Swaziland - Multiple Indicator Cluster Survey -2010

Publication date: 2010

Monitoring the situation of children, women and men Multiple Indicator Cluster Survey 2010 Government of Swaziland National Emergency Response Council on HIV and AIDS United Nations Population Fund Joint United Nation’s Programme on HIV/AIDS United Nations Children’s Fund NFP United Nations Population Fund - Swaziland N AE CR H Swaziland i Swaziland Multiple Indicator Cluster Survey 2010 Final Report December 2011 ii ii The Swaziland Multiple Indicator Cluster Survey (MICS) was carried out in 2010 by the Central Statistical Office in collaboration with the United Nations Children’s Fund (UNICEF). Financial support was provided by the Government of the Kingdom of Swaziland, UNICEF, the United Nations Population fund (UNFPA), the National Emergency Response Council on HIV/AIDS (NERCHA) and the Joint United Nations Programme on HIV/AIDS. MICS is an international household survey programme developed by UNICEF. The Swaziland MICS was conducted as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Central Statistical Office and UNICEF. 2011. Swaziland Multiple Indicator Cluster Survey 2010. Final Report. Mbabane, Swaziland, Central Statistical Office and UNICEF. iii iii Preface In 2010, the Central Statistical Office (CSO) conducted the fourth round of the Multiple Indicator Cluster Survey (MICS), an international household survey developed by UNICEF to monitor progress towards the goals and targets of the Plan of Action for the World Fit For Children (WFFC) Declaration and the Millennium Declaration. The 2010 Swaziland MICS was implemented in collaboration with various ministries and agencies, including the Deputy Prime Minister’s Office, the Ministry of Health, the Ministry of Education and Training, the Ministry of Natural Resources and Energy, the National Emergency Response Council on HIV/AIDS (NERCHA), and United Nations agencies. This report presents results of the 2010 Swaziland MICS. CSO wishes to acknowledge the expert contributions of the MICS Technical and Steering Committees and the UNICEF Country Office for their invaluable guidance in all the phases of this work. We greatly appreciate the contribution and commitment made by CSO staff throughout the survey process. Special recognition is due to all field teams for working tirelessly to bring the survey to a successful conclusion. Lastly, sincere appreciation goes to all interviewed households for their time and cooperation, without which the survey could have not taken place. We are indebted to the UNICEF Global and Regional Offices for the technical backstopping for the survey. We are also grateful for the financial support from the Government of the Kingdom of Swaziland, UNICEF, UNFPA, NERCHA and UNAIDS. It is hoped that the findings will contribute to informed policies and programmes that help improve the lives of the Swazi population. Amos M. Zwane Director, Central Statistical Office iv iv Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Swaziland, 2010 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1.1 4.1 Under-five mortality rate 104 per thousand 1.2 4.2 Infant mortality rate 79 per thousand 1.3 Neonatal mortality rate 19 per thousand 1.4 Post-neonatal mortality rate 60 per thousand 1.5 Child mortality rate 27 per thousand NUTRITION Nutritional status 2.1a 2.1b 1.8 Underweight prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 5.8 1.0 percent percent 2.2a 2.2b Stunting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 30.9 10.0 percent percent 2.3a 2.3b Wasting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 0.8 0.4 percent percent Breastfeeding and infant feeding 2.4 Children ever breastfed 90.9 percent 2.5 Early initiation of breastfeeding 54.5 percent 2.6 Exclusive breastfeeding under 6 months 44.1 percent 2.7 Continued breastfeeding at 1 year 60.0 percent 2.8 Continued breastfeeding at 2 years 10.7 percent 2.9 Predominant breastfeeding under 6 months 59.2 percent 2.10 Duration of breastfeeding 13.8 months 2.11 Bottle feeding 29.8 percent 2.12 Introduction of solid, semi-solid or soft foods 66.3 percent 2.13 Minimum meal frequency 55.4 percent 2.14 Age-appropriate breastfeeding 40.3 percent 2.15 Milk feeding frequency for non-breastfed children 39.0 percent Salt iodization 2.16 Iodized salt consumption 51.6 percent Vitamin A 2.17 Vitamin A supplementation (children under age 5) 68.0 percent Low birth weight 2.18 Low birth weight infants 8.7 percent 2.19 Infants weighed at birth 91.3 percent CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage 98.2 percent 3.2 Polio immunization coverage 85.0 percent 3.3 Immunization coverage for diphtheria, pertussis and tetanus (DPT) 90.6 percent 3.4 4.3 Measles immunization coverage 97.8 percent 3.5 Hepatitis B immunization coverage 90.6 percent v v Topic MICS4 Indicator Number MDG Indicator Number Indicator Value Tetanus toxoid 3.7 Neonatal tetanus protection 79.0 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 48.1 percent 3.9 Care seeking for suspected pneumonia 57.6 percent 3.10 Antibiotic treatment of suspected pneumonia 60.5 percent Solid fuel use 3.11 Solid fuels 69.5 percent Malaria 3.12 Household availability of insecticide-treated nets (ITNs) 9.9 percent 3.13 Households protected by a vector control method 16.2 percent 3.14 Children under age 5 sleeping under any mosquito net 1.7 percent 3.15 6.7 Children under age 5 sleeping under insecticide-treated nets (ITNs) 1.5 percent 3.16 Malaria diagnostics usage 13.6 percent 3.17 Antimalarial treatment of children under 5 the same or next day 1.0 percent 3.18 6.8 Antimalarial treatment of children under age 5 1.7 percent 3.19 Pregnant women sleeping under insecticide-treated nets (ITNs) 1.7 percent 3.20 Intermittent preventive treatment for malaria 9.9 percent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 67.3 percent 4.2 Water treatment 15.0 percent 4.3 7.9 Use of improved sanitation facilities 53.8 percent 4.4 Safe disposal of child’s faeces 60.6 percent 4.5 Place for handwashing 47.0 percent 4.6 Availability of soap 88.8 Percent REPRODUCTIVE HEALTH Contraception and unmet need 5.1 5.4 Adolescent birth rate 89 per 1,000 5.2 Early childbearing 22.1 percent 5.3 5.3 Contraceptive prevalence rate 65.2 percent 5.4 5.6 Unmet need 13.0 percent Maternal and newborn health 5.5a 5.5b 5.5 Antenatal care coverage At least once by skilled personnel At least four times by any provider 96.8 76.6 percent percent 5.6 Content of antenatal care 80.6 percent 5.7 5.2 Skilled attendant at delivery 82.0 percent 5.8 Institutional deliveries 80.4 percent 5.9 Caesarean section 12.3 percent CHILD DEVELOPMENT Child development 6.1 Support for learning 50.0 percent 6.2 Father’s support for learning 9.8 percent 6.3 Learning materials: children’s books 3.8 percent 6.4 Learning materials: playthings 68.6 percent 6.5 Inadequate care 14.9 percent 6.6 Early child development index 62.0 percent 6.7 Attendance to early childhood education 33.0 percent vi vi Topic MICS4 Indicator Number MDG Indicator Number Indicator Value EDUCATION Literacy and education 7.1 2.3 Literacy rate among (young women) 94.2 percent (young men) 90.9 percent 7.2 School readiness 52.5 percent 7.3 Net intake rate in primary education 88.3 percent 7.4 2.1 Primary school net attendance ratio (adjusted) 96.5 percent 7.5 Secondary school net attendance ratio (adjusted) 47.2 percent 7.6 2.2 Children reaching last grade of primary 92.7 percent 7.7 Primary completion rate 91.3 percent 7.8 Transition rate to secondary school 84.0 percent 7.9 Gender parity index (primary school) 1.01 ratio 7.10 Gender parity index (secondary school) 1.24 ratio CHILD PROTECTION Birth registration 8.1 Birth registration 49.5 percent Child labour 8.2 Child labour 42.2 percent 8.3 School attendance among child labourers 93.0 percent 8.4 Child labour among students 42.5 percent Child discipline 8.5 Violent discipline 88.9 percent Early marriage and polygamy 8.6 Marriage before age 15 (women) 2.3 percent (men) 0.4 Percent 8.7 Marriage before age 18 (women) 10.9 Percent (men) 1.7 Percent 8.8 Young women age 15-19 currently married or in union 4.3 Percent Young men age 15-19 currently married or in union 0.0 Percent 8.9 Polygamy among women 13.1 percent Polygamy among men 6.5 percent 8.10 Spousal age difference 5-9 years (women age 20-24 years ) 21.5 percent Domestic violence 8.14 Attitudes towards domestic violence (women) 39.1 Percent (men) 33.4 percent vii vii Topic MICS4 Indicator Number MDG Indicator Number Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention (women) 58.7 percent (men) 54.6 Percent 9.2 6.3 Comprehensive knowledge about HIV prevention among young women (age 15-24 years) 58.2 Percent young men (age 15-24 years) 53.6 percent 9.3 Knowledge of mother-to-child transmission of HIV (women) 60.7 percent (men) 50.1 percent 9.4 Accepting attitude towards people living with HIV (women) 47.1 percent (men) 45.7 percent 9.5 Women who know where to be tested for HIV 94.4 percent Men who know where to be tested for HIV 90.0 Percent 9.6 Women who have been tested for HIV and know the results 47.3 Percent Men who have been tested for HIV and know the results 32.2 Percent 9.7 Sexually active young women who have been tested for HIV and know the results 59.0 percent Sexually active men who have been tested for HIV and know the results 31.6 percent 9.8 HIV counselling during antenatal care 81.5 Percent 9.9 HIV testing during antenatal care 77.4 percent Sexual behaviour 9.10 Young women who have never had sex 55.0 percent Young men who have never had sex 64.0 percent 9.11 Sex before age 15 (young women) 3.8 percent (young men) 2.6 percent 9.12 Age-mixing among sexual partners (women) 14.1 percent (men) 0.5 percent 9.13 Sex with multiple partners (women) 2.7 percent (Men) 15.4 percent 9.14 Condom use during sex with multiple partners (women) 73.1 percent (men) 69.2 percent 9.15 Sex with non-regular partners (women) 67.0 percent (men) 93.1 percent 9.16 6.2 Condom use with non-regular partners (women) 73.1 percent (men) 90.6 percent Male circumcision 9.21 Men age 15-59 circumcised 19.1 percent Orphaned children 9.17 Children living with both parents 22.1 percent 9.18 Children with at least one parent dead 23.6 percent 9.19 6.4 School attendance of orphans 97.2 percent 9.20 6.4 School attendance of non-orphans 98.6 percent Vulnerable children 29.5 percent Orphans and vulnerable children 45.1 percent viii viii Table of Contents Preface iii Summary Table of Findings iv Table of Contents viii List of Tables xi List of Figures and Boxes xvi Acronyms xix Executive Summary xxi 1. Introduction 1 Background 1 Survey objectives 2 2. Sample and Survey Methodology 4 Sample design 4 Questionnaires 4 Training and Fieldwork 6 Data processing 7 3. Sample Coverage and Characteristics of Households and Respondents 8 Sample coverage and response rate 8 Characteristics of households 8 Age and sex distribution 11 Characteristics of respondents 14 4. Child Mortality 22 Results 23 Demographic and socio-economic results 26 5. Nutrition 29 Nutritional status 29 Infant and young child feeding 32 Salt iodization 44 Vitamin A supplements 45 Low birth weight 48 6. Child Health 50 Immunization 50 Tetanus Toxoid 54 Oral rehydration treatment 56 Care seeking and antibiotic treatment of pneumonia 63 Solid fuel use 66 Malaria transmission 69 Malaria endemicity 69 ix ix Ownership of mosquito nets 70 Indoor residual spraying 72 Use of mosquito nets by children under five and pregnant women 72 Malaria diagnostic usage in children 75 Intermittent preventive treatment 75 7. Water and Sanitation 80 Use of improved and unimproved water sources 80 Household water treatment 83 Time to source water 84 Person collecting water 86 Types of sanitation facilities 87 Use and sharing of sanitation facilities 88 Disposal of child’s faeces 91 Drinking water and sanitation ladders 93 Hand washing 94 Availability of soap 95 8. Reproductive Health 99 Fertility 99 Contraception 105 Unmet need 112 Antenatal care 115 Assistance at delivery 119 Place of delivery 122 Abortions and miscarriages 122 Occurrence of stillbirths 123 Obstetric fistula 123 Age at first sex 123 9. Child Development 128 Early childhood care and education 128 Support for learning 129 Inadequate care 134 Early Childhood Development Index 136 10. Literacy and Education 139 Adult literacy 139 Pre-school attendance and school readiness 141 Primary and secondary school participation 142 Primary School attendance 143 Secondary School attendance 146 11. Child Protection 154 Birth registration 154 Child labour 157 Child Discipline 161 Early marriage 163 Median age at marriage 168 Polygamy 168 x x Spousal age difference 172 Attitudes towards domestic violence 174 Occurrence of domestic violence 177 12. HIV/AIDS and Sexual Behaviour 180 Knowledge about HIV transmission and misconception about HIV/AIDS 180 Misconceptions about HIV/AIDS among young people 186 Knowledge of mother-to-child transmission of HIV 189 Accepting attitudes towards people living with HIV/AIDS 192 Knowledge of a place for HIV testing and testing for HIV 195 Knowledge of a place for HIV testing and testing for HIV among sexually active youth 198 HIV testing during antenatal care 201 Sexual behaviour related to HIV transmission 203 Sex with multiple partners and condom use 206 Sex with multiple partners among young women and men 209 Sex with non-marital, non-cohabiting partner and condom use 212 13. Sexually Transmitted Infections 215 Knowledge of STIs and symptoms of STIs 215 Knowledge of STIs for partners 218 Self-reporting 218 Actions taken for a STI or symptoms of a STI 223 Informing partners of STI or STI symptoms 226 14. Male Circumcision 229 Prevalence of male circumcision and age at circumcision 229 Main reason for circumcision 231 Main reason for non-circumcision 231 Attitudes towards male circumcision for sons 232 15. Orphaned and Vulnerable Children 236 Children’s living arrangements, orphanhood and vulnerability status 236 Basic material needs among orphaned and vulnerable children 240 School attendance among OVC 242 Malnutrition among OVC 245 Sexual behaviour among OVC 247 References 249 Appendix A. Sample Design A1 Appendix B. List of personnel involved in the survey A8 Appendix C. Estimates of sampling errors A13 Appendix D. Data quality tables A38 Appendix E. MICS Indicators: Numerators and Denominators A56 Appendix F. Questionnaires A64 Appendix G. Referral Forms A145 xi xi List of Tables Preface iii Summary Table of Findings iv Table of Contents viii List of Tables xi List of Figures and Boxes xvi Acronyms xix Executive Summary xxi 1. Introduction 1 2. Sample and Survey Methodology 4 3. Sample Coverage and Characteristics of Households and Respondents 8 Table HH.1: Results of household, women's, men's and under-fives’ interviews 9 Table HH.2: Household age distribution by sex 10 Table HH2A: Population distribution by sex 11 Table HH.4: Women's background characteristics 16 Table HH.4M: Men's background characteristics 17 Table HH.5: Under-fives’ background characteristics 18 Table HH.6: Current marital status: women 20 Table HH.6M: Current marital status: men 21 4. Child Mortality 22 Table CM.1: Early childhood mortality rates 24 Table CM.2: Early childhood mortality rates by socio-economic characteristics 27 Table CM.3: Early childhood mortality rates by demographic characteristics 28 5. Nutrition 29 Table NU.1: Nutritional status of children 31 Table NU.2: Initial breastfeeding 34 Table NU.3: Breastfeeding 37 Table NU.4: Duration of breastfeeding 39 Table NU.5: Age-appropriate breastfeeding 40 Table NU.6: Introduction of solid, semi-solid or soft food 41 Table NU.7: Minimum meal frequency 42 Table NU.8: Bottle-feeding 43 Table NU.9: Iodized salt consumption 45 Table NU.10: Children's vitamin A supplementation 47 Table NU.11: Low birth weight infants 49 6. Child Health 50 Table CH.1: Vaccinations in the first year of life 51 Table CH.2: Vaccinations by background characteristics 53 Table CH.3: Neonatal tetanus protection 55 xii xii Table CH.4: Oral rehydration solutions and recommended homemade fluids 58 Table CH.4A: Preparation of recommended homemade fluids for treatment of diarrhoea 59 Table CH.5: Feeding practices during diarrhoea 61 Table CH.6: Oral rehydration therapy with continued feeding and other treatments 62 Table CH.7: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia 64 Table CH.8: Knowledge of the two danger signs of pneumonia 65 Table CH.9: Solid fuel use 67 Table CH.10: Solid fuel use by place of cooking 68 Table CH.10A: Malaria endemicity 70 Table CH.11: Household availability of insecticide-treated nets and protection by a vector control methods 71 Table CH.11A: Indoor residual spraying 73 Table CH.12: Children sleeping under mosquito nets 74 Table CH.14: Anti-malarial treatment of children with anti-malarial drugs 76 Table CH.15: Malaria diagnostics usage 78 Table CH.16: Intermittent preventive treatment for malaria 79 7. Water and Sanitation 80 Table WS.1: Use of improved water sources 82 Table WS.2: Household water treatment 83 Table WS.3: Time to source of drinking water 85 Table WS.4: Person collecting water 87 Table WS.5: Types of sanitation facilities 89 Table WS.6: Use and sharing of sanitation facilities 90 Table WS.7: Disposal of child's faeces 92 Table WS.8: Drinking water and sanitation ladders 96 Table WS.9: Water and soap at place for hand washing 97 Table WS.10: Availability of soap 98 8. Reproductive Health 99 Table RH.1A: Current fertility 100 Table RH.1: Adolescent birth rate and total fertility rate 100 Table RH.2: Early childbearing 102 Table RH.3: Trends in early childbearing 103 Table RH.4A: Use of contraception: women currently married or in union 106 Table RH.4: Use of contraception: all women 108 Table RH.4B: Non-use of contraception: women currently married or in union 110 Table RH.5: Unmet need for contraception 114 Table RH.6: Antenatal care provider 116 Table RH.7: Number of ANC visits 117 Table RH.8: Content of antenatal care 118 Table RH.9: Assistance during delivery 120 Table RH.10: Place of delivery 121 Table RH.10A: Occurrence of abortions or miscarriages 124 Table RH.10B: Occurrence of stillbirth 125 Table RH.10C: Information on fistula 126 Table RH.10D: Median age at first sex 127 9. Child Development 128 xiii xiii Table CD.1: Early childhood education 131 Table CD.2: Support for learning 132 Table CD.3: Learning materials 133 Table CD.4: Inadequate care 135 Table CD.5: Early child development index 138 10. Literacy and Education 139 Table ED.1A: Literacy among young women and men 140 Table ED.2: School readiness 142 Table ED.3: Primary school entry 144 Table ED.4: Primary school attendance 145 Table ED.5: Secondary school attendance 148 Table ED.6: Children reaching the last grade of primary school 149 Table ED.7: Primary school completion and transition to secondary school 151 Table ED.8: Education gender parity 152 Table ED.8A: School attendance 153 11. Child Protection 154 Table CP.1: Birth registration 155 Table CP.1A: Reasons for not registering the birth 156 Table CP.2: Child labour 159 Table CP.3: Child labour and school attendance 160 Table CP.4: Child discipline 162 Table CP.5: Early marriage and polygamy: women 165 Table CP.5M: Early marriage and polygamy: men 166 Table CP.6: Trends in early marriage: women 167 Table CP.6M: Trends in early marriage: men 167 Table CP.6B: Marriage status and median age at marriage 169 Table CP.6C: Age at first marriage and polygamy: women 170 Table CP.6CM: Age at first marriage and polygamy: men 171 Table CP.7: Spousal age difference: women 173 Table CP.11: Attitudes toward domestic violence: women 175 Table CP.11M: Attitudes toward domestic violence: men 176 Table CP.12: Occurrences of domestic violence: women 178 Table CP.12M: Occurrences of domestic violence: men 179 12. HIV/AIDS and Sexual Behaviour 180 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission: women 182 Table HA.1M: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission: men 184 Table HA.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission among young people: women 187 Table HA.2M: Knowledge about HIV transmission, misconceptions about HIV/AIDS and comprehensive knowledge about HIV transmission among young people: men 188 Table HA.3: Knowledge of mother-to-child HIV transmission: women 190 Table HA.3M: Knowledge of mother-to-child HIV transmission: men 191 Table HA.4: Accepting attitudes toward people living with HIV/AIDS: women 193 Table HA.4M: Accepting attitudes toward people living with HIV/AIDS: men 194 xiv xiv Table HA.5: Knowledge of a place for HIV testing: women 196 Table HA.5M: Knowledge of a place for HIV testing: men 197 Table HA.6: Knowledge of a place for HIV testing among sexually active young women 199 Table HA.6M: Knowledge of a place for HIV testing among sexually active young men 200 Table HA.7: HIV counseling and testing during antenatal care: women 202 Table HA.8: Sexual behaviour that increases the risk of HIV infection: women 204 Table HA.8M: Sexual behaviour that increases the risk of HIV infection: men 205 Table HA.9: Sex with multiple partners: women 207 Table HA.9M: Sex with multiple partners: men 208 Table HA.10: Sex with multiple partners: women 210 Table HA.10M: Sex with multiple partners: men 211 Table HA.11: Sex with non-regular partners: women 213 Table HA.11M: Sex with non-regular partners: men 214 13. Sexually Transmitted Infections 215 Table ST.1: Knowledge of Sexually Transmitted Infections: women 216 Table ST.1M: Knowledge of Sexually Transmitted Infections: men 217 Table ST.2: Knowledge of Sexually Transmitted Infections: women 219 Table ST.2M: Knowledge of Sexually Transmitted Infections: men 220 Table ST.3: Self-reported prevalence of STIs and STI symptoms: women 221 Table ST.3M: Self-reported prevalence of STIs and STI symptoms: men 222 Table ST.4: Actions taken when STI or STI symptoms: women 224 Table ST.4M: Actions taken when STI or STI symptoms: men 225 Table ST.5: Informing partners of STI or STI symptoms: women 227 14. Male Circumcision 229 Table MC.1: Male Circumcision 230 Table MC.2: Reasons for male circumcision 233 Table MC.3: Reasons for male circumcision 234 Table MC.4: Attitudes towards male circumcision 235 15. Orphaned and Vulnerable Children 236 Table HA.12: Children's living arrangements and orphanhood 237 Table OV.1: Prevalence of orphanhood and vulnerability among children 239 Table OV.2: Possession of basic material needs by orphans and vulnerable children 241 Table OV.03: School attendance of orphans and vulnerable children 243 Table OV.03A: School attendance of orphans and vulnerable children 244 Table OV.04: Nutritional status of OVCs and non-OVCs 246 Table OV.05: Sexual intercourse before age 15 by OVC status 248 References 249 Appendix A. Sample Design A1 Table 1: Total number of 2007 Census EAs and households by region and rural/urban residence, Swaziland A2 Table 2: Allocation of sample EAs and number of households by region, urban and rural stratum, Swaziland MICS, 2010 A3 Appendix B. List of personnel involved in the survey A8 Appendix C. Estimates of sampling errors A13 xv xv Table SE.1: Indicators selected for sampling error calculations A15 Table SE.2: Sampling errors: national A17 Table SE.3: Sampling errors: urban areas A20 Table SE.4: Sampling errors: rural areas A23 Table SE.5: Sampling errors: Hhohho A26 Table SE.6: Sampling errors: Manzini A29 Table SE.7: Sampling errors: Shiselweni A32 Table SE.8: Sampling errors: Lubombo A35 Appendix D. Data quality tables A38 Table DQ.1: Age distribution of household population A38 Table DQ.2: Age distribution of eligible and interviewed women A39 Table DQ.2M: Age distribution of eligible and interviewed men A39 Table DQ.3: Age distribution of under-fives in household and under-5 questionnaires A40 Table DQ.4: Women's completion rates by socio-economic characteristics of households A41 Table DQ.4M: Men's completion rates by socio–economic characteristics of households A42 Table DQ.5: Completion rates for under-5 questionnaires by socio-economic characteristics of households A43 Table DQ.6: Completeness of reporting A44 Table DQ.7: Completeness of information for anthropometric indicators A45 Table DQ.7: Completeness of information for anthropometric indicators A46 Table DQ.8: Heaping in anthropometric measurements A47 Table DQ.9: Observation of bednets and places for hand washing A47 Table DQ.10: Observation of women's health cards A48 Table DQ.11: Observation of under-fives birth certificates A48 Table DQ.12: Observation of vaccination cards A49 Table DQ.13: Presence of mother in the household and the person interviewed for the under-five questionnaire A49 Table DQ.14: Selection of children age 2–14 years for the child discipline module A50 Table DQ.15: School attendance by single age A51 Table DQ.16: Sex ratio at birth among children ever born and living A52 Table DQ.17: Births by calendar years A53 Table DQ.18: Reporting of age at death in days A54 Table DQ.19: Reporting of age at death in months A55 Appendix E. MICS Indicators: Numerators and Denominators A56 Appendix F. Questionnaires A64 Appendix G. Referral Forms A145 xvi xvi List of Figures and Boxes Preface iii Summary Table of Findings iv Table of Contents viii List of Tables xi List of Figures and Boxes xvi Acronyms xix Executive Summary xxi 1. Introduction 1 Box 1: A commitment to action: national and international reporting responsibilities 1 2. Sample and Survey Methodology 4 3. Sample Coverage and Characteristics of Households and Respondents 8 Figure HH.1: Age and sex distribution of household population, Swaziland, 2010 11 4. Child Mortality 22 Figure CM.1: Trend in under-five mortality rates, Swaziland, 2010 25 5. Nutrition 29 Figure NU.1: Percentage of children under age five who are underweight, stunted and wasted, Swaziland, 2010 32 Figure NU.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Swaziland, 2010 35 Figure NU.3: Percentage distribution of children age 0–23 months by feeding pattern, Swaziland, 2010 36 Figure NU.4 Percentage of households consuming adequately iodized salt, Swaziland, 2010 44 Figure NU.5 Percentage of infants weighing less than 2,500 grams at birth, Swaziland, 2010 49 6. Child Health 50 Box 2: Swaziland National Immunization Calendar 50 Figure CH.1 Percentage of children aged 12–23 months who received the recommended vaccinations by 12 months, Swaziland, 2010 52 Figure CH.2 Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus, Swaziland, 2010 54 7. Water and Sanitation 80 Figure WS.1 Percent distribution of household members by source of drinking water Swaziland, 2010 81 Figure WS.2: Percentage distribution of person who usually collects water in the household, Swaziland, 2010 86 Figure WS.3: Percentage of households using both improved drinking water sources and improved sanitation facilities, Swaziland, 2010 94 8. Reproductive Health 99 xvii xvii Figure RH.1: Percentage of women age 20–24 years who have had a live birth before age 18, Swaziland, 2010 101 Figure RH.2: Percentage of currently married or in-union women age 15–49 years and currently married or in-union men age 15-59 years who are using (or partner is using) a contraceptive method, Swaziland, 2010 104 Figure RH.3: Percentage of women age 15–49 years and men age 15–59 years who are using (or partner is using) a contraceptive method, Swaziland, 2010 104 Figure RH. 4: Reasons for non-use of contraception among currently married women and men, Swaziland, 2010 112 9. Child Development 128 10. Literacy and Education 139 Figure ED.1: Percentage of children attending the first grade who attended pre-school in the previous year, Swaziland, 2010 141 Figure ED.2: Percentage of children of secondary school age attending secondary school or higher and percentage of children attending primary school, Swaziland, 2010 146 11. Child Protection 154 Figure CP.1: Percentage of women age 15–49 years and men 15–59 years who have ever been hit or beaten by husband/partner on such occasions, and whether it has happened during the year before the survey, Swaziland, 2010 177 12. HIV/AIDS and Sexual Behaviour 180 Figure HA.1: Percentage of women who have comprehensive knowledge of HIV/AIDS transmission, Swaziland, 2010 181 Figure HA.1A: Percentage of men who have comprehensive knowledge of HIV/AIDS transmission, Swaziland, 2010 181 Figure HA.2A: Percent of men and women who have heard of AIDS and who expressed an accepting attitude towards people living with HIV/AIDS, Swaziland, 2010 192 Figure HA3: Women and men who knows where to be tested for HIV, have been tested and have received results, Swaziland, 2010 198 Figure HA.4: percentage of women and men who had sex with more than one partner in the last 12 months by sex, Swaziland, 2010 209 Figure HA.5: Percentage of men and women age 15–24 years who had sex with a non-marital, non- cohabiting partner in the last 12 months, who also reported that a condom was used the last time they had sex with such a partner, Swaziland, 2010 212 13. Sexually Transmitted Infections 215 Figure ST.1: Percentage of women and men with STI or symptoms of STI who sought advice from various health facilities, Swaziland, 2010 223 Figure ST.2: Reasons for not seeking treatment for STI after knowing their STI status, Swaziland, 2010 228 14. Male Circumcision 229 Figure MC.1: Percentage of men aged 15-59 who have been circumcised by age groups, Swaziland, 2010 231 15. Orphaned and Vulnerable Children 236 Figure OV.1: Percentage of children orphaned or vulnerable by region and area of residence, Swaziland, 2010 238 Figure OV2: Percentage of children orphaned or vulnerable by wealth, Swaziland, 2010 239 xviii xviii Figure OV.3: Possession of basic material needs among children age 5–17 years, orphaned and vulnerable children, Swaziland, 2010 240 Figure OV.4: Percentage of children under age five stunted by OVC status, Swaziland, 2010 245 Figure OV.5: Percentage of children under age five underweight by OVC status, Swaziland, 2010 245 References 249 Appendix A. Sample Design A1 Appendix B. List of personnel involved in the survey A8 Appendix C. Estimates of sampling errors A13 Appendix D. Data quality tables A38 Appendix E. MICS Indicators: Numerators and Denominators A56 Appendix F. Questionnaires A64 Appendix G. Referral Forms A145 xix xix Acronyms AIDS Acquired Immune-Deficiency Syndrome ANC Antenatal Care ART Anti-Retroviral Therapy BCG Bacillus Calmette-Guérin (tuberculosis vaccine) BFHI Baby Friendly Hospital Initiative CDC Centers for Disease Control and Prevention CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CPR Contraceptive Prevalence Rate CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DPT Diphtheria, Pertussis, Tetanus EA Enumeration Area ECCE Early Childhood Care and Education ECCI Early Childhood Care Index EFA Education For All EPI Expanded Programme on Immunization GDP Gross Domestic Product GPI Gender Parity Index HIV Human Immunodeficiency Virus HMIS Health Management Information System IDD Iodine Deficiency Disorders IGME Inter-agency Group for Child Mortality Estimation ILO International Labour Organization IPT Intermittent preventive therapy (for malaria) IRS Indoor Residual Spraying ITN Insecticide-treated Net IUD Intrauterine device LAM Lactational amenorrhea method LLIN Long-lasting Insecticide Net MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MoEPD Ministry of Economic Planning and Development MoET Ministry of Education and Training MoH Ministry of Health MTCT Mother-to-Child Transmission (of HIV) NAR Net Attendance Ratio NERCHA National Emergency Response Council on HIV/AIDS NGO Non-governmental Organization NPA National Plan of Action for Children NCP Neighbourhood Care Point NSF National Multi-Sectoral Strategic Framework for HIV/AIDS ORS Oral Rehydration Salts xx xx ORT Oral Rehydration Therapy OVC Orphaned and Vulnerable Children PMTCT Prevention of Mother-to-Child Transmission ppm Parts per million PSU Primary Sampling Unit SACMEQ Southern and Eastern Africa Consortium for Monitoring Educational Quality SDHS Swaziland Demographic and Health Survey SPSS Statistical Package for Social Sciences STI Sexually transmitted infection TB Tuberculosis TFR Total Fertility Rate UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDAF United Nations Development Assistance Framework UNFPA United Nations Population Fund UNGASS United Nations General Assembly 26th Special Session UNICEF United Nations Children’s Fund WFFC World Fit For Children WFP World Food Programme WHO World Health Organization xxi xxi Executive Summary This report presents results of the fourth round of the Multiple Indicator Cluster Survey (MICS) carried out by Central Statistical Office (CSO) in 2010. MICS is an international household survey initiative developed by UNICEF to monitor progress towards the goals and targets of the Plan of Action for the World Fit For Children (WFFC) Declaration and the Millennium Declaration. The 2010 Swaziland MICS was designed to provide estimates for indicators on the situation of the country at the national level, for urban and rural areas, and for the four administrative regions of Swaziland: Hhohho, Manzini, Shiselweni and Lubombo. The 2010 Swaziland MICS consists of four main questionnaires including a household questionnaire, women’s and men’s questionnaires and a questionnaire for children under age five. The survey includes information on key indicators on the following topics: Household questionnaire: age, sex, urban vs. rural residency, household composition, education of household members, household assets, water and sanitation, use of iodized salt, use of insecticide- treated nets (ITNs), orphanhood and vulnerability of children, child labor and child discipline. Questionnaire for children under five: birth registration, early childhood development, infant and young child feeding, care of illness (including diarrhoea and pneumonia), malaria, immunization and anthropometry. Women’s questionnaire: child mortality, birth history, desire for last birth, maternal an newborn health, illness symptoms, contraception, unmet need, marriage/union, sexual behaviour, HIV/AIDS, sexually transmitted infections (STIs), and attitudes towards domestic violence. Men’s questionnaire: marriage/union, attitudes towards contraception, sexual behaviour, HIV/AIDS, STIs, male circumcision and attitudes towards domestic violence. Sample Coverage The 2010 Swaziland MICS is based on a nationally representative sample of 5,475 households selected from 365 enumeration areas distributed in the four regions of the country. The target populations were men age 15–59 years, women age 15–49 years and children under five years of age. Among the sampled households, a total of 4,834 households were successfully interviewed, which included 4,956 women age 15–49 years, 4,646 men age 15–59 years and 2,711 children age five years. Response rates were generally high for all target population. The overall household response rate was 95 percent. Child Mortality Identifying groups of children with the highest risk of dying enables policy makers and programme planners to better channel resources and efforts to improve child survival and lower the exposure of infants and young children to risk. Age specific child mortality is defined as follows:  Neonatal mortality: the probability of dying within the first month of life  Infant mortality: the probability of dying before the first birthday  Postneonatal mortality: the difference between infant and neonatal mortality  Child mortality: the probability of dying between the first and fifth birthday  Under-five mortality: the probability of dying between birth and the fifth birthday xxii iv In the 2010 Swaziland MICS, a direct method based on birth histories of women was used to estimate child mortality rates in Swaziland. All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. The results indicate that infant mortality in the five years preceding the survey is 79 per 1,000 live births and under-five mortality in the five years preceding the survey is 104 per 1, 000 live births. Nutrition Children’s nutritional status is a reflection of their overall health. When children are not exposed to repeated illnesses, are well cared for and have access to an adequate food supply – varied enough and rich in micronutrients, such as vitamin A – they have better chances to reach their growth potential. In the 2010 Swaziland MICS, weights and heights of all children under five years of age were measured using anthropometric equipment recommended by UNICEF. The reference population used in this report is based on new WHO growth standards. Underweight: Nationally, six percent of children under five are underweight, i.e., they are thin for their age. Children most affected are those within 6–11 months of age (nine percent), those born from mothers with no or primary education and those from the poorest households (eight percent) for each group. Stunting: Overall, 31 percent of under-five children are stunted, i.e., they are short for their age. Stunting is more prevalent in rural areas compared with urban areas (33 percent vs. 23 percent). The stunting rate is especially high in Shiselweni region (38 percent). Children whose mothers have no education or primary education and those from the poorest households have the highest rates of stunting (40 percent, 38 percent and 42 percent, respectively). Wasting: Only one percent of under-five children are wasted, meaning that they are thin for their height. Overweight: Eleven percent of under-five children are overweight for their age. WHO guidelines on infant and young child feeding recommend that infants be breastfed within one hour of birth, breastfeed exclusively for the first six months of life and continue to breastfeed for two years or more, while introducing nutritionally adequate, safe and age appropriate, complementary feeding starting at six month. The Swaziland MICS shows that 55 percent of children are breastfed within the first hour of birth and 44 percent of children less than six months are exclusively breastfed. The mean duration of exclusive breastfeeding is three months. Further analysis shows that other foods are introduced too early before the age of six months. At six months of age onwards, children should be introduced to two or more meals of solid, semi- solid or soft foods. Only 67 percent children 6–8 months are introduced to other foods and 53 percent are fed adequately, which means they receive solids, semi-solids and soft foods a minimum number of times required per day. Thirty percent of children 0–2 months are bottle-fed. Use of non-iodized salt can pose a risk to children’s mental growth and development and can contribute to poor school performance, reduced intellectual ability and impaired work performance. Only 52 percent of households use iodized salt. Use of adequately iodized salt is lowest in the Lubombo region (41 percent) and highest in the Hhohho region (61 percent). Fifty-seven percent of urban households were found to be using adequately iodized salt compared with 49 percent in rural areas. Vitamin A is essential for proper functioning of the immune system, including eye health. The 2010 Swaziland MICS shows that 68 percent of children xxiii v age 6–59 months received vitamin A during the six months preceding the survey. The percentage of children who received vitamin A supplementation was highest in the Shiselweni region (81 percent) and lowest in the Lubombo region (55 percent). Low birth weight is when a newborn baby weighs less than 2,500 grams. This carries a range of critical health risks for children, such as death during their early months and years, and those who survive have impaired immune function and increased risk of disease among other risks. The 2010 Swaziland MICS shows that nine percent of infants have low birth weight. The low birth weight prevalence is higher for children born from mothers with no education (12 percent) compared with those born from mothers with high education (five percent). Child Health Overall, 83 percent of children aged 12–23 months are fully immunized before they reach their fifth birthday. Almost all these children receive recommended vaccinations at birth; 98 percent and 97 percent received BCG and polio vaccination at birth, respectively. The coverage for measles vaccine by 12 months is 98 percent. The tetanus toxoid vaccine (TT) prevents tetanus among pregnant women and among infants. Nationally, 79 percent women age 15–49 years with a live birth in the last 12 months received TT. A higher proportion of women residing in the Manzini region (84 percent) are vaccinated against tetanus compared with those in the Hhohho and Lubombo regions (75 percent and 74 percent, respectively). The 2010 Swaziland MICS found that 16 percent of children had diarrhoea the two weeks preceding the survey. A total of 81 percent of these children received oral rehydration therapy (ORT), that is, they received an oral rehydration solution or a recommended sugar salt solution with increased fluids while only 48 percent received ORT and continued feeding. Educating mothers or caretakers on the signs of pneumonia is important to this major killer of young children. The two most dangerous signs of pneumonia for children are fast breathing and difficult breathing. The survey indicates that only two percent of mothers know of these two danger signs. Nationally, 11 percent of households have at least one mosquito net. Ownership of a mosquito net is higher among households in endemic areas compared with those in non-endemic areas (28 percent vs. three percent). Twelve percent of households had interior walls sprayed to prevent against mosquitoes in the past 12 months. Indoor residual spraying (IRS) is high in households within endemic areas (36 percent) and in households located in the Lubombo region (50 percent). Use of mosquito nets is low for both children and pregnant women (2 percent). Sleeping under an ITN for these populations is most common in malaria-endemic areas and in the Lubombo region. However, caution is necessary when interpreting the results as the survey was conducted in August– November, a period outside the malaria transmission period. Water and Sanitation Nationally, 67 percent of the population is using an improved source of drinking water – 91 percent in urban areas and 60 percent in rural areas. The main source of drinking water is piped water into the dwelling, yard or plot (used by 37 percent of the population), followed by a public tape (16 percent). Improved water sources are piped water into the dwelling, yard or plot, a public water tap, a borehole, a protected well, and a protected spring or rain water. Improved sanitation facilities refer to: (1) flush or pour-flush to a piped water system, a septic tank or pit latrine; (2) a ventilated improved pit latrine; and (3) a pit latrine with a slab. Data form the 2010 Swaziland MICS indicate that 54 percent of the population use improved (and non-shared) sanitation. A total of 15 percent use the veld or xxiv vi open place for excreting waste. Open defecation is most common in the Lubombo region (27 percent), in rural areas (20 percent), among populations with no education (30 percent) and those from the poorest households (47 percent). Hand washing with water and soap is an effective measure to prevent the spread of diarrhoea and other communicable diseases among children. Seventy-four percent of the households have visible places for hand washing and of these 47 percent have both water and soap available. Reproductive Health Overall, a Swazi woman gives birth to 3.7 children during her entire reproductive lifespan. Rural women have a higher fertility rate (3.9) compared with urban women (3.1). Sexual debut is earlier for women compared with men. By the time women reach the age of 17, half of them would have had their first sex, while among men this occurs at age 19. The contraceptive prevalence is 65 percent among married or in union women and 49 percent for all women. The most frequently used contraceptive methods are male condoms (used by 22 percent of married or in union women), injectables (15 percent) and pills (7 percent). The total unmet need, i.e., the proportion of women who are not using any method of contraception but who wish to postpone the next birth or who wish to stop childbearing altogether, is 13 percent. Ninety-seven percent of pregnant women visit qualified health personnel for ANC and most (77 percent) visit four or more times. Overall, 80 percent of deliveries occur in health facilities and 82 percent of pregnant women are delivering babies with the assistance of skilled personnel. A total of 15 percent of deliveries occur at home. Nine percent of women who have ever been pregnant had an abortion or miscarriage. Two percent of ever pregnant women have at least one stillbirth. Almost eight percent of women in the reproductive age group who gave birth the two years preceding the survey have or have had obstetric fistula, a condition in which a woman suffers from incontinence of urine and/ or stool. Child Development In Swaziland, one in three children age 36–59 months is attending Early Childhood Care and Education (ECCE). There are marked differences of attendance by region with the highest attendance rate in Lubombo (49 percent) and the lowest attendance rate in Manzini (23 percent). Engagement of adult household members in activities that promote learning and school readiness (such as playing, reading, counting and drawing) for children age 36–59 months is essential. Overall, among 50 percent of the children, an adult household member participated in more than four activities that promote learning and school readiness during the three days preceding the survey. Sixty-nine percent of children age 0–59 months had two or more types of playthings to play with in their homes. However, only four percent of households have three or more books to enhance learning for these children. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. The results reveal that 15 percent of under-five children are exposed to that risk. The practice is more common in rural areas (16 percent of children) than in urban area (10 percent). Literacy and Education The literacy rate is 94 percent among women age 15-24 years and 91 percent among men age 15–24 years. Overall, 53 percent of children attended pre-school the previous year. Pre-school attendance is higher xxv vii among children residing in urban areas compared with those in rural areas (74 percent vs. 50 percent). Regional disparity is also pronounced; 62 percent of first graders in Hhohho and Manzini attended pre-school compared with 44 percent for Shiselweni and 40 percent for Lubombo. Nationally, 97 percent of children age 6–12 years attend primary or secondary school. The net primary school attendance is 96 percent for boys and 97 percent for girls, indicating gender parity in primary school attendance. School attendance is substantially lower for secondary school children, with a net secondary school attendance ratio of 47 percent. There is a high proportion of over-aged children in primary and secondary schools: out of children age 13–17 years who are expected to be in secondary school at the beginning of the 2010 school year, 14 percent of those age 17 years were still in primary school. About 40 percent of children age 15 years and 25 percent of children age 16 years were still attending primary school. The primary completion rate is the ratio of the total number of students, regardless of age, entering the last grade of primary school for the first time, to the number of children of the primary graduation age at the beginning of the current (or most recent) school year. The rate can exceed 100 percent. In Swaziland, the primary school completion rate is 91 percent. The high completion ratio is likely to reflect the high proportion of secondary school going age children still attending primary school. The transition rate to secondary school is defined as the proportion 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 to the total number of children who are attending the first grade of secondary school. The transition rate to secondary school in Swaziland is 84 percent. Child Protection The Birth, Marriage and Death Registration Act mandates the compulsory registration of births in Swaziland. The target in 2011 is to increase the registration of births to 80 percent by year 2015. The 2010 Swaziland MICS found that overall, 50 percent of children under five years have been officially registered and 30 percent own birth certificates. In the 2010 Swaziland MICS, a child is considered to be involved in child labour activities at the moment of the survey if during the week preceding the survey they did 28 hours of domestic work or at least one hour of economic work for those age 5–11 years or 14 hours of economic work for those age 12–14 years. The survey found that overall, 42 percent of children in Swaziland engage in child labour. This largely reflects a high proportion of children age 5–11 years performing one or more hours of economic work (59 percent). Overall, child labour is more prevent in rural areas compared to urban areas (46 percent vs. 20 percent) and is highest in the Lubombo region (49 percent). The levels of child discipline are high. Eighty-nine percent of children age 2–14 years experience at least one form of psychological aggression or physical punishment by their caretakers or other household members. Boys are more prone to receiving physical discipline than girls. Noteworthy is that 82 percent of respondents believe that children should be physically punished. Overall, (39 percent) of women and (33 percent) of men believe that there are circumstances under which hitting their partner could be justified. For both women and men, the most frequently cited reason was when spouses or partners ‘sleep with another man or woman.’ It is interesting to note that the percentage of respondents that believe that spouse/partner beating could be justified is the highest among the youngest age groups (15–19 years and 20–24 years). xxvi viii HIV and AIDS Nationally, almost all women and men (99 percent) have heard of HIV. However, only 59 percent of women and 55 percent of men have comprehensive knowledge about HIV transmission. Knowledge of a place to get tested is 94 percent for women and 90 percent for men. More women have ever been tested (73 percent) compared with men (47 percent). The proportion of women and men ever been tested for HIV and received results is relatively low, at 47 percent for women and 32 percent for men. Eighty-nine percent of women who attended ANC tested for HIV during pregnancy. In the 2010 Swaziland MICS, a sexual behaviour module was administered to women age 15–49 years and men age 15–59 years to assess risk of HIV infection. The results are also tabulated separately for young women and men (age 15–24 years). The survey found that nationally, 55 percent of never married women age 15–24 years and 64 percent of never married men age 15–24 years have never had sex. Only a small proportion (four percent of women age 15–24 years and three percent of men age 15–24 years) had sex before age 15. Sex with multiple partners is more common among men than among women; 15 percent of men age 15–59 years had sex with more than one partner in the last 12 months, whereas only three percent of women age 15–49 years engaged in such an activity in the last 12 months. Of those that had sex with more than one partner, 69 percent of men and 73 percent of women reported using a condom during last sex. Sexually Transmitted Infections (STIs) The self-reported prevalence of STI symptoms in the last 12 months is six percent for both women and men. Among those who have had STI symptoms in the last 12 months, a larger proportion of women than men reported to their partners with whom they had sex (82 percent vs. 64 percent). Among those who reported having had STIs in the last 12 months, 86 percent of women and 80 percent of men sought advice or treatment. Male Circumcision The male circumcision rate among men age 15–59 years is 19 percent; the rate is higher among urban men compared with rural men (26 percent vs. 16 percent). Male circumcision varies according to region. The rate is higher for men residing in the Manzini region compared with those residing in the Shiselweni region (25 percent vs. 14 percent). Of those who are circumcised, 20 percent reported that they were circumcised below age one. The most frequently reported reason for getting circumcised was “health/hygiene” (52 percent), followed by “HIV/AIDS prevention” and “tradition/religion” (22 percent and 18 percent, respectively). A significant 81 percent of men reported that they want their sons to be circumcised. Among those who reported that they would not want their sons to be circumcised, the most frequently cited reason was “tradition/religion” (37 percent), followed by “fear/pain” and “other” (29 percent and 27 percent, respectively). Orphaned and Vulnerable Children (OVC) The proportion of OVC is 45 percent; 24 percent are single or double orphans and 30 percent are considered vulnerable. The Shiselweni region tends to have a slightly higher percentage of orphaned children (26 percent) while the Lubombo region has the highest percentage of vulnerable children (37 percent). In the 2010 Swaziland MICS, the availability of basic material needs (one meal per day, two pairs of clothing and one pair of shoes) was assessed for all children age 5–17 years. The survey shows that when compared with non-OVC, OVC are generally disadvantaged in terms of meeting their basic material needs: 62 percent of OVC have all three xxvii ix material needs met compared with 80 percent for non-OVC. The percentage of OVC currently attending school is 98 percent for age 10–14 years and 94 percent for age of 6–17 years, while that of non-OVC currently attending school is 98 percent for age 0–14 years and 96 percent for age 6–17 years. The comparisons of school attendance rates between OVC and non-OVC suggest that OVC do almost as well as non-OVC in terms of school attendance, especially for those age 10–14 years. Overall, malnutrition is more prevalent among OVC compared with children non-OVC. Nationally, 39 percent of OVC under five years of age are stunted compared with 28 percent for non-OVC counterparts. For underweight, the comparable figures are eight percent for OVC and five percent for non-OVC. The percentage of children age 15–17 years who had sex before 15 years of age is marginally higher among OVC than those not orphaned or vulnerable. This differential is driven primarily by female children; 4.3 percent of orphaned or vulnerable females age 15–17 years had sex before age 15 years, while 2.4 percent of females not orphaned or vulnerable had sex before age 15 years. xxviii 1 1 1. Introduction Background This report presents results of the 2010 Swaziland MICS, carried out by CSO in collaboration with UNICEF and other partners. Since its launch in the mid-1990s, MICS has become one of the largest sources of information on a range of indicators including child health, nutrition, water and sanitation, reproductive health, education, child protection and HIV/AIDS. The 2010 Swaziland MICS was implemented to assess the current situation of the Swazi population, particularly children and women, as well as to measure progress towards goals and targets emanating from international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the WFFC Plan of Action, adopted by 189 Member States at the United Nations (UN) Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see Box 1). Box 1: A commitment to action: national and international reporting responsibilities The governments that signed the Millennium Declaration and the WFFC Declaration and plan of action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present plan of action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyze 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.” (WFFC, 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.…” (WFFC, paragraph 61) The plan of action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, UNICEF is requested to continue to prepare and disseminate, in close collaboration with governments, relevant funds, programmes and the specialized agencies of the UN 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 2 In addition to the Millennium Declaration and WFFC Plan of Action, Swaziland is party to a number of international conventions and treaties supporting the rights of children, including the Convention on the Rights of the Child (CRC) and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW). In line with the Government of Swaziland’s commitments under the CRC and CEDAW, a number of policies and laws have been developed to improve policy and legal framework for the protection of children’s rights. Above all, the Constitution of the Kingdom of Swaziland (2005) provides a legal framework for the protection of its population. It specifically provides for the right of children to be cared for by their parents or guardians, access to education, medical treatment, and protection from all forms of exploitation and abuse, and abolishes the status of illegitimacy for children born out of wedlock. Other legal instruments and policies that have been put in place to promote the protection of children as well as their overall well-being include: the People Trafficking and People Smuggling Prohibition Act, the Child Protection and Welfare Bill, the Sexual Offences and Domestic Violence Bill, the Free Primary Education Act, the Children’s Policy, the Social Development Policy, the Gender Policy, the Health Policy and the Education Policy. A battery of strategic plans has also been developed to guide implementation of these policies. The draft National Plan of Action (NPA) for Children 2011–2015 is a strategic plan for the Children’s Policy and provides an overarching framework for the implementation of children’s programmes and interventions in Swaziland. The NPA is not only aligned with the Children’s Policy but also the National Multi-Sectoral Strategic Framework for HIV/AIDS 2009–2014 (referred to as NSF 2009– 2014), which provides a guiding framework for the national response to HIV/AIDS. The 2010 Swaziland MICS is an important source of information for measuring progress towards targets set by these various strategic plans, as well international declarations including the MDGs, the United Nations General Assembly Special Session Declaration of Commitment on HIV/AIDS (UNGASS) and others commitments. The Swaziland MICS was carried out by CSO under the Ministry of Economic Planning and Development (MoEPD), with support from UNICEF, UNFPA, UNAIDS and NERCHA. Other ministries supporting children’s overall development also took part in the survey. These included the Deputy Prime Minister’s Office, the Ministry of Education and Training, the Ministry of Health (MoH), the Ministry of Home Affairs and the Ministry of Natural Resources. This report presents the results of the indicators and topics covered in the 2010 Swaziland MICS survey. Survey objectives The primary objectives of the 2010 Swaziland MICS are as follows:  Assess the current situation of women, children and other vulnerable populations in Swaziland to provide a baseline for the country’s development priorities; 3 3  Provide decision makers with evidence on children’s, women’s and vulnerable populations’ rights;  Provide data not covered in the national routine data collection system;  Shed light on current infant and child mortality issues; and  Strengthen national capacity in data collection and analysis. 4 4 2. Sample and Survey Methodology Sample design The sample for the 2010 Swaziland MICS was designed to provide estimates for indicators on the situation of the country at the national level, for urban and rural areas, and for the four administrative regions of Swaziland: Hhohho, Manzini, Shiselweni and Lubombo. A two-staged stratified cluster sample was used. A representative sample of 5,475 households was selected in 365 enumeration areas (EAs) (55 percent rural and 45 percent urban) of the 2007 Swaziland Population and Housing Census to serve as primary sampling units (PSUs). This included a necessary oversampling of the Shiselweni region, as a selection in accordance with probability proportional to size would have made the number of households selected in the region inadequate for presentation of regional estimates of a large number of indicators. Prior to the survey implementation, a complete listing of households in all the 365 EAs was conducted. Based on the total number of households in each EA, a systematic sample of 15 households was selected and included in the survey. In the selected households, all females age 15– 49 and men age 15–59 were identified for individual interviews. In addition, all children under five years in all selected households were also identified and their mothers (or caretakers) were interviewed on their behalf. This formed the second stage of sampling. A more detailed description of the sample design can be found in Appendix A. Questionnaires Four sets questionnaires were used in the survey:  A household questionnaire which was used to collect information on all household members, dwelling, household characteristics and to identify eligible individuals;  An under-five children’s questionnaire, administered to mothers or caretakers of all children under five years1 living in the household. Usually, this questionnaire was administered to mothers of under-five children. In cases when the mother was not listed in the household roster or was incapacitated, a primary caretaker for the child was identified and interviewed  A women’s questionnaire administered in each selected household to all women age 15–49 years; and  A men’s questionnaire administered in each selected household to all men age 15–59 years. The questionnaires included the following modules:  Household questionnaire o Household listing form o Children orphaned or made vulnerable 1 The terms “children under five”, “children age 0–4 years”, “under-fives”, and “children age 0–59 months” are used interchangeably in this report. 5 5 o Education and basic needs o Water and sanitation o Household characteristics o Insecticide-treated nets o Indoor residual spraying o Child labour o Child discipline o Hand washing o Salt iodization  Questionnaire for individual women o Women’s background o Child mortality o Birth history o Desire for last birth o Maternal and newborn health o Illness symptoms o Contraception o Unmet need o Marriage/union o Sexual behaviour o Attitudes toward domestic issues (violence) o HIV/AIDS o Other sexually transmitted infections (STIs)  Questionnaire for children under five o Age o Birth registration o Early childhood development o Breastfeeding o Care of illness o Malaria o Immunization o Anthropometry  Questionnaire for individual men o Men’s background o Marriage/union o Attitudes towards contraception o Sexual behaviour o Attitude towards domestic issues (violence) o HIV/ AIDS o Other STIs o Other health issues (male circumcision) The questionnaires were based on the version of the global MICS4 model questionnaires that was available at the time of the survey. The generic questionnaires were then customized to fit country- specific conditions and standards. In addition, a number of county-specific modifications were also made to better serve the data needs of the country. The modifications include the following: 6 6 Modules that are not part of generic MICS4 modules that have been added either from MICS3 modules or the 2006/07 Swaziland Demographic Health Survey (SDHS):  Household Questionnaire o Children orphaned or made vulnerable (children age 0–17) o Basic needs (children age 5–17)  Questionnaire for individual women o Attitudes toward domestic issues (violence) o STIs  Questionnaire for individual men o Attitudes toward domestic issues (violence) o STIs o Male circumcision Modules that are not part of generic MICS that have been added:  Questionnaire for individual women o Obstetric fistula Modules that are part of generic MIC4 modules that have been omitted:  Questionnaire for individual women o Female genital mutilation/cutting After the modifications, the questionnaires were translated from English into siSwati. Both the English and siSwati versions were pre-tested in the Mbabane and Lubombo regions during the training of trainers workshop conducted over the period of 28 June through 6 July 2010. Two teams made up of a supervisor and eight interviewers were formed, who were then assigned to two pre- selected localities (one urban and one rural) outside the sampled clusters to test the entirety of survey procedures and questionnaires. Based on the results of the two pre-tests, further modifications were made, including the wording and flow of the questionnaires. Non-MICS questions that did not yield the intended results were dropped from the questionnaires. All four siSwati questionnaires were back-translated into English. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, measured children’s weights and heights and also tested for the presence of oedema in children under five years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork A total of 67 interviewers (including some of the trainees of the training of trainers), two office editors, data entry administrators and supervisors participated in the main fieldwork training, conducted from 19 July to 7 August 2010. Office editors and data entry administrators and supervisors participated in the main training to get a better understanding of the questionnaires and survey techniques. The training included lectures on interviewing techniques, background presentations on the various themes, presentation and discussion of the questionnaires, local 7 7 language (siSwati) discussion of the questionnaires, class exercises and mock interviews among trainees to acquire skills in the asking of questions. All interviewers were further trained in testing and identification of oedema, salt testing and taking of anthropometric (height and weight) measurements of under-five children. Towards the end of the training period, trainees spent three days conducting field interviews in different urban and rural settings. Areas outside the sample were selected to provide the field staff a better understanding of working in different environments. Supervisors and interviewers were selected based on their performance in the field practices, participation in class, assessment tests, fluency and understanding of siSwati and leadership qualities. A total of 48 out of the 67 enumerators trained were selected to be part of the data collection team. The remaining trainees were put on stand-by teams and were called upon as and when the need arose. Data collection commenced on 12 August and ended on 27 November 2010. The data were collected by six teams. Each team was made up of six interviewers, a driver, a field editor, a measurer and a supervisor. As part of the data collection activities, and for ethical reasons, female respondents suffering from fistula were asked if they wanted to be referred to medical practitioners for further examination and treatment. Those who responded in the affirmative were asked to complete a referral form or the form was completed on their behalf by the field supervisor and returned to the survey coordinator in the office. The same was done for respondents who had suffered from domestic abuse and for under-five children suffering from oedema. This protocol was specific to the 2010 Swaziland MICS and was not part of the standard procedures for the MICS4 globally. See Appendix G for a sample of the referral forms. Data processing Data entry commenced on 3 September after an initial training and ended on 17 December 2010. Data were entered on 10 computers by 10 data entry operators and two data entry supervisors using the CSPro software. In order to ensure quality control, all questionnaires were double entered and two secondary editors complemented the efforts of entry supervisors to perform internal consistency checks. Procedures and standard programmes developed under the global MICS4 survey were adapted, based on the modified Swaziland MICS questionnaires, and used throughout the processing. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software programme, and syntax and tabulation plans developed for the global MICS4 were customized for this purpose. 8 8 3. Sample Coverage and Characteristics of Households and Respondents This section presents information on the sample coverage and respondents, and socio-economic and demographic characteristics of the household population, focusing on age, sex, district, place of residence, and socio-economic conditions of households. Sample coverage and response rate Of the 5,475 households selected for the sample nationally, 5,074 households were found to be occupied. Of these, 4,834 households were interviewed successfully yielding a household response rate of 95 percent. Among the interviewed households, 4,956 women age 15–49 years and 4,646 men age 15–59 years were identified. Of this number, 4,688 women and 4,179 men were successfully interviewed, yielding a response rate of 95 percent and 90 percent respectively. In addition, 2,711 children under age five were listed in the household questionnaire. Of these, questionnaires were completed for 2,647, corresponding to a response rate of 98 percent. Overall response rates of 90, 86 and 93 percent are calculated for under-five’s, women’s and men’s interviews respectively (Table HH.1). Responses varied slightly by residence with higher rates for women and men in rural areas than in urban areas. The situation was the reverse for children under-five where rural areas had higher response rates than urban areas. The overall response rate for women, men and children under five years in rural areas were, however, higher than in urban areas. The main reason for non-response among households and eligible individuals was the failure to find these individuals at home despite several visits to the households. Regional differentials also exist with all the regions having a 90 percent or higher response rate for all the questionnaires with the exception of Hhohho and Shiselweni regions that had 88 and 89 percent response rate, respectively, for the men’s questionnaire. Characteristics of households The age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 4,834 households successfully interviewed in the survey, 20,600 household members were listed. Of these, 9,710 were males, and 10,891 were females. These figures also indicate that the survey estimated the average household size at 4.3. 9 9 Table HH.1: Results of household, women's, men's and under-fives’ interviews Numbers of households, women, men and children under five by results of the household, women's, men's and under-fives’ interviews, and household, women's, men's and under-fives’ response rates, Swaziland, 2010 Residence Region Total Urban Rural Hhohho Manzini Shiselweni Lubombo Households Sampled 2,490 2,985 1,455 1,515 1,170 1,335 5,475 Occupied 2,260 2,814 1,324 1,430 1,102 1,218 5,074 Interviewed 2,095 2,739 1,237 1,368 1,079 1,150 4,834 Response rate 92.7 97.3 93.4 95.7 97.9 94.4 95.3 Women Eligible 1,839 3,117 1,301 1,364 1,223 1,068 4,956 Interviewed 1,757 2,931 1,212 1,309 1,143 1,024 4,688 Response rate 95.5 94.0 93.2 96.0 93.5 95.9 94.6 Overall response rate 88.6 91.5 87.0 91.8 91.5 90.5 90.1 Men Eligible 1,900 2,746 1,241 1,326 1,044 1,035 4,646 Interviewed 1,721 2,458 1,097 1,195 926 961 4,179 Response rate 90.6 89.5 88.4 90.1 88.7 92.9 89.9 Overall response rate 84.0 87.1 82.6 86.2 86.8 87.7 85.7 Children Under 5 Eligible 699 2,012 593 690 781 647 2,711 Mother/ Caretaker Interviewed 672 1,975 570 666 772 639 2,647 Response rate 96.1 98.2 96.1 96.5 98.8 98.8 97.6 Overall response rate 89.1 95.5 89.8 92.3 96.8 93.2 93.0 10 10 Table HH.2: Household age distribution by sex Per cent 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, Swaziland, 2010 Males Females Total Number Per cent Number Per cent Number Per cent Age 0–4 1,369 14.1 1,490 13.7 2,860 13.9 5–9 1,501 15.5 1,399 12.8 2,899 14.1 10–14 1,532 15.8 1,454 13.4 2,986 14.5 15–19 1,186 12.2 1,199 11.0 2,385 11.6 20–24 888 9.1 989 9.1 1,876 9.1 25–29 729 7.5 906 8.3 1,635 7.9 30–34 542 5.6 647 5.9 1,189 5.8 35–39 399 4.1 480 4.4 879 4.3 40–44 348 3.6 465 4.3 813 3.9 45–49 252 2.6 383 3.5 634 3.1 50–54 204 2.1 381 3.5 585 2.8 55–59 175 1.8 253 2.3 428 2.1 60–64 205 2.1 265 2.4 471 2.3 65–69 149 1.5 194 1.8 343 1.7 70–74 120 1.2 150 1.4 270 1.3 75–79 50 0.5 87 0.8 137 0.7 80–84 34 0.3 72 0.7 106 0.5 85+ 25 0.3 73 0.7 98 0.5 Missing/DK 2 0.0 4 0.0 6 0.0 Dependency age groups 0–14 4,402 45.3 4,343 39.9 8,745 42.4 15–64 4,927 50.7 5,968 54.8 10,895 52.9 65+ 3,79 3.9 576 5.3 955 4.6 Missing/DK 2 0.0 4 0.0 6 0.0 Children and adult populations Children age 0–17 years 5,129 52.8 5,106 46.9 10,234 49.7 Adults age 18+ years 4,579 47.2 5,781 53.1 10,360 50.3 Missing/DK 2 0.0 4 0.0 6 0.0 Total 9,710 100.0 10,891 100.0 20,600 100.0  DK = Don’t Know 11 11 Figure HH.1: Age and sex distribution of household population, Swaziland, 2010 Source: Swaziland MICS 2010 Table HH2A: Population distribution by sex Percent of population by broad age groups and sex Age Group 2010 MICS 2007 Population Census Male Female Total Male Female Total 0–14 45.3 39.9 42.4 41.4 37.7 39.6 15–64 50.7 54.8 52.9 55.6 58.0 56.6 65+ 3.9 5.3 4.6 3.0 4.3 3.9 Missing/don’t know - - - 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Age and sex distribution Table HH.2A compares the age and sex distribution of the 2010 Swaziland MICS survey population with that from the 2007 Census. While these two data sets are not exactly comparable, the analysis will serve to give a rough indication of the quality of the Swaziland MICS survey data. The comparison shows that the population age and sex distributions of the two data sets do not differ markedly. As expected, the proportion of the population below 15 years is large and is approximately 40 percent. Children age 0–17 years compose 53 percent of the MICS survey population, which is a reflection of the youthful nature of the Swazi population. The proportion of the population in the 0–14 and 65+ age groups obtained from the MICS is slightly higher than from the Census. Consequently the 12 12 proportion of the population in the economically active age groups (age 15–64 years) is somewhat lower in the Swaziland MICS than in the Census. A comparison of the age distribution of the female population from the two surveys shows striking similarities, especially for the age groups below 65 years. The comparison of the age and sex distribution of the two data sets suggests that the 2010 Swaziland MICS data are representative of the population of Swaziland. The population pyramid is typically cone shaped with a broad base which is again a reflection of the youthful nature of the population (Figure HH.1). The proportion of the population in the 0–4 age group is less than that in the 5–9 age group for males. This is a typical characteristic of the Swaziland population pyramid, which may be attributable to factors such as delining fertlity, increasing mortality for the 0–4 age group, and under-enumeration of children in this age group. However, this is not the case for females as there are more 0–4 year-olds than 5–9 year-olds. The pyramid shows that the largest number of household members are in the 10–14 age group but the proportions decrease thereafter, especially for the age groups below 40 years, to an extent that has been not been observed previously. This notable attrition is presumably due to HIV/AIDS. One other notable feature is that the number of both male and female respondents in the 60–64 age group is larger than in the preceeding one. Also for females, the proportion of the population in the 50–54 age group is almost equal to the preceding one (age 45–49 years). This may be due to varous factors such as digit preference or a deliberate effort to avoid certain components of the questionnaire that require detailed responses. These factors may also have caused the heaping in the 10–14 age group. Refer to the data quality tables presented in Appendix D for detailed information. Table HH.3 provides basic background information on the households. Within households, the sex of the household head, region, urban/rural residency, number of household members, education of household head, households with at least one child, and religion are shown in the table. The total weighted and unweighted numbers of households are equal, since sample weights were normalized (see Appendix A). The table also shows the proportions of households where at least one child under 18 years, at least one child under five years of age, and at least one eligible woman age 15–49 years were found. Table HH.3 also indicates that 53 percent of households are headed by males while 47 percent have female heads. The Manzini region has the highest proportion of sampled households at 34 percent followed by the Hhohho region at 26 percent. Thirty-five percent of households reside in urban areas while 65 percent are in rural areas. Close to 70 percent of surveyed households had at least one child under 18 years, 40 percent had at least one child under five years of age, and 67 percent at least one eligible woman age 15–49 years. The table also shows that 22 percent of households have only one member while only six percent have 10 or more members. Close to 20 percent of households are headed by persons with no education. The majority of household heads have primary education (30 percent) followed by secondary education (21 percent). Only 17 percent and 12 percent have high school and tertiary education, respectively. 13 13 Table HH.3: Household composition Percent distribution of households by selected characteristics, Swaziland, 2010 Weighted percent Number of households Weighted Unweighted Sex of household head Male 53.1 2,565 2585 Female 46.9 2,269 2249 Region Hhohho 26.1 1,261 1237 Manzini 33.6 1,624 1368 Shiselweni 20.1 969 1079 Lubombo 20.3 979 1150 Area Urban 34.8 1,680 2095 Rural 65.2 3,154 2739 Number of household members 1 22.0 1,061 1,153 2 12.7 613 635 3 13.2 640 641 4 13.0 629 622 5 10.5 508 495 6 8.4 407 382 7 6.4 310 288 8 4.2 201 191 9 3.2 153 141 10+ 6.4 311 286 Education of household head None 19.7 950 888 Primary 29.8 1,439 1,405 Secondary 20.8 1,005 1,004 High 17.4 842 894 Tertiary 12.2 589 634 Missing/DK 0.2 10 9 Total 100.0 4,834 4,834 Households with at least One child age 0–4 years 40.1 4,834 4,834 One child age 0–17 years 67.4 4,834 4,834 One woman age 15–49 years 68.8 4,834 4,834 One man age 15–59 years 63.1 4,834 4,834 Mean household size 4.3 4,834 4,834 14 14 Characteristics of respondents Tables HH.4, HH.4M and HH.5 provide information on the background characteristics of female respondents age 15–49 years, male respondents age 15–59 years, and children under age five. In addition to providing useful information on the background characteristics of women, men and children under five, the tables are also intended to show the number of observations in each background category. These categories are used in the subsequent tabulations of this report. Tables HH.4 and HH.4M include information on the distribution of female respondents age 15–49 years and male respondents age 15–59 years according to region, urban/rural areas, age, marital status, motherhood status, births in the last two years, education2 and wealth index quintiles3. Table HH.4M shows background characteristics of male respondents 15–59 years of age. These are region, urban-rural areas, age, marital status, education and wealth index quintiles. The results in Table HH.4 reveal that Manzini has the highest distribution of women and men at 32 percent and 34 percent, respectively, followed by Hhohho (27 percent for both women and men), Shiselweni (22 percent for women and 20 percent for men) and Lubombo (18 percent for women and 19 percent for men). In terms of urban vs. rural residency, about one in three women and men reside in urban areas compared to one in seven for rural areas. The table shows that the majority of respondents have never been married or in a union, with the proportion of women and men who are in this category at 50 percent and 60 percent, respectively. This is consistent with results from various surveys and censuses that indicate that a large proportion of the Swazi population remains unmarried. Forty percent of women are married or in a union compared with 35 percent for men. Only a negligible proportion of respondents (less than one percent) are officially divorced, while close to four percent are separated. This is true for both women and men. This is to be expected since divorce is not condoned culturally and lobola (bride price) is primarily aimed at cementing the relationship between the couple and the two families for life. Over 70 percent of women have given birth to at least one child and 22 percent of women had given birth in the past two years. Five percent of women respondents are uneducated while 27 percent, 34 percent, 26 percent and eight percent have completed primary education, secondary education, high school and tertiary education, respectively. The corresponding proportions for men are seven percent, 30 percent, 29 percent, 26 percent and 10 percent, respectively. The results indicate that a slightly higher proportion of men have no education compared with women. They also show that a larger proportion of women have secondary education. However, a slightly higher proportion of men have tertiary education 2 Unless otherwise stated, “education” refers to the educational level attended by the respondent throughout this report when it is used as a background variable. 3 Principal components analysis was performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth to assign weights (factor scores) to each of the household assets. Each household was then assigned a wealth score based on these weights and the assets owned by that household. The survey household population was then ranked according to the wealth score of the household they are living in, and was finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). Further information on the construction of the wealth index can be found in Filmer and Pritchett, 2001, Gwatkin, Rutstein, Johnson et al., 2000, and Rutstein and Johnson, 2004. 15 15 compared with women. In respect to the other educational levels, men and women are almost at par, which bodes well for socio-economic development. Table HH.4 further shows that the largest proportion of women and men are classified under the richest wealth quintile (25 percent for women and 27 percent for men), followed by those in the fourth quintile (22 percent for women and 23 percent for men). Only 16 percent and 14 percent of all women and men, respectively, fall under the poorest wealth quintile. As wealth is measured at the household level and the wealth quintiles each represent 20 percent of the households, this finding is expected: households with members from the economically active age groups are generally wealthier. Background characteristics of children under five are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area of residence, age in months, mother’s or caretaker’s education and household wealth. The results show that 52 percent of children are female and 48 percent are male. Eighty percent of children live in rural areas with only 20 percent residing in urban areas. The largest proportion of children under five is found in the Manzini region (30 percent), followed by the Shiselweni, Hhohho and Lubombo regions (26 percent, 25 percent and 20 percent, respectively). Ten percent are less than six months old or 6–11 months old. The remaining children under five are equally distributed among the 12–23, 24–35, 36–47, and 48–59 month age groups (20 percent for each). Most mothers have either primary education (34 percent) or secondary education (29 percent). Only 12 percent have no education and seven percent have tertiary education. The result shows that children under five in the household are more concentrated among poorer households; close to a quarter of under fives belong to the poorest wealth quintile compared to 16 percent for the richest quintile. 16 16 Per cent and frequency distribution of women age 15–49 years by selected characteristics, Swaziland, 2010 Weighted per cent Number of womenWeighted Unweighted Region Hhohho 27.4 1,286 1,212 Manzini 32.3 1,515 1,309 Shiselweni 22.0 1,033 1,143 Lubombo 18.2 854 1,024 Area Urban 28.9 1,353 1,757 Rural 71.1 3,335 2,931 Age of woman 15–19 23.4 1,098 1,079 20–24 19.3 904 909 25–29 18.1 847 857 30–34 12.7 595 601 35–39 9.7 456 465 40–44 9.2 433 431 45–49 7.6 355 346 Marital/Union status Currently married/in union 40.1 1,882 1,851 Widowed 5.0 232 220 Divorced (0.7) 33 35 Separated 3.8 179 189 Never married/in union 50.4 2,362 2,393 Motherhood status Ever gave birth 70.2 3,292 3,291 Never gave birth 29.8 1,396 1,397 Births in the last two years Had a birth in the last two years 22.0 1,031 1,018 Had no birth in the last two years 78.0 3,657 3,670 Education None 5.2 242 222 Primary 27.1 1,269 1,231 Secondary 34.0 1,592 1,565 High 25.6 1,202 1,247 Tertiary 8.2 382 423 Wealth index quintiles Poorest 15.7 737 698 Second 17.1 802 738 Middle 19.8 930 906 Fourth 22.2 1,041 1,024 Richest 25.1 1,179 1,322 Total 100.0 4,688 4,688 Note: Figures in parentheses are based on 25–49 unweighted cases. Table HH.4: Women's background characteristics 17 17 Table HH.4M: Men's background characteristics Per cent and frequency distribution of men age 15–59 years by selected characteristics, Swaziland, 2010 Weighted per cent Number of men Weighted Unweighted Region Hhohho 27.4 1,143 1,097 Manzini 33.7 1,406 1,195 Shiselweni 20.3 847 926 Lubombo 18.7 782 961 Area Urban 32.2 1,347 1,721 Rural 67.8 2,832 2,458 Age of man 15–19 25.7 1,075 1,036 20–24 18.7 783 781 25–29 15.1 629 647 30–34 11.6 484 496 35–39 8.5 354 361 40–44 7.0 292 302 45–49 5.3 221 218 50–54 4.4 183 187 55–59 3.8 159 151 Marital/Union status Currently married/in union 34.9 1,459 1,476 Widowed 1.5 63 59 Divorced 0.3 11 12 Separated 3.6 152 154 Never married/in union 59.7 2,495 2,478 Education None 6.7 280 275 Primary 29.7 1,240 1,198 Secondary 28.6 1,195 1,176 High 25.5 1,067 1,114 Tertiary 9.5 397 416 Wealth index quintiles Poorest 13.6 570 537 Second 17.7 740 667 Middle 19.7 821 804 Fourth 22.5 940 942 Richest 26.5 1,107 1,229 Total 100.0 4,179 4,179 18 18 Table HH.5: Under-fives’ background characteristics Per cent and frequency distribution of children under five years of age by selected characteristics, Swaziland, 2010 Weighted per cent Number of childrenWeighted Unweighted Sex Male 47.8 1,265 1,272 Female 52.2 1,382 1,375 Region Hhohho 24.7 655 570 Manzini 29.7 787 666 Shiselweni 25.8 683 772 Lubombo 19.7 523 639 Area Urban 19.9 527 672 Rural 80.1 2,120 1,975 Age 0–5 months 10.3 273 269 6–11 months 9.5 251 258 12–23 months 19.7 521 515 24–35 months 20.2 534 530 36–47 months 20.1 533 537 48–59 months 20.2 536 538 Mother's education None 11.5 303 296 Primary 33.7 891 877 Secondary 28.6 757 748 High 19.7 523 534 Tertiary 6.5 171 189 Missing/DK 0.1 3 3 Wealth index quintiles Poorest 24.4 646 641 Second 21.0 557 525 Middle 20.5 544 536 Fourth 18.5 489 479 Richest 15.5 411 466 Total 100.0 2,647 2,647 Tables HH.6 and HH.6M present the percentage of women and men by current marital status and by type of marriage/union. A total of 50 percent of women and 60 percent of men reported that they were never married. Approximately 33 percent of women and 28 percent of men reported that they were married or in union. The most common type of marriage/union is marriage through Swazi law and custom4 (26 percent for women and 21 percent for men). This is followed by civil rites (6 percent for both women and men) and living with a partner (8 percent for women and 7 percent for men). Disaggregation of the results by background characteristics shows that marriage through Swazi law and custom is more common in rural areas at 29 percent, compared with urban areas at 18 percent. Swazi marriage is most prevalent in the Lubombo region and least prevalent in the Shiselweni region: 31 percent of women and 25 percent of men have been married through Swazi law and custom in the Lubombo region, while in the Shiselweni region the comparative figures 4 Swaziland has a dual legal system comprising of both common law and Swazi traditional law and custom. 19 19 were 22 percent for women and 13 percent for men. For both women and men civil marriage is more common in urban than rural areas. Living with partner is most common among women and men with no education (19 percent for women and 12 percent for men) compared with three percent among women with tertiary education and seven percent among men with tertiary education. Divorce is higher among women with tertiary education with three percent, compared with two percent among women with tertiary education and less than one percent among women with primary education. Civil marriage is also higher among women and men in the highest wealth quintile (16 percent among both women and men) compared to those in the lowest quintile (less than one percent among women and zero percent among men). 20 20 Ta ble H H. 6: Cu rre nt ma rit al sta tus : w om en Pe rce nt dis trib uti on of w om en ag e 1 5– 49 ye ars by m ari tal st atu s, by se lec ted ch ara cte ris tic s, Sw az ila nd , 2 01 0 Pe rce nta ge of w om en w ho : Nu mb er of wo me n a ge 15 – 49 ye ars Ar e c ur ren tly m arr ied /in un ion : We re for me rly m arr ied /in un ion : We re for me rly ma rrie d/i n u nio n Ar e c urr en tly ma rrie d/i n un ion We re ne ve r ma rrie d/i n un ion To tal By ty pe of m arr iag e: In un ion Wi do we d Div orc ed Se pa rat ed Fo rm erl y i n un ion Sw az i ma rria ge Civ il ma rria ge Ot he r/ Mi ss ing An y typ e Re gio n Hh oh ho 29 .0 6.0 0.1 35 .1 6.1 3.8 1.4 1.3 3.1 9.5 41 .2 49 .3 10 0.0 1,2 86 Ma nz ini 23 .5 8.6 0.8 32 .9 9.4 4.6 0.5 1.3 4.2 10 .7 42 .3 47 .0 10 0.0 1,5 15 Sh ise lwe ni 21 .5 4.5 0.2 26 .2 6.8 4.9 0.1 1.7 2.0 8.8 33 .0 58 .2 10 0.0 1,0 33 Lu bo mb o 31 .2 4.5 0.2 35 .9 7.4 3.1 0.7 0.9 3.5 8.2 43 .3 48 .6 10 0.0 85 4 Ar ea Ur ba n 18 .4 10 .9 0.8 30 .1 11 .0 3.3 0.9 1.7 4.9 10 .8 41 .1 48 .1 10 0.0 1,3 53 Ru ral 29 .0 4.4 0.2 33 .6 6.2 4.5 0.6 1.2 2.6 8.9 39 .8 51 .3 10 0.0 3,3 35 Ag e o f w om an 15 –1 9 2.1 0.1 0.1 2.3 2.0 0.0 0.0 0.1 0.1 0.2 4.3 95 .6 10 0.0 1,0 98 20 –2 4 18 .0 2.1 0.3 20 .4 10 .5 0.1 0.2 0.4 1.7 2.4 30 .9 66 .7 10 0.0 90 4 25 –2 9 31 .6 5.9 0.7 38 .2 10 .7 1.4 0.4 1.7 3.4 6.8 48 .9 44 .3 10 0.0 84 7 30 –3 4 38 .4 11 .6 0.3 50 .3 8.1 4.7 1.6 2.4 5.0 13 .7 58 .4 27 .9 10 0.0 59 5 35 –3 9 43 .8 12 .7 0.3 56 .9 9.8 8.4 0.8 1.5 5.6 16 .4 66 .7 16 .9 10 0.0 45 6 40 –4 4 42 .3 11 .7 0.5 54 .5 7.9 12 .9 2.2 3.1 6.9 25 .1 62 .4 12 .5 10 0.0 43 3 45 –4 9 43 .0 12 .8 0.5 56 .3 5.6 17 .1 1.5 2.4 6.6 27 .6 62 .0 10 .5 10 0.0 35 5 Ed uc ati on No ne 40 .5 1.2 0.8 42 .4 19 .4 11 .1 1.7 1.1 8.2 22 .2 61 .8 16 .0 10 0.0 24 2 Pr im ary 31 .6 2.1 0.4 34 .1 10 .4 5.3 0.7 1.3 4.5 11 .9 44 .5 43 .6 10 0.0 1,2 69 Se co nd ary 25 .3 3.8 0.3 29 .3 6.9 3.6 0.4 1.4 2.8 8.3 36 .3 55 .5 10 0.0 1,5 92 Hig h 19 .4 7.8 0.3 27 .6 4.5 2.4 0.2 1.2 2.3 6.1 32 .1 61 .8 10 0.0 1,2 02 Te rtia ry 21 .5 28 .2 0.7 50 .4 3.1 3.7 2.5 1.4 1.4 8.9 53 .5 37 .6 10 0.0 38 2 We alt h i nd ex qu int ile s Po ore st 31 .2 0.3 0.1 31 .6 10 .9 4.9 1.0 1.1 3.3 10 .3 42 .5 47 .2 10 0.0 73 7 Se co nd 27 .3 2.1 0.4 29 .8 6.8 5.5 0.4 1.1 3.4 10 .5 36 .7 52 .8 10 0.0 80 2 Mi dd le 29 .0 1.8 0.1 30 .8 7.9 4.0 0.6 2.1 4.2 10 .8 38 .7 50 .4 10 0.0 93 0 Fo urt h 26 .5 6.6 0.2 33 .2 6.8 3.2 0.5 0.8 3.1 7.7 40 .1 52 .2 10 0.0 1,0 41 Ric he st 19 .0 16 .0 0.9 35 .9 6.4 3.7 1.0 1.4 2.6 8.7 42 .2 49 .1 10 0.0 1,1 79 To tal 26 .0 6.2 0.4 32 .6 7.6 4.2 0.7 1.3 3.3 9.5 40 .1 50 .4 10 0.0 4,6 88 21 21 Ta ble H H. 6M : C ur ren t m ari tal st atu s: me n Pe rce nt dis trib uti on of m en ag e 1 5– 59 ye ars by m ari tal st atu s, by se lec ted ch ara cte ris tic s, Sw az ila nd , 2 01 0 Pe rce nta ge of m en w ho : Nu mb er of me n ag e 1 5– 59 ye ars Ar e c ur ren tly m arr ied /in un ion : We re for me rly m arr ied /in un ion : We re for me rly ma rrie d/i n un ion Ar e c urr en tly ma rrie d/i n un ion We re ne ve r ma rrie d/i n un ion To tal By ty pe of m arr iag e: In un ion Wi do we d Div orc ed Se pa rat ed Fo rm erl y in un ion Sw az i ma rria ge Civ il ma rria ge Ot he r/ Mi ss ing An y typ e Re gio n Hh oh ho 24 .3 7.1 0.5 31 .8 5.1 1.1 0.1 1.0 2.5 4.8 36 .9 58 .3 10 0.0 1,1 43 Ma nz ini 20 .9 7.8 1.1 29 .9 9.4 1.2 0.4 1.1 3.9 6.6 39 .2 54 .2 10 0.0 1,4 06 Sh ise lwe ni 13 .3 4.0 0.2 17 .5 5.4 1.1 0.1 1.2 3.1 5.6 22 .8 71 .6 10 0.0 84 7 Lu bo mb o 25 .3 4.9 0.2 30 .5 6.8 0.7 0.4 0.7 2.3 4.1 37 .3 58 .7 10 0.0 78 2 Ar ea Ur ba n 23 .0 10 .5 1.2 34 .7 11 .1 0.8 0.3 0.8 3.7 5.6 45 .7 48 .7 10 0.0 1,3 47 Ru ral 20 .2 4.3 0.3 24 .8 4.9 1.2 0.3 1.1 2.7 5.3 29 .8 64 .9 10 0.0 2,8 32 Ag e o f w om an 15 –1 9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 10 0.0 10 0.0 1,0 74 20 –2 4 2.6 0.1 0.1 2.9 3.8 0.0 0.0 0.0 1.2 1.2 6.7 92 .1 10 0.0 78 4 25 –2 9 15 .4 2.6 0.7 18 .7 10 .8 0.6 0.2 0.4 4.4 5.6 29 .5 64 .9 10 0.0 62 9 30 –3 4 30 .4 10 .6 1.6 42 .6 11 .6 0.3 0.6 1.8 7.2 9.9 54 .1 35 .9 10 0.0 48 4 35 –3 9 44 .2 15 .7 0.3 60 .2 10 .6 2.2 0.2 3.4 3.9 9.7 70 .8 19 .5 10 0.0 35 4 40 –4 4 51 .9 14 .7 1.0 67 .6 10 .1 3.5 1.0 2.0 6.0 12 .6 77 .7 9.7 10 0.0 29 2 45 –4 9 52 .5 19 .3 1.1 72 .9 14 .1 1.3 0.4 2.3 4.3 8.3 87 .0 4.7 10 0.0 22 1 50 –5 4 55 .1 17 .0 2.4 74 .5 11 .8 6.1 1.2 1.9 2.6 11 .9 86 .3 1.8 10 0.0 18 3 55 –5 9 58 .5 14 .3 0.4 73 .2 9.6 4.6 0.0 3.3 5.8 13 .6 82 .8 3.6 10 0.0 15 9 Ed uc ati on No ne 43 .7 1.3 1.0 46 .0 12 .4 3.7 0.7 4.1 5.9 14 .4 58 .4 27 .2 10 0.0 28 0 Pr im ary 22 .1 2.2 0.7 25 .0 8.0 1.1 0.2 1.4 4.4 7.0 33 .0 59 .9 10 0.0 1,2 40 Se co nd ary 19 .3 3.1 0.5 22 .9 5.7 1.1 0.2 0.3 2.4 3.9 28 .5 67 .6 10 0.0 1,1 95 Hig h 16 .7 7.0 0.6 24 .3 5.6 0.5 0.2 0.5 2.3 3.5 30 .0 66 .6 10 0.0 1,0 67 Te rtia ry 19 .2 30 .5 0.3 50 .0 6.6 0.7 0.6 1.3 1.0 3.7 56 .7 39 .7 10 0.0 39 7 We alt h i nd ex qu int ile s Po ore st 20 .9 0.0 0.3 21 .2 8.6 2.6 0.2 2.3 4.1 9.1 29 .7 61 .1 10 0.0 57 0 Se co nd 18 .1 1.3 0.3 19 .7 6.6 1.4 0.3 1.2 3.2 6.2 26 .3 67 .5 10 0.0 74 0 Mi dd le 21 .6 2.3 0.7 24 .6 7.1 0.7 0.3 0.9 4.1 6.0 31 .6 62 .4 10 0.0 82 1 Fo urt h 21 .7 6.0 0.6 28 .2 6.3 1.1 0.1 0.5 1.9 3.6 34 .5 61 .9 10 0.0 94 0 Ric he st 22 .4 16 .1 1.0 39 .5 6.6 0.3 0.4 0.8 2.6 4.0 46 .1 49 .9 10 0.0 1,1 07 To tal 21 .1 6.3 0.6 28 .0 6.9 1.1 0.3 1.0 3.0 5.4 34 .9 59 .7 10 0.0 4,1 79 22 22 4. Child Mortality One of the overarching goals of the MDGs is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions such as, “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. However, the indirect methods cannot provide estimates of the age at death distribution beyond infant and child mortality and do not provide the richness of data available from collecting birth histories. As child mortality drops across the world, due to commitment and action, evidence shows that reductions are predominantly made in deaths occurring past infancy and increasingly there is a demand for precision in and analysis of the period where most deaths occur. The 2010 Swaziland MICS therefore employed a full birth history as part of the women’s questionnaire and paid exceptional attention to meeting the known pitfalls and shortcomings of the technique through careful training and fieldwork monitoring. Regardless of these efforts, measuring mortality is one of the most difficult tasks undertaken in a household survey and special attention has therefore also been given to reporting of estimates and the quality of these in this chapter – and in annexed tables and deeper analysis. Understanding child mortality in Swaziland is further complicated due to the HIV/AIDS pandemic. The birth histories of women only represent those of living women age 15–49 residing in the randomly selected sample of households. In a typical population without any major emigration or adult mortality in the eligible age group (such as from a disaster), the birth histories of living and deceased women will be more or less the same, that is, without biasing the mortality results. However, the impact of an estimated HIV prevalence among women in the eligible age group of near 30 percent has profound impact. This is because there is a higher probability of death among young children of mothers who have died of AIDS than among children whose mothers are alive. Part of this is due to the vertical transmission of HIV, which has a significant impact on the survival of children. Prevention of mother-to-child transmission (PMTCT) programmes, paediatric anti-retroviral therapy (ART) and preventive measures in general are starting to reverse the impact of the problem of mortality measurement through birth histories, but currently there is still need to look at any mortality 23 23 results carefully and – as done by the Inter-Agency Group for Mortality Estimation5 (IGME) – make appropriate adjustments to the measured rates. Besides this measurement issue that exists and regardless of the quality of the household survey, there are three main issues that could influence the precision of measurement6: 1) birth transference (aging children to reduce workload); 2) event omission (excluding children to reduce workload or avoiding painful recollection); and 3) incorrect sampling frame (poor or severely outdated censuses). In almost every case perceivable, each of the three issues contributes to underestimation of mortality and it is therefore safe to say that nearly every household survey underestimates child mortality. Attention is here directed to the specific data quality tables (Appendix D) produced for the birth history data. The quality of birth history data is briefly addressed under the findings, but specifically related to the impact of HIV/AIDS on the Swazi population, further studies of quality and results are necessary. The issue of missing data is important to all variables in the survey. Generally, data for missing cases are not imputed, with the exception of the variables in the birth history, where a bias would often be significant, as dates of events are more often missing for the least educated and the less wealthy women. It is typical that children of these women also suffer the largest mortality, and without imputation, mortality would often be underestimated. However, in the 2010 Swaziland MICS, imputation was only necessary in just over 20 cases and therefore had insignificant impact on the results. The imputed data can be accessed in the MICS data set. Results The mortality results presented are defined as follows:  Neonatal mortality: the probability of dying within the first month of life  Infant mortality: the probability of dying before the first birthday  Post-neonatal mortality: the difference between infant and neonatal mortality  Child mortality: the probability of dying between the first and fifth birthday  Under-five mortality: the probability of dying between birth and the fifth birthday All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. Table CM.1 shows the trends in neonatal, post-neonatal, infant, child, and under-five mortality rates for the three successive five-year periods preceding the survey. For the most recent five-year period preceding the survey, infant mortality is 79 deaths per 1,000 live births, and under-five mortality is 104 deaths per 1,000 live births. This means that more than one in every 10 children born in Swaziland dies before reaching his or her fifth birthday. 5 Sullivan JM, 2008. Visit www.childmortality.org for information on IGME’s work and global estimates. 6 UNICEF, Childinfo, http://www.childinfo.org/files/IGME_Overall_Results_of_Analysis.pdf 24 24 Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, Infant, child and under-five mortality rates for five year periods preceding the survey, Swaziland, 2010 Neonatal mortality rate1 Post-neonatal mortality rate2 Infant mortality rate 3 Child mortality rate4 Under-five mortality rate5 Years preceding the survey 0–4 19 60 79 27 104 5–9 19 51 70 26 94 10–14 20 39 59 18 76 1 MICS indicator 1.3 2 MICS indicator 1.4 3 MICS indicator 1.2; MDG indicator 4.2 4 MICS indicator 1.5 5 MICS indicator 1.1; MDG indicator 4.1 Note: Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Looking at the age pattern of mortality during the five-year period immediately prior to the survey, three-quarters of the deaths took place during the first year of the child’s life. Examining infancy deaths, again three-quarters of these deaths occurred during the post-neonatal period, i.e., the child had survived at least one month before dying. Nevertheless, it is observed that nearly one in five of under-five deaths happen in the first month of life. The trend in early childhood mortality since the mid-1990s can also be examined by looking at changes in the mortality rates over the three successive five-year periods prior to the survey. From the 2010 Swaziland MICS results, there is evidence that all mortality rates but that of neonatals have increased over the period. For example, post-neonatal and child mortality rates during the most recent period (2006–2010) are 50 percent higher than the levels estimated for the period 10–14 years before the survey (1996–2000). This confirms the upward trend observed in the 2006/07 SDHS, albeit at a somewhat lower rate of increase. In the Swaziland MICS it can be seen that the rate of increase between the two most recent five-year periods is smaller than the rate of increase in the previous period. Figure CM.1 shows the series of under-five mortality rate estimates of the survey and those estimated in the 2006/07 SDHS. As mentioned, the Swaziland MICS results are in broad agreement with the SDHS results in terms of having measured increasing mortality. Other recent data points confirm this finding as well. However, the survey results differ somewhat on the level of mortality. Further qualification of these apparent increases and differences as well as their determinants should be taken up in a more detailed and separate analysis. 24 Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, Infant, child and under-five mortality rates for five year periods preceding the survey, Swaziland, 2010 Neonatal mortality rate1 Post-neonatal mortality rate2 Infant mortality rate 3 Child mortality rate4 Under-five mortality rate5 Years preceding the survey 0–4 19 60 79 27 104 5–9 19 51 70 26 94 10–14 20 39 59 18 76 1 MICS indicator 1.3 2 MICS indicator 1.4 3 MICS indicator 1.2; MDG indicator 4.2 4 MICS indicator 1.5 5 MICS indicator 1.1; MDG indicator 4.1 Note: Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Looking at the age pattern of mortality during the five-year period immediately prior to the survey, three-quarters of the deaths took place during the first year of the child’s life. Examining infancy deaths, again three-quarters of these deaths occurred during the post-neonatal period, i.e., the child had survived at least one month before dying. Nevertheless, it is observed that nearly one in five of under-five deaths happen in the first month of life. The trend in early childhood mortality since the mid-1990s can also be examined by looking at changes in the mortality rates over the three successive five-year periods prior to the survey. From the 2010 Swaziland MICS results, there is evidence that all mortality rates but that of neonatals have increased over the period. For example, post-neonatal and child mortality rates during the most recent period (2006–2010) are 50 percent higher than the levels estimated for the period 10–14 years before the survey (1996–2000). This confirms the upward trend observed in the 2006/07 SDHS, albeit at a somewhat lower rate of increase. In the Swaziland MICS it can be seen that the rate of increase between the two most recent five-year periods is smaller than the rate of increase in the previous period. Figure CM.1 shows the series of under-five mortality rate estimates of the survey and those estimated in the 2006/07 SDHS. As mentioned, the Swaziland MICS results are in broad agreement with the SDHS results in terms of having measured increasing mortality. Other recent data points confirm this finding as well. However, the survey results differ somewhat on the level of mortality. Further qualification of these apparent increases and differences as well as their determinants should be taken up in a more detailed and separate analysis. 25 25 Figure CM.1: Trend in under-five mortality rates, Swaziland, 2010 Data quality observations Some caution is necessary when interpreting the mortality trend suggested by the 2010 Swaziland MICS. As described and seen above, a thorough analysis of data quality including the impact of HIV/AIDS is necessary, as well as comparisons between data sources. Typically, a large difference between estimates from comparable surveys and overlapping periods, such as the 2006/07 SDHS estimate plotted in 2004 and the 2010 MICS estimate plotted in 2003, is pointing towards relatively less quality of the lowest estimate. However, in the case of Swaziland this may not be the case and may be due to the impact of HIV/AIDS as described earlier. In a brief overview of the data quality tables presented in Appendix D, the following observations also point to caution. However, these observations are not different from what is found in the majority of other surveys, in Swaziland and globally: 25 Figure CM.1: Trend in under-five mortality rates, Swaziland, 2010 Data quality observations Some caution is necessary when interpreting the mortality trend suggested by the 2010 Swaziland MICS. As described and seen above, a thorough analysis of data quality including the impact of HIV/AIDS is necessary, as well as comparisons between data sources. Typically, a large difference between estimates from comparable surveys and overlapping periods, such as the 2006/07 SDHS estimate plotted in 2004 and the 2010 MICS estimate plotted in 2003, is pointing towards relatively less quality of the lowest estimate. However, in the case of Swaziland this may not be the case and may be due to the impact of HIV/AIDS as described earlier. In a brief overview of the data quality tables presented in Appendix D, the following observations also point to caution. However, these observations are not different from what is found in the majority of other surveys, in Swaziland and globally: 26 26  Table DQ.1: The large number of 50 year-old women compared with those of age 49 years is of concern, as well as the large number of 14 year-old girls. While this age heaping is common – both for natural reasons and because of work-reducing behaviour of interviewers, the impact on quality is the loss of birth histories of probably up to 100 women or around two percent of the sample.  Table DQ.4A: Here it can be observed that there are marginally worse interview completion rates for women in settings that typically carry a higher risk of mortality: rural, large households and poor.  Table DQ.16: While there is room for slight fluctuation, the sex ratio (boys:girls) of children ever born should be around 1.05. None of the age groups presented achieve this, and for women age 15–24 the data reveal more girls than boys. While this is possible, due to sampling error, the age group of 20–24 year-old women, in particular, looks uncomfortably low. Assuming that all births of female children were captured, there is evidence that the MICS failed to capture less than five percent of male births. Although this seems relatively low, it contributes to cautionary interpretation of results.  Table DQ.17: While interviewers performed very well in obtaining complete birth dates (column 2), a similar picture to that observed in DQ.16 appears; the sex ratio is lower than expected (column 3). However, there is evidence of some distortion (column 4). Were the obtained birth dates correct? Again allowing room for sampling error, there seems to be typical heaping on calendar years 1990 and 2000, where some women without readily available precise information may have ‘rounded off’ – often with the assistance of the interviewer. This heaping is not critical as such, but does have a slight impact of past mortality figures. Instead, focus is drawn to the period of 2006–2008, where there is high fluctuation in ratios. This can partly be explained by the survey finding that there are more two year-olds than one year-old children, but closer investigation is necessary.  Table DQ.18: This table should clarify on the quality of information obtained on age at death, when the death occurred before age one month. Overall the figures show some heaping, particularly for the most recent period of 0–4 years before the survey, on age one day and one, two, and three weeks old.  Table DQ.19: A similar table is designed to capture quality of information obtained on age at death in months. The focus is to review whether respondents and interviewers are heaping at age one month and at age 12 months as these are the cut-offs for the specific mortality rates. While there is evidence of some heaping, the data do not suggest heaping at cut-off points. In summary, while the data show some of the typical quality issues, there is no apparent major concern on overall quality. Demographic and socio-economic results Differentials in early childhood mortality rates by selected socio-economic and demographic characteristics are presented in Tables CM.2 and CM.3. In order to ensure a sufficient number of births to study mortality differentials across the population sub-groups, period-specific rates are presented 27 27 for the 10-year period preceding the survey (approximately 2001 to 2010) in these tables. Differences in the mortality rates across the sub-groups should, nevertheless, be interpreted cautiously because the sampling error remains comparatively large even for the 10-year rates (see Appendix C). The results in Table CM.2 indicate that the risk of dying early is near identical for urban and rural children and within their respective confidence intervals. Overall, the under-five mortality rate is 98 deaths per 1,000 live births in rural areas and 102 in urban areas. The differentials in mortality levels are somewhat larger by region. Hhohho has the lowest under-five mortality rate of 78 per 1,000 live births, which is predominantly due to the lowest post-neonatal and child mortality rates. Manzini has the highest under-five mortality rate of 114, which is due to the highest mortality rates in all but that of neonates. Table CM.2: Early childhood mortality rates by socio-economic characteristics Neonatal, post-neonatal, infant, child and under-five mortality rates for the ten year period preceding the survey, by socio-economic characteristics, Swaziland, 2010 Neonatal mortality rate Post-neonatal mortality rate[**] Infant mortality rate Child mortality rate Under-five mortality rate Region Hhohho 21 36 57 22 78 Manzini 17 68 86 32 114 Shiselweni 22 59 81 30 108 Lubombo 16 57 73 23 94 Residence Urban 18 59 77 28 102 Rural 19 54 74 26 98 Mother's education None (20) (51) (70) (41) (108) Primary 25 62 86 30 114 Secondary 20 62 81 27 106 High 11 50 61 17 76 Tertiary (13) (22) (36) (16) (51) Wealth index quintile Poorest 24 58 82 36 115 Second 13 53 66 29 93 Middle 18 63 81 29 108 Fourth 19 52 71 18 87 Richest 20 51 71 22 92 [**] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates. Note: Estimates in parentheses are based on 250–499 years of exposure. Caution is advised with these figures. As expected, a mother’s education is near inversely related to a child’s risk of dying, although the under-five mortality rate for children of mothers with no education is lower than that of mothers with primary education. Looking at the child mortality rates, however, the pattern is completely as expected. Overall, children of mothers with no education have twice the mortality rates of children of mothers with tertiary education. 28 28 The relationship between wealth and mortality is not consistent, although children born to mothers in the highest wealth quintile have a much lower risk of dying than children born to mothers in the poorest quintiles. The demographic characteristics of both mother and child have been found to play an important role in the survival probability of children. Table CM.3 presents mortality rates by demographic characteristics (i.e., sex of child, mother’s age at birth, birth order, and previous birth interval). The data show some difference in mortality between male and female children in infancy, with infant mortality rates at 79 and 70 per 1,000 live births for males and females, respectively. Typically, the relationship between maternal age at birth and childhood mortality is U-shaped, being relatively higher among children born to mothers under age 20 years and over age 35 years than among mothers in the middle age groups. This pattern is also found in Swaziland, where mortality among children born to mothers whose age at birth was less than 20 years, in particular, is high across all mortality rates. The birth order of the child has little influence on children’s mortality risks, although there is a slightly reduced risk for first-borns observed in the under-five mortality rate. Research has shown that short birth intervals significantly reduce a child’s chance of survival, and this is confirmed by the Swaziland MICS: children have an elevated risk of dying if they were born within two years of a preceding birth. The risk reduces to its lowest at a birth spacing of three years, but then increases sharply at four years or more between births. Table CM.3: Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child and under-five mortality rates for the ten year period preceding the survey, by demographic characteristics, Swaziland, 2010 Neonatal mortality rate Post-neonatal mortality rate[**] Infant mortality rate Child mortality rate Under-five mortality rate Sex of child Male 22 57 79 27 104 Female 16 54 70 27 95 Mother's age at birth Less than 20 25 63 88 32 117 20–34 16 54 70 25 93 35–49 24 54 78 (26) (102) Birth order 1 20 51 71 21 91 2–3 17 61 78 27 103 4–6 19 55 74 33 104 7+ (25) (49) (74) (28) (100) Previous birth interval [*] < 2 years 24 (65) (90) (34) (121) 2 years 19 47 66 32 96 3 years 11 47 57 (28) (84) 4+ years 19 67 86 25 109 [*] Excludes first order births [**] Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates. Note: Estimates in parentheses are based on 250-499 years of exposure. Caution is advised with these figures. 29 29 5. Nutrition Nutritional status Children’s nutritional status is a reflection of their overall health. When children have access to adequate and nutritious 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 directly and indirectly with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and those who survive, have recurring sicknesses and faltering growth. Such children may not reach their full potential as productive adults. The MDG 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 assist in the goal to reduce child mortality, especially for Swaziland, which has a high child mortality rate. 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 the reference population. The reference population used in this report is based on new WHO growth standards.7 Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age (underweight) is a measure of both acute and chronic malnutrition. It is a reflection of both recent and prolonged deprivation of food and or illness. 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 (stunting) is a measure of linear growth. It is a reflection of deprivation of nutritious food over a long period and/or recurrent or chronic illness. 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. Weight-for-height (wasting) is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. 7 WHO, 2007, WHO Child Growth Standards. 30 30 In the 2010 Swaziland MICS, weights and heights of all children under five years of age were measured using anthropometric equipment recommended by UNICEF. Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight-for-height is above two standard deviations from the median of the reference population. Almost six percent of children under age five in Swaziland are underweight and one percent are classified as severely underweight. Almost one in every three children (31 percent) is stunted and 10 percent are severely stunted. One percent of children under five are wasted and half of these are classified as severely wasted. Stunting is more prevalent among males than females (34 percent vs. 28 percent) and in rural areas than urban areas (33 percent vs. 23 percent). Across the four regions, the prevalence is highest in the Shiselweni region at 38 percent. Children whose mothers have secondary or higher education are the least likely to be underweight, wasted and stunted compared with children of mothers with lower or no education. The same applies to household wealth: children from richer households are less likely to be underweight, wasted and stunted compared with those from poorer households. The age pattern shows that underweight was most prevalent among children age 6–11 months (nine percent) compared with other age groups, which range from four to six percent. Stunting is highest in the 24–35 months age group, at 39 percent, and lowest in the 0–5 months age group at 19 percent. This pattern is expected and is related to the age when children ceased to be breastfed. In contrast, wasting is more likely in the 0–11 month age group, a group that is expected to be well taken care of nutritionally. The results also show that 11 percent of under-five children are overweight. Urban children are slightly more likely to be overweight than rural children (15 percent vs. 10 percent). There is no significant difference between regions. Similarly, there is no significant difference between boys and girls. Children whose mothers reached higher levels of education are more likely to be overweight than those whose education levels are low or did not attend school at all. Similarly, children from the richest households are more likely to be overweight than children from the poorest households (18 percent vs. eight percent). 31 31 Ta ble N U. 1: Nu tri tio na l s tat us of ch ild ren Pe rce nta ge of ch ild ren un de r a ge fiv eb y n utr itio na l s tat us ac co rdi ng to th ree an thr op om etr ic ind ice s: we igh t-fo r-a ge , h eig ht- for -ag e, an d w eig ht- for -he igh t, S wa zila nd , 2 01 0 We igh t-f or -ag e Nu mb er of ch ild ren un de r a ge fiv e He igh t-f or -ag e Nu mb er of ch ild ren un de r a ge fiv e We igh t-f or -he igh t Nu mb er of ch ild ren un de r ag e f ive Un de rw eig ht St un ted Wa ste d Ov erw eig ht Me an Z- Sc ore (S D) pe rce nt be low Me an Z- Sc ore (S D) pe rce nt be low Me an Z- Sc ore (S D) pe rce nt be low pe rce nt ab ov e -2 SD 1 -3 SD 2 -2 SD 3 -3 SD 4 -2 SD 5 -3 SD 6 +2 SD Se x M ale 6.7 1.2 -.0 3 1,2 26 34 .0 11 .7 -1. 5 12 22 0.5 0.1 10 .1 0.7 1,2 22 F em ale 5.0 0.8 -.0 3 1,3 46 28 .1 8.4 -1. 4 13 40 1.0 0.6 11 .2 0.7 1,3 38 Ar ea U rba n 4.2 0.6 .00 50 6 23 .1 5.9 -1. 1 50 8 1.2 0.6 14 .6 0.8 50 6 R ura l 6.2 1.1 -.0 4 2,0 66 32 .9 11 .0 -1. 5 20 54 0.6 0.3 9.7 0.7 2,0 54 Re gio n H ho hh o 6.4 1.3 -.0 3 64 1 28 .2 11 .5 -1. 4 63 6 0.9 0.7 12 .1 0.8 63 6 M an zin i 5.0 0.8 -.0 2 76 1 28 .1 7.8 -1. 2 76 5 1.1 0.4 11 .4 0.7 76 3 S his elw en i 6.8 1.2 -.0 4 65 3 37 .7 12 .7 -1. 7 64 7 0.3 0.0 10 .5 0.8 64 8 L ub om bo 5.2 0.7 -.0 4 51 6 30 .1 8.1 -1. 4 51 4 0.7 0.2 8.2 0.6 51 4 Ag e 0 –5 m on ths 4.4 1.7 .00 26 6 19 .0 6.1 -1. 1 26 4 2.7 1.9 25 .4 1.2 26 0 6 –1 1 m on ths 9.1 1.5 -.0 1 24 4 22 .1 7.2 -1. 1 24 3 1.7 0.0 14 .1 0.7 24 4 1 2– 23 m on ths 5.5 1.7 -.0 3 51 3 33 .8 10 .4 -1. 5 50 9 1.1 0.6 9.2 0.6 51 1 2 4– 35 m on ths 5.9 0.7 -.0 3 52 5 38 .8 15 .4 -1. 6 52 3 0.0 0.0 9.8 0.8 52 6 3 6– 47 m on ths 5.5 0.4 -.0 4 51 1 33 .8 9.6 -1. 5 51 1 0.0 0.0 9.5 0.7 51 0 4 8– 59 m on ths 5.7 0.5 -.0 5 51 2 27 .6 7.9 -1. 3 51 3 0.6 0.3 5.3 0.5 51 0 Mo the r's ed uc ati on N on e 7.7 1.0 -0. 6 29 5 39 .9 16 .0 -1. 7 29 4 0.2 0.2 5.8 0.6 29 8 P rim ary 8.0 1.6 -0. 5 87 0 38 .2 13 .0 -1. 6 86 7 1.3 0.6 9.2 0.6 86 8 S ec on da ry 4.3 0.7 -0. 2 73 7 28 .1 7.6 -1. 4 73 4 0.6 0.3 11 .1 0.8 73 2 H igh 4.7 0.7 -0. 2 50 4 25 .1 7.5 -1. 3 50 1 0.8 0.3 11 .9 0.7 50 0 T ert iar y 1.3 0.0 0.6 16 3 7.0 1.9 -0. 3 16 2 0.0 0.0 22 .5 1.1 16 1 Mi ss ing /D K * * * 3 * * * 3 * * * * 3 We alt h i nd ex qu int ile s P oo res t 8.4 1.4 -0. 6 63 1 41 .9 14 .4 -1. 8 62 7 0.5 0.0 7.5 0.6 62 8 S ec on d 5.1 1.4 -0. 4 53 9 32 .3 11 .6 -1. 6 53 6 0.5 0.4 10 .9 0.8 53 8 M idd le 6.1 0.4 -0. 4 53 3 33 .4 10 .6 -1. 5 53 4 1.1 0.6 9.1 0.6 53 1 F ou rth 4.9 0.8 -0. 2 47 3 26 .3 7.4 -1. 3 47 0 0.7 0.2 10 .4 0.7 46 8 R ich es t 3.6 0.6 0.2 39 7 14 .0 3.1 -0. 7 39 5 1.2 0.8 18 .1 0.9 39 5 To tal 5.8 1.0 -0. 3 2,5 72 30 .9 10 .0 -1. 4 25 62 0.8 0.4 10 .7 0.7 2,5 60 1 M IC S i nd ica tor 2. 1a an d M DG in dic ato r 1 .8 2 M IC S i nd ica tor 2. 1b 3 M IC S i nd ica tor 2. 2a , 4 MI CS in dic ato r 2 .2b 5 M IC S i nd ica tor 2. 3a , 6 MI CS in dic ato r 2 .3b No te: An as ter isk in dic ate s t ha t a n e sti ma te is ba se d o n f ew er tha n 2 5u nw eig hte d c as es 32 32 Figure NU.1: Percentage of children under age five who are underweight, stunted and wasted, Swaziland, 2010 Figure NU.1 shows the pattern of under-nutrition as the child grows. Stunting starts off low and peaks in the 24–35 months age group, while underweight is almost static except for a peak in the 6–11 months age group. Due to survivor bias wasting levels go down with age. Infant and young child feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition. Formula is also unsafe if clean water is not readily available. In Swaziland there are also high maternal HIV infections and this often leads to mothers not wanting to breastfeed or stopping breastfeeding earlier than recommended. WHO/UNICEF have the following feeding recommendations:  Early initiation of breastfeeding within the first hour of birth. • Exclusive breastfeeding for first six months. • Continued breastfeeding for two years or more. • Safe, appropriate and adequate complementary foods beginning at six months. • Frequency of complementary feeding: two times per day for 6–8 month olds; three times per day for 9–11 month olds. It is also recommended that breastfeeding be initiated within one hour of birth.32 Figure NU.1: Percentage of children under age five who are underweight, stunted and wasted, Swaziland, 2010 Figure NU.1 shows the pattern of under-nutrition as the child grows. Stunting starts off low and peaks in the 24–35 months age group, while underweight is almost static except for a peak in the 6–11 months age group. Due to survivor bias wasting levels go down with age. Infant and young child feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition. Formula is also unsafe if clean water is not readily available. In Swaziland there are also high maternal HIV infections and this often leads to mothers not wanting to breastfeed or stopping breastfeeding earlier than recommended. WHO/UNICEF have the following feeding recommendations:  Early initiation of breastfeeding within the first hour of birth. • Exclusive breastfeeding for first six months. • Continued breastfeeding for two years or more. • Safe, appropriate and adequate complementary foods beginning at six months. • Frequency of complementary feeding: two times per day for 6–8 month olds; three times per day for 9–11 month olds. It is also recommended that breastfeeding be initiated within one hour of birth. 33 33 While the above recommendations do apply to the general population, the new infant feeding guidelines in maternal HIV recommend that breastfeeding may be stopped at 12 months of age to reduce the transmission of HIV from the mother to the child. According to the 2010 ANC sentinel surveillance, this means that 42 percent of all mothers may stop breastfeeding at 12 months. The indicators for recommended child feeding practices are as follows:  Early initiation of breastfeeding within the first hour of birth. • Exclusive breastfeeding rate (< 6 months). • Timely complementary feeding rate (6–9 months). • Continued breastfeeding rate (12–15 and 20–23 months). • Frequency of complementary feeding (6–11 months). • Adequately fed infants (0–11 months). • Minimum meal frequency (6–23 months). • Milk feeding frequency for non-breastfeeding children (6–23 months). • Bottle-feeding (0–23 months). Table NU.2 provides the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). Nationally 54 percent of children were breastfed within the first hour of birth and 82 percent were breastfed within the first day of birth. Figure NU.2 shows that across the four regions, children in the Manzini region were least likely to be breastfed within the first hour of birth but most likely to be breastfed within the first day of birth. Both rural and children were more or less equally likely to have been breastfed within the first hour or within the first day of birth. About nine in every 10 children (91 percent) have ever been breastfed. There are no significant differences among groups of different backgrounds. Table NU.2 further shows differences by place of delivery, mother’s education and household wealth. The results show that mothers who delivered in public sector health facilities were more likely to initiate breastfeeding within the first hour than those who delivered in private sector health facilities or at home, while those who delivered in public and private sector health facilities were more likely than those who delivered at home to have breastfed within one day of birth. There is no clear linear relationship between patterns of breastfeeding and mothers’ education or household wealth. 34 34 Table NU.2: Initial breastfeeding Percentage of last-born children in the two years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within 1 day of birth, and percentage who received a prelacteal feed, Swaziland, 2010 Percentage ever breastfed 1 Percentage who were first breastfed: within one hour of birth 2 Percentage who were first breastfed: within one day of birth Percentage who received a prelacteal feed Number of last- born children in the two years preceding the survey Region Hhohho 89.2 55.7 79.7 17.7 253 Manzini 92.1 49.6 84.6 16.3 329 Shiselweni 90.8 56.3 81.7 17.2 253 Lubombo 91.3 58.7 79.3 12.9 195 Area Urban 87.8 52.6 79.9 13.5 255 Rural 92.0 55.1 82.3 17.1 776 Months since last birth 0–11 months 92.7 52.0 81.6 18.4 531 12–23 months 91.6 57.9 83.9 14.2 471 Assistance at delivery Skilled attendant 93.2 56.6 84.6 16.0 845 Traditional birth attendant * * * * 4 Other 89.4 50.9 76.9 17.6 160 Missing (10.6) (4.6) (10.6) (0.0) 22 Place of delivery Public sector health facility 93.1 56.9 84.7 15.8 785 Private sector health facility 96.3 50.2 85.9 24.3 44 Home 91.8 50.7 77.6 20.1 151 Other 80.9 51.7 69.6 6.2 30 Missing (4.9) (4.9) (4.9) (0.0) 21 Mother’s education None 91.3 54.4 79.2 11.4 57 Primary 93.4 62.4 85.8 13.8 291 Secondary 89.8 50.4 80.8 18.6 363 High 89.7 51.3 78.9 14.8 257 Tertiary 90.6 54.2 81.1 23.9 63 Wealth index quintiles Poorest 93.8 60.0 83.1 14.5 210 Second 90.5 49.4 77.8 20.4 204 Middle 91.4 53.7 81.7 14.4 222 Fourth 91.2 58.1 85.8 13.3 211 Richest 87.3 50.5 79.6 19.0 183 Total 90.9 54.5 81.7 16.2 1,031 1 MICS indicator 2.4 2 MICS indicator 2.5 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Figures in parentheses are based on 25–49 unweighted cases. 35 35 Figure NU.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Swaziland, 2010 About 16 percent of last-born children in the two years preceding the survey received prelacteal feeds. Children in the Lubombo region were least likely to receive prelacteal feeds (13 percent) compared with other regions (16–18 percent). Rural children were also slightly more likely than urban children to receive prelacteal feeds (17 percent vs. 14 percent). The percentage of children who received a prelacteal feed was highest among those who were delivered in private sector health facilities (24 percent), followed by home (20 percent) and public sector health facilities (16 percent). Children with mothers with tertiary education were most likely to receive a prelacteal feed (24 percent) compared with other children. While prelacteal feeding in relation to household wealth follows no particular pattern, the proportions of children who received prelacteal feeds were somewhat higher among households in the highest and second lowest wealth quintiles. In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12–15 and 20–23 months of age. Exclusive breastfeeding is recommended for the first six months for all mothers regardless of their HIV status. Nationally 44 percent of children less than six months of age are exclusively breastfed while 60 percent are predominantly breastfed. By age 12–15 months, 60 percent of children are still being breastfed, but by age 20–23 months, only 11 percent are still breastfed. Girls are slightly more likely to be continued on breastmilk than boys at age 20–23 months (15 percent versus seven percent). 36 36 Both exclusive breastfeeding and predominant breastfeeding are higher in the Lubombo and Hhohho regions compared with the Manzini and Shiselweni regions. Children from rural areas are more likely to be exclusively breastfed compared with those from urban areas (47 percent vs. 36 percent). Mother’s education is linearly related to exclusive breastfeeding or dominant breastfeeding. The percentages of children who are exclusively breastfed or dominantly breastfed are highest among those with mothers who attended primary school only and lowest among those with mothers with tertiary education. A similar trend can also be observed within household wealth where the poorest mothers practice exclusive breastfeeding more (61 percent) than other groups with the richest group least likely to exclusively breastfeed (32 percent). The richer the household gets, the less likely the mother is to exclusively or predominantly breastfeed. However, children of the higher wealth quintiles are slightly more likely to be continued on breastmilk into the second year of life than other groups. Figure NU.3 shows the detailed pattern of breastfeeding by age in months. Even during the early age before six months, many children are receiving liquids or foods other than breast milk. Exclusive breastfeeding is at its peak just over 60 percent by the first month and drops drastically at age 2–3 months. By the end of the fourth month less than 40 percent of children are still being exclusively breastfed. By the age of 22–23 months, only about 10 percent of children are receiving breast milk. Figure NU.3: Percentage distribution of children age 0–23 months by feeding pattern, Swaziland, 2010 36 Both exclusive breastfeeding and predominant breastfeeding are higher in the Lubombo and Hhohho regions compared with the Manzini and Shiselweni regions. Children from rural areas are more likely to be exclusively breastfed compared with those from urban areas (47 percent vs. 36 percent). Mother’s education is linearly related to exclusive breastfeeding or dominant breastfeeding. The percentages of children who are exclusively breastfed or dominantly breastfed are highest among those with mothers who attended primary school only and lowest among those with mothers with tertiary education. A similar trend can also be observed within household wealth where the poorest mothers practice exclusive breastfeeding more (61 percent) than other groups with the richest group least likely to exclusively breastfeed (32 percent). The richer the household gets, the less likely the mother is to exclusively or predominantly breastfeed. However, children of the higher wealth quintiles are slightly more likely to be continued on breastmilk into the second year of life than other groups. Figure NU.3 shows the detailed pattern of breastfeeding by age in months. Even during the early age before six months, many children are receiving liquids or foods other than breast milk. Exclusive breastfeeding is at its peak just over 60 percent by the first month and drops drastically at age 2–3 months. By the end of the fourth month less than 40 percent of children are still being exclusively breastfed. By the age of 22–23 months, only about 10 percent of children are receiving breast milk. Figure NU.3: Percentage distribution of children age 0–23 months by feeding pattern, Swaziland, 2010 37 37 Table NU.3: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Swaziland, 2010 Children 0–5 months Children 12–15 months Children 20–23 months Percent exclusively breastfed 1 Percent predominantly breastfed 2 Number of children Percent breastfed (continued breastfeeding at one year) 3 Number of children Percent breastfed (continued breastfeeding at two years) 4 Number of children Sex Male 44.4 59.0 121 60.0 86 7.2 103 Female 43.9 59.5 153 59.9 78 14.6 94 Region Hhohho 47.3 67.2 75 (53.7) 37 (16.2) 48 Manzini 42.5 51.6 97 (61.0) 40 5.5 61 Shiselweni 38.2 57.0 58 60.5 50 9.2 45 Lubombo 50.0 65.5 43 (64.3) 37 13.5 43 Area Urban 35.5 46.4 73 (63.0) 28 (14.2) 35 Rural 47.3 63.9 200 59.3 136 10.0 162 Mother's education None * * 12 * 13 * 21 Primary 57.0 70.9 74 58.2 46 10.9 74 Secondary 41.3 55.8 102 67.3 58 (10.5) 49 High 41.7 58.0 64 (56.2) 37 (3.6) 39 Tertiary * * 21 * 10 * 14 Wealth index quintiles Poorest (60.9) (70.7) 45 (68.4) 40 (7.9) 52 Second 43.2 67.2 60 (62.7) 35 (4.2) 41 Middle 49.4 62.1 55 (60.9) 36 (14.5) 30 Fourth 38.4 57.1 60 (52.2) 29 (16.1) 38 Richest 31.6 39.8 53 (50.1) 24 (13.4) 35 Total 44.1 59.2 273 (60.0) 164 10.7 197 1 MICS indicator 2.6 2 MICS indicator 2.9 3 MICS indicator 2.7 4 MICS indicator 2.8 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Figures in parentheses are based on 25–49 unweighted cases. 38 38 Table NU.4 shows the median duration of breastfeeding by selected background characteristics. Among children under age three, the median duration of breastfeeding is 14 months. There are no significant differences among mothers of different backgrounds. The median duration of exclusive breastfeeding is three months and predominant breastfeeding is four months. This shows that liquids and other foods are introduced too early before the age of six months. The adequacy of infant feeding in children under 24 months is provided in Table NU.5. Different criteria of adequate feeding are used depending on the age of the child. For infants age 0–5 months, exclusive breastfeeding is considered as adequate feeding, while infants age 6–23 months are considered to be adequately fed if they are receiving breastmilk and solid, semi-solid or soft food (breastfeeding is recommended to be continued up to 24 months of age or beyond). The results show that most children are not fed in the appropriate way. Only 44 percent of children 0–5 months are exclusively breastfed. From six months of age, complementary feeding is to be introduced while breastfeeding continues. However, only 39 percent of children of children 6–23 months were receiving complementary foods and breastmilk at the same time. Overall, only about 40 percent of children of children 0–23 months are appropriately breastfed. Adequate complementary feeding of children from six months to two years of age is particularly important for growth and development and the prevention of under nutrition.9 Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary food that help meet nutritional requirements when breastmilk is no longer sufficient. This means that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9–23 months of age. For children 6–23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Table NU.6 below shows the percentages of children receiving complementary foods from six to eight months. Approximately two-thirds (67 percent) of currently breastfeeding infants age 6–8 months received solid, semi-solid of soft foods the day preceding the survey. Females were more likely to receive complementary foods compared with males (76 percent vs. 53 percent). Due to small numbers of unweighted cases, no inferences can be made on patterns of complementary feeding for infants who are not currently breastfeeding. 9 The Swaziland Infant and Young Feeding Guidelines also recommend introduction of complementary feeding at six completed months. 38 Table NU.4 shows the median duration of breastfeeding by selected background characteristics. Among children under age three, the median duration of breastfeeding is 14 months. There are no significant differences among mothers of different backgrounds. The median duration of exclusive breastfeeding is three months and predominant breastfeeding is four months. This shows that liquids and other foods are introduced too early before the age of six months. The adequacy of infant feeding in children under 24 months is provided in Table NU.5. Different criteria of adequate feeding are used depending on the age of the child. For infants age 0–5 months, exclusive breastfeeding is considered as adequate feeding, while infants age 6–23 months are considered to be adequately fed if they are receiving breastmilk and solid, semi-solid or soft food (breastfeeding is recommended to be continued up to 24 months of age or beyond). The results show that most children are not fed in the appropriate way. Only 44 percent of children 0–5 months are exclusively breastfed. From six months of age, complementary feeding is to be introduced while breastfeeding continues. However, only 39 percent of children of children 6–23 months were receiving complementary foods and breastmilk at the same time. Overall, only about 40 percent of children of children 0–23 months are appropriately breastfed. Adequate complementary feeding of children from six months to two years of age is particularly important for growth and development and the prevention of under nutrition.9 Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary food that help meet nutritional requirements when breastmilk is no longer sufficient. This means that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9–23 months of age. For children 6–23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Table NU.6 below shows the percentages of children receiving complementary foods from six to eight months. Approximately two-thirds (67 percent) of currently breastfeeding infants age 6–8 months received solid, semi-solid of soft foods the day preceding the survey. Females were more likely to receive complementary foods compared with males (76 percent vs. 53 percent). Due to small numbers of unweighted cases, no inferences can be made on patterns of complementary feeding for infants who are not currently breastfeeding. 9 The Swaziland Infant and Young Feeding Guidelines also recommend introduction of complementary feeding at six completed months. 39 39 Table NU.4: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0–35 months, Swaziland, 2010 Median duration (in months) of Number of children age 0–35 monthsAny breastfeeding 1 Exclusive breastfeeding Predominant breastfeeding Sex Male 15.0 2.1 3.2 749 Female 15.2 1.6 3.4 830 Region Mbabane 14.5 2.2 3.7 399 Manzini 15.0 1.7 2.7 485 Shiselweni 15.0 0.7 3.1 395 Lubombo 16.1 2.5 3.7 300 Area Urban 14.8 1.4 2.2 336 Rural 15.2 2.2 3.7 1,243 Mother's education None 13.3 1.7 3.4 146 Primary 15.2 2.9 3.8 514 Secondary 16.0 1.7 3.2 487 High 14.5 0.9 3.2 337 Tertiary 11.4 0.4 0.6 95 Wealth index quintile Poorest 16.8 3.1 3.8 342 Second 15.5 1.7 4.1 341 Middle 14.3 2.5 3.6 335 Fourth 13.2 1.1 3.1 304 Richest 12.2 0.7 1.0 256 Median 15.1 1.9 3.3 1,579 Mean for all children (0–35 months) 13.8 2.6 3.6 1,579 1 MICS indicator 2.10 40 40 Table NU.5: Age-appropriate breastfeeding Percentage of children age 0–23 months who were appropriately breastfed during the previous day, Swaziland, 2010 Children age 0–5 months Children age 6–23 months Children age 0–23 months Percent exclusively breastfed 1 Number of children Percent currently breastfeeding and receiving solid, semi-solid or soft foods Number of children Percent appropriately breastfed 2 Number of children Sex Male 44.4 121 36.0 390 38.0 511 Female 43.9 153 42.0 382 42.5 534 Region Hhohho 47.3 75 36.4 184 39.6 260 Manzini 42.5 97 36.9 231 38.6 328 Shiselweni 38.2 58 44.5 206 43.1 264 Lubombo 50.0 43 37.8 151 40.5 193 Area Urban 35.5 73 34.6 152 34.9 225 Rural 47.3 200 40.1 620 41.8 820 Mother's education None * 12 29.8 75 31.3 88 Primary 57.0 74 39.0 246 43.1 320 Secondary 41.3 102 46.8 227 45.1 328 High 41.7 64 34.4 183 36.3 247 Tertiary * 21 (33.4) 41 29.4 62 Wealth index quintiles Poorest (60.9) 45 46.1 181 49.1 226 Second 43.2 60 38.4 151 39.8 211 Middle 49.4 55 40.2 170 42.4 226 Fourth 38.4 60 36.8 152 37.2 212 Richest 31.6 53 29.9 118 30.4 170 Total 44.1 273 39.0 772 40.3 1,045 1 MICS indicator 2.6 2 MICS indicator 2.14 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Figures in parentheses are based on 25-49 unweighted cases. 41 41 To meet the nutritional needs of growing children, it is recommended that the meal frequency increases with age. Table NU.7 presents the proportion of children age 6–23 months who received semi-solid or soft foods the minimum number of times or more during the previous day according to breastfeeding status (see the note in Table NU.7 for the definitions of minimum number of times for different age groups). For breastfeeding children, more than half (53 percent) receive solids, semi-solid and soft foods the minimum number of times required per day. This is also referred to as adequate feeding. Females are more likely to be adequately fed than males (59 percent vs. 46 percent). The percentage increases from age 6–8 months (48 percent) to a peak at 9–11 months (57 percent) and goes down again to 50 percent at 18–23 months. Children in the Manzini region are most likely to be adequately fed among all regions (at 61 percent). The percentage of children who are adequately fed is smallest in the Lubombo region (44 percent). Children of non-educated mothers are least likely to be adequately fed compared with other groups. There is no clear linear relationship between minimum meal frequency and household wealth. Within the currently not breastfeeding group only 39 percent receive at least two milk feeds a day while 55 percent are adequately fed per day. Again, females are more likely to be adequately fed than males (60 percent vs. 55 percent). Only 61 percent of the children in the age group 6–8 months are adequately fed, with the rate peaking up to 79 percent at 9–11 months and eventually going down to 50 percent by 18–23 months. Children from the Manzini region are the most likely to be adequately fed (66 percent) while those from the Lubombo region are the least likely (46 percent). There is a significant difference between urban and rural children (74 percent vs. 53 percent). The percentage of children who are adequately fed increases positively with the mother’s education: 82 percent of children whose mothers have attended tertiary education are adequately fed while 42 percent of children with non-educated mothers are adequately fed. The same trend is also noted for household wealth, where the richer the household, the more likely a child gets the minimum number of feeds. Table NU.6: Introduction of solid, semi-solid or soft food Percentage of infants age 6–8 months who received solid, semi-solid or soft foods during the previous day, Swaziland, 2010 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6–8 months Percent receiving solid, semi-solid or soft foods Number of children age 6–8 months Percent receiving solid, semi-solid or soft foods 1 Number of children age 6–8 months Sex Male (52.7) 39 * 11 54.8 52 Female 75.7 61 * 9 74.8 70 Area Urban * 21 * 5 (56.7) 28 Rural 69.3 78 * 14 69.2 94 Total 66.7 100 * 19 66.3 122 1 MICS indicator 2.12 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Figures in parentheses are based on 25-49 unweighted cases. 42 42 Table NU.7: Minimum meal frequency Percentage of children age 6–23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Swaziland, 2010 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6–23 months Percent receiving at least two milk feeds 1 Percent receiving solid, semi-solid and soft foods or milk feeds four times or more Number of children age 6–23 months Percent with minimum meal frequency 2 Number of children age 6–23 months Sex Male 46.3 168 37.7 55.2 222 51.3 390 Female 59.1 193 40.4 59.9 189 59.5 382 Age 6–8 months 48.3 100 83.9 (61.3) 23 50.7 122 9–11 months 57.3 91 76.0 (79.2) 37 63.6 128 12–17 months 54.9 133 42.3 64.7 110 59.3 243 18–23 months (50.0) 37 27.5 50.3 242 50.2 278 Region Hhohho 56.2 81 30.8 53.5 103 54.7 184 Manzini 60.5 104 45.5 65.7 127 63.4 231 Shiselweni 49.7 103 39.1 60.0 102 54.9 206 Lubombo 44.0 72 38.8 45.5 79 44.8 151 Area Urban 55.2 66 65.5 74.0 86 65.9 152 Rural 52.7 295 31.9 52.9 325 52.8 620 Mother's education None (39.9) 29 31.3 (41.5) 47 40.9 75 Primary 53.9 112 23.6 46.8 134 50.0 246 Secondary 55.2 130 46.3 65.1 97 59.4 227 High 55.4 72 48.2 64.9 111 61.2 183 Tertiary * 18 68.1 (81.5) 23 (66.1) 41 Wealth index quintiles Poorest 57.1 97 20.5 39.1 84 48.7 181 Second 48.1 68 25.3 50.5 83 49.4 151 Middle 51.7 83 40.4 54.9 87 53.3 170 Fourth 54.9 65 47.7 70.2 87 63.6 152 Richest 52.5 47 64.3 74.3 71 65.6 118 Total 53.1 360 39.0 57.4 411 55.4 772 1 MICS indicator 2.15 2 MICS indicator 2.13 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Figures in parentheses are based on 25-49 unweighted cases. Minimum number of meal frequency: solid, semi-solid, or soft foods, two times for infants age 6–8 months, 3 times for children 9–23 months; non-breastfeeding children: solid, semi-solid, or soft foods, or milk feeds, four times for children age 6–23 months. 43 43 Table NU.8: Bottle-feeding Percentage of children age 0–23 months who were fed with a bottle with a nipple during the previous day, Swaziland, 2010 Percentage of children age 0–23 months fed with a bottle with a nipple 1 Number of children age 0–23 months: Sex Male 28.8 511 Female 30.8 534 Age 0–5 months 31.7 273 6–11 months 44.3 251 12–23 months 21.9 521 Region Hhohho 32.7 260 Manzini 29.6 328 Shiselweni 30.6 264 Lubombo 25.4 193 Area Urban 41.2 225 Rural 26.7 820 Mother's education None 23.3 88 Primary 21.7 320 Secondary 31.6 328 High 34.2 247 Tertiary 54.1 62 Wealth index quintiles Poorest 16.3 226 Second 29.1 211 Middle 28.2 226 Fourth 32.7 212 Richest 47.3 170 Total 29.8 1,045 1 MICS indicator 2.11 Bottle-feeding is discouraged because of the possible contamination from unsafe water and lack of hygiene in preparation. However, a significant number of children still get their feeds from a bottle. Table NU.8 shows that bottle-feeding is prevalent in Swaziland. Thirty percent of children age 0-23 months are fed from a bottle. There is no difference between males and females. The 6-11 months age group are the highest at 44 percent while the least is the 12-23 months age group at 22 percent. There is no significant difference among the regions although urban children are more likely to be fed from bottles compared to their rural counterparts (41 percent vs. 27 percent). Children whose mothers attended tertiary education are most likely to be fed from bottles compared with the other levels of education. The same trend can be noted within the wealth index quintiles where the richer the household gets, the more likely the mothers are to have their children fed from a bottle (47 percent within the richest group down to 16 percent within the poorest group). 44 44 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 compromised work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In about 92 percent of households, salt used for cooking was tested for iodine content by using salt test kits. Table NU.9 shows that in a small proportion of households (six percent), there was no salt available. In 52 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine (adequately iodized). Use of adequately iodized salt was lowest in the Lubombo region (41 percent) and highest in the Hhohho region (61 percent). About 57 percent of urban households were found to be using adequately iodized salt compared with 49 percent in rural areas. Figure NU.9 shows the trend in regions and areas. Use of adequately iodized salt is positively correlated with the level of education of the household head. It ranges between 44 percent among the least educated group and 63 percent among the most educated group. This trend is also observed for household wealth, where use of adequately iodized salt increases from 40 percent among the poorest households to 63 percent among the richest households. Figure NU.4 Percentage of households consuming adequately iodized salt, Swaziland, 2010 45 45 Table NU.9: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Swaziland, 2010 Percentage of households in which salt was tested Number of house- holds Percent of households with Total Number of households in which salt was tested or with no salt No salt salt test result Not iodized (0 PPM) >0 and <15 PPM Adequately iodized (15+ PPM ) 1 Region Hhohho 89.5 1,261 6.4 5.6 27.1 60.9 100.0 1,205 Manzini 93.5 1,624 4.9 10.0 34.5 50.6 100.0 1,597 Shiselweni 92.7 969 5.3 10.2 32.5 52.0 100.0 949 Lubombo 92.3 979 6.7 9.9 42.3 41.1 100.0 968 Area Urban 92.1 1,680 5.5 7.4 29.7 57.4 100.0 1,636 Rural 92.0 3,154 5.9 9.7 35.9 48.5 100.0 3,084 Education of household head None 88.8 950 9.5 10.6 35.6 44.3 100.0 932 Primary 92.7 1,439 5.5 9.0 36.6 48.9 100.0 1,411 Secondary 92.0 1,005 5.6 8.7 33.0 52.6 100.0 980 High 93.6 842 4.3 7.3 33.0 55.4 100.0 823 Tertiary 93.7 589 2.3 8.6 26.3 62.7 100.0 565 Missing/DK * 10 * * * * * 10 Wealth index quintiles Poorest 86.8 825 11.8 11.5 36.9 39.9 100.0 811 Second 91.6 785 6.7 8.9 35.8 48.7 100.0 770 Middle 91.7 923 5.9 8.4 35.3 50.4 100.0 900 Fourth 93.7 1,025 4.0 10.2 36.0 49.8 100.0 1,000 Richest 94.6 1,276 2.6 6.5 27.6 63.3 100.0 1,239 Total 92.0 4,834 5.7 8.9 33.8 51.6 100.0 4,720 1 MICS indicator 2.16 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Vitamin A supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world, and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A for child health and immune 45 Table NU.9: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Swaziland, 2010 Percentage of households in which salt was tested Number of house- holds Percent of households with Total Number of households in which salt was tested or with no salt No salt salt test result Not iodized (0 PPM) >0 and <15 PPM Adequately iodized (15+ PPM ) 1 Region Hhohho 89.5 1,261 6.4 5.6 27.1 60.9 100.0 1,205 Manzini 93.5 1,624 4.9 10.0 34.5 50.6 100.0 1,597 Shiselweni 92.7 969 5.3 10.2 32.5 52.0 100.0 949 Lubombo 92.3 979 6.7 9.9 42.3 41.1 100.0 968 Area Urban 92.1 1,680 5.5 7.4 29.7 57.4 100.0 1,636 Rural 92.0 3,154 5.9 9.7 35.9 48.5 100.0 3,084 Education of household head None 88.8 950 9.5 10.6 35.6 44.3 100.0 932 Primary 92.7 1,439 5.5 9.0 36.6 48.9 100.0 1,411 Secondary 92.0 1,005 5.6 8.7 33.0 52.6 100.0 980 High 93.6 842 4.3 7.3 33.0 55.4 100.0 823 Tertiary 93.7 589 2.3 8.6 26.3 62.7 100.0 565 Missing/DK * 10 * * * * * 10 Wealth index quintiles Poorest 86.8 825 11.8 11.5 36.9 39.9 100.0 811 Second 91.6 785 6.7 8.9 35.8 48.7 100.0 770 Middle 91.7 923 5.9 8.4 35.3 50.4 100.0 900 Fourth 93.7 1,025 4.0 10.2 36.0 49.8 100.0 1,000 Richest 94.6 1,276 2.6 6.5 27.6 63.3 100.0 1,239 Total 92.0 4,834 5.7 8.9 33.8 51.6 100.0 4,720 1 MICS indicator 2.16 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Vitamin A supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world, and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A for child health and immune 46 46 function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth MDG: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted at all children between the ages of six to 59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective and efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of the vitamin, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programmes, the definition of the indicator is the percentage of children 6–59 months of age receiving at least one high-dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, MoH recommends that children age 6-11 months be given one high dose (100 000μg) vitamin A capsule and children age 12–59 months given a vitamin A capsule (200 000μg) every six months. Vitamin A capsules are linked to immunization services both routine and mass campaigns and are given when the child has contact with these services after six months of age. It is also recommended that mothers take a vitamin A supplement within eight weeks of giving birth. Table NU.10 shows receipt of vitamin A supplementation nationally and by background characteristics. Within the six months preceding the MICS survey, 68 percent of children age 6–59 months received at least one high-dose vitamin A supplement. Age pattern of vitamin A supplementation shows that the receipt of vitamin A supplementation decreases with the age of the child (85 percent among the youngest age group and 54 percent among the oldest age group). Receipt of vitamin A supplementation was highest in Shiselweni (81 percent), followed by Manzini (72 percent) and Hhohho (60 percent). Lubombo had the lowest coverage of vitamin A supplementation at 55 percent. There were no gender differences in receipt of vitamin A supplementation. 47 47 Table NU.10: Children's vitamin A supplementation Percent distribution of children age 6–59 months by receipt of a high-dose vitamin A supplement in the last six months, Swaziland, 2010 Percentage who received Vitamin A according to: Percentage of children who received vitamin A during the last six months 1 Number of children age 6–59 monthsChild health book/card/vaccination card Mother's report Sex Male 32.5 62.1 65.9 1,144 Female 34.2 66.8 69.8 1,230 Region Hhohho 30.1 52.1 60.2 579 Manzini 33.0 68.9 71.5 690 Shiselweni 34.2 79.2 81.0 625 Lubombo 36.7 54.3 55.3 480 Area Urban 34.6 67.4 69.1 454 Rural 33.0 63.9 67.7 1,920 Age 6–11 months 67.1 80.3 85.3 251 12–23 months 55.6 76.1 81.0 521 24–35 months 32.4 69.0 73.8 534 36–47 months 18.1 54.2 55.6 533 48–59 months 12.0 51.8 53.6 536 Mother's education None 28.3 58.6 61.9 291 Primary 31.1 62.8 65.1 817 Secondary 35.4 67.1 71.8 655 High 40.2 67.1 72.0 458 Tertiary 25.1 67.3 67.3 150 Missing/DK * * * 3 Wealth index quintiles Poorest 30.6 62.9 65.9 601 Second 30.2 63.6 66.6 497 Middle 36.4 62.3 66.5 488 Fourth 35.9 67.0 71.5 429 Richest 35.1 69.0 71.1 359 Total 33.3 64.6 68.0 2,374 1 MICS indicator 2.17 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. 48 48 Low birth weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. Table NU.11 and Figure NU.5 show the number of children weighed at birth and those with a low birth weight. In Swaziland, it is relatively easy to weigh the babies soon after delivery because 80 percent of deliveries occur in health facilities (see Table RH.10). Overall, 91 percent of infants are weighed at birth and nine percent of infants weigh less than 2,500 grams at birth (Table NU.11). There is no significant variation by region as well as urban and rural areas. However there is some slight variation with the mother’s educational level as well as slight differences within the different wealth quintiles. Children whose mothers have reached tertiary education are least likely to be of low birth weight (five percent) than other groups while children whose mothers did not attend school (12 percent) are most likely to be of low birth weight. 49 49 Figure NU.5 Percentage of infants weighing less than 2,500 grams at birth, Swaziland, 2010 Table NU.11: Low birth weight infants Percentage of last-born children in the two years preceding the survey that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Swaziland, 2010 Percent of live births: Number of live births in the last two yearsBelow 2,500 grams 1 Weighed at birth 2 Region Hhohho 9.5 90.3 253 Manzini 8.1 93.1 329 Shiselweni 9.5 94.8 253 Lubombo 7.9 85.1 195 Area Urban 8.5 92.7 255 Rural 8.8 90.9 776 Education None 11.5 82.0 57 Primary 9.3 85.2 291 Secondary 8.9 92.7 363 High 8.1 96.9 257 Tertiary 5.4 97.5 63 Wealth index quintiles Poorest 8.0 86.8 210 Second 10.6 87.6 204 Middle 9.1 92.4 222 Fourth 8.9 95.1 211 Richest 6.9 95.1 183 Total 8.7 91.3 1,031 1 MICS indicator 2.18 2 MICS indicator 2.19 50 50 6. Child Health Immunization MDG 4 is to reduce child mortality by two-thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than two million deaths every year. A WFFC goal is to ensure full immunization of children less than one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. The National Expanded Programme on Immunization (EPI) is committed to reducing morbidity, disability and mortality rates. Diseases that are targeted for prevention are tuberculosis, polio, diphtheria, whooping cough, tetanus, hepatitis B, rubella, and mumps and haemophilus influenza type B. The national immunization calendar in Box 2 shows the vaccine schedule in Swaziland. The calendar recommends that a child should receive BCG and polio vaccines at birth, and by the age of nine months, a child should been vaccinated against all other preventable diseases. Swaziland has recently introduced pentavalent vaccine, which has five vaccines in one, referred to as the DPT/HepB/Hib vaccine. It prevents against diphtheria, pertussis, tetanus, haemophilus influenza type B and Hepatitis B. Box 2: Swaziland National Immunization Calendar Age Vaccine At birth BCG and Polio 0 6 weeks DPT/HepB/Hib1 OPV1 10 weeks DPT/HepB/Hib2 OPV2 14 weeks DPT/HepB/Hib3 OPV3 9 months Measles 18 months Measles booster 5 years DT and Polio In the 2010 Swaziland MICS, mothers/caretakers were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. If the card was not available mothers/caretakers were asked to recall if the child was given the vaccination. Table CH.1 shows that about eight in 10 children age 12–23 months have a vaccination card. 51 51 Table CH.1: Vaccinations in the first year of life Percentage of children age 12–23 months immunized against childhood diseases at any time before the survey and before the first birthday, Swaziland, 2010 Vaccinated at any time before the survey according to: Vaccinated by 12 months of age Vaccination card Mother's report Either BCG 1 87.6 10.6 98.2 97.9 Polio At birth 86.5 10.1 96.7 96.3 1 87.0 10.0 97.0 96.3 2 86.2 5.9 92.1 90.1 3 2 82.7 2.3 85.0 83.8 DPT 1 87.8 10.1 97.8 96.4 2 87.0 9.7 96.7 94.6 3 3, 5 84.1 6.5 90.6 89.4 HEPB 1 87.8 10.1 97.8 96.4 2 87.0 9.7 96.7 94.6 3 3, 5 84.1 6.5 90.6 89.4 HIB 1 87.8 10.1 97.8 96.4 2 87.0 9.7 96.7 94.6 3 3, 5 84.1 6.5 90.6 89.4 Measles 4 84.7 13.1 97.8 93.9 Measles (Booster) * 33.5 0.0 33.5 2.1 All vaccinations ** 82.1 1.0 83.1 77.3 No vaccinations ** 0.0 1.6 1.6 1.6 Number of children age 12–23 months 521 521 521 521 1 MICS indicator 3.1 2 MICS indicator 3.2 3 MICS indicator 3.3 4 MICS indicator 3.4; MDG indicator 4.3 5 MICS indicator 3.5 Note: * It is not possible to establish the coverage of measles booster from mothers’ report because the vaccine was inadvertently omitted from the questionnaire. ** All and no vaccinations do not include Polio at birth and the Measles Booster . 52 52 Figure CH.1 and Table CH.2 show the percentage of children age 12–23 months who received each of the vaccinations based on the immunization card. Overall, 83 percent of children age 12–23 months are fully immunized. The graph indicates that most children receive the recommended vaccinations at birth. Ninety- eight percent and 97 percent received BCG and polio vaccination at birth, respectively. The coverage for measles vaccine by 12 months is 98 percent. Coverage is high in the Shiselweni and Lubombo regions at 86 percent and 85 percent, respectively, and somewhat lower in the Manzini and Hhohho regions at 82 percent and 80 percent, respectively. Children residing in rural areas are most likely to be vaccinated compared with those residing in urban areas (85 percent vs. 77 percent). There are no differentials with regards to the education and the wealth status of the mother (Table CH.2). Figure CH.1 Percentage of children aged 12–23 months who received the recommended vaccinations by 12 months, Swaziland, 2010 53 53 Ta ble C H. 2: Va cc ina tio ns by ba ck gr ou nd ch ara cte ris tic s Pe rce nta ge of ch ild ren ag e 1 2– 23 m on ths cu rre ntl y v ac cin ate d a ga ins t c hil dh oo d d ise as es , S wa zila nd , 2 01 0 Pe rce nta ge of ch ild ren w ho re ce ive d: Pe rce nt- ag e w ith va cc ine - ati on ca rd se en Nu mb er of ch ild ren ag e 1 2- 23 mo nth s BC G Po lio DP T HE PB HI B Me a- sle s Me a- sle s Bo o-s ter * No ne ** All ** At bir th 1 2 3 1 2 3 1 2 3 1 2 3 Se x M ale 98 .7 97 .9 97 .1 92 .6 84 .6 98 .3 97 .4 90 .8 98 .3 97 .4 90 .8 98 .3 97 .4 90 .8 97 .9 34 .9 1.3 82 .8 87 .1 28 1 F em ale 97 .6 95 .2 96 .9 91 .5 85 .5 97 .2 95 .8 90 .4 97 .2 95 .8 90 .4 97 .2 95 .8 90 .4 97 .7 31 .8 2.0 83 .5 88 .5 24 0 Re gio n H ho hh o 97 .2 96 .1 95 .2 89 .7 81 .4 97 .2 97 .2 87 .8 97 .2 97 .2 87 .8 97 .2 97 .2 87 .8 97 .1 31 .0 2.8 80 .4 84 .9 13 3 M an zin i 99 .1 98 .3 98 .5 90 .5 83 .0 98 .5 95 .1 86 .6 98 .5 95 .1 86 .6 98 .5 95 .1 86 .6 99 .1 32 .3 0.9 82 .0 89 .5 15 2 S his elw en i 97 .2 95 .8 97 .2 94 .4 87 .0 96 .5 96 .5 93 .7 96 .5 96 .5 93 .7 96 .5 96 .5 93 .7 95 .2 32 .7 2.8 85 .5 86 .3 12 9 L ub om bo 99 .2 96 .1 96 .9 94 .6 89 .9 99 .2 98 .4 96 .2 99 .2 98 .4 96 .2 99 .2 98 .4 96 .2 10 0.0 39 .3 0.0 85 .3 90 .7 10 7 Ar ea U rba n 99 .4 98 .5 97 .0 91 .6 79 .7 98 .3 98 .3 89 .1 98 .3 98 .3 89 .1 98 .3 98 .3 89 .1 98 .8 35 .8 0.6 76 .8 82 .0 91 R ura l 97 .9 96 .3 97 .0 92 .2 86 .1 97 .7 96 .3 90 .9 97 .7 96 .3 90 .9 97 .7 96 .3 90 .9 97 .6 33 .0 1.9 84 .5 89 .0 43 1 Mo the r's ed uc ati on N on e 98 .5 98 .5 96 .9 92 .0 84 .6 98 .4 96 .0 90 .2 98 .4 96 .0 90 .2 98 .4 96 .0 90 .2 99 .1 26 .2 0.0 79 .9 87 .8 54 P rim ary 98 .2 95 .3 97 .4 92 .4 85 .8 97 .7 95 .7 92 .1 97 .7 95 .7 92 .1 97 .7 95 .7 92 .1 98 .1 33 .1 1.8 84 .1 87 .8 17 1 S ec on da ry 96 .1 95 .5 95 .3 88 .7 82 .1 95 .3 94 .4 87 .2 95 .3 94 .4 87 .2 95 .3 94 .4 87 .2 94 .6 29 .7 3.9 79 .9 85 .2 14 1 H igh 10 0.0 99 .3 97 .6 95 .5 89 .7 10 0.0 10 0.0 94 .3 10 0.0 10 0.0 94 .3 10 0.0 10 0.0 94 .3 10 0.0 39 .0 0.0 89 .1 92 .1 12 4 T ert iar y (10 0.0 ) (95 .7) (10 0.0 ) (92 .3 ) (75 .5) (10 0.0 ) (10 0.0 ) (83 .8 ) (10 0.0 ) (10 0.0 ) (83 .8 ) (10 0.0 ) (10 0.0 ) (83 .8) ) (10 0.0 ) (43 .8) (0. 0) (74 .8) (81 .6) 30 We alt h i nd ex qu int ile s P oo res t 99 .2 97 .8 97 .9 93 .6 84 .3 97 .8 96 .0 89 .7 97 .8 96 .0 89 .7 97 .8 96 .0 89 .7 99 .2 33 .3 0.8 83 .6 8 8.4 12 1 S ec on d 98 .6 97 .1 96 .5 92 .5 87 .0 98 .6 97 .5 91 .7 98 .6 97 .5 91 .7 98 .6 97 .5 91 .7 97 .2 36 .6 1.4 83 .3 89 .8 11 3 M idd le 98 .4 96 .2 97 .4 91 .5 87 .5 99 .2 98 .0 94 .0 99 .2 98 .0 94 .0 99 .2 98 .0 94 .0 98 .2 26 .1 0.8 83 .8 87 .7 11 0 F ou rth 94 .9 93 .6 94 .9 92 .6 85 .8 94 .9 94 .9 92 .1 94 .9 94 .9 92 .1 94 .9 94 .9 92 .1 94 .6 30 .7 5.1 85 .2 87 .6 10 2 R ich es t 10 0.0 99 .0 98 .7 89 .3 78 .6 98 .7 96 .9 83 .6 98 .7 96 .9 83 .6 98 .7 96 .9 83 .6 10 0.0 43 .7 0.0 78 .4 84 .0 76 To tal 98 .2 96 .7 97 .0 92 .1 85 .0 97 .8 96 .7 90 .6 97 .8 96 .7 90 .6 97 .8 96 .7 90 .6 97 .8 33 .5 1.6 83 .1 87 .8 52 1 *B as ed on ch ild ren w ith im mu niz ati on ca rds on ly. **A ll a nd no va cc ina tio ns do no t in clu de Po lio at bi rth an d t he M ea sle s B oo ste r. N ote : F igu res in pa ren the se s a re ba se d o n 2 5– 49 un we igh ted ca se s. 54 54 Tetanus Toxoid One of the MDGs is to reduce by three-quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births in every district. A WFFC goal is to eliminate maternal and neonatal tetanus by 2005. Preventing maternal and neonatal tetanus means making sure that all pregnant women receive at least two doses of the tetanus toxoid (TT) vaccine. However, if women have not received two doses of the vaccine during the pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met:  Received at least two doses of tetanus toxoid vaccine, the last within the prior three years;  Received at least three doses, the last within the prior five years;  Received at least four doses, the last within 10 years;  Received at least five doses during lifetime. Table CH.3 shows the tetanus protection status of women who had had a live birth within the last 12 months preceding the survey by major background characteristics. Almost eight in 10 women age 15–49 years with a live birth in the last two years are protected against tetanus. Residential area and education status of the mother seem to have an influence on how well a mother is protected from tetanus, as indicated in Figure CH.2. Mothers residing in urban areas are more likely to be protected against tetanus compared with those residing in rural areas. The likelihood of protection against tetanus increases with the increase in the educational status of the mother. Figure CH.2 Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus, Swaziland, 2010 54 Tetanus Toxoid One of the MDGs is to reduce by three-quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births in every district. A WFFC goal is to eliminate maternal and neonatal tetanus by 2005. Preventing maternal and neonatal tetanus means making sure that all pregnant women receive at least two doses of the tetanus toxoid (TT) vaccine. However, if women have not received two doses of the vaccine during the pregnancy, they (and their newborn) are also considered to be protected if the following conditions are met:  Received at least two doses of tetanus toxoid vaccine, the last within the prior three years;  Received at least three doses, the last within the prior five years;  Received at least four doses, the last within 10 years;  Received at least five doses during lifetime. Table CH.3 shows the tetanus protection status of women who had had a live birth within the last 12 months preceding the survey by major background characteristics. Almost eight in 10 women age 15–49 years with a live birth in the last two years are protected against tetanus. Residential area and education status of the mother seem to have an influence on how well a mother is protected from tetanus, as indicated in Figure CH.2. Mothers residing in urban areas are more likely to be protected against tetanus compared with those residing in rural areas. The likelihood of protection against tetanus increases with the increase in the educational status of the mother. Figure CH.2 Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus, Swaziland, 2010 55 55 Table CH.3: Neonatal tetanus protection Percentage of women age 15–49 years with a live birth in the last two years protected against neonatal tetanus, Swaziland, 2010 Percentage of women who received at least two doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus 1 Number of women with a live birth in the last two yearsTwo doses, the last within prior three years Three doses, the last within prior five years Four doses, the last within prior 10 years Five or more doses during lifetime Area Urban 71.1 9.7 0.8 0.0 0.0 81.6 255 Rural 70.8 6.8 0.4 0.0 0.2 78.1 776 Region Hhohho 67.2 7.1 0.6 0.0 0.0 74.9 253 Manzini 72.8 9.9 1.0 0.0 0.4 84.2 329 Shiselweni 73.9 6.1 0.0 0.0 0.0 80.0 253 Lubombo 68.4 5.8 0.0 0.0 0.0 74.2 195 Education None 59.3 12.1 0.0 0.0 0.0 71.4 57 Primary 66.0 8.2 0.4 0.0 0.0 74.6 291 Secondary 73.6 6.5 0.3 0.0 0.4 80.7 363 High 73.7 7.8 1.1 0.0 0.0 82.7 257 Tertiary 76.0 5.2 0.0 0.0 0.0 81.2 63 Wealth index quintiles Poorest 67.1 6.7 0.6 0.0 0.6 75.1 210 Second 68.1 5.7 0.0 0.0 0.0 73.8 204 Middle 72.3 8.2 1.6 0.0 0.0 82.2 222 Fourth 73.8 8.9 0.0 0.0 0.0 82.6 211 Richest 73.0 8.1 0.0 0.0 0.0 81.1 183 Total 70.8 7.5 0.5 0.0 0.1 79.0 1,031 1 MICS indicator 3.7 56 56 Oral rehydration treatment Diarrhoea is a leading cause of death among children under five across the world including Swaziland. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid – can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one-half deaths due to diarrhoea among children under five by 2010 compared with 2000 (WFFC); and 2) reduce by two-thirds the mortality rate among children under five by 2015 compared with 1990 (MDGs). In addition, WFFC calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are:  Prevalence of diarrhoea  Oral rehydration therapy (ORT)  Home management of diarrhoea  ORT with continued feeding In the 2010 Swaziland MICS, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. It is worthwhile to note that diarrhoea is mostly prevalent during the rainy season and in Swaziland, this is the period between October and March. The survey data collection was undertaken in the months of August to November. This period is outside the diarrhoea endemic period and this seasonality may have influenced the prevalence of diarrhoea among children under five found during the survey. Table CH.4 shows that overall, 16 percent of under-five children had diarrhoea in the two weeks preceding the survey. The likelihood of a child to have diarrhoea decreases as the child grows. Diarrhoea is more prevalent among children age 0–11 months and 12–23 months, at 23 percent and 27 percent, respectively. The table also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. About 74 percent received ORS or a recommended sugar salt solution; however, 57 percent of mothers reported to give ORS fluids from an ORS packet or pre-packed ORS fluids. Mothers residing in the Hhohho region are most likely to give ORS fluids from ORS packets or pre- packed ORS fluids (68 percent) compared with mothers residing in the Manzini region (50 percent). Mothers in the highest quintile are more likely to give their children ORT compared with those in the lowest quintile. Again, children residing in urban areas are more likely to receive recommended fluids during diarrhoea. There is no variation with regards to mother’s education. Mothers reporting to have given their children sugar salt solution as treatment for diarrhoea were asked to indicate how they prepare the solution. Table CH.4A highlights the lack of knowledge of some mothers to prepare the solution. A total of 24 percent of mothers either put eight level caps of salt and one cap of 57 57 sugar when preparing the solution or use other incorrect measurements. This practice is common in the Lubombo and Shiselweni regions. 58 58 Table CH.4: Oral rehydration solutions and recommended homemade fluids Percentage of children age 0–59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recommended homemade fluids, Swaziland, 2010 Had diarrhoea in last two weeks Number of children age 0–59 months Children with diarrhoea who received: ORS or recommended sugar salt solution Number of children age 0– 59 months with diarrhoea ORS (fluid from ORS packet or pre- packaged ORS fluid) Recommended sugar salt solution Sex Male 16.1 1,265 55.8 27.9 74.6 204 Female 15.7 1,382 58.1 23.6 74.3 217 Region Hhohho 16.2 655 67.9 24.0 81.2 106 Manzini 15.9 787 50.3 28.1 68.8 125 Shiselweni 14.8 683 56.3 29.3 77.0 101 Lubombo 17.0 523 54.1 20.2 71.4 89 Area Urban 13.8 527 64.7 19.1 76.7 73 Rural 16.4 2,120 55.4 27.0 74.0 349 Age 0–11 months 22.8 524 54.3 20.5 68.5 119 12–23 months 26.5 521 61.1 28.5 79.1 138 24–35 months 14.7 534 59.6 23.7 76.0 78 36–47 months 8.8 533 (53.6) (32.4) (77.5) 47 48–59 months 7.2 536 (49.2) (27.5) (69.3) 39 Mother's education None 13.1 303 (59.1) (20.5) (67.4) 40 Primary 17.7 891 57.9 25.6 75.8 158 Secondary 16.0 757 54.3 22.8 72.9 121 High 15.8 523 57.3 30.8 74.5 82 Tertiary 11.5 171 * * * 20 Missing/DK * 3 * * * 1 Wealth index quintiles Poorest 17.4 646 58.0 21.4 71.8 112 Second 16.7 557 55.8 28.3 74.3 93 Middle 17.2 544 60.5 30.6 79.4 94 Fourth 14.7 489 49.8 21.0 68.1 72 Richest 12.2 411 60.3 27.9 80.5 50 Total 15.9 2,647 57.0 25.7 74.4 421 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Figures in parentheses are based on 25–49 unweighted cases. 59 59 Table CH.4A: Preparation of recommended homemade fluids for treatment of diarrhoea Percentage of children age 0–59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and preparation of sugar salt solution, Swaziland, 2010 Had diarrhoea in the last two weeks Number of children age 0–59 months Percentage of children with diarrhoea who were given sugar salt solution Preparation of sugar salt solution: Number of children age 0–59 months with diarrhoea who were given sugar salt solution Eight level caps of sugar and one cap salt (correct method) Eight level caps of salt and 1 cap sugar Other DK/ Missing Total Sex Male 16.1 1,265 27.9 73.7 3.4 16.9 5.9 100.0 204 Female 15.7 1,382 23.6 66.3 8.8 18.0 6.8 100.0 217 Region Hhohho 16.2 655 24.0 83.5 6.1 4.4 6.1 100.0 106 Manzini 15.9 787 28.1 79.4 6.6 6.6 7.4 100.0 125 Shiselweni 14.8 683 29.3 55.3 3.1 32.4 9.2 100.0 101 Lubombo 17.0 523 20.2 57.9 9.4 32.8 0.0 100.0 89 Area Urban 13.8 527 19.1 73.8 7.4 18.8 0.0 100.0 73 Rural 16.4 2,120 27.0 69.7 5.8 17.3 7.3 100.0 349 Age 0–11 months 22.8 524 20.5 63.4 3.4 29.4 3.7 100.0 119 12–23 months 26.5 521 28.5 74.3 7.8 12.3 5.6 100.0 138 24–35 months 14.7 534 23.7 50.7 13.8 20.2 15.3 100.0 78 36–47 months 8.8 533 (32.4) (79.6) (0.0) (14.5) (6.0) 100.0 47 48–59 months 7.2 536 (27.5) (91.4) (0.0) (8.6) (0.0) 100.0 39 Mother's education None 13.1 303 (20.5) (78.5) (0.0) (10.3) (11.2) 100.0 40 Primary 17.7 891 25.6 79.3 2.1 12.1 6.4 100.0 158 Secondary 16.0 757 22.8 55.7 6.7 32.0 5.6 100.0 121 High 15.8 523 30.8 65.0 14.8 13.0 7.2 100.0 82 Tertiary 11.5 171 * * .* * * * 20 Missing/DK * 3 * * * * * * 1 Wealth index quintiles Poorest 17.4 646 21.4 64.3 3.5 23.1 9.2 100.0 112 Second 16.7 557 28.3 64.8 10.8 17.5 6.9 100.0 93 Middle 17.2 544 30.6 79.7 3.6 12.2 4.5 100.0 94 Fourth 14.7 489 21.0 66.1 5.6 18.1 10.3 100.0 72 Richest 12.2 411 27.9 75.7 6.5 17.8 0.0 100.0 50 Total 15.9 2,647 25.7 70.2 6.0 17.5 6.4 100.0 421 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. Figures in parentheses are based on 25–49 unweighted cases. 60 60 Feeding practices during diarrhoeal episodes are important to avoid dehydration and further complications among children. Table CH.5 shows the amount of liquids and food given to children during an episode of diarrhoea. Twenty-three percent of under-five children with diarrhoea drank more than usual while 74 percent were given about the same to drink, less or much less. Two percent of children were given nothing to drink during the episode of diarrhoea. Regarding food given to children during a diarrhoeal episode, 28 percent were given the same amount to eat while 53 percent ate somewhat or much less. Ten percent of children did not take any food during an episode of diarrhoea. Children in urban areas are least likely to stop eating during a diarrhoeal episode compared with children in rural areas (two percent vs. 11 percent). There is also a variation with regards to wealth status of the mother; the poorer the mother, the most likely that the child would stop eating during a diarrhoeal episode. Table CH.6 provides the proportion of children age 0–59 months with diarrhoea in the last two weeks who received ORT with continued feeding, and the percentage of children with diarrhoea who received other treatments. Overall, 66 percent of children with diarrhoea received ORS or increased fluids, 81 percent received ORT (ORS or recommended homemade fluids or increased fluids). Combining the information in Table CH.5 with those in Table CH.4 on ORT, it is observed that 48 percent of children received ORT and, at the same time, feeding was continued, as is the recommendation. There are marked differences in the home management of diarrhoea by background characteristics. In the Shiselweni region, only 39 percent of children received ORT and continued feeding while 51 percent of children in all the other regions received ORT and continued feeding. Almost one in five of children (21 percent) with diarrhoea received antibiotic and only two percent received antimotility medication, in the form of a pill or syrup, as treatment for diarrhoea. One in 10 children (11 percent) was not given any treatment or drug and five percent were given a home remedy or herbal medicine. Treatment of diarrhoea with antibiotic syrup or pills is likely in urban areas compared with rural areas (29 percent vs. 19 percent), while treatment of diarrhoea using home remedy or herbal medicine is more common in rural areas compared with urban areas (six percent vs. one percent). 61 61 Ta ble C H. 5: Fe ed ing pr ac tic es du rin g d iar rh oe a Pe rce nt dis trib uti on of ch ild ren ag e 0 –5 9 m on ths w ith di arr ho ea in th e l as t tw ow ee ks by am ou nt of liq uid s a nd fo od gi ve n d uri ng an ep iso de of di arr ho ea , S wa zila nd , 2 01 0 Ha d dia rrh oe a in the las t tw o w ee ks Nu mb er of ch ild ren ag e 0 -59 mo nth s Dr ink ing pr ac tic es du rin g d iar rh oe a: To tal Ea tin g p rac tic es du rin g d iar rh oe a: To tal Nu mb er of ch ild ren ag e0 –5 9 mo nth s wit h dia rrh oe a Gi ve n mu ch les s t o dri nk Gi ve n so me wh at les s t o d rin k Gi ve n ab ou t the sa me to dri nk Gi ve n mo re to dri nk Gi ve n no thi ng to dri nk Mi ss - ing / DK Gi ve n mu ch les s t o ea t Gi ve n so me - wh at les s t o ea t Gi ve n ab ou t the sa me to ea t Gi ve n mo re to ea t Sto p- pe d foo d Ha d ne ve r be en giv en foo d Se x M ale 16 .1 12 65 13 .1 22 .8 38 .0 24 .5 0.9 0.6 10 0.0 22 .9 27 .1 31 .5 7.5 8.4 2.7 10 0.0 20 4 F em ale 15 .7 13 82 15 .9 24 .2 34 .5 21 .5 3.5 0.4 10 0.0 29 .2 25 .7 25 .3 4.0 11 .1 4.7 10 0.0 21 7 Re gio n H ho hh o 16 .2 65 5 15 .1 28 .5 41 .6 12 .8 2.0 0.0 10 0.0 27 .8 29 .6 30 .2 2.5 6.4 3.5 10 0.0 10 6 M an zin i 15 .9 78 7 9.3 17 .3 44 .1 24 .4 3.9 1.0 10 0.0 25 .4 22 .6 33 .6 7.8 6.0 4.5 10 0.0 12 5 S his elw en i 14 .8 68 3 16 .2 25 .2 31 .5 24 .3 1.8 0.9 10 0.0 22 .5 22 .5 24 .8 5.0 20 .7 4.5 10 0.0 10 1 L ub om bo 17 .0 52 3 19 .3 24 .4 23 .9 31 .5 0.9 0.0 10 0.0 29 .3 32 .3 22 .6 7.4 6.6 1.9 10 0.0 89 Ar ea U rba n 13 .8 52 7 17 .9 23 .0 40 .4 15 .4 3.2 0.0 10 0.0 22 .9 34 .2 28 .6 7.1 2.2 5.0 10 0.0 73 R ura l 16 .4 21 20 13 .8 23 .6 35 .3 24 .5 2.1 0.6 10 0.0 26 .8 24 .8 28 .3 5.4 11 .3 3.4 10 0.0 34 9 Ag e 0 –1 1 m on ths 22 .8 52 4 14 .7 24 .3 44 .2 14 .2 1.8 0.8 10 0.0 18 .7 19 .7 34 .1 5.7 11 .9 10 .0 10 0.0 11 9 1 2– 23 m on ths 26 .5 52 1 14 .0 29 .6 30 .9 22 .2 2.4 0.9 10 0.0 21 .6 36 .6 24 .9 4.0 10 .9 2.0 10 0.0 13 8 2 4– 35 m on ths 14 .7 53 4 9.9 18 .6 32 .6 36 .5 2.4 0.0 10 0.0 32 .0 23 .6 27 .0 12 .0 5.4 .0 10 0.0 78 3 6– 47 m on ths 8.8 53 3 (18 .5) (17 .7) (38 .9) (24 .9) (0. 0) (0. 0) 10 0.0 (31 .7) (26 .0) (28 .3) (3. 1) (8. 9) (1. 9) 10 0.0 47 4 8– 59 m on ths 7.2 53 6 (20 .5) (16 .2) (34 .9) (22 .7) (5. 7) (0. 0) 10 0.0 (46 .5) (17 .1) (25 .2) (2. 2) (9. 1) (0. 0) 10 0.0 39 Mo the r's ed uc ati on N on e 13 .1 30 3 (8. 7) (23 .2) (41 .4) (17 .0) (6. 5) (3. 3) 10 0.0 (23 .6) (35 .6) (28 .2) (5. 4) (4. 6) (2. 6) 10 0.0 40 P rim ary 17 .7 89 1 12 .7 28 .0 34 .7 22 .0 1.9 0.6 10 0.0 31 .6 24 .1 27 .4 4.7 8.4 3.8 10 0.0 15 8 S ec on da ry 16 .0 75 7 15 .6 22 .5 29 .2 31 .0 1.7 0.0 10 0.0 23 .5 23 .7 30 .1 8.5 11 .6 2.7 10 0.0 12 1 H igh 15 .8 52 3 17 .8 19 .5 42 .8 17 .5 2.3 0.0 10 0.0 24 .1 28 .1 24 .6 5.1 13 .5 4.6 10 0.0 82 T ert iar y 11 .5 17 1 * * * * * * * * * * * * * * 20 M iss ing /D K * 3 * * * * * * * * * * * * * 1 We alt h i nd ex qu int ile s P oo res t 17 .4 64 6 16 .9 22 .7 28 .3 27 .9 2.2 2.0 10 0.0 34 .4 24 .5 19 .6 2.7 13 .6 5.3 10 0.0 11 2 S ec on d 16 .7 55 7 12 .5 22 .1 38 .0 26 .0 1.4 0.0 10 0.0 29 .1 23 .9 26 .9 8.3 9.5 2.4 10 0.0 93 M idd le 17 .2 54 4 15 .7 23 .6 36 .5 20 .1 4.0 0.0 10 0.0 24 .1 29 .0 30 .4 6.0 9.5 1.0 10 0.0 94 F ou rth 14 .7 48 9 13 .3 24 .1 41 .0 19 .8 1.8 0.0 10 0.0 15 .5 25 .8 40 .3 6.7 8.8 2.9 10 0.0 72 R ich es t 12 .2 41 1 12 .4 26 .8 43 .4 15 .9 1.5 0.0 10 0.0 21 .1 31 .4 29 .4 5.8 3.5 8.8 10 0.0 50 To tal 15 .9 2,6 47 14 .5 23 .5 36 .2 22 .9 2.3 0.5 10 0.0 26 .1 26 .4 28 .3 5.7 9.7 3.7 10 0.0 42 1 No te: An as ter isk in dic ate s t ha t a n e sti ma te is ba se d o n f ew er tha n 2 5 u nw eig hte d c as es . F igu res in pa ren the se s a re ba se d o n 2 5– 49 un we igh ted ca se s. 62 62 Ta ble C H. 6: Or al reh yd rat ion th era py w ith co nti nu ed fe ed ing an d o the r t rea tm en ts Pe rce nta ge of ch ild ren ag e 0 –5 9 m on ths w ith di arr ho ea in th e l as t tw ow ee ks w ho re ce ive d O RT wit h c on tin ue d f ee din g, an d p erc en tag e o f c hil dre n w ith di arr ho ea w ho re ce ive d o the r tr ea tm en ts, Sw az ila nd , 2 01 0 Ch ild ren w ith di arr ho ea w ho re ce ive d: Ot he r t rea tm en t: No t g ive n an y tre atm en t or dru g Nu mb er of ch ild ren ag e 0– 59 mo nth s w ith dia rrh oe a OR S o r inc rea se d flu ids OR T ( OR S o r a rec om me nd ed su ga r s alt so lut ion or inc rea se d f lui ds ) OR T w ith co nti nu ed fee din g 1 Pil l o r s yru p: Inj ec tio n: Int ra- ve no us Ho me rem ed y/ He rba l me dic ine Ot he r An ti- bio tic An ti- mo tilit y Ot he r Un - kn ow n An ti- bio tic No n- an tib iot ic Un kn ow n Se x M ale 65 .9 81 .3 53 .0 22 .4 3.1 0.9 18 .9 1.2 0.3 1.3 0.9 4.1 10 .1 10 .0 20 4 F em ale 66 .7 79 .9 43 .4 19 .0 1.1 2.8 15 .1 1.1 0.0 2.0 0.3 6.2 7.4 12 .8 21 7 Re gio n H ho hh o 69 .9 83 .2 50 .9 20 .7 4.1 2.0 20 .6 0.5 0.5 0.5 1.1 1.5 6.5 8.5 10 6 M an zin i 63 .1 79 .6 50 .7 25 .9 2.9 1.0 13 .6 2.7 0.0 3.1 1.0 11 .2 2.7 13 .6 12 5 S his elw en i 65 .3 79 .7 39 .2 20 .7 0.0 3.6 16 .7 0.9 0.0 1.8 0.0 3.6 9.9 9.9 10 1 L ub om bo 67 .7 79 .8 51 .0 13 .0 0.9 0.9 17 .5 0.0 0.0 0.9 0.0 2.8 18 .6 13 .6 89 Ar ea U rba n 71 .3 82 .8 57 .3 28 .8 5.2 0.8 9.2 3.6 0.8 0.8 1.5 1.4 9.0 11 .2 73 R ura l 65 .3 80 .1 46 .1 18 .9 1.4 2.1 18 .5 0.6 0.0 1.9 0.4 5.9 8.7 11 .5

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