 Kassala 14.5 190 Gadarif 4.7 309 Khartoum 13.8 694 Gezira 5.9 915 White Nile 8.6 284 Sinnar 5.6 227 Blue Nile 1.6 288 North Kordofan 4.4 345 South Kordofan 7.4 189 West Kordofan 5.6 371 North Darfur 2.6 463 West Darfur 8.1 180 South Darfur 5.0 547 Central Darfur 16.2 101 East Darfur 5.1 202 Area Urban 10.6 1,503 Rural 6.2 4,133 Mother's education 6.0 2,225 None 5.3 2,059 Primary 9.7 927 Secondary 19.0 421 64 Background characteristics Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months: Higher * 2 Wealth index quintile Poorest 4.0 1,212 Second 5.8 1,225 Middle 5.5 1,199 Fourth 8.3 1,142 Richest 15.7 858 [1] MICS indicator 2.18 - Bottle feeding [*] Based on less than 25 unweighted cases and has been suppressed. 5.4 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). National laws required to support key nutrition interventions such as food fortification, salt iodisation and the breast milk substitute code are absent or are not been enforced. During 2014 MICS field data collection, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of indicate whether salt was tested for potassium iodide or potassium iodate content or both. Table NU.10 shows that cooking salt was tested in 93.9 percent of households surveyed. The table also shows that in 4.8 percent of households, there was no salt available. These households are included in the denominator of the indicator. As a result of absence of national law, in Sudan, only 7.6 percent of households have adequately iodized salt (which contains 15 parts per million ppm or more of iodine). Use of adequately iodized salt is lowest in States of West Kordofan (2.9 percent), Blue Nile (3.1 percent), Red Sea (3.2 percent) and Khartoum (3.3 percent) and relatively highest use in recorded in East Darfur (18.1 percent), Central Darfur (14.8 percent) and Sinnar (15.6 percent). Disparity is very low between Urban (9.0 percent) and rural area (7.0 percent). There is no difference of iodized salt consumption between the richest (8.8 percent) and poorest households (8.1 percent). Figure NU.5 below presents the percentage of adequately iodized salt and also salt containing less 15 ppm. 65 Figure NU.5: Consumption of iodized salt: Percentage of households consuming adequately iodized salt, Sudan MICS, 2014 55 42 33 35 41 29 32 25 23 28 20 24 18 22 17 19 17 14 34 35 32 36 33 36 35 34 70 54 51 45 44 44 43 36 35 32 29 27 27 26 24 23 22 17 9 7 8 8 7 7 9 8 10 30 50 70 90 110 130 P er c en t 15+ PPM of iodine Any iodine 66 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Sudan MICS, 2014 Background characteristics Percent of households in which salt was tested Number of households Percent of households with salt test result Number of households in which salt was tested or with no salt Percent of households with no salt Not iodized 0 PPM >0 and <15 PPM 15+ PPM [1] Sudan 93.9 16,801 4.8 60.7 26.8 7.6 16,574 State Northern 96.5 423 1.1 72.6 22.3 4.0 413 River Nile 98.6 666 0.9 56.0 31.5 11.5 663 Red Sea 94.6 519 3.3 79.4 14.1 3.2 508 Kassala 94.6 722 5.2 50.2 34.6 10.0 721 Gadarif 92.7 858 6.0 39.6 42.3 12.2 847 Khartoum 95.5 2,317 2.5 74.8 19.4 3.3 2,270 Gezira 96.3 2,629 3.6 63.9 27.6 4.8 2,626 White Nile 93.7 874 5.8 72.3 17.1 4.9 869 Sinnar 91.4 661 7.7 22.1 54.6 15.6 654 Blue Nile 93.4 656 6.4 66.5 24.0 3.1 654 North Kordofan 93.6 1,125 2.8 70.5 17.7 9.0 1,084 South Kordofan 94.9 462 3.5 67.2 20.2 9.1 455 West Kordofan 94.2 1,003 4.5 51.5 41.2 2.9 990 North Darfur 90.6 1,243 6.7 57.7 25.2 10.4 1,208 West Darfur 95.6 553 2.9 73.2 17.3 6.6 545 South Darfur 88.7 1,282 10.8 54.1 23.2 11.9 1,274 Central Darfur 92.5 299 5.2 51.3 28.8 14.8 292 East Darfur 89.2 508 9.8 39.5 32.6 18.1 502 Area Urban 94.9 5,000 3.6 62.8 24.6 9.0 4,921 Rural 93.5 11,801 5.4 59.9 27.7 7.0 11,652 Wealth index quintile Poorest 90.7 3,368 7.7 60.0 24.1 8.1 3,310 Second 92.2 3,592 6.2 57.5 28.3 8.0 3,534 Middle 93.2 3,339 5.5 61.2 26.6 6.7 3,293 Fourth 95.7 3,209 3.5 61.0 29.1 6.5 3,181 Richest 97.8 3,293 1.1 64.3 25.8 8.8 3,256 [1] MICS indicator 2.18 - Bottle feeding 67 5.5 Children’s Vitamin A supplementation Tables Nu.11 and Figure NU.6 below show that 78. percent of children in Sudan have received the Vitamin A during the last 6 months preceding the survey. The coverage of Vitamin A varies by State, age of children, mother’s education and wealth index quintile. Table NU.11: Children's vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Sudan MICS, 2014 Background characteristics Percentage of children who received Vitamin A during the last 6 months [1] Number of children age 6-59 months Sudan 78.1 12,565 Child’s Sex Male 78.5 6,422 Female 77.6 6,143 State Northern 83.2 215 River Nile 85.2 355 Red Sea 79.0 226 Kassala 74.3 442 Gadarif 82.3 668 Khartoum 87.1 1,576 Gezira 83.3 1,924 White Nile 83.5 636 Sinnar 83.6 497 Blue Nile 83.2 621 North Kordofan 73.6 816 South Kordofan 79.1 472 West Kordofan 55.1 767 North Darfur 81.0 1,090 West Darfur 81.2 438 South Darfur 68.4 1,171 Central Darfur 58.1 220 East Darfur 62.0 430 Area Urban 84.5 3,463 Rural 75.6 9,102 Child’s age in month 6-11 30.0 1,448 12-23 78.4 2,672 24-35 85.8 2,618 36-47 85.8 3,268 48-59 87.1 2,559 Mother's education None 73.8 5,346 Primary 80.0 4,355 Secondary 82.6 1,959 Higher 83.9 890 Wealth index quintile Poorest 67.7 2,824 68 Background characteristics Percentage of children who received Vitamin A during the last 6 months [1] Number of children age 6-59 months Second 74.6 2,666 Middle 81.4 2,624 Fourth 84.7 2,410 Richest 84.8 2,042 Figure NU.6. Percentage of children who received Vitamin A during the last 6 months in Sudan MICS, 2014 55.1 58.1 62 68.4 73.6 74.3 78.1 79 79.1 81 81.2 82.3 83.2 83.2 83.3 83.5 83.6 85.2 87.1 0 10 20 30 40 50 60 70 80 90 100 West Kordofan Central Darfor East Darfor South Darfor North Kordofan Kassala Sudan Red Sea South Kordofan North Darfor West Darfor Gadarif Northern Blue Nile Gezira White Nile Sinnar River Nile Khartoum 69 VI. Child Health 6.1 Vaccinations Providing a safe and healthy start in life for all children and avoiding child deaths due to preventable diseases are critical to the task of reducing infant and under-five mortality rates. Immunization plays a key part towards achieving the goal of reducing infant and under-five mortality rates. The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015.In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still millions of children not reached by routine immunization and as a result, vaccine- preventable diseases account for more than 2 million child deaths every year. The WHO Recommended Routine Immunizations for Children18 recommends all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B, haemophilus influenza type b, pneumonia/meningitis, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiology of disease in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly with local epidemiology and may include booster doses later in childhood. The vaccination schedule followed by the Sudan National Immunization Programme provides all the above mentioned vaccinations with birth doses of BCG, Polio, and Hepatitis B vaccines (within 24 hours of birth), three doses of the Pentavalent vaccine containing DPT, Hepatitis B, and Haemophilus influenza type b (Hib) antigens, three doses of Polio vaccine, and measles. All vaccinations should be received during the first year of life. Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the Sudan MICS 2014 are based on children aged 12-23/24-35 months. 18http://www.who.int/immunization/diseases/en.Table 2 includes recommendations for all children and additional antigens recommended only for children residing in certain regions of the world or living in certain high-risk population groups. 70 Vaccination Schedule for Sudan as of 2014 Age Vaccination Type Birth/First contact BCG International 6 weeks OPV1, Pentavalent1 , Oral drops, IM right, IM left, Thigh, oral drops 10 weeks OPV2, Pentavalent2 Oral drops, IM right, IM left, Thigh, oral drops 14 weeks OPV3, Pentavalent3 Oral drops, IM right, IM left, Thigh 9 months Measles Subcutaneously 18 months OPV Booster, DPT booster Oral Drops, IM right Thigh Information on vaccination coverage was collected for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied vaccination information from the cards onto the MICS questionnaire. If no vaccination card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations, and for Polio, DPT and Hepatitis B, how many doses were received. Information was also obtained from vaccination records at health facilities. The final vaccination coverage estimates are based on information obtained from the vaccination card and the mother’s report of vaccinations received by the child. The percentage of children age 12-23 months and 24-35 months who have received each of the specific vaccinations by source of information (vaccination card or vaccination records at health facilities and mother’s recall) is shown in Table CH.1 above and Figure CH.1 below. The denominators for the table are comprised of children age 12-23 months and 24-35 months so that only children who are old enough to be fully vaccinated are counted. In the first three columns in each panel of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the vaccination records at health facilities or the mother’s report. In the last column in each panel, only those children who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards/records, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards/records. 71 Table CH.1: Vaccinations in the first years of life Percentage of children age 12-23 months and 24-35 months vaccinated against vaccine preventable childhood diseases at any time before the survey and by their first birthday, Sudan MICS, 2014 Background characteristics Children Age 12-23

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