The Gambia - Demographic and Health Survey - 2014

Publication date: 2014

The Gambia Demographic and Health Survey 2013 The G am bia 2013 D em ographic and H ealth Survey Republic of The Gambia The Gambia Demographic and Health Survey 2013 Gambia Bureau of Statistics Banjul, The Gambia ICF International Rockville, Maryland USA September 2014 The Global Fund To Fight AIDS, Tuberculosis and Malaria REPUBLIC OF THE GAMBIA This report summarizes the findings of the 2013 Gambia Demographic and Health Survey (GDHS) carried out by The Gambia Bureau of Statistics (GBOS). The survey was funded by the government of The Gambia, the US Agency for International Development (USAID), the United Nations Population Fund (UNFPA), the United Nations Development Program (UNDP), the United Nations Children’s Fund (UNICEF), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), and the Global Fund. ICF International provided technical assistance through its MEASURE DHS program, which is designed to collect data on fertility, family planning, maternal and child health, maternal mortality, and domestic violence. Additional information about The Gambia DHS survey may be obtained from The Gambia Bureau of Statistics, Kanifing Institutional Layout, PO Box 3504, Serrekunda, The Gambia; Telephone: (220) 437-7847; Fax: (220) 437-7848/437-7917. Information about the DHS Program may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850-5971, USA; Telephone: +1-301-407-6500; Fax: +1-301-407-6501; Email: reports@DHSprogram.com; Internet: www.DHSprogram.com. Cover photo of two bearded barbets ©2012 Alastair Stewart, used with permission. Cover photo of the Gambia River ©2011 Ardjan van der Blonk, used with permission. Suggested citation: The Gambia Bureau of Statistics (GBOS) and ICF International. 2014. The Gambia Demographic and Health Survey 2013. Banjul, The Gambia, and Rockville, Maryland, USA: GBOS and ICF International. Contents • iii CONTENTS TABLES AND FIGURES . ix FOREWORD . xv MILLENNIUM DEVELOPMENT GOAL INDICATORS . xvii MAP OF THE GAMBIA . xviii 1 INTRODUCTION . 1 1.1 History, Geography, and Economy . 1 1.1.1 History . 1 1.1.2 Geography . 1 1.1.3 Economy . 2 1.2 Population . 2 1.3 Population and Health Policies . 2 1.3.1 National Population Policy . 2 1.3.2 National Health Policy . 3 1.4 Objectives of the 2013 Gambia Demographic and Health Survey . 3 1.5 Organisation of the Survey . 4 1.6 Sample Design . 4 1.7 Questionnaires . 5 1.8 Listing, Pretest, Main Training, Fieldwork, and Data Processing . 6 1.8.1 Listing . 6 1.8.2 Pretest and Main Training . 7 1.8.3 Fieldwork . 7 1.8.4 Data Processing . 7 1.9 Anthropometry, Anaemia, Malaria, and HIV Testing . 8 1.9.1 Height and Weight Measurements . 8 1.9.2 Anaemia Testing . 8 1.9.3 Malaria Testing . 8 1.9.4 HIV Testing . 8 1.10 Response Rates . 9 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 11 2.1 Household Characteristics . 11 2.1.1 Drinking Water . 11 2.1.2 Household Sanitation Facilities . 13 2.1.3 Housing Characteristics . 14 2.1.4 Household Possessions . 15 2.2 Wealth Index . 16 2.3 Hand Washing . 17 2.4 Population by Age and Sex . 18 2.5 Household Composition . 20 2.6 Birth Registration . 20 2.7 Children’s Living Arrangements and Parental Survival . 21 2.8 Education of the Household Population . 23 2.8.1 School Attendance by Survivorship of Parents . 23 2.8.2 Educational Attainment . 24 2.8.3 School Attendance Ratios . 27 2.9 Disability . 29 iv • Contents 3 CHARACTERISTICS OF RESPONDENTS . 31 3.1 Characteristics of Survey Respondents . 31 3.2 Educational Attainment by Background Characteristics . 33 3.3 Literacy . 35 3.4 Access to Mass Media . 36 3.5 Employment . 38 3.6 Occupation . 41 3.7 Health Insurance Coverage . 44 3.9 Smoking . 46 4 MARRIAGE AND SEXUAL ACTIVITY . 49 4.1 Current Marital Status . 49 4.2 Polygyny . 50 4.3 Age at First Marriage . 52 4.4 Age at First Sexual Intercourse . 53 4.5 Recent Sexual Activity . 54 5 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS . 59 5.1 Introduction . 59 5.2 Current Fertility . 59 5.3 Fertility Trends . 61 5.4 Children Ever Born and Children Surviving . 61 5.5 Birth Intervals . 63 5.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 64 5.7 Menopause . 65 5.8 Age at First Birth . 65 5.9 Teenage Fertility . 66 6 FERTILITY PREFERENCES . 69 6.1 Desire for More Children . 69 6.2 Desire to Limit Childbearing by Background Characteristics. 70 6.3 Ideal Number of Children . 71 6.4 Mean Ideal Number of Children by Background Characteristics . 73 6.5 Fertility Planning Status . 73 6.6 Wanted Fertility Rates . 74 7 FAMILY PLANNING . 75 7.1 Knowledge of Contraceptive Methods . 75 7.2 Knowledge of Contraceptive Methods by Background Characteristics . 77 7.3 Current Use of Contraceptive Methods . 78 7.4 Differentials in Contraceptive Use by Background Characteristics . 80 7.5 Source of Contraception . 80 7.6 Brands of Pills Used and Informed Choice . 81 7.7 Contraceptive Discontinuation . 82 7.8 Knowledge of the Fertile Period . 84 7.9 Need for Family Planning Services . 84 7.10 Future Use of Contraception . 87 7.11 Exposure to Family Planning Messages in the Media. 87 7.12 Contact of Nonusers with Family Planning Providers . 89 8 INFANT AND CHILD MORTALITY . 91 8.1 Assessment of Data Quality . 92 8.2 Levels and Trends in Infant and Child Mortality . 93 8.2.1 Early Childhood Mortality Rates . 93 8.2.2 Trends in Early Childhood Mortality . 93 8.3 Early Childhood Mortality Rates by Socioeconomic Characteristics . 94 8.4 Demographic Differentials in Early Childhood Mortality . 94 8.5 Perinatal Mortality . 95 8.6 High-Risk Fertility Behaviour . 97 Contents • v 9 REPRODUCTIVE HEALTH . 99 9.1 Antenatal Care . 99 9.1.1 Number and Timing of Antenatal Visits . 100 9.1.2 Components of Antenatal Care . 101 9.1.3 Tetanus Toxoid Injections . 102 9.2 Delivery . 103 9.2.1 Place of Delivery . 103 9.2.2 Assistance during Delivery . 104 9.3 Postnatal Care . 106 9.3.1 Timing of First Postnatal Checkup for the Mother . 106 9.3.2 Type of Provider of First Postnatal Checkup for the Mother . 107 9.3.3 Timing of First Postnatal Checkup for the Newborn . 108 9.3.4 Type of Provider of First Postnatal Checkup for the Newborn . 109 9.4 Problems in Accessing Health Care . 110 10 CHILD HEALTH . 113 10.1 Child’s Size at Birth . 113 10.2 Vaccination Coverage . 115 10.2.1 Vaccination Coverage by Background Characteristics . 116 10.3 Trends in Vaccination Coverage . 117 10.4 Acute Respiratory Infection . 117 10.5 Fever . 119 10.6 Diarrhoeal Disease . 120 10.6.1 Prevalence of Diarrhoea . 120 10.6.2 Treatment of Diarrhoea . 121 10.6.3 Feeding Practices during Diarrhoea . 123 10.7 Knowledge of ORS Packets . 125 10.8 Stool Disposal . 125 11 NUTRITION OF WOMEN AND CHILDREN . 127 11.1 Nutritional Status of Children . 128 11.1.1 Measurement of Nutritional Status among Young Children . 128 11.1.2 Data Collection . 129 11.1.3 Levels of Child Malnutrition . 129 11.2 Initiation of Breastfeeding . 131 11.3 Breastfeeding Status by Age . 133 11.4 Duration of Breastfeeding . 135 11.5 Types of Complementary Foods . 135 11.6 Infant and Young Child Feeding Practices . 136 11.7 Prevalence of Anaemia in Children . 139 11.8 Micronutrient Intake among Children . 140 11.9 Nutritional Status of Women . 143 11.10 Prevalence of Anaemia in Women . 144 11.11 Micronutrient Intake among Mothers . 145 12 MALARIA . 149 12.1 Ownership of Mosquito Nets . 150 12.2 Indoor Residual Spraying . 153 12.3 Access to an Insecticide-Treated Net (ITN) . 154 12.4 Use of Mosquito Nets . 155 12.4.1 Use of Mosquito Nets by Persons in the Household . 155 12.4.2 Use of Existing Mosquito Nets . 157 12.4.3 Use of Mosquito Nets by Children Under Age 5 . 158 12.4.4 Use of Mosquito Nets by Pregnant Women . 159 12.5 Use of Intermittent Preventive Treatment of Malaria during Pregnancy . 160 12.6 Prevalence, Diagnosis, and Prompt Treatment of Children with Fever . 161 12.7 Prevalence of Low Haemoglobin in Children . 164 12.8 Prevalence of Malaria in Children . 164 vi • Contents 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR . 167 13.1 Knowledge of AIDS and of HIV Prevention Methods . 167 13.2 Comprehensive Knowledge about AIDS . 169 13.3 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 172 13.4 Attitudes towards Those Living with HIV and AIDS . 173 13.5 Attitudes towards Negotiating Safer Sex . 175 13.6 Adult Support for Education about Condom Use . 176 13.7 Higher-Risk Sex . 177 13.7.1 Multiple Sexual Partners . 177 13.7.2 Point Prevalence . 179 13.7.3 Payment for Sex . 180 13.8 Coverage of HIV Testing and Counselling . 181 13.9 HIV Testing during Antenatal Care . 183 13.10 Self-Reported Sexually Transmitted Infections . 185 13.11 Prevalence of Medical Injections . 186 13.12 HIV- and AIDS-Related Knowledge and Behaviour among Youth . 187 13.12.1 Knowledge about HIV and AIDS and of Sources for Condoms . 188 13.12.2 Age at First Sexual Intercourse among Youth . 189 13.12.3 Premarital Sex . 190 13.12.4 Multiple Sexual Partners among Youth . 190 13.12.5 Age Mixing in Sexual Relationships among Young Women Age 15-19 . 190 13.12.6 Recent HIV Tests among Youth . 191 14 HIV PREVALENCE . 193 14.1 Coverage Rates for HIV Testing . 193 14.2 HIV Prevalence . 196 14.2.1 HIV Prevalence by Age and Sex . 196 14.2.2 HIV Prevalence by Socioeconomic Characteristics . 196 14.2.3 HIV Prevalence by Demographic Characteristics. 197 14.2.4 HIV Prevalence by Sexual Behaviour . 198 14.3 HIV Prevalence among Young People . 200 14.4 HIV Prevalence by Other Characteristics Related to HIV Risk . 201 14.5 HIV Prevalence among Couples . 202 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 205 15.1 Women’s and Men’s Employment . 206 15.2 Women’s Control over their Own Earnings and Relative Magnitude of Women’s Earnings . 207 15.3 Ownership of Assets . 210 15.4 Women’s Participation in Household Decision Making . 212 15.5 Attitudes towards Wife Beating . 214 15.6 Women’s Empowerment Indicators . 216 15.7 Current Use of Contraception by Women’s Empowerment Status . 217 15.8 Ideal Family Size and Unmet Need by Women’s Status . 218 15.9 Women’s Status and Reproductive Health Care . 219 15.10 Differentials in Infant and Child Mortality by Women’s Status . 219 15.11 Female Genital Cutting . 220 15.11.1 Knowledge of Female Genital Cutting . 220 15.11.2 Prevalence of Female Genital Cutting . 221 15.11.3 Attitudes towards Female Genital Cutting . 223 16 DOMESTIC VIOLENCE . 225 16.1 Valid Measures of Domestic Violence . 226 16.1.1 Use of Valid Measures of Violence . 226 16.1.2 Ethical Considerations in the 2013 GDHS . 227 16.1.3 Sample for the Violence Module . 227 16.2 Women Experiencing Physical Violence . 227 16.3 Persons Committing Physical Violence . 229 16.4 Experience of Sexual Violence . 229 16.5 Persons Committing Sexual Violence . 231 Contents • vii 16.6 Age at First Experience of Sexual Violence . 231 16.7 Experience of Different Forms of Violence . 231 16.8 Violence during Pregnancy . 232 16.9 Marital Control by Husband. 232 16.10 Experience of Spousal Violence . 234 16.11 Spousal Violence by Background Characteristics . 235 16.12 Spousal Violence by Husband’s Characteristics and Women’s Empowerment Indicators . 236 16.13 Recent Physical or Sexual Violence by Any Husband or Partner . 237 16.14 Experience of Spousal Violence by Duration of Marriage . 238 16.15 Physical Consequences of Spousal Violence . 238 16.16 Women’s Violence Against Their Husbands . 239 16.17 Help-Seeking Behaviour by Women Who Experience Violence . 241 16.18 Sources of Help to Stop Violence . 242 17 ADULT AND MATERNAL MORTALITY . 243 17.1 Assessment of Data Quality . 243 17.2 Estimates of Adult Mortality . 244 17.3 Estimates of Maternal Mortality . 245 REFERENCES . 247 APPENDIX A SAMPLE DESIGN . 251 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 263 APPENDIX C DATA QUALITY TABLES . 279 APPENDIX D PARTICIPANTS IN THE 2013 GAMBIA DEMOGRAPHIC AND HEALTH SURVEY . 287 APPENDIX E QUESTIONNAIRES . 293 Tables and Figures • ix TABLES AND FIGURES 1 INTRODUCTION . 1 Table 1.1 Basic demographic indicators . 2 Table 1.2 Results of the household and individual interviews . 10 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 11 Table 2.1 Household drinking water . 12 Table 2.2 Household sanitation facilities . 13 Table 2.3 Household characteristics . 14 Table 2.4 Household possessions . 16 Table 2.5 Wealth quintiles . 17 Table 2.6 Hand washing . 18 Table 2.7 Household population by age, sex, and residence . 19 Table 2.8 Household composition . 20 Table 2.9 Birth registration of children under age 5 . 21 Table 2.10 Children’s living arrangements and orphanhood . 22 Table 2.11 School attendance by survivorship of parents . 23 Table 2.12.1 Educational attainment of the female household population . 25 Table 2.12.2 Educational attainment of the male household population . 26 Table 2.13 School attendance ratios . 27 Table 2.14 Prevalence of physical disability . 30 Figure 2.1 Population pyramid . 19 Figure 2.2 Age-specific attendance rates . 29 3 CHARACTERISTICS OF RESPONDENTS . 31 Table 3.1 Background characteristics of respondents . 32 Table 3.2.1 Educational attainment: Women . 33 Table 3.2.2 Educational attainment: Men . 34 Table 3.3.1 Literacy: Women . 35 Table 3.3.2 Literacy: Men . 36 Table 3.4.1 Exposure to mass media: Women . 37 Table 3.4.2 Exposure to mass media: Men . 38 Table 3.5.1 Employment status: Women . 40 Table 3.5.2 Employment status: Men . 41 Table 3.6.1 Occupation: Women . 42 Table 3.6.2 Occupation: Men . 43 Table 3.7 Type of employment: Women . 44 Table 3.8.1 Health insurance coverage: Women . 45 Table 3.8.2 Health insurance coverage: Men . 45 Table 3.9 Use of tobacco: Men . 47 Figure 3.1 Women’s employment status in the past 12 months . 39 4 MARRIAGE AND SEXUAL ACTIVITY . 49 Table 4.1 Current marital status . 50 Table 4.2.1 Number of women’s co-wives . 51 Table 4.2.2 Number of men’s wives . 51 Table 4.3 Age at first marriage . 52 Table 4.4 Median age at first marriage by background characteristics . 53 x • Tables and Figures Table 4.5 Age at first sexual intercourse . 54 Table 4.6 Median age at first sexual intercourse by background characteristics . 54 Table 4.7.1 Recent sexual activity: Women . 55 Table 4.7.2 Recent sexual activity: Men . 56 5 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS . 59 Table 5.1 Current fertility . 60 Table 5.2 Fertility by background characteristics . 60 Table 5.3 Trends in age-specific fertility rates . 61 Table 5.4 Children ever born and living . 62 Table 5.5 Birth intervals . 63 Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility . 64 Table 5.7 Median duration of amenorrhoea, postpartum abstinence, and postpartum insusceptibility . 65 Table 5.8 Menopause . 65 Table 5.9 Age at first birth . 66 Table 5.10 Median age at first birth . 66 Table 5.11 Teenage pregnancy and motherhood . 67 6 FERTILITY PREFERENCES . 69 Table 6.1 Fertility preferences by number of living children . 70 Table 6.2.1 Desire to limit childbearing: Women . 71 Table 6.2.2 Desire to limit childbearing: Men . 71 Table 6.3 Ideal number of children by number of living children . 72 Table 6.4 Mean ideal number of children . 73 Table 6.5 Fertility planning status . 74 Table 6.6 Wanted fertility rates . 74 7 FAMILY PLANNING . 75 Table 7.1 Knowledge of contraceptive methods . 76 Table 7.2 Knowledge of contraceptive methods by background characteristics . 77 Table 7.3 Current use of contraception by age . 79 Table 7.4 Current use of contraception by background characteristics . 80 Table 7.5 Source of modern contraception methods . 81 Table 7.6 Informed choice . 82 Table 7.7 Twelve-month contraceptive discontinuation rates . 83 Table 7.8 Reasons for discontinuation . 84 Table 7.9 Knowledge of fertile period . 84 Table 7.10 Need and demand for family planning among currently married women . 86 Table 7.11 Future use of contraception . 87 Table 7.12 Exposure to family planning messages . 88 Table 7.13 Contact of nonusers with family planning providers . 89 8 INFANT AND CHILD MORTALITY . 91 Table 8.1 Early childhood mortality rates . 93 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 94 Table 8.3 Early childhood mortality rates by demographic characteristics . 95 Table 8.4 Perinatal mortality . 96 Table 8.5 High-risk fertility behaviour . 97 Tables and Figures • xi 9 REPRODUCTIVE HEALTH . 99 Table 9.1 Antenatal care . 100 Table 9.2 Number of antenatal care visits and timing of first visit . 101 Table 9.3 Components of antenatal care . 102 Table 9.4 Tetanus toxoid injections . 103 Table 9.5 Place of delivery . 104 Table 9.6 Assistance during delivery . 105 Table 9.7 Timing of first postnatal checkup . 107 Table 9.8 Type of provider of first postnatal checkup for the mother . 108 Table 9.9 Timing of first postnatal checkup for the newborn . 109 Table 9.10 Type of provider of first postnatal checkup for the newborn . 110 Table 9.11 Problems in accessing health care . 111 Figure 9.1 Mother’s duration of stay in the health facility after giving birth . 106 10 CHILD HEALTH . 113 Table 10.1 Child’s size and weight at birth. 114 Table 10.2 Vaccinations by source of information . 115 Table 10.3 Vaccinations by background characteristics . 116 Table 10.4 Vaccinations in first year of life . 117 Table 10.5 Prevalence and treatment of symptoms of ARI . 118 Table 10.6 Prevalence and treatment of fever . 119 Table 10.7 Prevalence of diarrhoea . 120 Table 10.8 Diarrhoea treatment . 122 Table 10.9 Feeding practices during diarrhoea . 124 Table 10.10 Knowledge of ORS packets or pre-packaged liquids. 125 Table 10.11 Disposal of children’s stools . 126 11 NUTRITION OF WOMEN AND CHILDREN . 127 Table 11.1 Nutritional status of children . 130 Table 11.2 Initial breastfeeding . 132 Table 11.3 Breastfeeding status by age . 133 Table 11.4 Median duration of breastfeeding . 135 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 136 Table 11.6 Infant and young child feeding (IYCF) practices . 138 Table 11.7 Prevalence of anaemia in children . 140 Table 11.8 Micronutrient intake among children . 141 Table 11.9 Presence of iodised salt in household . 143 Table 11.10 Nutritional status of women . 144 Table 11.11 Prevalence of anaemia in women . 145 Table 11.12 Micronutrient intake among mothers . 147 Figure 11.1 Nutritional status of children by age . 131 Figure 11.2 Infant feeding practices by age . 134 Figure 11.3 IYCF indicators on breastfeeding status . 135 12 MALARIA . 149 Table 12.1 Household possession of mosquito nets . 152 Table 12.2 Indoor residual spraying against mosquitoes . 153 Table 12.3 Access to an insecticide-treated net (ITN) . 154 Table 12.4 Use of mosquito nets by persons in the household . 156 Table 12.5 Use of existing ITNs . 157 xii • Tables and Figures Table 12.6 Use of mosquito nets by children . 159 Table 12.7 Use of mosquito nets by pregnant women . 160 Table 12.8 Use of Intermittent Preventive Treatment (IPTp) by women during pregnancy . 161 Table 12.9 Prevalence, diagnosis, and prompt treatment of children with fever . 162 Table 12.10 Source of advice or treatment for children with fever . 163 Table 12.11 Haemoglobin <8.0 g/dl in children . 164 Table 12.12 Coverage of malaria testing among children by background characteristics . 165 Table 12.13 Prevalence of malaria in children . 166 Figure 12.1 Percentage of the de facto population with access to an ITN in the household . 155 Figure 12.2 Ownership of, access to, and use of ITNs . 157 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR . 167 Table 13.1 Knowledge of AIDS . 168 Table 13.2 Knowledge of HIV prevention methods . 169 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 170 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 171 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 172 Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women . 173 Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men . 174 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 175 Table 13.7 Adult support of education about condom use to prevent AIDS . 176 Table 13.8.1 Multiple sexual partners: Women . 177 Table 13.8.2 Multiple sexual partners: Men . 178 Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners . 180 Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse . 181 Table 13.11.1 Coverage of prior HIV testing: Women . 182 Table 13.11.2 Coverage of prior HIV testing: Men . 183 Table 13.12 Pregnant women counselled and tested for HIV . 184 Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 185 Table 13.14 Prevalence of medical injections . 187 Table 13.15 Comprehensive knowledge about AIDS and of a source of condoms among youth . 188 Table 13.16 Age at first sexual intercourse among young people . 189 Table 13.17 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 190 Table 13.18 Age mixing in sexual relationships among women and men age 15-19 . 191 Table 13.19 Recent HIV tests among youth . 191 Figure 13.1 Women and men seeking treatment for STIs . 186 14 HIV PREVALENCE . 193 Table 14.1 Coverage of HIV testing by residence and Local Government Area . 194 Table 14.2 Coverage of HIV testing by selected background characteristics . 195 Table 14.3 HIV prevalence by age . 196 Table 14.4 HIV prevalence by socioeconomic characteristics . 197 Table 14.5 HIV prevalence by demographic characteristics . 198 Table 14.6 HIV prevalence by sexual behaviour . 199 Table 14.7 HIV prevalence among young people by background characteristics . 200 Tables and Figures • xiii Table 14.8 HIV prevalence among young people by sexual behaviour . 201 Table 14.9 HIV prevalence by other characteristics . 202 Table 14.10 Prior HIV testing by current HIV status . 202 Table 14.11 HIV prevalence among couples . 203 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 205 Table 15.1 Employment and cash earnings of currently married women and men . 206 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 208 Table 15.2.2 Control over men’s cash earnings . 209 Table 15.3 Women’s control over their own earnings and over those of their husbands . 210 Table 15.4.1 Ownership of assets: Women . 211 Table 15.4.2 Ownership of assets; Men . 212 Table 15.5 Participation in decision making . 213 Table 15.6 Women’s participation in decision making by background characteristics . 213 Table 15.7.1 Attitude towards wife beating: Women . 215 Table 15.7.2 Attitude towards wife beating: Men . 216 Table 15.8 Indicators of women’s empowerment . 217 Table 15.9 Current use of contraception by women’s empowerment . 218 Table 15.10 Ideal number of children and unmet need for family planning by women’s empowerment . 218 Table 15.11 Reproductive health care by women's empowerment . 219 Table 15.12 Early childhood mortality rates by women’s status . 220 Table 15.13 Knowledge of female circumcision . 221 Table 15.14 Prevalence of female circumcision . 222 Table 15.15 Age at circumcision . 222 Table 15.16 Person performing circumcision among circumcised women age 15-49 . 223 Table 15.17 Attitudes towards female genital cutting . 223 Figure 15.1 Number of decisions in which currently married women participate . 214 16 DOMESTIC VIOLENCE . 225 Table 16.1 Experience of physical violence . 228 Table 16.2 Persons committing physical violence . 229 Table 16.3 Experience of sexual violence. 230 Table 16.4 Persons committing sexual violence . 231 Table 16.5 Experience of different forms of violence . 231 Table 16.6 Experience of violence during pregnancy . 232 Table 16.7 Marital control exercised by husbands . 233 Table 16.8 Forms of spousal violence . 234 Table 16.9 Spousal violence by background characteristics . 235 Table 16.10 Spousal violence by husband’s characteristics and empowerment indicators . 236 Table 16.11 Physical or sexual violence in the past 12 months by any husband/partner . 237 Table 16.12 Experience of spousal violence by duration of marriage . 238 Table 16.13 Injuries to women due to spousal violence . 238 Table 16.14 Women’s violence against their spouse . 239 Table 16.15 Women’s violence against their spouse . 240 Table 16.16 Help seeking to stop violence . 241 Table 16.17 Sources of help to stop the violence . 242 xiv • Tables and Figures 17 ADULT AND MATERNAL MORTALITY . 243 Table 17.1 Adult mortality rates . 244 Table 17.2 Adult mortality probabilities . 245 Table 17.3 Maternal mortality . 245 APPENDIX A SAMPLE DESIGN . 251 Table A.1 Households . 252 Table A.2 Population . 252 Table A.3 Enumeration areas . 252 Table A.4 Sample allocation of clusters and households . 253 Table A.5 Sample allocation of completed interviews with women and men . 254 Table A.6 Sample implementation: Women . 255 Table A.7 Sample implementation: Men . 265 Table A.8 Coverage of HIV testing by social and demographic characteristics: Women . 258 Table A.9 Coverage of HIV testing by social and demographic characteristics: Men . 259 Table A.10 Coverage of HIV testing by sexual behaviour characteristics: Women . 260 Table A.11 Coverage of HIV testing by sexual behaviour characteristics: Men . 261 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 263 Table B.1 List of selected variables for sampling errors, Gambia 2013 . 265 Table B.2 Sampling errors: Total sample, Gambia 2013 . 267 Table B.3 Sampling errors: Urban sample, Gambia 2013 . 268 Table B.4 Sampling errors: Rural sample, Gambia 2013 . 269 Table B.5 Sampling errors: Banjul sample, Gambia 2013 . 270 Table B.6 Sampling errors: Kanifing sample, Gambia 2013 . 271 Table B.7 Sampling errors: Brikama sample, Gambia 2013 . 272 Table B.8 Sampling errors: Mansakonko sample, Gambia 2013 . 273 Table B.9 Sampling errors: Kerewan sample, Gambia 2013 . 274 Table B.10 Sampling errors: Kuntaur sample, Gambia 2013 . 275 Table B.11 Sampling errors: Janjanbureh sample, Gambia 2013 . 276 Table B.12 Sampling errors: Basse sample, Gambia 2013 . 277 Table B.13 Sampling errors for adult and maternal mortality rates, Gambia, 2013 . 278 APPENDIX C DATA QUALITY TABLES . 279 Table C.1 Household age distribution . 279 Table C.2.1 Age distribution of eligible and interviewed women . 280 Table C.2.2 Age distribution of eligible and interviewed men . 280 Table C.3 Completeness of reporting . 281 Table C.4 Births by calendar years . 282 Table C.5 Reporting of age at death in days . 282 Table C.6 Reporting of age at death in months . 283 Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 284 Foreword • xv FOREWORD he 2013 Gambia Demographic and Health Survey (GDHS) was conducted by the Gambia Bureau of Statistics (GBoS) in collaboration with the Ministry of Health and Social Welfare and the National Population Secretariat Commission. The National Public Health Laboratory Services was responsible for HIV testing of dried blood samples. This is the first Demographic and Health Survey (DHS) conducted in The Gambia under the worldwide DHS programme, a project funded by the United States Agency for International Development (USAID) that provides support and technical assistance in the implementation of population and health surveys in countries worldwide. The main objective of the survey was to provide comprehensive data on fertility and mortality, family planning, maternal and child health and nutrition, as well as information on maternal mortality and domestic violence. The survey also provides household-based data on the prevalence of malaria and HIV, two of the most life-threatening infectious diseases in sub-Saharan Africa. The survey was intentionally planned to be fielded at the beginning of the last term of the Millennium Development Goals (MDGs) reporting period so that it would provide information on progress towards the attainment of set MDG targets in The Gambia. Furthermore, the 2013 GDHS, in conjunction with statistical information obtained from the Integrated Household Survey (2010), provides critical information for monitoring and evaluating targets set in the Programme for Accelerated Growth and Employment as well as various sector development policies and programmes. The survey covers a nationally representative sample and was designed to produce estimates of the major survey variables at the national, urban and rural areas, and Local Government Area levels (Banjul municipality, Kanifing municipality, Brikama, Mansakonko, Kerewan, Kuntaur, Janjanbureh, and Basse). A total of 6,217 households were contacted during the survey. In these households, 10,233 women age 15-49 and 3,821 men age 15-59 were interviewed. Major stakeholders from various government, nongovernmental, and United Nations (UN) agencies were involved in contributing technically and financially towards the success of the survey. The GBoS management and staff appreciate the individual and institutional contributions in various ways to the successful completion of the 2013 GDHS. The Bureau is grateful for the commitment of the Government of The Gambia towards the success of the survey. On behalf of the Government, I wish to express sincere appreciation for all the support received from USAID, the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the World Health Organization (WHO), the Global Fund (through the Malaria, HIV/AIDS, and TB grants and ActionAid Gambia); and the Joint United Nations Programme on HIV/AIDS (UNAIDS). In addition, the Bureau wishes to express its gratitude to ICF International, which provided technical assistance through the worldwide DHS programme. On behalf of the Bureau I wish to extend special thanks to the Office of The Vice President for the overall coordination of the implementation process; the Ministry of Finance and Economic Affairs for ensuring that government commitments in terms of financial contributions were fulfilled; and the Ministry of Health and Social Welfare for coordination and undertaking of voluntary counselling and testing activities. We are also appreciative of the invaluable contribution of all to the institutions represented in the 2013 GDHS Steering Committee and Technical Advisory Committee (Office of the Vice President, the Ministry of Finance and Economic Affairs, the Ministry of Health and Social Welfare, the Ministry of Agriculture, the Ministry of Information and Communication Technology, the Ministry of Basic and Secondary Education, the National Nutrition Agency, the National Malaria Control Programme, the National AIDS Secretariat, the National Leprosy and Tuberculosis Programme, the Women’s Bureau, the National Population Commission Secretariat, the Association of Non-Governmental Organisations, the Department T xvi • Foreword of Social Welfare, UNICEF, UNDP, WHO, UNAIDS, UNFPA, and USAID) towards the success of GDHS. Special thanks also go to the National Public Health Laboratory Services, which handled the complicated task of testing the dry blood samples collected in the field and worked with a consultant to determine survey respondents’ HIV status. We also wish to acknowledge the tireless efforts of all Bureau staff who were in the field or the office that made this survey a success. The contribution of every staff member of the Bureau was critical to the successful completion of this survey. Nyakassi M.B. Sanyang Statistician General Gambia Bureau of Statistics Millennium Development Goal Indicators • xvii MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators Gambia 2013 Indicator Sex Total Female Male 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under age 5 14.9 17.5 16.2 2. Achieve universal primary education 2.1 Net attendance ratio in primary education1 61.0 60.8 60.9 2.3 Literacy rate of 15-24 year-olds2 62.7 76.7a 69.7b 3. Promote gender equality and empower women 3.1 Ratio of girls to boys in primary, secondary, and tertiary education 3.1a Ratio of girls to boys in primary education3 na na 1.0 3.1b Ratio of girls to boys in secondary education3 na na 0.9 3.1c Ratio of girls to boys in tertiary education3 na na 1.0 4. Reduce child mortality 4.1 Under-5 mortality rate4 59 65 54 4.2 Infant mortality rate4 38 42 34 4.3 Proportion of 1-year-old children immunized against measles 88.1 87.6 87.8 5. Improve maternal health 5.1 Maternal mortality ratio5 na na 433 5.2 Percentage of births attended by skilled health personnel6 na na 57.2 5.3 Contraceptive prevalence rate7 9.0 na na 5.4 Adolescent birth rate8 88.1 na na 5.5 Antenatal care coverage 5.5a Antenatal care coverage: at least one visit9 98.9 na na 5.5b Antenatal care coverage: four or more visits10 77.6 na na 5.6 Unmet need for family planning 24.9 na na 6. Combat HIV/AIDS, malaria, and other diseases 6.1 HIV prevalence among the population age 15-24 0.4 0.2 0.3 6.2 Condom use at last high-risk sex11 26.7 59.8 43.3 6.3 Percentage of the population age 15-24 with comprehensive correct knowledge of HIV/AIDS12 25.8 32.3a 29.1b 6.4 Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 0.92 0.88 0.90 6.7 Percentage of children under 5 sleeping under insecticide-treated bed nets 46.6 47.3 47.0 6.8 Percentage of children under 5 with fever who are treated with appropriate antimalarial drugs13 5.9 7.4 6.7 Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved drinking water source14 94.3 84.8 89.6 7.9 Percentage of population with access to improved sanitation15 50.4 29.0 39.8 na = Not applicable 1 The ratio is based on reported attendance, not enrolment, in primary education among primary school age children (age 7-12). The rate also includes children of primary school age enrolled in secondary education. This is a proxy for MDG indicator 2.1, Net enrolment ratio. 2 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence 3 Based on reported net attendance, not gross enrolment, among 7-12 year-olds for primary, 13-17 year-olds for secondary, and 18-22 year-olds for tertiary education 4 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the 5-year period preceding the survey. 5 Expressed in terms of maternal deaths per 100,000 live births in the 7-year period preceding the survey 6 Among births in the five years preceding the survey 7 Percentage of currently married women age 15-49 using any method of contraception 8 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19 9 With a skilled provider 10 With any health care provider 11 High-risk sex refers to sexual intercourse with a nonmarital, noncohabitating partner. Expressed as a percentage of men and women age 15- 24 who had high-risk sex in the past 12 months. 12 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting HIV, knowing a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about transmission or prevention of HIV. 13 Measured as the percentage of children age 0-59 months who were ill with a fever in the two weeks preceding the interview and received any antimalarial drug 14 Percentage of de jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, or bottled water. 15 Percentage of de jure population whose household has a flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share this facility with other households a Restricted to men in sub-sample of households selected for the male interview b The total is calculated as the simple arithmetic mean of the percentages in the columns for male and females. xviii • Map of The Gambia Introduction • 1 INTRODUCTION 1 1.1 HISTORY, GEOGRAPHY, AND ECONOMY 1.1.1 History fter over two centuries of colonial rule under the British, The Gambia became self-governing in 1963 and gained full independence and dominion status on February 18, 1965. The country became a sovereign republic in 1970. Maintenance of multiparty democracy, adherence to the rule of law, and preservation of fundamental human rights are integral parts of the country’s political framework. In July 1994, the country came under military rule following a coup d’état. After a two-year transition period, presidential elections were held in September 1996, and the democratic civilian rule was restored. Since then, presidential and parliamentary elections have been held every five years. The president nominates five non-voting members to the National Assembly. Council members are selected through local government elections held every four years. The country is divided into seven administrative areas (two municipalities and five regions): Banjul municipality (the seat of the government), Kanifing municipality, and the West Coast, Lower River, North Bank, Central River, and Upper River regions. The municipalities are headed by mayors and the regions by governors. The regions are administered by chiefs. Councils in the provincial regions are headed by elected chairpersons. Districts and municipalities are divided into wards headed by elected councillors. For the purposes of surveys and censuses, the country is divided into eight Local Government Areas (LGAs): Banjul, Kanifing, Brikama, Mansakonko, Kerewan, Kuntaur, Janjabureh, and Basse. 1.1.2 Geography The Gambia is located midway on the bulge of the West Africa coast and stretches over 400 kilometres inland from west to east on either side of the River Gambia, varying in width from about 50 km near the mouth of the river to about 24 km upstream. The country is bound to the north, south, and east by the Republic of Senegal and to the west by the Atlantic Ocean. The River Gambia, which runs the entire length of the country from the Futa Jallon highlands in the Republic of Guinea to the Atlantic Ocean, divides the country’s land area of 10,689 square kilometres almost equally into two halves: the South Bank and the North Bank (Gambia Bureau of Statistics [GBoS], 2007). A Key Findings • The 2013 Gambia Demographic and Health Survey (GDHS) is a nationally representative survey of 10,233 women age 15-49 and 3,821 men age 15-59. • The 2013 GDHS is the first comprehensive survey conducted in The Gambia as part of the worldwide Demographic and Health Surveys program. • The primary purpose of the GDHS is to furnish policymakers and planners with detailed information on fertility; family planning; infant, child, adult, and maternal mortality; maternal and child health; nutrition; and knowledge of HIV/AIDS and other sexually transmitted infections. • A subsample of one in every two households was selected for the male survey and for collection of blood samples for HIV, anaemia, and malaria testing. 2 • Introduction The Gambian climate is typically Sahelian, with a long dry season from November to May and a short rainy season between June and October. The estuary basin of the River Gambia is virtually a tidal inlet with salt water intrusion ranging from 180 km upstream in the rainy season to 250 km in the dry season. Irrigable land areas are limited, and therefore agriculture, which is the backbone of the Gambian economy, is mostly rain fed. As a result, agricultural activities are subject to wide seasonal fluctuations and production levels are vulnerable to variations in rainfall. 1.1.3 Economy The Gambia has a market-based economy characterised by traditional subsistence agriculture and a significant tourism industry. The World Bank estimates the 2012 gross domestic product (GDP) in The Gambia at $944 million (current prices) and $707 million (constant prices). The services sector continues to be the leading contributor to the GDP. Agriculture accounted for roughly 22 percent of the GDP in 2012 and 2013, and this sector employs about 70 percent of the labour force.1 The Gambian economy continues to recover from the drought experienced in 2011, which caused a decrease in GDP of 4.3 percent. This was due to a fall in crop production of about 40 percent (Ministry of Agriculture, 2013). Preliminary figures show a rebound in GDP growth of 6.1 percent in 2012 as a result of recovery in crop production and strong growth in tourism, wholesale and retail, and construction activities. The increase in crop production is largely attributed to the significant investments made in the agricultural sector by the government and its development partners to mitigate the effects of the drought. 1.2 POPULATION The 2003 population and housing census estimated the population of The Gambia at 1.4 million (GBoS, 2007). The 2013 census estimated it at 1.9 million, an annual growth rate of 3.3 percent (GBoS, 2013). According to the 2003 census, 50 percent of the country’s residents live in rural areas, and women constitute 51 percent of the total population. The total fertility rate is 5.4 births per woman. This high fertility level has resulted in a very youthful population structure. Forty-two percent of the country’s residents are below age 15, and about 22 percent are between age 15 and age 24. Average life expectancy at birth is 63.4 years (62.5 years for males and 65 years for females) (GBoS, 2007). Life expectancy increased between the 1993 and 2003 censuses (GBoS, 1994; GBoS, 2007). Table 1.1 provides a summary of the basic demographic indicators for The Gambia from the 1993, 2003, and 2013 censuses. Table 1.1 Basic demographic indicators Indicator 1993 census1 2003 census2 2013 census3 Population (millions) 1.0 1.4 1.9 Growth rate (percentage) 4.2 2.7 3.1 Density (population/km2) 97 127 173.7 Percentage urban 37.1 50 na Life expectancy (years) Male 58.3 62.5 na Female 60.0 65.0 na na = Not available 1 GBoS, 1994 2 GBoS, 2007 3 GBoS, 2013 1.3 POPULATION AND HEALTH POLICIES 1.3.1 National Population Policy The overall goal of the 2007-2015 National Population Policy is to improve quality of life in The Gambia by raising the standard of living (National Population Commission Secretariat, 2010). The 1 Source: L. Fox, C. Haines, J.H. Munoz, and A. Thomas. 2013. Africa’s Got Work to Do: Employment Prospect in the New Century. IMF Working Paper. Introduction • 3 National Population Policy responds to the priorities reflected in Vision 2020 and the Programme for Accelerated Growth and Employment (PAGE). It seeks to achieve universal access to sexual and reproductive health, promote reproductive rights, reduce maternal mortality, and accelerate progress toward Millennium Development Goal (MDG) 5 and the International Conference on Population and Development agenda. The National Population Policy is implemented through the collaborative participation of national, regional, and district entities. 1.3.2 National Health Policy The main philosophy of the National Health Policy 2012-2020 is that “a healthy population is a wealthy population.” This philosophy is based on the belief that a healthy population can contribute to improved productivity, increased GDP, and sustained economic growth (MoH&SW, 2011). The National Health Policy seeks to make quality health care accessible for the country’s population by providing services within an enabling environment and ensuring that care at all levels is delivered by adequately trained, skilled, and motivated personnel. Thus, services will be accessible at the point of demand, especially for women, children, and marginalised and underserved individuals, irrespective of political, ethnic, or religious affiliations; in addition, gender-sensitive issues, including equal involvement of women in decision making, will be addressed in care delivery. The National Health Policy is expected to reform the health system by addressing both the major traditional health problems and new challenges, as well as the double burden of communicable and noncommunicable diseases and the HIV and AIDS pandemic. Its primary objective is “to reduce morbidity and mortality in The Gambia in order to contribute significantly to the improvement of quality of life of the population.” This reform is in line with local government decentralisation and planning based on the 2002 Local Government Act, Vision 2020, and PAGE. Thus, implementation of the National Health Policy is expected to result in reductions in morbidity and mortality related to major diseases, to promote healthy lifestyles, and to reduce health risks and exposures associated with negative environmental consequences. Morbidity and mortality rates due to both communicable and noncommunicable diseases are high in The Gambia, especially among infants, children, and women. Some of the diseases and conditions of concern include malaria, pneumonia, anaemia, diarrhoeal diseases, pregnancy complications, cardiovascular diseases, tuberculosis, and HIV and AIDS. Other important factors that contribute to high morbidity among the country’s population include poverty, unhealthy environments, unsafe working conditions, poor sanitation, poor nutrition, road traffic accidents, lack of or poor access to safe water, and poor housing conditions. The National Health Policy provides an institutional and legal framework for implementation of the various measures it entails. Furthermore, it identifies relevant stakeholders that can contribute to health service delivery and mobilises sector-wide resources for health development. The policy provides an impetus and a new direction for health sector development that will serve as the basis for driving the health sector in the next few years. 1.4 OBJECTIVES OF THE 2013 GAMBIA DEMOGRAPHIC AND HEALTH SURVEY The 2013 Gambia Demographic and Health Survey (GDHS) is the first survey conducted in The Gambia under the auspices of the worldwide Demographic and Health Surveys (DHS) programme. The primary objective of the 2013 GDHS is to provide current data on fertility and family planning behaviour, child mortality, adult and maternal mortality, children’s nutritional status, use of maternal and child health services, knowledge of HIV/AIDS, and the prevalence of HIV/AIDS and anaemia. The specific objectives are to: • Collect data at the national level that will allow calculation of key demographic trends • Analyse the direct and indirect factors that determine fertility levels and trends 4 • Introduction • Measure women’s and men’s contraceptive knowledge and practices • Collect high-quality data on family health, including immunisation coverage among children, prevalence and treatment of diarrhoea and other diseases among children under age 5, and maternity care indicators such as antenatal visits and assistance at delivery • Collect data on infant and child mortality and maternal mortality • Obtain data on child feeding practices, including breastfeeding, and administer anthropometric measurements to assess the nutritional status of women and children • Estimate the prevalence of malaria among children • Collect data on women’s and men’s knowledge of and attitudes toward sexually transmitted diseases and HIV/AIDS and evaluate condom use patterns • Conduct haemoglobin testing among women age 15-49 and children age 6-59 months to provide information on the prevalence of anaemia in these groups • Carry out anonymous HIV testing among women and men of reproductive age to provide information on the prevalence of HIV The medium- and long-term objectives of the survey include strengthening the technical capacity of the Gambia Bureau of Statistics and other partners in the National Statistical System to plan, conduct, and process and analyse data from complex national population and health surveys. The 2013 GDHS provides national and regional estimates on population and health that are comparable to information collected in similar surveys in other developing countries and to data that will be gathered in future DHS surveys in The Gambia. Data collected in the 2013 GDHS add to the large and growing international database of demographic and health indicators. 1.5 ORGANISATION OF THE SURVEY The 2013 GDHS was conducted at the request of the Gambian government, the Ministry of Health and Social Welfare (MoH&SW), the Gambia Bureau of Statistics, the National Population Secretariat Office of the Vice President, key stakeholders, and donors and partners. All parties played an important role in the planning of the survey and in the analysis of the results. The GBoS and the MoH&SW served as the implementing agencies for the GDHS. The Gambia Bureau of Statistics was responsible for operational matters, including planning and conducting fieldwork, data entry and processing, and report writing. More specifically, the GBoS was in charge of recruitment and training of the field, data entry, and data processing personnel; of transportation during fieldwork; and of supervision of survey activities. The MoH&SW provided the laboratory staff for HIV testing and malaria microscopy, as well as health technicians for the field teams. The 2013 GDHS was funded by the government of The Gambia, the U.S. Agency for International Development (USAID), the United Nations Population Fund (UNFPA), the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), and the Global Fund. ICF International provided technical assistance through the worldwide Demographic and Health Surveys programme. 1.6 SAMPLE DESIGN The Gambia is divided into eight Local Government Areas. In turn, each LGA is subdivided into districts and each district (with the exception of Banjul) into settlements. An enumeration area (EA) is a Introduction • 5 geographic section delineated so that a team of enumerators can easily cover it during a census. In the case of The Gambia, an EA can be a settlement, a cluster of small settlements, or part of a large settlement. The 2013 GDHS sample was designed to produce reliable estimates of the most important variables for the country as a whole, for urban and rural areas, and for each of the municipalities and LGAs. The sampling frame used for the 2013 GDHS was the latest population and housing census, conducted in 2003 (census data were provided by the Gambia Bureau of Statistics). The frame excluded individuals living in collective housing units such as hotels, hospitals, work camps, prisons, and boarding schools. The 2013 GDHS sample was a stratified sample selected in two stages. Stratification was done by dividing each LGA into urban and rural areas (except Banjul and Kanifing, which are entirely urban settlements), achieving a total of 14 sampling strata. In the first stage, 281 EAs were selected with probability proportional to size and with independent selection in each sampling stratum. These EAs constituted the primary sampling units (PSUs). After selection of the EAs and before the main fieldwork, a household listing operation was carried out in all of the selected EAs. The listing operation consisted of visiting each of the 281 selected EAs, drawing a location map and detailed sketch map, and recording on the household listing forms all structures found in the EA, as well as all residential households within these structures (including the address and name of the household head). The resulting list of households served as the sampling frame for the selection of households in the second stage of sampling. In the second stage, 25 households per EA were selected via equal probability systematic selection. All women age 15-49 who were usual household members or who spent the night before the survey in the selected households were eligible for individual interviews. A subsample of one in every two sampled households was selected for the male survey (all men age 15-59 who were usual household members or who spent the night before the survey in the household were eligible for individual interviews) as well as for collection of blood samples for HIV, anaemia, and malaria testing. 1.7. QUESTIONNAIRES Three questionnaires were used in the 2013 GDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. These questionnaires were based on the models developed by the DHS programme and were adapted to reflect The Gambia’s specific needs, based on discussions between ICF International and a technical working group that included staff from various governmental institutions, nongovernmental organisations, donors, and development partners. The Household Questionnaire was used to list all usual household members as well as non- members who spent the night preceding the interview in the selected households. Information was obtained on relationship to the head of the household and the age, sex, and educational attainment of each individual age 3 or older listed in the household. In addition, several questions were included to determine the physical characteristics of the dwelling, such as source of water, presence of sanitation facilities, and availability of durable goods. The Household Questionnaire was also used to identify women and men eligible for individual interviews (women age 15-49 in all households and men age 15-59 in half of the households). In the households selected for the male survey, the Household Questionnaire was used to determine individuals eligible for anthropometry measurements and collection of biomarkers as follows: • All women age 15-49 were eligible for anthropometry measurements and for anaemia and HIV testing. • All men age 15-59 were eligible for HIV testing. 6 • Introduction • All children age 0-59 months were eligible for anthropometry measurements. • All children age 6-59 months were tested for anaemia and malaria. The Woman’s Questionnaire was administered to women age 15-49 in all of the survey households. Information was collected on the following topics: • Background characteristics • Birth history • Knowledge of, attitudes toward, and use of family planning and exposure to family planning messages • Maternal health, including antenatal, delivery, and postnatal care • Immunisation and health of children under age 5 • Breastfeeding and infant feeding practices • Marriage, sexual activity, and husband’s background characteristics • Fertility preferences • Employment • Knowledge of AIDS and sexually transmitted infections • Other women’s health issues, including female circumcision • Maternal mortality • Domestic violence The Man’s Questionnaire was administered to all men age 15-59 in half of the households. It collected much of the same information as the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health. 1.8 LISTING, PRETEST, MAIN TRAINING, FIELDWORK, AND DATA PROCESSING 1.8.1 Listing Training of trainers (of mapping and listing supervisors) took place in April 2012 and was led by a specialist from ICF. A manual that described the listing and mapping procedures was prepared as a guideline, and the training involved both classroom demonstrations and field practice. Training of trainers was followed by the recruitment and training of 30 mappers and listers and three coordinators in August 2012. After the selection of the 281 clusters throughout the eight regions, a listing operation was conducted for six weeks, starting in August 2012. The listing was performed by organising the listing staff into 15 teams, each composed of one lister and one mapper. Three supervisors from the GBoS were also assigned to perform quality checks and handle all of the administrative and financial aspects of the listing operation. Introduction • 7 1.8.2 Pretest and Main Training The training of interviewers and supervisors was conducted from November 26 through December 14, 2012, and training of health technicians took place from December 10-14, with assistance from ICF consultants. Because of some delays with the schedule, a decision was made to train all of the main fieldwork interviewers during the pretest training and provide a two-week refresher training session prior to launching the main fieldwork. A total of 105 individuals were recruited for training. Interviewer training consisted of instructions on interviewing techniques and field procedures, a detailed review of the questionnaire content, instruction and practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews with real respondents in areas outside the 2013 GDHS sample points. Team supervisors and editors were trained in data quality control procedures and fieldwork coordination. Sixteen individuals with previous experience in lab techniques and handling blood samples were trained as health technicians for the survey. In addition, three interviewers were trained in the preparation of dry blood spot samples and in conducting anaemia and rapid diagnostic tests to support the health technicians in the field if necessary. Pretest fieldwork was carried out from December 15-21, 2012, in four areas that were not selected for the main survey. A total of 24 field staff participated, divided into four teams. Each team consisted of three female interviewers, one male interviewer, one health technician, and one supervisor. Four field coordinators were also assigned to coordinate and supervise the teams in the field. A total of 90 interviewers were selected for the main fieldwork. They underwent a six-day refreshment training session that was conducted between January 28 and February 2, 2013. 1.8.3 Fieldwork A total of 15 teams carried out data collection for the 2013 GDHS. Each team consisted of one supervisor, one editor, two female interviewers, one male interviewer, one health technician, and one driver. Data collection took place between February 2 and April 28, 2013. Six regional coordinators, three from the GBoS, two from the MoH&SW, and one from the National Population Commission Secretariat, were responsible for supervising the data collection teams and monitoring data quality. They regularly visited the field teams, checked the quality of the data collected in the field, and transported completed questionnaires and blood samples to GBoS. 1.8.4 Data Processing All questionnaires and blood samples for the 2013 GDHS were returned to the GBoS office in Kanifing for data processing, which consisted of office editing, coding of open-ended questions, data entry, and editing computer-identified errors. The data were processed by a team of data entry operators, office editors, secondary editors, and supervisors, supported with technical assistance from ICF International. Data entry and editing were accomplished using CSPro software. Processing of data was initiated in March 2013 and completed in May; tabulations were completed in July 2013 by the GBoS in collaboration with ICF International. Analyses of blood tests were conducted at the National Public Health Laboratories (NPHL) in Kotu. Questionnaires were incinerated to ensure that HIV data could not be linked to individual respondents. The 2013 GDHS preliminary report was prepared and launched in July 2013. 8 • Introduction 1.9 ANTHROPOMETRY, ANAEMIA, MALARIA, AND HIV TESTING Anthropometry measurements and biomarker testing were done in half of the households selected for the male survey. 1.9.1 Height and Weight Measurements Height and weight measurements were carried out on women age 15-49 and children age 0-59 months in half of the households selected for the male survey. Weight measurements were obtained using lightweight SECA mother-infant scales with digital screens, designed and manufactured under the guidance of UNICEF. Height measurements were carried out using a measuring board. Children younger than age 24 months were measured for height while lying down, and older children were measured while standing. 1.9.2 Anaemia Testing Blood specimens were collected for anaemia testing from all children age 6-59 months and from women age 15-49 who voluntarily consented to testing. Blood samples were drawn from a drop of blood taken from a finger prick (or a heel prick in the case of young children with small fingers) and collected in a microcuvette. Haemoglobin analysis was carried out on-site using a battery-operated portable HemoCue analyser. Results were given verbally and in writing. Parents of children with a haemoglobin level under 7 g/dl (considered to be severely anaemic) were instructed to take the child to a health facility for follow-up care. Likewise, non-pregnant women were referred for follow-up care if their haemoglobin level was below 7 g/dl and pregnant women were referred to a health facility for follow-up care if their haemoglobin level was below 9 g/dl. 1.9.3 Malaria Testing Children age 6-59 months were also tested for malaria in the field using SDBioline Malaria Ag P.f/Pan, a rapid diagnostic test. This high-sensitivity and high-specificity test detects malaria antigens from capillary blood samples. Respondents were informed of their results, and a free referral was given to the nearest health facility. In addition, blood was collected on glass slides and sent to the NPHL for malaria microscopy through reading of thick-smear slides. 1.9.4 HIV Testing Blood specimens for laboratory testing of HIV were collected by the GDHS health technicians from all women age 15-49 and men age 15-59 who consented to the test. The protocol for blood specimen collection and analysis was based on the anonymous linked protocol developed for the DHS programme. This protocol allows for the merging of HIV test results with sociodemographic data collected in the individual questionnaires after all information that can potentially identify an individual respondent has been destroyed. Interviewers explained the procedure, the confidentiality of the data, and the fact that the test results would not be made available to the respondent. If a respondent consented to HIV testing, five blood spots from the finger prick were collected on a filter paper card labelled with a barcode unique to the respondent. Respondents were asked whether they would consent to having the laboratory store their blood sample for future unspecified testing. If they did not consent to additional testing using their sample, the words “no additional testing” were written on the filter paper card. For each barcoded blood sample, a duplicate label was attached to the biomarker data collection form. A third copy of the same barcode was affixed to the blood sample transmittal form to track the blood Introduction • 9 samples from the field to the laboratory. Blood samples were dried overnight and packaged for storage the following morning. Samples were periodically collected in the field, along with the completed questionnaires, and transported to the GBoS in Kanifing to be logged in and checked; the samples were then transported to the National Public Health Laboratories in Kotu and submitted for testing. Upon arrival at the NPHL, each blood sample was logged into the CSPro HIV Test Tracking System (CHTTS) database, given a laboratory number, and stored at −20˚C until tested. The HIV testing protocol stipulates that testing of blood can be conducted only after questionnaire data entry is completed, verified, and cleaned and all unique identifiers except the anonymous barcode number are removed from the questionnaire file. At the first level, the protocol used the Vironostika HIV Ag/Ab; positive samples in the first level and 10 percent of negative samples were tested with the Enzygnost HIV Integral II assay, and discordant samples were tested with the Western blot. The final result was considered positive if the Western blot confirmed it to be positive and negative if the Western blot confirmed it to be negative. When the Western blot results were indeterminate, the sample result was recorded as indeterminate. Following laboratory testing, the HIV test results for the 2013 GDHS were entered into the CHTTS database with a barcode as the unique identifier. The barcodes identifying HIV test results were linked with the data from the individual interviews to enable analysis and publication of HIV data linked with other GDHS data. 1.10 RESPONSE RATES Table 1.2 shows household and individual response rates for the 2013 GDHS. A total of 7,0092 households were selected for the sample, of which 6,543 were occupied during data collection. Of the occupied households, 6,217 were successfully interviewed, yielding a response rate of 95 percent. In the interviewed households, 11,279 eligible women were identified for individual interviews. Complete interviews were conducted with 10,233 women, yielding a response rate of 91 percent. Similarly, a total of 4,668 eligible men were identified for individual interviews in the households selected for the male survey. Complete interviews were conducted with 3,821 men, yielding a response rate of 82 percent. In general, response rates were higher in rural areas than urban areas among both women and men. 2 Two of the 281 EAs had less than 25 listed households (11 and 23 households, respectively), resulting in a total of 7,009 households. 10 • Introduction Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), The Gambia 2013 Result Residence Total Urban Rural Household interviews Households selected 3,661 3,348 7,009 Households occupied 3,322 3,221 6,543 Households interviewed 3,095 3,122 6,217 Household response rate1 93.2 96.9 95.0 Interviews with women age 15-49 Number of eligible women 5,043 6,236 11,279 Number of eligible women interviewed 4,498 5,735 10,233 Eligible women response rate2 89.2 92.0 90.7 Interviews with men age 15-59 Number of eligible men 2,343 2,325 4,668 Number of eligible men interviewed 1,831 1,990 3,821 Eligible men response rate2 78.1 85.6 81.9 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 11 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 his chapter summarises demographic and socioeconomic characteristics of the population sampled in the 2013 GDHS. The survey collected information from all usual residents of a selected household (the de jure population) and persons who had stayed in the household the night before the interview (the de facto population). Since the difference between these two populations is very small, and to maintain comparability with other DHS reports, all tables in this report refer to the de facto population unless otherwise specified. In the GDHS, a household was defined as a person or a group of related or unrelated persons who live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as the head of the household, and who have common arrangements for cooking and eating. The Household Questionnaire (see Appendix E) included a schedule collecting basic demographic and socioeconomic information (e.g., age, sex, educational attainment, and current school attendance) from all usual residents and from visitors who spent the night preceding the interview in the household. The Household Questionnaire also obtained information on housing characteristics (e.g., sources of water supply and sanitation facilities) and household possessions. The information presented in this chapter is intended to facilitate interpretation of the key demographic, socioeconomic, and health indices presented later in the report. It is also intended to assist in the assessment of the representativeness of the survey sample. 2.1 HOUSEHOLD CHARACTERISTICS The physical characteristics of a household’s environment are important determinants of the health status of household members, especially children. They can also serve as indicators of the socioeconomic status of households. The 2013 GDHS asked respondents about their household environment, including access to electricity, source of drinking water, type of sanitation facility, type of flooring material, and number of rooms in the dwelling. Results are presented for households and for the de jure population. 2.1.1 Drinking Water Increasing access to improved drinking water is one of the Millennium Development Goals being adopted worldwide (United Nations General Assembly, 2002). Table 2.1 includes a number of indicators T Key Findings • Ninety-one percent of households in The Gambia use an improved source of drinking water. • Thirty-seven percent of households in The Gambia use improved toilet facilities that are not shared with other households. • Forty-five percent of households have access to electricity, with a large disparity between urban and rural areas (66 percent and 13 percent, respectively). • Ninety-one percent of households use solid fuel for cooking. • More than seven in ten children under age 5 (72 percent) have been registered with civil authorities and more than half (57 percent) have a birth certificate. • Approximately 8 percent of children under age 18 are orphaned (that is, one or both parents are not living). • Fifty-two percent of females and 43 percent of males age 6 and older have never attended school. 12 • Housing Characteristics and Household Population that are useful in monitoring household access to improved drinking water (WHO and UNICEF, 2012a). The source of drinking water is an indicator of whether it is suitable for drinking. Sources that are more likely to provide water suitable for drinking are identified in Table 2.1 as improved sources. These include a piped source within the dwelling, yard, or plot; a public tap, tube well, or borehole; a hand pump/protected well or protected spring; and rainwater or bottled water.1 Lack of ready access to a water source may limit the quantity of suitable drinking water that is available to a household. Even if the water is obtained from an improved source, it may be contaminated during transport or storage if it is fetched from a source that is not immediately accessible to the household,. Home water treatment can be effective in improving the quality of household drinking water. Table 2.1 Household drinking water Percent distribution of households and the de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, The Gambia 2013 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 95.3 84.7 91.0 94.3 84.8 89.6 Piped into dwelling 5.5 0.4 3.4 4.3 0.3 2.3 Piped to yard/plot 60.4 6.1 38.2 59.2 5.0 32.5 Public tap/standpipe 24.6 44.7 32.8 25.2 44.7 34.8 Tubewell or borehole 1.8 18.9 8.8 1.6 18.6 10.0 Protected well 2.4 14.5 7.4 3.9 16.1 9.9 Bottled water 0.6 0.1 0.4 0.1 0.0 0.1 Non-improved source 3.7 14.5 8.1 4.3 14.6 9.4 Unprotected well 3.7 14.3 8.0 4.3 14.5 9.3 Surface water 0.0 0.2 0.1 0.0 0.1 0.1 Other source 0.9 0.7 0.8 1.3 0.5 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 69.8 11.8 46.1 67.2 10.8 39.4 Less than 30 minutes 24.6 67.7 42.3 25.6 67.2 46.1 30 minutes or longer 5.1 19.3 10.9 6.6 21.1 13.8 Don’t know/missing 0.4 1.2 0.7 0.6 1.0 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 0.3 0.2 0.2 0.2 0.1 0.1 Bleach/chlorine added 2.9 3.1 3.0 3.0 3.1 3.1 Strained through cloth 5.1 23.5 12.6 7.3 25.5 16.2 Ceramic, sand, or other filter 0.3 0.1 0.2 0.2 0.1 0.1 Other 0.2 0.4 0.3 0.2 0.2 0.2 No treatment 91.2 73.5 84.0 89.7 71.9 81.0 Percentage using an appropriate treatment method2 3.4 3.3 3.4 3.3 3.3 3.3 Number 3,671 2,546 6,217 25,939 25,202 51,142 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, filtering, and solar disinfecting. Table 2.1 shows that 9 out of 10 households in The Gambia (91 percent) get their drinking water from an improved source. However, disparities exist by urban-rural residence, with a higher proportion of urban households (95 percent) than rural households (85 percent) having an improved source of drinking water. The most common source of improved drinking water is piped water into the plot (38 percent), with a much higher percentage in urban than in rural areas (60 percent versus 6 percent). Thirty-three percent of households have access to drinking water from a public tap/standpipe, and this is the leading improved drinking water source among rural households (45 percent). Eight percent of households in The Gambia get their drinking water from a non-improved source, mainly unprotected wells (8 percent). More than three times as many rural households as urban households use non-improved sources of drinking water (15 percent versus 4 percent). 1 The categorisation into improved and non-improved categories follows that proposed by the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (WHO/UNICEF, 2012). Housing Characteristics and Household Population • 13 Forty-six percent of all households have water on their premises, with a huge urban-rural disparity (70 percent of urban households compared with 12 percent of rural households). Overall, 42 percent of households report that it takes less than 30 minutes for the round trip to obtain drinking water (25 percent in urban areas and 68 percent in rural areas). The remaining households (11 percent) must travel 30 minutes or longer (round trip) to obtain their drinking water (19 percent of rural households versus 5 percent of urban households). Very few households (3 percent) in The Gambia treat their drinking water using an appropriate treatment method, and there are no urban-rural differences. The main method of treatment is straining through cloth (13 percent of households), with 24 percent of rural households following this method compared with only 5 percent of households in urban areas. Three percent of households add bleach or chlorine to make water safer for drinking. 2.1.2 Household Sanitation Facilities Ensuring adequate sanitation facilities is another Millennium Development Goal that The Gambia shares with other countries. A household is classified as having an improved toilet if the toilet is used only by members of one household (i.e., it is not shared) and if the facility used by the household separates waste from human contact (WHO and UNICEF, 2012a). The types of facilities considered improved are toilets that flush or pour flush into a piped sewer system, septic tank, or pit latrine; ventilated improved pit (VIP) latrines; and pit latrines with a slab. As shown in Table 2.2, more than one-third (37 percent) of households in The Gambia use an improved toilet facility that is not shared with other households. Urban households are much more likely than rural households to have an improved toilet facility that is not shared (46 percent and 24 percent, respectively). Twenty-four percent of all households use an improved toilet facility that is shared with other households (32 percent of households in urban areas compared with 13 percent of those in rural areas). About four in ten households use a non-improved sanitation facility, with a much higher percentage in rural than in urban areas (63 percent and 23 percent, respectively). Overall, only 2 percent of households have no toilet facility at all, almost all in rural areas (5 percent). Table 2.2 Household sanitation facilities Percent distribution of households and the de jure population by type of toilet/latrine facilities, according to residence, The Gambia 2013 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 45.9 24.3 37.0 50.4 29.0 39.8 Flush/pour flush to piped sewer system 2.0 0.0 1.2 1.9 0.0 1.0 Flush/pour flush to septic tank 26.2 2.0 16.3 25.6 1.7 13.8 Flush/pour flush to pit latrine 2.1 0.4 1.4 2.2 0.5 1.4 Ventilated improved pit (VIP) latrine 4.3 4.2 4.2 5.8 4.2 5.0 Pit latrine with slab 11.3 17.7 13.9 14.8 22.5 18.6 Shared facility1 31.5 12.8 23.8 26.8 10.8 18.9 Flush/pour flush to piped sewer system 2.3 0.0 1.3 1.2 0.0 0.6 Flush/pour flush to septic tank 4.6 0.2 2.8 3.9 0.1 2.1 Flush/pour flush to pit latrine 1.5 0.2 1.0 1.3 0.2 0.8 Ventilated improved pit (VIP) latrine 6.9 2.1 4.9 6.1 1.7 4.0 Pit latrine with slab 16.3 10.2 13.8 14.1 8.8 11.5 Non-improved facility 22.6 62.9 39.1 22.9 60.2 41.3 Pit latrine without slab/open pit 22.1 58.0 36.8 22.6 56.5 39.3 No facility/bush/field 0.3 4.7 2.1 0.2 3.5 1.8 Other 0.1 0.2 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,671 2,546 6,217 25,939 25,202 51,142 1 Facilities that would be considered improved if they were not shared by 2 or more households 14 • Housing Characteristics and Household Population The most common types of facilities among urban households are toilets that flush or pour flush into a septic tank (26 percent), followed by pit latrines with a slab (11 percent not shared and 16 percent shared). In rural areas, the leading type of sanitation facility is an open pit latrine without a slab or an open pit (58 percent), followed by a pit latrine with a slab (18 percent not shared and 10 percent shared). 2.1.3 Housing Characteristics Table 2.3 presents information on housing characteristics in The Gambia, which reflect a household’s socioeconomic situation. They also may influence environmental conditions (for example, use of biomass fuels and resulting exposure to indoor air pollution) that have a direct bearing on the health and welfare of household members. Table 2.3 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, The Gambia 2013 Housing characteristic Residence Total Urban Rural Electricity Yes 66.4 12.9 44.5 No 33.6 87.0 55.5 Total 100.0 100.0 100.0 Flooring material Earth, sand 2.7 40.9 18.4 Parquet or polished wood 0.0 0.3 0.1 Vinyl or asphalt strips 0.0 0.2 0.1 Ceramic tiles 27.9 4.0 18.1 Cement 24.4 41.1 31.3 Carpet 5.7 1.0 3.8 Plastic carpet 38.6 12.1 27.8 Other 0.5 0.1 0.3 Total 100.0 100.0 100.0 Rooms used for sleeping One 24.6 9.5 18.4 Two 29.8 19.3 25.5 Three or more 44.3 70.7 55.1 Missing 1.3 0.5 1.0 Total 100.0 100.0 100.0 Place for cooking In the house 4.3 1.2 3.1 In a separate building 54.0 81.0 65.0 Outdoors 32.4 15.2 25.3 No food cooked in household 9.2 2.5 6.5 Total 100.0 100.0 100.0 Cooking fuel Electricity 0.0 0.0 0.0 LPG/natural gas/biogas 3.6 0.4 2.3 Kerosene 0.2 0.0 0.1 Charcoal 41.0 4.1 25.9 Wood 44.3 92.7 64.1 Straw/shrubs/grass 0.1 0.2 0.1 Saw dust 1.4 0.1 0.9 No food cooked in household 9.2 2.5 6.5 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 86.8 97.1 91.0 Frequency of smoking in the home Daily 22.2 26.5 24.0 Weekly 2.2 2.4 2.3 Monthly 0.5 0.8 0.6 Less than monthly 0.7 0.8 0.8 Never 74.3 69.3 72.2 Total 100.0 100.0 100.0 Number 3,671 2,546 6,217 LPG = Liquid petroleum gas 1 Includes charcoal, wood/straw/shrubs/grass, and saw dust Housing Characteristics and Household Population • 15 Less than half (45 percent) of households in The Gambia have electricity, with a large disparity between urban (66 percent) and rural (13 percent) areas. About three in ten households (31 percent) live in dwellings with floors made of cement (24 percent of urban households and 41 percent of rural households). The next most common type of flooring material is plastic carpet, accounting for 28 percent of all households (39 percent in urban areas compared with 12 percent in rural areas). Earth or sand floors and ceramic floors each account for 18 percent of flooring materials. As expected, earth or sand floors are much more common in rural households than in urban households (41 percent versus 3 percent), while floors made of ceramic tiles are much more common in urban than in rural households (28 percent versus 4 percent). The number of rooms used for sleeping is an indicator of the extent of crowding in households. Overcrowding increases the risk of contracting diseases such as acute respiratory infections, tuberculosis, and skin diseases. Overall, more than half of households in The Gambia use three or more rooms for sleeping (55 percent), while slightly more than one-quarter (26 percent) use two rooms. The remainder (18 percent) use one room for sleeping. Urban households tend to have fewer rooms for sleeping; 25 percent use only one room for sleeping (compared with 10 percent of rural households), and 44 percent use three or more rooms (compared with 71 percent of rural households). With regard to cooking arrangements, the large majority of households in The Gambia (65 percent) cook in a separate building (54 percent in urban households compared with 81 percent in rural households). One in four households (25 percent) do their cooking outdoors (32 percent in urban areas and 15 percent in rural areas). Very few households in The Gambia (3 percent) do their cooking inside the house (4 percent of urban households compared with 1 percent of rural households). Cooking and heating with solid fuels can lead to high levels of indoor smoke, a complex mix of health-damaging pollutants that can increase the risk of acute respiratory diseases. Solid fuels are defined as charcoal, wood, straw, shrubs, and saw dust. In the 2013 GDHS, household respondents were asked about their primary source of fuel for cooking. Table 2.3 shows that 91 percent of households use solid fuel for cooking (87 percent of urban households and 97 percent of rural households). The most common cooking fuel in The Gambia is wood, used by close to two-thirds (64 percent) of households, with a much higher percentage in rural (93 percent) than urban (44 percent) households. Twenty-six percent of households use charcoal as cooking fuel, with the proportion being substantially higher in urban households (41 percent) than in rural households (4 percent). Use of other types of cooking fuels is not common in The Gambia. Information on frequency of smoking inside the home was obtained to assess the percentage of households in which there is exposure to second-hand smoke, which causes health risks in children and adults who do not smoke. Pregnant women who are exposed to second-hand smoke have a higher risk of delivering a low birth weight baby (Windham et al., 1999), and children exposed to second-hand smoke are at increased risk for respiratory and ear infections and poor lung development (U.S. Department of Health and Human Services, 2006). About one in four (24 percent) households in The Gambia report that someone smokes at the home daily, 2 percent report that someone smokes at least once a week, and less than 1 percent report that someone smokes monthly or less frequently than once a month. In 72 percent of households, smoking never occurs in the home. Overall, smoking inside the home is somewhat less frequent in urban areas than in rural areas; 74 percent of urban households report that smoking never occurs in the home, as compared with 69 percent of rural households. 2.1.4 Household Possessions Possession of durable consumer goods is another indicator of a household’s socioeconomic status. Moreover, particular goods have specific benefits. For instance, a radio or a television can bring household members information and new ideas, a refrigerator prolongs the wholesomeness of foods, and a means of transport can increase access to many services that are beyond walking distance. 16 • Housing Characteristics and Household Population Table 2.4 shows the extent of possession of selected consumer goods by urban-rural residence. Ownership of durable goods varies according to residence and the nature of the asset. Of the 12 selected items asked about in the survey, mobile phones and radios stand out as the assets most commonly owned by households. More than 9 in every 10 households in The Gambia (91 percent) own a mobile phone and about three-fourths (74 percent) own a radio, with no major difference by residence. About half (49 percent) of households own a television, and less than one in four (23 percent) own a refrigerator. Television ownership is about three times as high in urban as in rural households (67 percent versus 22 percent). Similarly, 35 percent of urban households own a refrigerator, as compared with only 5 percent of rural households. Looking at means of transport, less than half of households own a bicycle (47 percent), with a much higher percentage in rural areas (56 percent) than in urban areas (41 percent). Animal-drawn carts are owned by 16 percent of households (2 percent in urban areas compared with 35 percent in rural areas). Eleven percent of households own a car or truck, with the percentage being three times as high in urban as in rural areas (15 percent versus 5 percent). Agricultural land is owned by 37 percent of households, and 51 percent own farm animals (cattle, cows, bulls, horses, donkeys, mules, goats, sheep, or chickens). As expected, ownership of agricultural land and farm animals is notably higher among rural households (74 percent and 85 percent, respectively) than among urban households (12 percent and 28 percent, respectively). Table 2.4 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, The Gambia 2013 Possession Residence Total Urban Rural Household effects Radio 72.9 74.7 73.6 Television 66.6 22.4 48.5 Mobile telephone 93.4 86.6 90.6 Non-mobile telephone 5.7 1.3 3.9 Refrigerator 34.8 5.3 22.7 Means of transport Bicycle 41.1 55.6 47.0 Animal-drawn cart 2.3 35.0 15.7 Motorcycle/scooter 4.8 10.4 7.1 Car/truck 15.3 5.3 11.2 Boat with a motor 0.2 0.6 0.4 Ownership of agricultural land 11.8 73.8 37.2 Ownership of farm animals1 27.6 85.1 51.1 Number 3,671 2,546 6,217 1 Cattle, cows, bulls, horses, donkeys, goats, sheep, or chickens 2.2 WEALTH INDEX Information on household assets was used to create an index that is used throughout this report to represent the wealth of the households interviewed in the 2013 GDHS. This method for calculating a country-specific wealth index was developed and tested in a large number of countries in relation to inequalities in household income, use of health services, and health outcomes (Rutstein and Johnson, 2004). It has been shown to be consistent with expenditure and income measures. The wealth index is constructed using household asset data, including ownership of consumer items ranging from a television to a bicycle or car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities, and type of flooring material. In its current form, which takes account of urban-rural differences in these items and characteristics, the wealth index is created in three steps. In the first step, a subset of indicators common to urban and rural areas is used to create wealth scores for Housing Characteristics and Household Population • 17 households in both areas. For purposes of creating scores, categorical variables are transformed into separate dichotomous (0-1) indicators. These indicators and those that are continuous are then examined using a principal components analysis to produce a common factor score for each household. In the second step, separate factor scores are produced for households in urban and rural areas using area-specific indicators (Rutstein, 2008). The third step combines the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting area-specific scores through a regression on the common factor scores. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index is computed, national-level wealth quintiles (from lowest to highest) are formed by assigning the household score to each de jure household member, ranking each person in the population by that score, and then dividing the ranking into five equal categories, each comprising 20 percent of the population. Thus, throughout this report, wealth quintiles are expressed in terms of quintiles of individuals in the overall population rather than quintiles of individuals at risk for any one health or population indicator. For example, quintile rates for infant mortality refer to infant mortality rates per 1,000 live births among all people in the population quintile concerned, as distinct from quintiles of live births or newly born infants, who constitute the only members of the population at risk of mortality during infancy. Table 2.5 presents wealth quintiles by residence and Local Government Area (LGA). Also included in the table is the Gini coefficient, which indicates the level of concentration of wealth (0 being an equal distribution and 1 a totally unequal distribution). Wealth is concentrated in urban areas, with 36 percent and 39 percent of the population in these areas falling in the fourth and highest wealth quintiles, respectively. In contrast, those living in rural areas are poorer, with 37 percent and 35 percent, respectively, falling in the lowest and second lowest wealth quintiles. Less than 1 percent of the rural population falls in the highest wealth quintile. In the urban LGAs of Banjul and Kanifing, 68 percent and 52 percent of residents, respectively, are in the highest wealth quintile. By contrast, 44 percent of the population in Mansakonko, a predominantly rural LGA, falls in the lowest wealth quintile, and 32 percent falls in the second lowest quintile. Table 2.5 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini coefficient, according to residence and Local Government Area, The Gambia 2013 Residence/Local Government Area Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 3.7 5.3 16.3 35.6 39.1 100.0 25,939 0.15 Rural 36.7 35.2 23.8 4.0 0.3 100.0 25,202 0.08 Local Government Area Banjul 0.0 0.2 1.5 30.5 67.8 100.0 989 0.03 Kanifing 0.0 3.0 10.9 34.1 52.0 100.0 9,890 0.13 Brikama 18.2 14.8 18.1 25.8 23.0 100.0 17,656 0.28 Mansakonko 44.1 32.1 15.7 6.3 1.7 100.0 2,696 0.06 Kerewan 31.8 35.9 21.5 8.6 2.2 100.0 6,043 0.33 Kuntaur 35.6 35.4 22.9 6.0 0.2 100.0 3,173 0.03 Janjanbureh 36.0 29.8 23.2 9.7 1.3 100.0 4,009 0.18 Basse 19.8 29.4 38.2 10.9 1.7 100.0 6,687 0.25 Total 20.0 20.0 20.0 20.0 20.0 100.0 51,142 0.25 2.3 HAND WASHING Hand washing with soap and water is ideal. However, hand washing with a non-soap cleansing agent such as ash or sand is an improvement over not using any cleansing agent. To obtain information on hand washing, interviewers asked to see the place where members of the household most often washed their hands; information on the availability of water, cleansing agents, or both was recorded only for households where a hand washing place was observed. Interviewers observed a place for hand washing in only 10 percent of households. 18 • Housing Characteristics and Household Population Among the households where a hand washing place was observed, 61 percent had soap and water, less than 1 percent had water and a cleansing agent other than soap, 19 percent had only water, 3 percent had soap but no water, and 13 percent had no water, soap, or any other cleansing agent at the hand washing place (Table 2.6). The percentage of households using soap and water for hand washing was higher in urban than rural areas (66 percent versus 26 percent) and increased with increasing wealth, reaching 79 percent among households in the highest wealth quintile. Table 2.6 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap, and other cleansing agents, The Gambia 2013 Background characteristic Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed, percentage with: Number of households with place for hand washing observed Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water2 No water, no soap, no other cleansing agent Missing Total Residence Urban 14.9 3,671 66.4 0.2 20.2 2.5 10.2 0.4 100.0 546 Rural 3.1 2,546 25.8 0.0 10.0 2.1 33.1 29.0 100.0 79 Local Government Area Banjul 21.5 188 62.1 0.4 24.1 4.6 7.7 1.0 100.0 40 Kanifing 17.1 1,520 68.9 0.3 16.6 3.0 11.2 0.0 100.0 260 Brikama 13.2 2,160 59.6 0.0 22.2 1.8 15.3 1.0 100.0 284 Mansakonko 5.1 356 (10.2) (0.0) (10.7) (2.5) (23.1) (53.5) 100.0 18 Kerewan 2.1 721 * * * * * * 100.0 15 Kuntaur 0.3 296 * * * * * * 100.0 1 Janjanbureh 1.1 410 * * * * * * 100.0 5 Basse 0.2 566 * * * * * * 100.0 1 Wealth quintile Lowest 2.5 1,423 (4.1) (0.0) 22.2) (3.3) (47.8) (22.6) 100.0 35 Second 3.5 995 28.3) (0.0) (7.7) (0.0) (32.4) (31.5) 100.0 35 Middle 4.0 1,053 23.5) (0.0) 23.0) (6.3) (37.7) (9.5) 100.0 42 Fourth 6.7 1,404 31.9 0.0 47.3 3.6 15.1 2.1 100.0 94 Highest 31.2 1,342 79.3 0.2 12.7 2.0 5.7 0.1 100.0 419 Total 10.1 6,217 61.3 0.2 18.9 2.5 13.1 4.1 100.0 625 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Includes households with soap only as well as those with soap and another cleansing agent 2.4 POPULATION BY AGE AND SEX Age and sex are important demographic variables and are the primary basis for demographic classifications in vital statistics, censuses, and surveys. They are also very important variables in the study of mortality, fertility, and marriage. The distribution of the de facto household population in the 2013 GDHS is shown in Table 2.7 by five-year age groups, according to sex and residence. A total of 49,553 individuals resided in the 6,217 households successfully interviewed; the female population (25,649) was slightly higher than the male population (23,904). Housing Characteristics and Household Population • 19 Table 2.7 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, The Gambia 2013 Age Urban Rural Male Female Total Male Female Total Male Female Total <5 16.2 15.3 15.7 21.0 17.6 19.2 18.5 16.4 17.4 5-9 14.3 13.7 14.0 19.2 16.9 18.0 16.6 15.3 15.9 10-14 11.6 11.7 11.7 14.1 13.3 13.7 12.8 12.5 12.6 15-19 11.0 11.3 11.2 9.5 9.5 9.5 10.3 10.4 10.3 20-24 10.2 10.8 10.5 6.7 7.4 7.1 8.5 9.1 8.8 25-29 8.3 9.3 8.8 5.1 6.6 5.9 6.8 8.0 7.4 30-34 6.7 7.3 7.0 4.2 5.7 5.0 5.5 6.5 6.0 35-39 5.4 5.0 5.2 3.5 4.4 4.0 4.5 4.7 4.6 40-44 4.4 3.2 3.8 3.1 3.3 3.2 3.8 3.3 3.5 45-49 3.0 2.5 2.7 2.7 2.4 2.5 2.9 2.4 2.6 50-54 2.2 3.7 3.0 1.9 4.4 3.2 2.1 4.1 3.1 55-59 1.6 1.5 1.6 1.5 2.4 1.9 1.5 1.9 1.7 60-64 2.1 1.6 1.9 2.4 2.1 2.3 2.3 1.9 2.1 65-69 1.4 1.2 1.3 1.6 1.2 1.4 1.5 1.2 1.3 70-74 0.8 0.7 0.7 1.2 1.2 1.2 1.0 0.9 1.0 75-79 0.4 0.3 0.3 1.0 0.6 0.8 0.7 0.5 0.6 80+ 0.5 0.8 0.7 1.1 1.3 1.2 0.8 1.0 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 12,462 12,891 25,352 11,443 12,758 24,201 23,904 25,649 49,553 The age-sex structure of the population is shown in the population pyramid in Figure 2.1. The broad base of the pyramid indicates that the population in The Gambia is young, a scenario typical of countries with high fertility rates. The proportion of the population under age 15 was 46 percent in 2013. Individuals age 15-64 accounted for 50 percent of the total population, and those age 65 and older made up 4 percent of the population. This indicates an age dependency ratio of 99 in The Gambia.2 The pyramid shows a rather sharp increase in population size between women age 45-49 and those age 50-54. To a certain extent, this may be due to a tendency on the part of some interviewers to estimate the ages of women as above the cut-off age of 49 for eligibility for individual interviews, thus reducing their workload. A similar trend is observed for men age 55-59 and those age 60-64. Figure 2.1 Population pyramid 10 5 0 5 10 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Percent Age group GDHS 2013 Male Female 2 The age dependency ratio is defined as the sum of all persons under age 15 or over age 64 divided by the number of persons age 15-64, multiplied by 100. 20 • Housing Characteristics and Household Population 2.5 HOUSEHOLD COMPOSITION Table 2.8 presents information about the composition of households by sex of the household head and size of the household. These characteristics are important because they are associated with household welfare. Results show that households in The Gambia are predominantly headed by men (78 percent). Twenty-two percent of households are headed by women, and such households are more common in urban areas (26 percent) than in rural areas (17 percent). The average household size is 8.2 persons, with rural households (9.9 persons) having more members than urban households (7.1 persons). Overall, more than one-third of households have nine or more members (37 percent), and households of this size are more common in rural (48 percent) than urban (30 percent) areas. Table 2.8 Household composition Percent distribution of households by sex of head of household and by household size, mean size of household, and percentage of households with orphans and foster children under age 18, according to residence, The Gambia 2013 Characteristic Residence Total Urban Rural Household headship Male 73.9 83.1 77.7 Female 26.1 16.9 22.3 Total 100.0 100.0 100.0 Number of usual members 1 11.2 4.5 8.5 2 7.2 2.9 5.5 3 8.5 5.2 7.1 4 8.6 5.7 7.4 5 11.1 7.9 9.8 6 9.4 9.4 9.4 7 8.1 8.8 8.4 8 5.8 7.5 6.5 9+ 30.1 48.0 37.4 Total 100.0 100.0 100.0 Mean size of households 7.1 9.9 8.2 Percentage of households with orphans and foster children under age 18 Foster children1 32.7 40.6 35.9 Double orphans 2.4 2.7 2.5 Single orphans2 12.9 18.2 15.1 Foster and/or orphan children 36.1 46.4 40.3 Number of households 3,671 2,546 6,217 Note: Table is based on de jure household members (i.e., usual residents). 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2 Includes children with one dead parent and an unknown survival status of the other parent Table 2.8 also provides information on the proportion of households with foster children (that is, children who live in households with neither biological parent present), double orphans (children with both parents dead), and single orphans (children with one parent dead). Overall, 40 percent of households in The Gambia have foster children and/or orphans under age 18. Thirty-six percent of households have foster children (33 percent in urban areas and 41 percent in rural areas). In addition, 3 percent of households have double orphans (2 percent of urban households and 3 percent of rural households) and 15 percent have single orphans, with a higher percentage in rural than in urban areas (18 percent versus 13 percent). 2.6 BIRTH REGISTRATION Birth registration is the inscription of the facts of the birth into an official log kept at the registrar’s office. A birth certificate is issued as proof of the registration of the birth. Birth registration is basic to ensuring a child’s legal status and, thus, fundamental rights (UNICEF, 2006; United Nations General Assembly, 2002). Housing Characteristics and Household Population • 21 Table 2.9 shows the percentage of children under age 5 whose births were officially registered and the percentage who had a birth certificate at the time of the survey. Not all children who are registered have a birth certificate because some certificates may have been lost or never issued. However, all children with a certificate have been registered. More than seven in ten children under age 5 in The Gambia (72 percent) have been registered with civil authorities; more than half (57 percent) have a birth certificate, and 15 percent have been registered but do not have a birth certificate. The percentage of children whose births have been registered is higher among those age 2-4 (78 percent) than among those younger than age 2 (64 percent). There are only slight variations by sex, urban-rural residence, and wealth. There are, however, variations by LGA; the percentage of registered births ranges from a high of 77 percent in Brikama to a low of 62 percent in Mansakonko. Table 2.9 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, The Gambia 2013 Background characteristic Children whose births are registered Number of children Percentage with a birth certificate Percentage without a birth certificate Percentage registered Age <2 44.9 19.4 64.4 3,689 2-4 65.9 11.6 77.5 5,077 Sex Male 58.2 15.1 73.3 4,485 Female 55.9 14.7 70.6 4,281 Residence Urban 58.4 13.3 71.7 4,011 Rural 55.9 16.3 72.2 4,755 Local Government Area Banjul 54.5 16.8 71.4 128 Kanifing 47.9 16.4 64.3 1,475 Brikama 67.3 10.0 77.3 2,910 Mansakonko 45.0 16.5 61.5 463 Kerewan 58.1 17.3 75.4 1,069 Kuntaur 60.2 13.0 73.2 618 Janjanbureh 52.2 13.7 65.9 746 Basse 49.8 22.8 72.6 1,356 Wealth quintile Lowest 55.4 13.2 68.5 1,867 Second 56.1 17.6 73.7 1,960 Middle 55.8 17.5 73.4 1,809 Fourth 58.5 11.5 70.0 1,666 Highest 60.5 14.3 74.8 1,464 Total 57.1 14.9 72.0 8,765 2.7 CHILDREN’S LIVING ARRANGEMENTS AND PARENTAL SURVIVAL Information was collected on the living arrangements and parental survival status of all children under age 18 residing in the GDHS sample households to assess the potential burden on households of the need to provide for orphaned or foster children. These data were also used to assess the situation from the perspective of the children themselves. Table 2.10 presents the proportion of children under age 18 who are not living with one or both parents, either because the parent(s) died or for other reasons. Forty percent of children under age 18 in The Gambia are not living with both parents. Twelve percent are not living with either parent, even if both are alive. Eight percent of children under age 18 are orphaned (that is, one or both parents are dead). The percentage of orphaned children increases rapidly with age, from 3 percent among children under age 5 to 17 percent among children age 15-17. There is no variation in the percentage of orphans by sex or urban-rural residence. Mansakonko and Kuntaur have the lowest percentage of orphaned children (6 percent each), while Banjul and Kanifing have the highest percentage (9 percent each). The percentage of children with one or both parents dead is somewhat higher among those in the lowest wealth quintile (10 percent) than among those in the other wealth quintiles (7 to 8 percent). 22 • H ou si ng C ha ra ct er is tic s an d H ou se ho ld P op ul at io n Ta bl e 2. 10 C hi ld re n’ s liv in g ar ra ng em en ts a nd o rp ha nh oo d P er ce nt d is tri bu tio n of d e ju re c hi ld re n un de r ag e 18 b y liv in g ar ra ng em en ts a nd s ur vi va l s ta tu s of p ar en ts , t he p er ce nt ag e of c hi ld re n no t l iv in g w ith a b io lo gi ca l p ar en t, an d th e pe rc en ta ge o f c hi ld re n w ith o ne o r bo th p ar en ts d ea d, ac co rd in g to b ac kg ro un d ch ar ac te ris tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic Li vi ng w ith bo th p ar en ts Li vi ng w ith m ot he r bu t n ot w ith fa th er Li vi ng w ith fa th er bu t n ot w ith m ot he r N ot li vi ng w ith e ith er p ar en t To ta l P er ce nt ag e no t l iv in g w ith a bi ol og ic al pa re nt P er ce nt ag e w ith o ne o r bo th p ar en ts de ad 1 N um be r o f ch ild re n Fa th er al iv e Fa th er de ad M ot he r al iv e M ot he r de ad B ot h al iv e O nl y fa th er al iv e O nl y m ot he r al iv e B ot h de ad M is si ng in fo rm at io n on fa th er / m ot he r A ge 0- 4 68 .8 22 .3 1. 6 1. 2 0. 2 4. 9 0. 2 0. 3 0. 1 0. 2 10 0. 0 5. 6 2. 5 8, 76 5 <2 71 .2 26 .1 1. 0 0. 4 0. 1 0. 8 0. 1 0. 0 0. 0 0. 3 10 0. 0 0. 9 1. 2 3, 68 9 2- 4 67 .1 19 .6 2. 0 1. 8 0. 3 7. 9 0. 3 0. 5 0. 2 0. 2 10 0. 0 9. 0 3. 5 5, 07 7 5- 9 60 .9 14 .8 3. 2 3. 9 0. 8 13 .3 0. 9 1. 1 0. 7 0. 4 10 0. 0 16 .0 6. 7 7, 99 4 10 -1 4 53 .7 12 .0 5. 4 5. 3 1. 3 16 .2 1. 6 2. 8 1. 2 0. 5 10 0. 0 21 .8 12 .3 6, 33 3 15 -1 7 44 .6 9. 0 7. 3 4. 7 1. 7 21 .0 1. 8 4. 7 1. 9 3. 3 10 0. 0 29 .4 17 .4 2, 90 0 Se x M al e 61 .8 15 .7 3. 6 3. 8 0. 9 10 .4 0. 8 1. 6 0. 7 0. 6 10 0. 0 13 .5 7. 7 12 ,9 77 Fe m al e 58 .2 16 .3 3. 7 3. 0 0. 7 13 .7 1. 1 1. 7 0. 8 0. 8 10 0. 0 17 .3 8. 0 13 ,0 16 R es id en ce U rb an 58 .0 17 .2 3. 5 3. 5 0. 5 12 .7 1. 2 1. 7 0. 9 0. 8 10 0. 0 16 .5 7. 8 12 ,0 52 R ur al 61 .7 15 .0 3. 8 3. 4 1. 1 11 .5 0. 8 1. 6 0. 6 0. 6 10 0. 0 14 .5 7. 9 13 ,9 41 Lo ca l G ov er nm en t A re a B an ju l 51 .3 23 .0 4. 5 2. 8 0. 4 13 .1 0. 8 3. 0 0. 5 0. 7 10 0. 0 17 .5 9. 2 40 4 K an ifi ng 54 .8 18 .9 3. 7 3. 8 0. 5 13 .2 0. 9 2. 0 1. 3 0. 8 10 0. 0 17 .5 8. 6 4, 45 3 B rik am a 61 .3 13 .9 3. 3 3. 8 0. 9 12 .2 1. 1 1. 9 0. 8 0. 8 10 0. 0 16 .0 8. 0 8, 61 0 M an sa ko nk o 55 .7 19 .2 3. 2 3. 3 0. 8 15 .0 0. 4 1. 0 0. 3 1. 2 10 0. 0 16 .6 5. 6 1, 46 3 K er ew an 59 .5 15 .4 3. 0 3. 3 0. 8 14 .1 1. 1 1. 8 0. 5 0. 5 10 0. 0 17 .5 7. 2 3, 31 6 K un ta ur 68 .3 10 .5 2. 2 3. 2 0. 9 11 .6 0. 9 1. 6 0. 2 0. 6 10 0. 0 14 .3 5. 8 1, 82 6 Ja nj an bu re h 59 .1 16 .0 4. 0 4. 0 1. 3 12 .1 1. 2 1. 3 0. 8 0. 4 10 0. 0 15 .3 8. 5 2, 15 6 B as se 62 .9 18 .5 5. 6 2. 2 0. 8 7. 4 0. 5 0. 8 0. 7 0. 5 10 0. 0 9. 5 8. 5 3, 76 5 W ea lth q ui nt ile Lo w es t 61 .4 13 .3 4. 9 2. 9 1. 4 11 .9 1. 0 1. 5 1. 0 0. 7 10 0. 0 15 .4 9. 8 5, 54 4 S ec on d 62 .4 14 .4 3. 3 3. 3 1. 0 12 .1 0. 8 1. 7 0. 4 0. 6 10 0. 0 15 .1 7. 1 5, 60 2 M id dl e 60 .2 16 .4 3. 2 4. 5 0. 7 11 .1 0. 9 1. 6 0. 6 0. 7 10 0. 0 14 .3 7. 1 5, 47 5 Fo ur th 62 .7 15 .4 2. 9 2. 9 0. 7 10 .9 1. 0 1. 7 0. 9 0. 9 10 0. 0 14 .5 7. 2 4, 96 9 H ig he st 51 .9 21 .5 4. 0 3. 4 0. 2 14 .6 1. 1 1. 7 0. 8 0. 7 10 0. 0 18 .2 7. 9 4, 40 3 To ta l < 15 61 .9 16 .9 3. 2 3. 3 0. 7 10 .9 0. 8 1. 3 0. 6 0. 4 10 0. 0 13 .6 6. 6 23 ,0 93 To ta l < 18 60 .0 16 .0 3. 6 3. 4 0. 8 12 .1 0. 9 1. 6 0. 8 0. 7 10 0. 0 15 .4 7. 8 25 ,9 93 N ot e: T ab le is b as ed o n de ju re h ou se ho ld m em be rs (i .e ., us ua l r es id en ts ). 1 I nc lu de s ch ild re n w ith fa th er d ea d, m ot he r d ea d, b ot h de ad , a nd o ne p ar en t d ea d bu t m is si ng in fo rm at io n on th e su rv iv al s ta tu s of th e ot he r p ar en t 22 • Housing Characteristics and Household Population Housing Characteristics and Household Population • 23 2.8 EDUCATION OF THE HOUSEHOLD POPULATION Education is a key determinant of individual opportunities, attitudes, and economic and social status. Studies have consistently shown that educational attainment has a strong effect on reproductive behaviour, fertility, infant and child mortality and morbidity, and attitudes and awareness related to family health, use of family planning, and sanitation. The 2013 GDHS collected data on educational attainment among household members and school attendance among youth. In The Gambia, the basic structure of the education system includes preschool, lower basic education (grades 1-6), upper basic education (grades 7-9), senior secondary education (grades 10-12), and postsecondary or tertiary education (grades higher than 12). Tertiary education covers all postsecondary education programmes, particularly technical education, teacher education, university education, and research. The official age of school enrolment is 7 years. 2.8.1 School Attendance by Survivorship of Parents The survival status of parents has an impact on their children’s school attendance. Table 2.11 shows the percentage of children age 10-14 attending school by parental survival, along with the ratio of attendance by parental survival, according to background characteristics. Children with both parents dead are less likely to attend school (67 percent) than children who have both parents alive and who are living with at least one parent (74 percent), resulting in a ratio of 0.90 between the percentage of children with both parents deceased and the percentage with both parents alive and living with a parent. Table 2.11 School attendance by survivorship of parents Among de jure children age 10-14, the percentage attending school by parental survival and the ratio of the percentage attending by parental survival, according to background characteristics, The Gambia 2013 Percentage attending school by survivorship of parents Background characteristic Both parents deceased Number Both parents alive and living with at least one parent Number Ratio1 Sex Male (66.7) 43 75.4 2,265 0.88 Female (66.9) 30 73.0 2,229 0.92 Residence Urban (71.2) 37 84.7 2,091 0.84 Rural (62.3) 36 65.1 2,403 0.96 Local Government Area Banjul * 1 89.7 68 0.65 Kanifing * 25 85.6 752 0.82 Brikama * 20 84.3 1,463 0.85 Mansakonko * 2 83.2 270 1.20 Kerewan * 6 66.6 583 1.00 Kuntaur * 1 45.4 337 0.00 Janjanbureh * 3 57.1 349 0.82 Basse * 14 64.3 671 0.88 Wealth quintile Lowest * 13 66.6 921 1.30 Second * 11 66.7 934 0.82 Middle * 14 68.8 982 0.56 Fourth * 19 79.9 933 0.87 Highest * 15 93.6 724 0.86 Total 66.8 73 74.2 4,494 0.90 Notes: Table is based only on children who usually live in the household. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent 24 • Housing Characteristics and Household Population 2.8.2 Educational Attainment The 2013 GDHS results can be used to look at educational attainment among household members and school attendance ratios among youth. Tables 2.12.1 and 2.12.2 show the percent distribution of the de facto female and male household population age 6 and older by highest level of education attended or completed, according to background characteristics. A comparison of the two tables reveals that there is a substantial gap in educational attainment between females and males. There are proportionally more females than males with no education (52 percent versus 43 percent). By contrast, a higher percentage of males than females have attended or completed secondary school (27 percent versus 21 percent) or have more than a secondary education (5 percent versus 3 percent). The gap in the proportion of females and males who have no education exists for all age categories other than the 6-9 age group, wherein females are slightly less likely to have no education than males (57 percent versus 58 percent). The disparity is highest in the 55-59 age group, with a gap of 30 percentage points (93 percent of women in this age group have no education, as compared with 63 percent of men). Educational attainment differs markedly by residence and among LGAs. Forty-one percent of females and 33 percent of males in urban areas have no education, as compared with 62 percent of females and 54 percent of males in rural areas. By LGA, the largest proportion of the household population over age 6 that has never been to school is found in Kuntaur (72 percent for both females and males). Banjul has the lowest proportion of household members who have never attended school (33 percent of females and 30 percent of males). The percentage of males and females with no education is inversely associated with wealth. For example, the percentage of females with no education decreases from 63 percent among those in the lowest wealth quintile to 30 percent among those in the highest quintile. Nationally, the median number of years of schooling completed is slightly higher for males (1.1 years) than females (0.0 years). Median number of years of schooling completed is highest among females age 15-24 and males age 20-29, among urban residents, among those in Banjul and Kanifing, and among those in the highest wealth quintile. H ou si ng C ha ra ct er is tic s an d H ou se ho ld P op ul at io n • 2 5 Ta bl e 2. 12 .1 E du ca tio na l a tta in m en t o f t he fe m al e ho us eh ol d po pu la tio n P er ce nt d is tri bu tio n of th e de fa ct o fe m al e ho us eh ol d po pu la tio n ag e 6 an d ov er b y hi gh es t l ev el o f s ch oo lin g at te nd ed o r c om pl et ed a nd m ed ia n ye ar s co m pl et ed , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic N o ed uc at io n S om e pr im ar y C om pl et ed pr im ar y1 S om e se co nd ar y C om pl et ed se co nd ar y2 M or e th an se co nd ar y D on ’t kn ow / m is si ng To ta l N um be r M ed ia n ye ar s co m pl et ed A ge 6- 9 56 .6 42 .9 0. 1 0. 0 0. 0 0. 0 0. 5 10 0. 0 3, 16 5 0. 0 10 -1 4 25 .8 60 .7 3. 7 9. 2 0. 4 0. 0 0. 3 10 0. 0 3, 20 1 2. 3 15 -1 9 24 .8 13 .9 7. 1 49 .8 2. 9 1. 1 0. 3 10 0. 0 2, 66 2 6. 2 20 -2 4 32 .2 6. 6 5. 1 31 .0 16 .7 8. 3 0. 1 10 0. 0 2, 32 6 7. 6 25 -2 9 47 .6 7. 9 4. 2 19 .6 11 .7 8. 4 0. 5 10 0. 0 2, 04 6 2. 9 30 -3 4 58 .7 7. 9 4. 6 14 .2 9. 1 5. 5 0. 1 10 0. 0 1, 67 0 0. 0 35 -3 9 68 .4 7. 4 4. 8 9. 7 5. 3 4. 2 0. 3 10 0. 0 1, 20 0 0. 0 40 -4 4 74 .5 3. 2 5. 4 10 .5 2. 5 3. 5 0. 5 10 0. 0 83 6 0. 0 45 -4 9 80 .0 2. 5 4. 3 7. 0 2. 6 3. 1 0. 3 10 0. 0 62 3 0. 0 50 -5 4 90 .3 2. 7 0. 8 3. 4 1. 5 1. 0 0. 4 10 0. 0 1, 04 0 0. 0 55 -5 9 92 .8 1. 1 1. 0 2. 9 1. 3 0. 8 0. 1 10 0. 0 49 8 0. 0 60 -6 4 92 .8 0. 3 1. 4 1. 2 1. 5 2. 5 0. 3 10 0. 0 48 0 0. 0 65 + 94 .2 0. 3 0. 6 1. 3 0. 6 1. 7 1. 3 10 0. 0 92 5 0. 0 R es id en ce U rb an 41 .1 19 .0 4. 1 21 .9 8. 1 5. 5 0. 3 10 0. 0 10 ,5 70 2. 2 R ur al 62 .3 22 .5 3. 1 9. 7 1. 5 0. 5 0. 5 10 0. 0 10 ,1 11 0. 0 Lo ca l G ov er nm en t A re a B an ju l 32 .9 17 .9 4. 4 26 .2 11 .3 6. 7 0. 5 10 0. 0 41 4 4. 7 K an ifi ng 37 .4 19 .4 3. 8 22 .8 10 .0 6. 5 0. 2 10 0. 0 4, 17 6 3. 3 B rik am a 44 .3 20 .5 4. 5 20 .0 6. 1 4. 1 0. 4 10 0. 0 6, 90 6 1. 0 M an sa ko nk o 53 .1 26 .6 3. 5 13 .0 2. 3 1. 1 0. 4 10 0. 0 1, 11 0 0. 0 K er ew an 63 .0 20 .5 2. 8 10 .7 2. 2 0. 4 0. 4 10 0. 0 2, 47 2 0. 0 K un ta ur 72 .0 16 .5 2. 6 7. 8 0. 7 0. 1 0. 4 10 0. 0 1, 25 8 0. 0 Ja nj an bu re h 62 .9 19 .6 2. 8 12 .1 1. 2 0. 9 0. 5 10 0. 0 1, 65 6 0. 0 B as se 67 .0 24 .1 2. 7 5. 5 0. 3 0. 2 0. 3 10 0. 0 2, 68 9 0. 0 W ea lth q ui nt ile Lo w es t 62 .8 22 .4 3. 1 9. 5 1. 5 0. 2 0. 5 10 0. 0 4, 05 6 0. 0 S ec on d 60 .7 22 .0 3. 3 11 .0 1. 8 0. 8 0. 4 10 0. 0 4, 08 0 0. 0 M id dl e 58 .9 21 .3 3. 6 13 .0 2. 1 0. 7 0. 3 10 0. 0 4, 08 4 0. 0 Fo ur th 46 .8 20 .8 4. 1 19 .8 5. 3 3. 0 0. 3 10 0. 0 3, 99 8 0. 3 H ig he st 30 .2 17 .4 3. 9 25 .5 12 .8 9. 9 0. 3 10 0. 0 4, 46 4 5. 5 To ta l 51 .5 20 .7 3. 6 15 .9 4. 9 3. 0 0. 4 10 0. 0 20 ,6 81 0. 0 N ot e: T ot al in cl ud es 8 c as es fo r w ho m in fo rm at io n on a ge is m is si ng . 1 C om pl et ed g ra de 6 a t t he p rim ar y le ve l 2 C om pl et ed g ra de 1 2 at th e se co nd ar y le ve l Housing Characteristics and Household Population • 25 26 • H ou si ng C ha ra ct er is tic s an d H ou se ho ld P op ul at io n Ta bl e 2. 12 .2 E du ca tio na l a tta in m en t o f t he m al e ho us eh ol d po pu la tio n P er ce nt d is tri bu tio n of th e de fa ct o m al e ho us eh ol d po pu la tio n ag e 6 an d ov er b y hi gh es t l ev el o f s ch oo lin g at te nd ed o r c om pl et ed a nd m ed ia n ye ar s co m pl et ed , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic N o ed uc at io n S om e pr im ar y C om pl et ed pr im ar y1 S om e se co nd ar y C om pl et ed se co nd ar y2 M or e th an se co nd ar y D on ’t kn ow / m is si ng To ta l N um be r M ed ia n ye ar s co m pl et ed A ge 6- 9 57 .6 41 .9 0. 0 0. 0 0. 0 0. 0 0. 5 10 0. 0 3, 23 7 0. 0 10 -1 4 24 .0 62 .7 3. 7 9. 1 0. 2 0. 0 0. 2 10 0. 0 3, 06 2 2. 2 15 -1 9 21 .9 15 .7 6. 8 52 .2 2. 6 0. 6 0. 1 10 0. 0 2, 45 8 6. 3 20 -2 4 24 .0 7. 2 4. 7 36 .4 19 .0 8. 4 0. 4 10 0. 0 2, 03 9 8. 3 25 -2 9 34 .3 5. 6 3. 8 22 .3 21 .6 12 .2 0. 1 10 0. 0 1, 61 6 8. 1 30 -3 4 43 .1 4. 3 5. 1 18 .6 19 .3 9. 4 0. 2 10 0. 0 1, 32 3 5. 5 35 -3 9 43 .5 6. 6 6. 4 18 .6 17 .2 7. 1 0. 5 10 0. 0 1, 07 7 4. 8 40 -4 4 54 .5 4. 2 4. 8 17 .6 9. 6 9. 0 0. 3 10 0. 0 89 9 0. 0 45 -4 9 60 .5 3. 6 5. 0 13 .7 9. 5 7. 2 0. 5 10 0. 0 68 4 0. 0 50 -5 4 65 .6 3. 0 2. 1 9. 1 7. 5 11 .2 1. 5 10 0. 0 49 5 0. 0 55 -5 9 63 .2 6. 7 4. 9 7. 6 8. 7 8. 3 0. 7 10 0. 0 36 7 0. 0 60 -6 4 81 .6 1. 8 1. 4 6. 4 3. 2 4. 7 0. 8 10 0. 0 54 1 0. 0 65 + 89 .8 0. 7 0. 3 2. 0 3. 0 3. 3 1. 0 10 0. 0 93 9 0. 0 R es id en ce U rb an 32 .6 20 .1 4. 2 23 .9 11 .9 6. 9 0. 4 10 0. 0 10 ,1 22 4. 2 R ur al 54 .2 24 .5 3. 1 12 .4 3. 6 1. 8 0. 4 10 0. 0 8, 62 1 0. 0 Lo ca l G ov er nm en t A re a B an ju l 30 .1 18 .1 5. 0 26 .9 13 .1 6. 5 0. 4 10 0. 0 40 6 5. 3 K an ifi ng 31 .8 19 .5 3. 6 23 .5 12 .6 8. 5 0. 6 10 0. 0 3, 78 8 4. 6 B rik am a 33 .6 22 .0 4. 3 23 .8 10 .5 5. 5 0. 3 10 0. 0 6, 90 5 3. 5 M an sa ko nk o 39 .8 29 .9 3. 9 17 .2 5. 6 3. 3 0. 3 10 0. 0 94 6 0. 9 K er ew an 51 .0 25 .2 3. 7 13 .6 4. 2 2. 0 0. 3 10 0. 0 2, 11 8 0. 0 K un ta ur 72 .0 15 .3 2. 2 7. 2 1. 9 0. 6 0. 7 10 0. 0 1, 03 6 0. 0 Ja nj an bu re h 58 .3 18 .9 3. 4 12 .5 4. 0 2. 5 0. 4 10 0. 0 1, 38 1 0. 0 B as se 61 .1 26 .6 2. 4 6. 9 1. 9 0. 7 0. 3 10 0. 0 2, 16 4 0. 0 W ea lth q ui nt ile Lo w es t 53 .8 24 .6 3. 5 12 .8 3. 8 1. 2 0. 4 10 0. 0 3, 51 5 0. 0 S ec on d 51 .6 24 .6 3. 1 14 .1 4. 0 2. 1 0. 5 10 0. 0 3, 55 0 0. 0 M id dl e 48 .6 22 .8 3. 7 16 .4 5. 7 2. 5 0. 4 10 0. 0 3, 72 3 0. 0 Fo ur th 38 .4 20 .4 4. 4 22 .9 9. 0 4. 6 0. 4 10 0. 0 4, 01 8 2. 7 H ig he st 22 .8 18 .8 3. 6 25 .8 16 .9 11 .8 0. 4 10 0. 0 3, 93 7 6. 9 To ta l 42 .5 22 .1 3. 7 18 .6 8. 1 4. 6 0. 4 10 0. 0 18 ,7 44 1. 1 N ot e: T ot al in cl ud es 5 c as es fo r w ho m in fo rm at io n on a ge is m is si ng . 1 C om pl et ed g ra de 6 a t t he p rim ar y le ve l 2 C om pl et ed g ra de 1 2 at th e se co nd ar y le ve l 26 • Housing Characteristics and Household Population Housing Characteristics and Household Population • 27 2.8.3 School Attendance Ratios Table 2.13 shows data on net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by school level and sex, according to residence, region, and wealth index. The NAR for primary school is the total number of students of primary school age (age 7-12), expressed as the percentage of the population of primary school age. The NAR for secondary school is the percentage of the population of secondary school age (age 13-18) that attends secondary school. By definition, the NAR cannot exceed 100 percent. Table 2.13 School attendance ratios Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by sex and level of schooling, and the Gender Parity Index (GPI), according to background characteristics, The Gambia 2013 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 73.4 72.6 73.0 0.99 96.7 97.0 96.8 1.00 Rural 57.8 61.3 59.5 1.06 83.8 83.5 83.7 1.00 Local Government Area Banjul 76.5 79.6 78.0 1.04 99.3 108.8 104.0 1.10 Kanifing 73.7 77.2 75.4 1.05 98.5 101.5 100.0 1.03 Brikama 72.7 71.2 72.0 0.98 99.4 95.4 97.5 0.96 Mansakonko 73.2 76.9 75.0 1.05 104.0 102.5 103.3 0.99 Kerewan 60.8 58.2 59.6 0.96 84.7 83.8 84.3 0.99 Kuntaur 35.7 44.2 40.0 1.24 51.7 61.2 56.5 1.18 Janjanbureh 52.0 53.6 52.8 1.03 73.2 74.2 73.7 1.01 Basse 56.9 63.7 60.3 1.12 82.1 84.3 83.2 1.03 Wealth quintile Lowest 60.8 61.1 61.0 1.00 88.2 80.8 84.4 0.92 Second 59.1 62.4 60.7 1.06 84.3 85.0 84.7 1.01 Middle 60.5 62.6 61.5 1.04 81.4 86.7 83.9 1.07 Fourth 69.0 72.7 70.8 1.05 95.0 95.8 95.4 1.01 Highest 78.8 76.3 77.6 0.97 103.6 104.0 103.8 1.00 Total 64.8 66.4 65.6 1.02 89.6 89.5 89.6 1.00 SECONDARY SCHOOL Residence Urban 53.7 50.0 51.8 0.93 72.4 65.0 68.6 0.90 Rural 31.5 26.4 28.8 0.84 46.0 32.9 39.1 0.71 Local Government Area Banjul 55.0 63.0 59.3 1.15 75.0 76.4 75.8 1.02 Kanifing 53.1 52.6 52.8 0.99 72.3 65.9 68.9 0.91 Brikama 51.4 45.6 48.5 0.89 70.1 61.1 65.7 0.87 Mansakonko 45.4 37.5 41.5 0.83 63.7 46.1 55.1 0.72 Kerewan 36.3 32.2 34.1 0.89 54.5 40.4 47.0 0.74 Kuntaur 23.7 26.0 25.0 1.10 34.1 33.8 33.9 0.99 Janjanbureh 34.7 34.5 34.6 0.99 51.5 42.2 46.0 0.82 Basse 19.3 10.3 14.4 0.53 25.3 12.7 18.5 0.50 Wealth quintile Lowest 35.7 26.6 30.8 0.75 53.5 32.5 42.2 0.61 Second 32.5 31.4 32.0 0.97 46.0 38.1 42.0 0.83 Middle 34.7 29.7 32.0 0.86 51.7 38.8 44.8 0.75 Fourth 47.7 44.4 46.1 0.93 61.6 58.6 60.2 0.95 Highest 65.8 59.4 62.2 0.90 87.9 77.4 82.1 0.88 Total 43.5 38.8 41.0 0.89 60.3 49.8 54.8 0.83 1 The NAR for primary school is the percentage of the primary school age (7-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary school age (13-18 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students expressed as a percentage of the official primary school age population. The GAR for secondary school is the total number of secondary school students expressed as a percentage of the official secondary school age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR (GAR) for males. 28 • Housing Characteristics and Household Population The GAR for primary school is the total number of primary school students of any age, expressed as a percentage of the official primary school age population. The GAR for secondary school is the total number of secondary school students of any age, expressed as a percentage of the official secondary school age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. Finally, the gender parity index (GPI), which is the ratio of female to male attendance rates at the primary and secondary levels, indicates the magnitude of the gender gap in school attendance. A GPI below one indicates that a smaller proportion of females than males attend school. Individuals are considered to be attending school currently if they attended formal academic school at any point during the school year. The results in Table 2.13 show that 66 percent of primary school age children attend primary school (65 percent of males and 66 percent of females) and that 41 percent of secondary school age youth attend secondary school (44 percent of males and 39 percent of females). At both levels, the NAR is much higher in urban areas than in rural areas (73 percent and 60 percent, respectively, at the primary school level and 52 percent and 29 percent, respectively, at the secondary school level). There are also large differences by LGA. For example, at the primary level, Banjul has the highest NAR (78 percent) and Kuntaur has the lowest (40 percent). At the secondary level, the NAR ranges from 14 percent in Basse to 59 percent in Banjul. The NAR is highest among children in the wealthiest households (78 percent at the primary level and 62 percent at the secondary level). The GAR at the primary school level is 90 percent. This figure exceeds the primary school NAR (66 percent) by 24 percentage points, indicating that a large number of children outside the official school age population are attending primary school. At the secondary level, the GAR (55 percent) is somewhat closer to the NAR (41 percent), indicating that fewer youth outside of the official school age population are attending secondary school than is the case for primary school. At the primary school level, the GPI is 1.02 for the NAR and 1.00 for the GAR, indicating that there is gender parity in primary school. However, at the secondary school level, the GPI is 0.89 for the NAR and 0.83 for the GAR, pointing to gender disparity in favour of males. This disparity is especially pronounced in rural areas. The GPI associated with the secondary school NAR is 0.84 in rural areas, as compared with 0.93 in urban areas; the GPI associated with the secondary school GAR is 0.71 and 0.90 in rural areas and urban areas, respectively. Large GPI differences are also observed according to LGA and wealth. The GPI for the NAR and GAR at the secondary school level is lowest among children living in Basse (0.53 and 0.50, respectively) and among children in the poorest households (0.75 and 0.61, respectively). Housing Characteristics and Household Population • 29 Figure 2.2 shows the age-specific attendance rates (ASARs) for the population age 5 and over, by sex. The ASAR indicates participation in schooling at any level, from primary to higher levels of education. At age 5 and age 6, attendance among males (8 percent and 22 percent, respectively) is higher than that among females (6 percent and 20 percent, respectively). However, from age 7 to age 9, female attendance is higher than male attendance. Attendance peaks at age 11 for males and age 12 for females. As school attendance begins to decline from age 14 onward, the gender differential increases, with more male than female youths attending. Figure 2.2 Age-specific attendance rates 8 22 45 62 65 74 75 72 72 70 67 67 60 49 48 33 23 21 16 16 6 20 47 63 73 71 71 76 73 69 60 60 44 40 37 18 17 16 7 7 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percentage Age Male Female GDHS 2013 2.9 DISABILITY In the 2013 GDHS, the Household Questionnaire asked if any household member(s) age 7 to age 69 had any form of disability and, if so, what type of disability. The objective of these questions was to provide estimates of the prevalence of physical disability among the household population, which are important for policy formulation and programmatic interventions. For example, disaggregating physical disability prevalence by LGA allows identification of areas in The Gambia where the problem is more common and, consequently, targeting of those areas with educational and rehabilitation programmes. Table 2.14 shows the prevalence of physical disability among the de facto household population by various background characteristics, such as age, sex, residence, LGA, education, and wealth, according to type of disability. The total prevalence of any physical disability among household members age 7-69 is 3 percent; 2 percent have difficulty seeing, less than 1 percent have difficulty hearing, and slightly over 1 percent have difficulty using their legs. Very few household members age 7-69 (less than 1 percent) use crutches, canes, or a wheelchair. Physical disability increases with increasing age, reaching its peak at 13 percent among individuals age 55-64. There are no major variations by sex, residence, or wealth. The prevalence of physical disability is lowest among those living in Basse (1 percent) and highest among those living in Banjul and Janjanbureh (6 percent each). In addition, physical disability is most common among individuals with no education and those in the lowest wealth quintile (4 percent each). 30 • Housing Characteristics and Household Population Table 2.14 Prevalence of physical disability Percentage of de facto household members age 7-69 with a reported physical disability1 by type of disability, according to background characteristics, The Gambia 2013 Type of disability Any disability Use crutches, canes, or wheelchair Number Background characteristic Difficulty seeing Difficulty hearing Difficulty using the legs Age 7-14 0.4 0.2 0.2 0.9 0.0 10,830 15-24 0.8 0.3 0.3 1.4 0.0 9,486 25-34 1.0 0.4 1.1 2.3 0.1 6,657 35-44 1.9 0.6 1.4 3.5 0.1 4,012 45-54 4.4 1.1 3.8 7.7 0.2 2,842 55-64 6.8 1.9 6.7 12.8 0.8 1,887 65+ 2.4 1.2 3.5 5.7 0.7 1,864 Sex Male 1.3 0.5 1.0 2.6 0.2 17,827 Female 1.7 0.5 1.5 3.2 0.1 19,763 Residence Urban 1.4 0.5 1.4 2.9 0.2 19,856 Rural 1.6 0.5 1.2 2.9 0.1 17,734 Local Government Area Banjul 2.9 0.8 2.9 5.6 0.2 795 Kanifing 1.8 0.4 1.4 3.2 0.1 7,648 Brikama 1.3 0.5 1.1 2.5 0.1 13,190 Mansakonko 0.9 0.3 0.5 1.6 0.1 1,958 Kerewan 2.0 0.6 2.2 4.1 0.2 4,373 Kuntaur 1.4 0.4 1.0 2.3 0.1 2,158 Janjanbureh 3.1 1.6 2.2 5.6 0.1 2,877 Basse 0.3 0.3 0.5 1.0 0.2 4,591 Education No education 1.9 0.7 1.9 3.8 0.2 17,108 Primary 0.8 0.3 0.6 1.5 0.0 9,554 Secondary or higher 1.5 0.5 1.0 2.6 0.1 10,792 Wealth quintile Lowest 1.9 0.7 1.4 3.5 0.2 7,133 Second 1.6 0.4 1.3 2.9 0.1 7,264 Middle 1.2 0.5 1.1 2.4 0.2 7,420 Fourth 1.0 0.5 1.1 2.3 0.1 7,669 Highest 1.8 0.5 1.5 3.4 0.1 8,104 Total 1.5 0.5 1.3 2.9 0.1 37,590 Note: Total includes 13 cases for whom information on age is missing and 136 cases for whom information on education level is missing. 1 Disability as reported by the respondent on the Household Questionnaire Characteristics of Respondents • 31 CHARACTERISTICS OF RESPONDENTS 3 his chapter provides a demographic and socioeconomic profile of the respondents interviewed in the 2013 GDHS, that is, women and men age 15-49. Information is presented on a number of basic characteristics including age at the time of the survey, religion, marital status, residence, education, literacy, media access, smoking status, and health insurance coverage. In addition, the chapter explores adults’ employment status, occupation, and earnings. An analysis of these variables provides the socioeconomic context within which demographic and reproductive health issues are examined in the subsequent chapters. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 presents the percent distribution of women and men age 15-49 by age, marital status, residence, Local Government Area (LGA), education, wealth, religion, and ethnicity. The distribution of the respondents according to age shows a generally similar pattern for men and women. As expected, the proportion of women and men in each age group declines with increasing age. Forty-four percent of women and 47 percent of men are in the 15-24 age group, 33 percent of women and 28 percent of men are age 25-34, and the remaining respondents are age 35-49. Sixty-six percent of women are currently married, as compared with 38 percent of men. On the other hand, 61 percent of men age 15-49 have never been married, compared with 29 percent of women. About 2 percent of women are widowed and 3 percent are either divorced or separated. Among men, these proportions are 1 percent or lower. Overall, 56 percent of women and 62 percent of men live in urban areas, while 44 percent and 38 percent, respectively, live in rural areas. Within the eight LGAs, Brikama has the largest proportions of both female and male respondents (35 percent and 41 percent, respectively), and Banjul has the smallest proportions (2 percent each). T Key Findings • Sixty-six percent of women and 38 percent of men are married, while 5 percent of women and 1 percent of men are divorced, separated, or widowed. • Forty-seven percent of women have no education, as compared with 31 percent of men. • A large majority of the respondents (96 percent of both women and men) are Muslims. • The majority of the respondents are members of the Mandinka/Jahanka ethnic group (34 percent of women and 35 percent of men), followed by the Fula/Tukulur/Lorobo ethnic group (22 percent of women and 23 percent of men). • Literacy rates are 45 percent for women and 70 percent for men. • Thirty percent of women and 16 percent of men do not have weekly access to newspapers, television, or a radio. • Ten percent of women working in agriculture are not paid. • Twenty-two percent of men age 15-49 use tobacco products. 32 • Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, The Gambia 2013 Women Men Background characteristic Weighted percentage Weighted number Unweighted number Weighted percentage Weighted number Unweighted number Age 15-19 23.5 2,407 2,463 23.4 836 867 20-24 20.8 2,125 2,101 23.7 849 789 25-29 17.8 1,822 1,755 16.4 586 547 30-34 14.7 1,504 1,480 11.9 425 399 35-39 10.3 1,056 1,098 10.9 391 385 40-44 7.4 761 765 7.6 270 274 45-49 5.5 559 571 6.2 220 261 Religion Islam 95.7 9,793 9,916 95.9 3,430 3,425 Christianity 4.2 427 302 4.0 144 93 No religion 0.1 6 3 0.0 2 2 Missing 0.1 6 12 0.0 1 2 Ethnic group Mandinka/Jahanka 33.8 3,462 3,366 34.5 1,234 1,153 Wollof 12.2 1,253 1,387 13.6 485 484 Jola/Karoninka 10.9 1,119 851 10.0 359 278 Fula/Tukulur/Lorobo 22.1 2,262 2,470 23.1 826 901 Serere 3.2 323 388 3.3 117 111 Serahuleh 7.0 714 744 5.4 192 208 Creole/Aku Marabout 0.8 79 88 0.6 21 33 Manjago 2.1 218 143 2.1 74 49 Bambara 1.0 107 123 1.1 38 52 Other 0.9 95 105 1.0 35 38 Non-Gambian 5.2 528 479 5.3 191 212 Missing 0.7 72 89 0.1 5 3 Marital status Never married 29.0 2,963 2,866 60.9 2,177 2,093 Married 66.1 6,764 6,871 38.0 1,358 1,385 Living together 0.3 27 34 0.1 2 3 Divorced/separated 3.2 326 321 1.1 38 37 Widowed 1.5 153 141 0.1 2 4 Residence Urban 56.0 5,730 4,498 62.3 2,228 1,692 Rural 44.0 4,503 5,735 37.7 1,349 1,830 Local Government Area Banjul 2.2 225 1,073 2.4 85 411 Kanifing 22.9 2,342 1,506 24.0 858 553 Brikama 34.7 3,550 1,833 40.6 1,454 742 Mansakonko 4.8 490 1,041 3.9 141 339 Kerewan 10.8 1,107 1,448 9.0 323 455 Kuntaur 5.1 526 1,039 4.0 141 310 Janjanbureh 7.2 739 1,024 6.7 240 326 Basse 12.3 1,254 1,269 9.4 336 386 Education No education 46.5 4,757 5,079 30.5 1,090 1,229 Primary 13.7 1,405 1,438 13.8 493 512 Secondary 34.3 3,512 3,268 46.5 1,665 1,508 More than secondary 5.5 559 448 9.2 330 273 Wealth quintile Lowest 17.1 1,745 2,144 14.4 517 680 Second 18.4 1,882 2,251 17.2 614 747 Middle 18.8 1,927 1,991 16.4 588 621 Fourth 20.9 2,135 1,714 26.3 940 700 Highest 24.9 2,545 2,133 25.7 919 774 Total 15-49 100.0 10,233 10,233 100.0 3,577 3,522 50-59 na na na na 244 299 Total 15-59 na na na na 3,821 3,821 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Respondents • 33 Table 3.1 also shows that men are more educated than women. Forty-seven percent of women age 15-49 have no education, as compared with 31 percent of men. Furthermore, 56 percent of men have a secondary education or higher, compared with 40 percent of women. About half of the respondents (46 percent of women and 52 percent of men) are in the highest two wealth quintiles, and the smallest proportions are in the lowest quintile (17 percent of women and 14 percent of men). The distribution of respondents by religion shows that the vast majority of both women and men (96 percent) believe in Islam, whereas 4 percent believe in Christianity. A negligible proportion of respondents (less than 1 percent) claimed to have no religion. Ethnic affiliation is associated with various demographic behaviours because of differences in cultural beliefs. For example, in The Gambia, certain ethnic groups encourage the practice of female genital cutting. Survey data show that the majority of the respondents are from the Mandinka/Jahanka ethnic group (34 percent of women and 35 percent of men), followed by the Fula/Tukulur/Lorobo ethnic group (22 percent of women and 23 percent of men). 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Tables 3.2.1 and 3.2.2 summarise the educational attainment of women and men, respectively, by their highest level of schooling attended or completed according to background characteristics. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, The Gambia 2013 Highest level of schooling Total Median years completed Number of women Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 27.9 10.2 6.4 41.5 9.0 5.0 100.0 6.7 4,532 15-19 23.9 13.4 7.8 50.7 3.1 1.3 100.0 6.4 2,407 20-24 32.5 6.6 4.9 31.1 15.7 9.3 100.0 7.5 2,125 25-29 47.9 8.4 4.5 20.0 10.7 8.5 100.0 2.7 1,822 30-34 58.0 8.2 4.2 14.9 9.0 5.8 100.0 0.0 1,504 35-39 69.4 6.8 4.8 9.5 5.0 4.4 100.0 0.0 1,056 40-44 74.8 2.8 6.0 11.0 1.8 3.6 100.0 0.0 761 45-49 79.8 2.5 4.6 7.4 2.9 2.8 100.0 0.0 559 Residence Urban 34.1 6.2 5.7 33.0 12.2 8.9 100.0 6.8 5,730 Rural 62.3 10.9 5.2 17.9 2.7 1.0 100.0 0.0 4,503 Local Government Area Banjul 25.7 7.4 4.3 38.0 14.1 10.5 100.0 8.3 225 Kanifing 31.5 5.9 4.9 33.0 14.6 10.3 100.0 7.4 2,342 Brikama 36.9 7.6 7.0 31.8 9.4 7.2 100.0 5.7 3,550 Mansakonko 51.4 11.7 6.0 24.1 4.7 2.0 100.0 0.0 490 Kerewan 60.0 9.3 4.5 20.5 4.6 1.0 100.0 0.0 1,107 Kuntaur 73.9 6.7 2.9 14.9 1.6 0.1 100.0 0.0 526 Janjanbureh 61.8 8.2 4.0 21.5 2.6 1.9 100.0 0.0 739 Basse 71.0 13.2 4.9 9.9 0.7 0.3 100.0 0.0 1,254 Wealth quintile Lowest 62.7 11.2 5.6 17.5 2.4 0.5 100.0 0.0 1,745 Second 59.1 9.2 5.5 21.2 3.5 1.5 100.0 0.0 1,882 Middle 56.8 10.4 5.9 21.8 3.7 1.4 100.0 0.0 1,927 Fourth 42.5 7.4 5.9 30.9 8.0 5.2 100.0 5.0 2,135 Highest 21.5 4.7 4.6 35.8 18.3 15.1 100.0 8.8 2,545 Total 46.5 8.3 5.5 26.3 8.0 5.5 100.0 3.2 10,233 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level 34 • Characteristics of Respondents Table 3.2.1 shows that 47 percent of women age 15-49 have no education. Fourteen percent have some primary education, 34 percent have some secondary education, and 6 percent have more than a secondary education. The percentage of women with no education increases steadily with age, from 24 percent among women age 15-19 to 80 percent among those age 45-49. A higher proportion of women in rural areas have no education (62 percent) than those in urban areas (34 percent). Fifty-four percent of urban women have attended or completed schooling at a secondary level or higher, as compared with only 22 percent of rural women. The percentage of women with no education ranges from a low of 26 percent in Banjul to a high of 74 percent in Kuntaur. The percentage of women with no education decreases steadily from 63 percent among the poorest women to 22 percent among those in the highest wealth quintile. By contrast, less than 1 percent of women in the lowest quintile have more than a secondary education, compared with 15 percent of women in the highest quintile. Table 3.2.2 shows that a much lower percentage of men than women have no education (31 percent versus 47 percent). Overall, patterns among men are similar to those among women. Men age 45- 49 are most likely to have no education (64 percent), whereas the youngest men (age 15-19) are least likely to have no education (18 percent). Twenty-one percent of urban men have no education, as compared with 47 percent of rural men. By LGA, the lowest percentage of men with no education is in Kanifing (19 percent), and the highest is in Kuntaur (67 percent). The percentage of uneducated men ranges from 13 percent among those in the highest wealth quintile to 43 percent among those in the lowest quintile. Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, The Gambia 2013 Highest level of schooling Total Median years completed Number of men Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 19.6 10.6 6.5 44.8 13.1 5.4 100.0 7.5 1,685 15-19 18.0 14.7 7.5 55.1 3.8 0.9 100.0 6.7 836 20-24 21.3 6.6 5.4 34.8 22.2 9.7 100.0 8.6 849 25-29 27.2 6.3 4.7 24.4 21.6 15.8 100.0 8.4 586 30-34 39.7 5.8 5.9 18.0 16.4 14.3 100.0 5.8 425 35-39 42.7 5.1 6.6 22.0 14.0 9.6 100.0 5.3 391 40-44 45.5 5.0 5.9 24.9 4.7 14.0 100.0 4.7 270 45-49 63.9 4.2 3.3 19.8 4.0 4.7 100.0 0.0 220 Residence Urban 20.6 6.3 5.7 37.0 18.2 12.2 100.0 8.6 2,228 Rural 46.8 10.5 6.1 25.8 6.5 4.3 100.0 2.8 1,349 Local Government Area Banjul 20.6 7.7 5.8 39.5 14.9 11.6 100.0 8.5 85 Kanifing 18.6 4.6 5.1 38.1 19.4 14.3 100.0 9.0 858 Brikama 22.6 7.8 5.9 37.8 15.9 10.1 100.0 8.1 1,454 Mansakonko 28.8 12.4 8.0 34.5 7.4 8.9 100.0 6.1 141 Kerewan 39.4 8.8 8.3 30.8 8.4 4.4 100.0 5.2 323 Kuntaur 67.4 7.6 3.6 16.6 3.3 1.6 100.0 0.0 141 Janjanbureh 47.7 7.6 6.2 20.6 11.1 6.8 100.0 3.0 240 Basse 61.8 14.7 5.3 12.6 4.1 1.6 100.0 0.0 336 Wealth quintile Lowest 43.1 11.8 7.4 27.7 7.3 2.7 100.0 4.1 517 Second 40.7 9.7 5.5 29.5 8.1 6.4 100.0 4.9 614 Middle 38.3 10.1 8.3 27.8 10.1 5.4 100.0 5.2 588 Fourth 29.4 6.3 4.5 36.2 14.3 9.4 100.0 7.8 940 Highest 12.6 4.6 5.2 37.4 23.1 17.0 100.0 9.9 919 Total 15-49 30.5 7.9 5.9 32.8 13.8 9.2 100.0 7.1 3,577 50-59 61.9 7.8 4.1 11.3 6.3 8.7 100.0 0.0 244 Total 15-59 32.5 7.9 5.8 31.4 13.3 9.2 100.0 6.7 3,821 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level Characteristics of Respondents • 35 3.3 LITERACY The ability to read and write is an important personal asset, increasing an individual’s opportunities in life. In addition, literacy statistics can help programme managers, especially those working in health and family planning, decide how to reach women and men with their messages. The literacy status of 2013 GDHS respondents was determined by assessing their ability to read all or part of a simple sentence from a card. The literacy test was administered only to respondents who had less than a secondary school education; those with a secondary education or higher were assumed to be literate. Tables 3.3.1 and 3.3.2, respectively, present literacy results for women and men age 15-49. Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, The Gambia 2013 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Missing Age 15-24 55.5 2.7 4.5 36.8 0.2 0.2 100.0 62.7 4,532 15-19 55.0 4.1 5.8 34.7 0.1 0.4 100.0 64.8 2,407 20-24 56.0 1.1 3.1 39.2 0.4 0.1 100.0 60.3 2,125 25-29 39.2 0.5 2.9 57.0 0.2 0.2 100.0 42.5 1,822 30-34 29.6 1.3 2.8 65.8 0.3 0.2 100.0 33.7 1,504 35-39 18.9 0.5 3.3 77.0 0.0 0.3 100.0 22.7 1,056 40-44 16.4 0.2 2.3 80.5 0.3 0.3 100.0 18.9 761 45-49 13.0 1.5 2.2 82.4 0.4 0.6 100.0 16.7 559 Residence Urban 54.1 2.1 3.2 40.1 0.3 0.2 100.0 59.3 5,730 Rural 21.6 1.0 4.0 72.9 0.1 0.3 100.0 26.7 4,503 Local Government Area Banjul 62.6 1.1 3.2 32.4 0.1 0.5 100.0 66.9 225 Kanifing 57.8 2.1 2.3 36.8 0.6 0.4 100.0 62.2 2,342 Brikama 48.4 2.0 4.1 45.0 0.3 0.2 100.0 54.5 3,550 Mansakonko 30.9 1.4 5.4 62.1 0.3 0.0 100.0 37.7 490 Kerewan 26.2 1.4 4.3 67.8 0.0 0.3 100.0 31.9 1,107 Kuntaur 16.6 1.1 3.2 78.8 0.0 0.3 100.0 20.9 526 Janjanbureh 26.0 0.8 2.7 70.3 0.0 0.2 100.0 29.5 739 Basse 10.8 0.8 3.7 84.6 0.0 0.1 100.0 15.4 1,254 Wealth quintile Lowest 20.5 1.3 3.7 73.8 0.4 0.4 100.0 25.4 1,745 Second 26.2 0.7 4.2 68.7 0.0 0.1 100.0 31.1 1,882 Middle 26.9 1.6 4.1 66.8 0.4 0.2 100.0 32.6 1,927 Fourth 44.2 1.8 3.3 50.1 0.4 0.2 100.0 49.3 2,135 Highest 69.2 2.3 2.8 25.4 0.1 0.3 100.0 74.3 2,545 Total 39.8 1.6 3.6 54.6 0.2 0.2 100.0 45.0 10,233 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence The data reveal that men are more literate than women (70 percent versus 45 percent). Among both women and men, the percentage who are literate decreases with age. For example, 65 percent of women age 15-19 are literate, as compared with only 17 percent of women age 45-49. In addition, literacy is much more common in urban areas (59 percent of women and 80 percent of men) than in rural areas (27 percent of women and 53 percent of men). Only 15 percent of women in Basse are literate, as compared with 67 percent of women in Banjul. Similarly, literacy among men ranges from a low of 38 percent in Basse to a high of 81 percent in Banjul. Respondents in the lowest wealth quintile have the lowest level of literacy (25 percent of women and 55 percent of men). Literacy increases substantially with wealth to 74 percent of women and 88 percent of men in the highest wealth quintile. 36 • Characteristics of Respondents Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, The Gambia 2013 Background characteristic Secondary school or higher No schooling or primary school Total Per- centage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 63.3 2.8 10.6 22.5 0.1 0.0 0.6 100.0 76.7 1,685 15-19 59.9 4.0 12.5 22.7 0.1 0.0 0.8 100.0 76.4 836 20-24 66.7 1.7 8.7 22.2 0.2 0.0 0.5 100.0 77.1 849 25-29 61.8 1.4 8.0 27.5 0.4 0.0 0.8 100.0 71.2 586 30-34 48.6 3.8 11.8 35.3 0.5 0.0 0.0 100.0 64.2 425 35-39 45.5 3.4 16.0 34.7 0.1 0.0 0.3 100.0 64.9 391 40-44 43.6 3.7 14.6 36.3 1.1 0.0 0.7 100.0 61.9 270 45-49 28.6 5.1 10.0 55.8 0.0 0.0 0.6 100.0 43.7 220 Residence Urban 67.4 2.7 10.2 18.8 0.4 0.0 0.5 100.0 80.2 2,228 Rural 36.6 3.4 12.8 46.5 0.1 0.0 0.6 100.0 52.8 1,349 Local Government Area Banjul 66.0 4.9 9.6 18.0 0.9 0.0 0.7 100.0 80.5 85 Kanifing 71.8 2.8 5.2 18.9 0.8 0.0 0.5 100.0 79.8 858 Brikama 63.7 2.6 13.6 19.3 0.2 0.0 0.6 100.0 79.9 1,454 Mansakonko 50.7 4.1 13.1 31.1 0.2 0.0 0.7 100.0 68.0 141 Kerewan 43.6 2.3 11.5 42.7 0.0 0.0 0.0 100.0 57.3 323 Kuntaur 21.5 6.6 11.3 60.1 0.0 0.0 0.6 100.0 39.4 141 Janjanbureh 38.5 1.5 11.1 48.1 0.0 0.0 0.8 100.0 51.1 240 Basse 18.2 4.2 15.3 61.7 0.0 0.0 0.6 100.0 37.7 336 Wealth quintile Lowest 37.6 3.8 13.3 44.4 0.1 0.0 0.8 100.0 54.7 517 Second 44.0 3.0 10.8 41.2 0.5 0.0 0.6 100.0 57.7 614 Middle 43.3 4.0 11.4 40.5 0.0 0.0 0.7 100.0 58.8 588 Fourth 59.8 2.1 13.4 23.6 0.5 0.0 0.6 100.0 75.3 940 Highest 77.5 2.7 7.8 11.4 0.3 0.0 0.3 100.0 88.1 919 Total 15-49 55.8 3.0 11.2 29.3 0.3 0.0 0.6 100.0 69.9 3,577 50-59 26.3 4.5 13.6 54.8 0.3 0.3 0.2 100.0 44.5 244 Total 15-59 53.9 3.1 11.3 30.9 0.3 0.0 0.5 100.0 68.3 3,821 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 3.4 ACCESS TO MASS MEDIA The 2013 GDHS collected information on respondents’ exposure to common print and electronic media. Respondents were asked how often they read a newspaper, listened to the radio, or watched television. This information is important because it indicates the extent to which people in The Gambia are regularly exposed to mass media, which are often used to convey messages on family planning and other health topics. Tables 3.4.1 and 3.4.2 show the percentages of female and male respondents, respectively, who were exposed to different types of mass media by age, residence, LGA, level of education, and wealth quintile. Sixty percent of women and 73 percent of men listen to the radio at least once a week, 47 percent of women and 61 percent of men watch television on a weekly basis, and 9 percent of women and 20 percent of men read newspapers at least once a week. Overall, only 7 percent of women and 14 percent of men are exposed to all three media at least once per week. Three in ten women (30 percent) and one in six men (16 percent) are not exposed to any of the three media on a regular basis. Characteristics of Respondents • 37 There are only slight variations by age, with the youngest and oldest age groups having a tendency to be less exposed to any of the three media than the other age groups. Huge disparities exist in media exposure by urban-rural residence. For example, 14 percent of women and 27 percent of men in urban areas read a newspaper at least once a week, as compared with only 3 percent of women and 9 percent of men in rural areas. Exposure to newspapers and television is highest among women and men in Banjul and Kanifing. For example, 23 percent of women in Banjul and 18 percent of those on Kanifing read a newspaper weekly, compared with 1 percent to 10 percent of women from other LGAs. Women and men with higher levels of education and in the higher wealth quintiles are more likely to access any of the three media. For example, less than 1 percent of women with no education have access to all three media, as compared with 16 percent of women with a secondary education or higher. Eighteen percent of women in the highest wealth quintile and only 1 percent of those in the lowest quintile have weekly access to all three media. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, The Gambia 2013 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 9.3 48.6 58.6 7.1 30.3 2,407 20-24 11.9 51.8 64.7 8.6 25.3 2,125 25-29 10.8 46.5 61.8 8.2 29.1 1,822 30-34 7.6 47.4 60.1 6.0 29.3 1,504 35-39 6.3 44.1 58.7 5.5 30.8 1,056 40-44 4.6 39.9 52.8 2.6 36.0 761 45-49 6.0 35.9 59.4 5.0 34.6 559 Residence Urban 14.1 62.8 63.5 10.8 22.8 5,730 Rural 2.5 26.7 56.2 1.8 38.3 4,503 Local Government Area Banjul 22.5 77.1 61.9 16.4 14.0 225 Kanifing 18.2 72.4 66.6 14.4 16.3 2,342 Brikama 10.2 53.4 67.5 7.6 23.3 3,550 Mansakonko 2.0 34.1 67.9 1.2 27.6 490 Kerewan 2.9 26.7 35.9 1.9 56.1 1,107 Kuntaur 1.5 22.8 44.8 1.1 48.7 526 Janjanbureh 1.9 17.0 36.4 1.2 58.5 739 Basse 1.4 26.2 66.7 0.8 27.4 1,254 Education No education 0.2 32.0 51.4 0.1 40.1 4,757 Primary 2.1 46.9 63.8 1.8 26.7 1,405 Secondary or higher 21.7 64.2 69.4 16.4 18.3 4,071 Wealth quintile Lowest 2.2 20.2 53.2 1.2 42.8 1,745 Second 3.2 29.7 56.6 2.5 37.1 1,882 Middle 3.5 34.7 57.8 2.5 34.4 1,927 Fourth 8.2 61.0 62.0 6.4 25.2 2,135 Highest 22.8 75.3 68.3 17.6 15.1 2,545 Total 9.0 46.9 60.3 6.8 29.6 10,233 38 • Characteristics of Respondents Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, The Gambia 2013 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of men Age 15-19 11.7 58.9 68.2 7.0 17.8 836 20-24 22.0 66.6 75.7 17.0 14.5 849 25-29 25.1 61.6 72.5 15.6 13.0 586 30-34 22.3 67.9 74.4 17.6 13.0 425 35-39 25.7 59.3 76.5 18.3 13.2 391 40-44 22.4 51.4 73.2 17.4 18.4 270 45-49 12.7 44.0 71.9 9.0 21.9 220 Residence Urban 26.5 74.1 76.1 19.4 10.0 2,228 Rural 9.3 38.8 67.7 5.5 24.5 1,349 Local Government Area Banjul 32.6 79.2 73.7 24.5 9.7 85 Kanifing 28.1 76.1 75.1 20.3 11.4 858 Brikama 24.2 65.5 76.3 17.3 11.8 1,454 Mansakonko 4.3 39.3 70.6 2.2 19.0 141 Kerewan 12.4 43.0 62.4 8.1 27.5 323 Kuntaur 3.9 28.7 49.1 1.5 39.4 141 Janjanbureh 10.1 40.6 73.0 7.2 18.3 240 Basse 5.5 51.2 73.5 3.3 18.1 336 Education No education 3.6 46.3 68.3 3.3 23.5 1,090 Primary 3.8 59.7 71.6 2.8 17.9 493 Secondary or higher 33.0 69.0 75.8 22.9 10.4 1,994 Wealth quintile Lowest 8.7 34.4 71.9 6.4 22.2 517 Second 11.0 42.2 69.5 5.3 22.1 614 Middle 13.9 51.4 71.3 8.7 19.3 588 Fourth 24.1 72.9 77.0 18.3 10.5 940 Highest 32.1 81.7 72.6 23.7 9.8 919 Total 15-49 20.0 60.8 72.9 14.2 15.5 3,577 50-59 16.0 41.6 71.6 11.1 20.1 244 Total 15-59 19.7 59.6 72.8 14.0 15.8 3,821 3.5 EMPLOYMENT Respondents were asked whether they were employed at the time of the survey (i.e., whether they had worked in the past 7 days) and, if not, whether they were employed at any time in the 12 months that preceded the survey. Because employment is viewed as a stock concept (measured at a particular point in time), the corresponding statistics must, in principle, refer to a precise moment in time. Respondents were asked a number of questions to elicit their current employment status and continuity of employment in the 12 months prior to the survey. Figure 3.1 and Table 3.5.1 present the proportion of women who were currently employed, the proportion who were not currently employed but had been employed at some time during the 12 months before the survey, and the proportion who had not been employed at any time during the 12-month period. Table 3.5.2 presents employment status data for men. Overall, 43 percent of women reported that they were currently employed. An additional 7 percent of women were not currently employed but had worked in the 12 months preceding the survey. Characteristics of Respondents • 39 Figure 3.1 Women’s employment status in the past 12 months Currently employed 43% Not currently employed, but worked in last 12 months 7% Not employed in the 12 months preceding the survey 50% GDHS 2013 Sixty-six percent of men were currently employed, and an additional 6 percent had worked in the year prior to the survey. The proportion of currently employed respondents is lowest in the 15-19 age group (17 percent of women and 30 percent of men), mostly due to the fact that many in this age cohort are students. Women and men who have never been married are less likely to be currently employed (25 percent and 50 percent, respectively) than those currently or previously married. Respondents with no children are less likely to be employed than those who have children. The percentage of women who are currently employed increases with increasing number of living children, while there are no variations among men according to number of children. A higher percentage of rural than urban women are currently employed (45 percent versus 41 percent), while the opposite is true among men; urban men are somewhat more likely to be currently employed than rural men (68 percent versus 64 percent). Women from Janjanbureh are least likely to be currently employed (38 percent), and those from Mansakonko and Banjul are most likely to be employed (50 percent and 49 percent, respectively). By contrast, men from Janjanbureh have the highest level of current employment (79 percent). Respondents with no education are more likely to be currently employed (51 percent of women and 80 percent of men) than respondents in the other education categories. 40 • Characteristics of Respondents Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, The Gambia 2013 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 16.7 4.6 78.7 100.0 2,407 20-24 33.6 6.7 59.6 100.0 2,125 25-29 50.7 8.7 40.6 100.0 1,822 30-34 53.7 8.5 37.8 100.0 1,504 35-39 59.0 10.2 30.8 100.0 1,056 40-44 67.7 8.8 23.4 100.0 761 45-49 67.5 7.9 24.6 100.0 559 Marital status Never married 24.5 3.1 72.4 100.0 2,963 Married or living together 49.5 9.3 41.2 100.0 6,791 Divorced/separated/widowed 57.9 7.1 35.0 100.0 478 Number of living children 0 25.2 4.0 70.8 100.0 3,530 1-2 45.2 8.4 46.4 100.0 2,644 3-4 50.8 9.5 39.8 100.0 1,955 5+ 61.2 10.1 28.7 100.0 2,103 Residence Urban 40.8 2.8 56.4 100.0 5,730 Rural 44.9 13.3 41.7 100.0 4,503 Local Government Area Banjul 49.0 3.4 47.6 100.0 225 Kanifing 41.8 2.5 55.7 100.0 2,342 Brikama 41.8 4.0 54.2 100.0 3,550 Mansakonko 49.8 3.5 46.6 100.0 490 Kerewan 46.4 1.9 51.7 100.0 1,107 Kuntaur 42.9 13.6 43.5 100.0 526 Janjanbureh 37.7 9.3 53.0 100.0 739 Basse 42.2 29.6 28.1 100.0 1,254 Education No education 50.5 10.3 39.2 100.0 4,757 Primary 39.1 9.2 51.8 100.0 1,405 Secondary or higher 34.7 3.4 61.9 100.0 4,071 Wealth quintile Lowest 45.8 11.0 43.1 100.0 1,745 Second 45.3 11.1 43.5 100.0 1,882 Middle 43.0 9.8 47.1 100.0 1,927 Fourth 42.9 4.3 52.8 100.0 2,135 Highest 37.9 3.1 59.0 100.0 2,545 Total 42.6 7.4 49.9 100.0 10,233 1 “Currently employed” is defined as having done work in the past 7 days. Includes persons who did not work in the past 7 days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Respondents • 41 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, The Gambia 2013 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 30.3 5.9 63.8 100.0 836 20-24 54.8 5.5 39.6 100.0 849 25-29 81.5 6.1 12.4 100.0 586 30-34 89.2 6.0 4.8 100.0 425 35-39 91.1 5.1 3.9 100.0 391 40-44 92.6 3.4 3.9 100.0 270 45-49 87.0 10.0 2.9 100.0 220 Marital status Never married 50.4 5.5 44.1 100.0 2,177 Married or living together 91.2 6.3 2.5 100.0 1,360 Divorced/separated/widowed (90.8) (4.6) (4.6) 100.0 40 Number of living children 0 52.8 5.5 41.7 100.0 2,282 1-2 90.1 6.2 3.7 100.0 558 3-4 90.1 6.5 3.4 100.0 336 5+ 90.4 6.6 3.0 100.0 400 Residence Urban 67.7 2.0 30.3 100.0 2,228 Rural 64.2 12.1 23.7 100.0 1,349 Local Government Area Banjul 73.8 5.0 21.2 100.0 85 Kanifing 67.1 2.7 30.1 100.0 858 Brikama 64.8 1.8 33.4 100.0 1,454 Mansakonko 61.9 4.1 34.0 100.0 141 Kerewan 69.6 0.5 29.8 100.0 323 Kuntaur 59.2 19.8 21.0 100.0 141 Janjanbureh 78.7 8.1 12.8 100.0 240 Basse 61.8 29.5 8.7 100.0 336 Education No education 80.2 10.2 9.6 100.0 1,090 Primary 68.1 5.7 26.3 100.0 493 Secondary or higher 58.3 3.5 38.2 100.0 1,994 Wealth quintile Lowest 66.0 8.3 25.7 100.0 517 Second 66.4 8.7 24.9 100.0 614 Middle 65.4 10.3 24.3 100.0 588 Fourth 70.0 3.5 26.4 100.0 940 Highest 63.3 2.0 34.6 100.0 919 Total 15-49 66.3 5.8 27.8 100.0 3,577 50-59 84.3 6.8 8.9 100.0 244 Total 15-59 67.5 5.9 26.6 100.0 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 “Currently employed” is defined as having done work in the past 7 days. Includes persons who did not work in the past 7 days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 3.6 OCCUPATION Respondents who were currently employed were asked about their occupation. The results are presented in Tables 3.6.1 and 3.6.2 for women and men age 15-49, respectively. The highest proportion of working women (44 percent) are engaged in sales and services, while the highest proportion of working men (40 percent) are engaged in skilled manual work. The next major occupation category among working women and men is agriculture (41 percent of women and 19 percent of men). Among women, 5 percent work in professional, technical, or managerial jobs, and 3 percent each work in domestic service and skilled manual labour. Among men, 19 percent are employed in sales and services; 14 percent work in professional, technical, or managerial jobs; and 2 percent are employed in unskilled manual labour. 42 • Characteristics of Respondents Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, The Gambia 2013 Background characteristic Pro- fessional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of women Age 15-19 0.9 0.0 32.0 3.0 0.1 1.8 58.7 3.5 100.0 512 20-24 5.2 2.2 43.1 2.6 1.1 3.7 40.6 1.6 100.0 858 25-29 7.1 1.2 48.5 2.0 0.8 3.4 34.4 2.7 100.0 1,083 30-34 6.2 0.9 43.9 3.0 1.4 3.0 40.1 1.4 100.0 936 35-39 5.4 0.7 45.9 2.0 1.2 2.8 40.9 1.0 100.0 731 40-44 5.4 0.0 43.5 3.3 1.5 4.4 41.2 0.6 100.0 582 45-49 4.8 0.4 45.1 1.4 1.3 3.4 42.9 0.6 100.0 421 Marital status Never married 8.7 2.5 47.6 3.5 1.0 6.9 26.7 3.2 100.0 819 Married or living together 4.6 0.6 41.9 2.1 1.1 2.3 45.9 1.5 100.0 3,993 Divorced/separated/widowed 5.9 1.2 59.1 4.8 1.3 6.1 20.5 1.1 100.0 311 Number of living children 0 7.8 2.3 42.2 2.9 0.9 3.6 36.9 3.4 100.0 1,031 1-2 8.1 1.1 45.2 2.5 1.1 3.2 36.7 2.1 100.0 1,416 3-4 4.6 0.6 45.7 2.6 0.9 3.9 40.4 1.2 100.0 1,178 5+ 1.7 0.0 42.4 2.0 1.3 2.5 49.4 0.7 100.0 1,498 Residence Urban 8.9 1.7 67.6 3.9 1.4 5.9 7.8 2.7 100.0 2,501 Rural 2.0 0.2 21.2 1.1 0.8 0.7 73.2 0.8 100.0 2,623 Local Government Area Banjul 11.0 2.0 62.5 6.2 1.8 12.7 1.1 2.8 100.0 118 Kanifing 9.9 2.6 66.2 4.3 2.6 9.0 2.1 3.3 100.0 1,038 Brikama 7.6 0.8 65.8 3.0 1.1 3.0 17.0 1.7 100.0 1,626 Mansakonko 4.7 0.5 30.3 1.0 1.0 0.7 61.2 0.6 100.0 261 Kerewan 2.2 0.2 28.5 1.0 1.0 1.1 64.9 1.1 100.0 535 Kuntaur 0.3 0.3 9.1 2.0 0.0 0.0 87.0 1.4 100.0 297 Janjanbureh 2.5 0.3 24.2 1.5 0.0 0.5 69.5 1.6 100.0 347 Basse 0.3 0.0 8.3 0.8 0.0 0.0 90.0 0.7 100.0 901 Education No education 0.5 0.0 38.6 1.9 1.1 2.5 54.7 0.8 100.0 2,893 Primary 1.0 0.0 44.3 3.0 0.5 4.5 46.0 0.8 100.0 678 Secondary or higher 16.4 3.0 53.6 3.3 1.3 4.1 14.3 3.8 100.0 1,553 Wealth quintile Lowest 1.4 0.0 29.4 0.7 0.9 1.1 65.5 1.0 100.0 993 Second 2.3 0.5 29.3 1.6 1.0 1.7 62.4 1.2 100.0 1,061 Middle 3.1 0.0 32.6 1.8 0.2 2.8 58.8 0.6 100.0 1,019 Fourth 5.0 0.3 61.8 4.6 1.6 7.0 17.3 2.3 100.0 1,007 Highest 14.8 3.6 66.1 3.8 1.6 3.7 2.9 3.4 100.0 1,043 Total 5.4 0.9 43.9 2.5 1.1 3.3 41.3 1.7 100.0 5,123 Urban women are most often employed in sales and services (68 percent) and urban men in skilled manual labour (46 percent). As expected, the majority of women (73 percent) and men (45 percent) in rural areas are employed in agriculture. The highest percentage of women and men who work in agriculture is in Basse (90 percent and 59 percent, respectively) and Kuntaur (87 percent and 60 percent, respectively). Kanifing and Brikama have the highest proportion of women working in sales and services (66 percent each) and the highest proportion of men engaged in skilled manual labour (44 percent and 49 percent, respectively). Occupation also varies with level of education. Sixteen percent of women and 24 percent of men with a secondary education or higher are employed in the professional, technical, and managerial sector, as compared with 1 percent to 6 percent of respondents with no education or a primary education. On the other hand, women and men with no education are much more likely to work in agriculture (55 percent of women and 35 percent of men). Employed women and men in the bottom three wealth quintiles are much more likely to work in agriculture. The percentage of women and men employed in professional, technical, or managerial jobs increases notably with increasing wealth. Characteristics of Respondents • 43 Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, The Gambia 2013 Background characteristic Pro- fessional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of men Age 15-19 1.2 0.1 10.1 45.9 1.7 1.2 34.6 5.1 100.0 302 20-24 12.3 0.5 14.5 47.8 2.6 1.2 17.0 4.2 100.0 512 25-29 19.5 1.6 19.4 37.2 3.9 0.5 12.4 5.4 100.0 513 30-34 13.8 2.2 23.1 38.5 1.0 0.8 16.7 4.0 100.0 404 35-39 16.4 1.5 25.9 37.8 0.8 0.4 14.3 2.8 100.0 376 40-44 17.3 1.2 22.7 31.2 1.7 0.7 21.2 4.0 100.0 259 45-49 11.9 0.6 16.4 31.9 3.2 1.8 30.7 3.6 100.0 214 Marital status Never married 11.4 0.9 16.0 44.8 2.9 1.2 17.5 5.4 100.0 1,217 Married or living together 15.8 1.4 21.2 34.9 1.6 0.6 21.2 3.3 100.0 1,326 Divorced/separated/widowed (15.6) (0.7) 33.1) 38.5) (1.4) (0.0) (8.9) (1.8) 100.0 38 Number of living children 0 12.4 0.5 16.6 43.4 2.8 1.0 18.0 5.4 100.0 1,330 1-2 16.0 2.6 22.2 38.8 1.1 0.6 15.6 3.1 100.0 538 3-4 14.4 2.8 22.0 37.1 1.6 0.4 19.0 2.8 100.0 325 5+ 14.9 0.1 20.1 29.8 2.1 1.0 28.9 3.2 100.0 388 Residence Urban 18.2 1.8 23.3 46.0 2.5 0.9 2.3 4.9 100.0 1,553 Rural 7.0 0.1 12.4 30.0 1.8 0.7 44.9 3.2 100.0 1,029 Local Government Area Banjul 13.8 2.7 29.8 40.0 5.1 1.2 2.4 5.0 100.0 67 Kanifing 19.6 3.3 24.5 44.0 2.1 0.8 1.4 4.2 100.0 600 Brikama 16.5 0.6 19.0 48.6 3.4 0.6 5.5 5.7 100.0 969 Mansakonko 15.1 0.0 13.8 40.3 0.3 0.9 28.9 0.8 100.0 93 Kerewan 9.9 0.0 16.8 37.9 1.2 0.8 31.4 2.0 100.0 226 Kuntaur 3.5 0.0 9.8 24.3 0.9 0.0 60.0 1.6 100.0 112 Janjanbureh 8.4 0.3 14.0 24.4 1.5 3.2 42.3 5.9 100.0 209 Basse 3.2 0.4 15.4 19.3 0.3 0.4 59.1 1.9 100.0 306 Education No education 3.6 0.0 20.1 37.2 1.6 0.4 34.7 2.5 100.0 986 Primary 5.8 0.1 14.6 53.4 1.0 0.6 22.1 2.4 100.0 364 Secondary or higher 24.2 2.4 19.3 37.4 3.1 1.3 6.1 6.2 100.0 1,232 Wealth quintile Lowest 8.4 0.0 13.5 34.1 2.4 0.4 37.2 4.0 100.0 384 Second 6.3 0.5 11.7 36.7 2.2 0.6 39.2 2.9 100.0 461 Middle 10.5 0.4 14.9 41.0 2.3 1.2 26.2 3.4 100.0 445 Fourth 14.6 1.1 24.9 43.4 1.2 1.0 7.8 6.0 100.0 691 Highest 24.3 2.9 24.1 39.9 3.2 1.0 0.6 4.0 100.0 601 Total 15-49 13.7 1.1 19.0 39.6 2.2 0.9 19.3 4.2 100.0 2,581 50-59 13.1 1.5 21.9 27.3 1.2 2.0 27.9 5.1 100.0 222 Total 15-59 13.7 1.2 19.2 38.6 2.1 0.9 20.0 4.3 100.0 2,803 Note: Figures in parentheses are based on 25-49 unweighted cases. Table 3.7 presents the percent distribution of employed women age 15-49 by type of earnings and employer characteristics, according to type of employment (agricultural or nonagricultural). Sixty-five percent of women receive cash only for their work, 26 percent are paid in cash and in-kind, and 6 percent are not paid at all. Women employed in agricultural work are much more likely to be paid in cash and in- kind only (45 percent) or not be paid at all (10 percent) than women employed in nonagricultural work (13 percent and 2 percent, respectively). Sixty-six percent of women are self-employed, 20 percent are employed by a non-family member, and 14 percent are employed by a family member. Women working in the agricultural sector are more likely to be self-employed (74 percent) or employed by a family member (21 percent) than are women working in nonagricultural jobs (61percent and 8 percent, respectively). By contrast, women who do nonagricultural work (31 percent) are more likely to be employed by non-family members than those who work in agriculture (5 percent). Most women who work in agriculture are engaged in seasonal work (66 percent), while the majority of women who do nonagricultural work have continuous yearly employment (81 percent). 44 • Characteristics of Respondents Table 3.7 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), The Gambia 2013 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 39.8 83.1 64.9 Cash and in-kind 45.0 13.0 26.2 In-kind only 4.8 1.2 2.8 Not paid 10.1 2.3 5.6 Total 100.0 100.0 100.0 Type of employer Employed by family member 20.8 8.2 13.5 Employed by non-family member 4.7 30.9 20.4 Self-employed 74.1 60.7 65.7 Total 100.0 100.0 100.0 Continuity of employment All year 32.2 81.3 60.7 Seasonal 66.1 13.8 35.6 Occasional 1.4 4.7 3.3 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 2,116 2,919 5,123 Note: Total includes women with missing information on type of employment who are not shown separately. 3.7 HEALTH INSURANCE COVERAGE Medical insurance provides peace of mind and, most importantly, essential care to save the life and/or ensure the well-being of the person with insurance coverage. In the 2013 GDHS, women and men were asked if they were covered by any health insurance and, if so, what type of insurance. Tables 3.8.1 and 3.8.2 indicate that only a small percentage of women and men in The Gambia have health insurance coverage (2 percent and 3 percent, respectively), mostly employer-based insurance. Health insurance coverage is more common among urban women and men (4 percent each), those in Banjul (5 percent and 6 percent, respectively), those with a secondary education or higher (5 percent each), and those in the highest wealth quintile (6 percent and 7 percent, respectively). Characteristics of Respondents • 45 Table 3.8.1 Health insurance coverage: Women Percentage of women age 15-49 with specific types of health insurance coverage, according to background characteristics, The Gambia 2013 Background characteristic Employer-based insurance Privately purchased commercial insurance None Number of women Age 15-19 0.6 0.4 98.9 2,407 20-24 2.1 0.2 97.8 2,125 25-29 3.0 0.2 96.7 1,822 30-34 2.6 0.5 96.9 1,504 35-39 2.7 0.4 96.8 1,056 40-44 1.0 0.0 99.0 761 45-49 1.4 1.0 97.6 559 Residence Urban 3.2 0.6 96.3 5,730 Rural 0.3 0.1 99.5 4,503 Local Government Area Banjul 4.9 0.5 94.5 225 Kanifing 3.6 0.6 95.9 2,342 Brikama 2.6 0.5 96.9 3,550 Mansakonko 0.3 0.1 99.6 490 Kerewan 0.4 0.2 99.4 1,107 Kuntaur 0.4 0.0 99.5 526 Janjanbureh 0.3 0.2 99.5 739 Basse 0.0 0.0 99.9 1,254 Education No education 0.5 0.1 99.4 4,757 Primary 0.9 0.0 99.1 1,405 Secondary or higher 4.0 0.8 95.3 4,071 Wealth quintile Lowest 0.2 0.0 99.8 1,745 Second 0.3 0.0 99.6 1,882 Middle 0.8 0.2 98.9 1,927 Fourth 1.8 0.3 97.8 2,135 Highest 5.2 1.0 93.9 2,545 Total 1.9 0.3 97.7 10,233 Table 3.8.2 Health insurance coverage: Men Percentage of men age 15-49 with specific types of health insurance coverage, according to background characteristics, The Gambia 2013 Background characteristic Employer-based insurance Privately purchased commercial insurance None Number of men Age 15-19 0.2 0.1 99.4 836 20-24 1.1 0.4 98.5 849 25-29 3.6 0.4 95.5 586 30-34 4.1 0.1 95.8 425 35-39 3.5 0.7 95.5 391 40-44 9.7 0.1 90.1 270 45-49 3.5 0.0 96.5 220 Residence Urban 3.9 0.4 95.4 2,228 Rural 0.7 0.1 99.2 1,349 Local Government Area Banjul 6.1 0.3 93.4 85 Kanifing 5.0 0.3 94.5 858 Brikama 2.6 0.4 96.6 1,454 Mansakonko 0.3 0.2 99.5 141 Kerewan 0.6 0.1 99.3 323 Kuntaur 0.0 0.4 99.6 141 Janjanbureh 0.7 0.2 99.1 240 Basse 2.0 0.0 98.0 336 Education No education 0.7 0.0 99.3 1,090 Primary 0.8 0.1 99.1 493 Secondary or higher 4.3 0.4 94.9 1,994 Wealth quintile Lowest 0.0 0.1 99.9 517 Second 1.6 0.1 98.3 614 Middle 0.3 0.0 99.7 588 Fourth 2.8 0.4 96.8 940 Highest 6.4 0.5 92.3 919 Total 15-49 2.7 0.3 96.8 3,577 50-59 2.7 1.4 95.9 244 Total 15-59 2.7 0.3 96.7 3,821 46 • Characteristics of Respondents 3.9 SMOKING Smoking and other forms of tobacco use can cause a wide variety of diseases and can lead to death. Smoking is a risk factor for cardiovascular disease, lung cancer, and other forms of cancer, and it contributes to the severity of pneumonia, emphysema, and chronic bronchitis symptoms. Also, second- hand smoke may adversely affect the health of children and aggravate childhood illnesses. In the 2013 GDHS, both women and men were asked a number of questions to ascertain the prevalence of use of tobacco products, and cigarette smokers were asked about the number of cigarettes smoked in the last 24 hours. Less than 1 percent of women age 15-49 smoke cigarettes or use any other types of tobacco (data not shown). Table 3.9 presents information on use of tobacco among men. Twenty-six percent of men age 15-49 use tobacco products. The majority (20 percent) smoke cigarettes, and 5 percent use other forms of tobacco. Use of tobacco gradually increases with age. For example, only 4 percent of men age 15-19 smoke cigarettes; this percentage peaks in the 35-39 age group (36 percent), after which it drops slightly. Cigarette smoking among men is highest in Janjanbureh (27 percent), while use of other types of tobacco is highest in Basse (13 percent). Tobacco use is highest among men with no education and those in the lowest wealth quintile. Among men who smoke cigarettes, the largest proportion (50 percent) smoked 10 or more cigarettes during the 24 hours preceding the survey; 30 percent smoked 3-5 cigarettes, and 11 percent smoked 6-9 cigarettes. C ha ra ct er is tic s of R es po nd en ts • 4 7 Ta bl e 3. 9 U se o f t ob ac co : M en P er ce nt ag e of m en a ge 1 5- 49 w ho s m ok e ci ga re tte s or a p ip e or u se o th er to ba cc o pr od uc ts a nd th e pe rc en t d is tri bu tio n of c ig ar et te s m ok er s by n um be r of c ig ar et te s sm ok ed in th e pr ec ed in g 24 h ou rs , a cc or di ng to ba ck gr ou nd c ha ra ct er is tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic U se s to ba cc o D oe s no t u se to ba cc o N um be r o f m en P er ce nt d is tri bu tio n of m en w ho s m ok e ci ga re tte s by n um be r o f c ig ar et te s sm ok ed in th e pa st 2 4 ho ur s To ta l N um be r o f ci ga re tte sm ok er s C ig ar et te s P ip e O th er to ba cc o 0 1- 2 3- 5 6- 9 10 + D on ’t kn ow / m is si ng A ge 15 -1 9 3. 6 0. 0 1. 1 95 .8 83 6 (1 2. 6) (6 .8 ) (1 7. 1) (8 .6 ) (4 2. 3) (1 2. 6) 10 0. 0 30 20 -2 4 16 .3 0. 1 4. 6 82 .8 84 9 1. 3 7. 2 46 .9 8. 8 33 .1 2. 8 10 0. 0 13 9 25 -2 9 23 .7 0. 3 6. 1 74 .1 58 6 0. 5 6. 4 31 .3 16 .4 40 .9 4. 5 10 0. 0 13 9 30 -3 4 28 .5 0. 1 8. 7 67 .5 42 5 0. 0 0. 7 43 .2 10 .2 44 .3 1. 7 10 0. 0 12 1 35 -3 9 35 .7 0. 1 5. 1 62 .5 39 1 0. 7 7. 9 16 .8 9. 2 65 .4 0. 0 10 0. 0 14 0 40 -4 4 34 .2 0. 3 9. 2 62 .2 27 0 0. 2 2. 0 18 .0 13 .1 65 .9 0. 8 10 0. 0 92 45 -4 9 29 .6 0. 2 8. 8 65 .9 22 0 1. 1 5. 1 20 .4 9. 6 62 .6 1. 1 10 0. 0 65 R es id en ce U rb an 19 .8 0. 0 4. 8 78 .2 2, 22 8 1. 1 5. 0 27 .0 10 .6 53 .1 3. 2 10 0. 0 44 0 R ur al 21 .2 0. 3 5. 7 77 .1 1, 34 9 1. 2 5. 5 35 .2 12 .0 44 .9 1. 2 10 0. 0 28 5 Lo ca l G ov er nm en t A re a B an ju l 22 .0 0. 0 8. 6 74 .5 85 7. 1 7. 2 32 .7 11 .0 39 .8 2. 1 10 0. 0 19 K an ifi ng 17 .1 0. 1 4. 7 81 .0 85 8 1. 6 7. 9 24 .1 8. 4 53 .3 4. 7 10 0. 0 14 7 B rik am a 21 .0 0. 0 4. 4 76 .9 1, 45 4 0. 7 4. 1 31 .3 11 .4 49 .9 2. 6 10 0. 0 30 5 M an sa ko nk o 23 .2 0. 0 4. 3 75 .1 14 1 1. 2 5. 7 28 .0 13 .5 51 .6 0. 0 10 0. 0 33 K er ew an 22 .3 0. 3 4. 6 75 .5 32 3 2. 6 2. 7 26 .7 10 .7 55 .3 2. 1 10 0. 0 72 K un ta ur 12 .7 2. 2 2. 3 85 .3 14 1 (0 .0 ) (1 0. 6) 27 .3 ) (2 2. 3) (3 9. 8) (0 .0 ) 10 0. 0 18 Ja nj an bu re h 26 .6 0. 2 3. 1 71 .6 24 0 0. 0 5. 4 29 .6 15 .9 48 .1 1. 0 10 0. 0 64 B as se 20 .5 0. 0 12 .5 78 .5 33 6 0. 0 4. 6 44 .1 8. 3 43 .0 0. 0 10 0. 0 69 Ed uc at io n N o ed uc at io n 22 .7 0. 3 6. 9 75 .0 1, 09 0 0. 7 5. 2 27 .8 10 .0 53 .4 2. 9 10 0. 0 24 7 P rim ar y 23 .0 0. 1 4. 2 75 .4 49 3 0. 3 3. 0 32 .9 14 .2 48 .1 1. 6 10 0. 0 11 4 S ec on da ry o r h ig he r 18 .3 0. 1 4. 5 79 .9 1, 99 4 1. 7 5. 9 31 .0 11 .0 48 .0 2. 3 10 0. 0 36 5 W ea lth q ui nt ile Lo w es t 26 .1 0. 7 5. 5 71 .6 51 7 0. 3 6. 2 39 .1 9. 4 42 .9 2. 0 10 0. 0 13 5 S ec on d 19 .8 0. 1 5. 5 78 .6 61 4 1. 4 5. 0 28 .7 11 .9 48 .0 5. 0 10 0. 0 12 1 M id dl e 20 .4 0. 1 5. 2 77 .5 58 8 2. 0 3. 1 33 .6 15 .1 45 .5 0. 6 10 0. 0 12 0 Fo ur th 20 .6 0. 0 6. 0 78 .0 94 0 0. 8 5. 0 28 .4 8. 6 54 .3 2. 9 10 0. 0 19 4 H ig he st 17 .0 0. 1 3. 9 80 .7 91 9 1. 3 6. 4 23 .4 12 .3 55 .1 1. 4 10 0. 0 15 6 To ta l 1 5- 49 20 .3 0. 1 5. 2 77 .8 3, 57 7 1. 1 5. 2 30 .2 11 .2 49 .9 2. 4 10 0. 0 72 6 50 -5 9 23 .3 0. 4 5. 5 73 .6 24 4 0. 3 5. 7 21 .7 18 .2 54 .1 0. 0 10 0. 0 57 To ta l 1 5- 59 20 .5 0. 2 5. 2 77 .5 3, 82 1 1. 1 5. 2 29 .6 11 .7 50 .2 2. 2 10 0. 0 78 2 N ot e: F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. Characteristics of Respondents • 47 Marriage and Sexual Activity • 49 MARRIAGE AND SEXUAL ACTIVITY 4 his chapter addresses the principal factors, other than contraception, that affect a woman’s risk of becoming pregnant. These factors include marriage, polygyny, age at marriage, age at first sexual intercourse, and recent sexual activities. The chapter also includes information on direct measures of the beginning of exposure to pregnancy and level of exposure. 4.1 CURRENT MARITAL STATUS Marriage is a primary indication of the regular exposure of women to the risk of pregnancy, and therefore it is important for an understanding of fertility. Populations in which age at first marriage is low tend to have early childbearing and high fertility. Table 4.1 presents the percent distribution of all women and men by marital status, according to age. The term married refers to legal or formal marriage, and the phrase living together designates an informal union in which a man and a woman live together even if a formal civil or religious ceremony has not occurred. In the tables that do not list living together as a separate category, these women and men are included in the currently married group. About three in ten women age 15-49 (29 percent) have never been married. Sixty-six percent of women are either married or living together with a man, and the remaining 5 percent are divorced, separated, or widowed. Very few women age 30 and older have never been married (5 percent or less). A much higher percentage of men than women (61 percent versus 29 percent) have never been married. Thirty-eighty percent of men are currently married or living together with a woman, while only 1 percent are divorced, separated, or widowed. T Key Findings • Women are much more likely than men to be married: 66 percent of women and 38 percent of men age 15-49 are currently married. • Polygynous marriages are common in The Gambia, with 39 percent of currently married women and 18 percent of currently married men living in polygynous unions. • Women in The Gambia tend to marry much earlier in life than men. The median age at first marriage is 18.6 years for women age 25-49 and 28.4 years for men age 30-49. • Among those in the 25-49 age group, women initiated sexual activity much earlier than men (18.6 years versus 23.1 years). • Among women and men age 15-49 who have never been married, men are five times as likely to report having had sexual intercourse in the past four weeks (10 percent versus 2 percent). 50 • Marriage and Sexual Activity Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, The Gambia 2013 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed WOMEN 15-19 75.7 23.8 0.0 0.5 0.0 0.1 100.0 23.8 2,407 20-24 38.8 58.1 0.1 2.0 0.4 0.6 100.0 58.2 2,125 25-29 12.6 83.3 0.5 2.8 0.3 0.4 100.0 83.9 1,822 30-34 4.5 87.6 0.1 4.5 1.4 1.9 100.0 87.7 1,504 35-39 1.4 90.7 0.8 4.4 0.5 2.2 100.0 91.5 1,056 40-44 0.2 88.0 0.3 4.4 1.3 5.8 100.0 88.4 761 45-49 0.6 88.4 0.3 3.5 0.9 6.3 100.0 88.7 559 Total 29.0 66.1 0.3 2.6 0.5 1.5 100.0 66.4 10,233 MEN 15-19 99.7 0.3 0.0 0.0 0.0 0.0 100.0 0.3 836 20-24 93.0 6.8 0.0 0.2 0.0 0.0 100.0 6.8 849 25-29 65.6 33.2 0.4 0.5 0.3 0.0 100.0 33.6 586 30-34 26.0 72.3 0.0 1.2 0.5 0.0 100.0 72.3 425 35-39 9.7 88.0 0.0 1.3 0.9 0.1 100.0 88.0 391 40-44 6.0 90.6 0.0 1.9 1.0 0.4 100.0 90.6 270 45-49 1.9 94.3 0.0 2.1 1.5 0.2 100.0 94.3 220 Total 15-49 60.9 38.0 0.1 0.7 0.4 0.1 100.0 38.0 3,577 50-59 2.1 95.5 0.1 1.4 0.5 0.3 100.0 95.6 244 Total 15-59 57.1 41.6 0.1 0.7 0.4 0.1 100.0 41.7 3,821 4.2 POLYGYNY Polygyny (having more than one wife) is common in Africa and has implications for frequency of sexual activity and fertility. Table 4.2.1 shows the percent distribution of currently married women by number of co-wives, according to background characteristics. Polygyny was measured by asking all currently married female respondents whether their husband or partner had other wives and, if so, how many. About four in ten currently married women (39 percent) live in polygynous unions (i.e., they have one or more co-wife). Older women are much more likely to be in polygynous unions than younger women. Polygyny is more prevalent in rural than in urban areas. The distribution by Local Government Area (LGA) shows substantial variation, with Basse having the highest proportion of women in polygynous marriages (53 percent) and Banjul having the lowest proportion (23 percent). The percentage of women in polygynous marriages decreases with increasing education, from 47 percent among women with no education to 22 percent among those with a secondary or higher education. Women in the highest two wealth quintiles are least likely to have co-wives (32-33 percent). Men were also asked if they had more than one wife. Data on polygynous unions among currently married men age 15-49 are shown in Table 4.2.2. Eighteen percent of currently married men report having more than one wife. Variations in polygyny among men by background characteristics follow patterns similar to those observed for women. Marriage and Sexual Activity • 51 Table 4.2.1 Number of women’s co-wives Percent distribution of currently married women age 15-49 by number of co-wives, according to background characteristics, The Gambia 2013 Background characteristic Number of co-wives Total Number of women 0 1 2+ Age 15-19 84.0 13.1 2.7 100.0 573 20-24 76.9 19.3 3.4 100.0 1,237 25-29 70.2 23.8 5.5 100.0 1,528 30-34 58.3 32.1 9.0 100.0 1,319 35-39 46.8 35.8 17.2 100.0 966 40-44 38.0 40.6 21.3 100.0 673 45-49 31.4 44.6 23.5 100.0 496 Residence Urban 68.2 23.1 8.3 100.0 3,356 Rural 53.8 34.0 11.8 100.0 3,435 Local Government Area Banjul 76.7 20.3 2.3 100.0 114 Kanifing 68.8 23.9 6.8 100.0 1,258 Brikama 66.7 24.0 8.8 100.0 2,282 Mansakonko 54.4 31.6 13.9 100.0 344 Kerewan 59.1 31.7 9.0 100.0 801 Kuntaur 50.5 36.3 12.7 100.0 427 Janjanbureh 56.3 32.8 10.8 100.0 550 Basse 46.9 36.6 15.9 100.0 1,015 Education No education 52.3 34.0 13.3 100.0 4,125 Primary 67.8 25.0 6.6 100.0 912 Secondary or higher 77.6 17.8 4.3 100.0 1,754 Wealth quintile Lowest 61.0 31.7 7.0 100.0 1,303 Second 53.9 33.6 11.9 100.0 1,404 Middle 56.1 29.2 14.1 100.0 1,386 Fourth 66.8 23.8 9.3 100.0 1,344 Highest 67.2 24.5 7.8 100.0 1,354 Total 60.9 28.6 10.1 100.0 6,791 Table 4.2.2 Number of men’s wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, The Gambia 2013 Background characteristic Number of wives Total Number of men 1 2+ Age 15-19 * * 100.0 2 20-24 99.5 0.5 100.0 57 25-29 95.9 4.1 100.0 197 30-34 93.8 6.2 100.0 307 35-39 85.3 14.7 100.0 344 40-44 68.6 31.4 100.0 245 45-49 58.8 41.2 100.0 208 Residence Urban 88.3 11.7 100.0 758 Rural 74.8 25.2 100.0 602 Local Government Area Banjul 89.0 11.0 100.0 30 Kanifing 89.4 10.6 100.0 286 Brikama 86.7 13.3 100.0 508 Mansakonko 78.0 22.0 100.0 59 Kerewan 73.8 26.2 100.0 143 Kuntaur 70.7 29.3 100.0 73 Janjanbureh 81.6 18.4 100.0 92 Basse 70.3 29.7 100.0 170 Education No education 75.2 24.8 100.0 649 Primary 85.1 14.9 100.0 161 Secondary or higher 89.9 10.1 100.0 550 Wealth quintile Lowest 77.9 22.1 100.0 247 Second 78.1 21.9 100.0 248 Middle 82.8 17.2 100.0 246 Fourth 82.0 18.0 100.0 330 Highest 89.7 10.3 100.0 289 Total 15-49 82.3 17.7 100.0 1,360 50-59 65.1 34.9 100.0 233 Total 15-59 79.8 20.2 100.0 1,593 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 52 • Marriage and Sexual Activity 4.3 AGE AT FIRST MARRIAGE Marriage is generally associated with fertility because it is correlated with exposure to risk of conception. Duration of exposure to the risk of pregnancy depends primarily on the age at which women first marry. Women who marry earlier, on average, have their first child earlier and give birth to more children, contributing to higher fertility rates. Table 4.3 shows the percentages of women and men who have married by specific ages, according to their current age. Sixteen percent of women age 20-49 married by age 15, and 41 percent married by age 18. The proportion of women who were married by age 15 and age 18 rises substantially with increasing age. For example, 25 percent of women in the 45-49 age group married by age 15, as compared with only 6 percent of those age 15-19. Almost no men age 20-49 married by age 15, and only 2 percent married before their 18th birthday. Table 4.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, The Gambia 2013 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 6.0 na na na na 75.7 2,407 a 20-24 9.3 30.4 46.9 na na 38.8 2,125 a 25-29 13.0 36.7 52.7 65.5 80.5 12.6 1,822 19.6 30-34 17.1 42.1 59.5 71.4 82.9 4.5 1,504 18.8 35-39 20.2 50.1 67.3 79.2 89.2 1.4 1,056 18.0 40-44 23.9 53.8 68.4 78.2 89.2 0.2 761 17.6 45-49 25.2 58.2 73.7 84.2 90.7 0.6 559 17.3 20-49 15.7 41.0 57.4 na na 14.6 7,826 19.0 25-49 18.1 45.0 61.4 73.1 84.9 5.6 5,701 18.6 MEN 15-19 0.0 na na na na 99.7 836 a 20-24 0.0 0.7 2.6 na na 93.0 849 a 25-29 0.0 0.7 3.8 7.4 20.4 65.6 586 a 30-34 0.0 2.0 8.0 12.8 22.8 26.0 425 28.4 35-39 0.0 4.3 7.5 14.6 24.8 9.7 391 28.4 40-44 0.0 2.6 10.1 20.0 34.2 6.0 270 28.1 45-49 0.0 2.4 9.3 14.1 25.4 1.9 220 28.5 20-49 0.0 1.8 5.7 na na 49.0 2,741 a 25-49 0.0 2.2 7.0 12.7 24.4 29.2 1,892 a 20-59 0.0 1.9 5.6 na na 45.2 2,985 a 25-59 0.0 2.4 6.8 12.2 24.3 26.1 2,136 a Note: Age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women or men began living with their spouse or partner for the first time before reaching the beginning of the age group Table 4.4 shows the median age at first marriage for women and men according to background characteristics. Because of the small numbers of married respondents below age 20 among women and below age 30 among men, these data have been omitted. Urban women age 25-49 tend to marry about two years later than their rural counterparts. The difference by LGA is more pronounced. Women from Banjul and Kanifing marry at older ages than women from other areas. For example, the median age at marriage among women in Banjul is four years older than that among women in Kuntaur (21.0 versus 17.0). Median age at marriage among women increases in a linear manner with increases in education and wealth. Marriage and Sexual Activity • 53 Men tend to marry later in life. The median age at marriage among men age 30-49 is 28.4 years. Similar to women, men in urban areas marry more than two years later than their rural counterparts (29.3 versus 27.0). Median age at marriage among men age 30-49 by background characteristics follows patterns similar to those for women. Table 4.4 Median age at first marriage by background characteristics Median age at first marriage among women age 20-49 and age 25-49, and median age at first marriage among men age 30-49 and age 30-59, according to background characteristics, The Gambia 2013 Background characteristic Women age Men age 20-49 25-49 30-49 30-59 Residence Urban a 19.7 29.3 29.2 Rural 17.7 17.5 27.0 27.1 Local Government Area Banjul a 21.0 a a Kanifing a 20.1 a 29.7 Brikama 19.5 19.0 28.2 28.3 Mansakonko 17.9 17.3 28.5 28.1 Kerewan 17.7 17.3 27.9 28.2 Kuntaur 17.2 17.0 26.3 26.4 Janjanbureh 18.3 18.1 27.0 27.2 Basse 17.5 17.6 27.2 27.4 Education No education 17.4 17.3 26.9 27.2 Primary 18.2 18.2 28.9 29.5 Secondary or higher a 22.2 29.7 29.4 Wealth quintile Lowest 17.6 17.2 27.1 27.2 Second 17.9 17.6 27.3 27.4 Middle 18.3 17.9 28.2 28.2 Fourth 19.5 19.3 29.1 29.1 Highest a 20.8 29.8 29.5 Total 19.0 18.6 28.4 28.3 Note: Age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50 percent of the respondents began living with their spouse/partner for the first time before reaching the beginning of the age group 4.4 AGE AT FIRST SEXUAL INTERCOURSE Although age at first marriage is often used as a proxy for first exposure to intercourse, the two events do not necessarily occur at the same time. Women and men sometimes engage in sexual relations before marriage. In the 2013 GDHS, women and men were asked how old they were when they first had sexual intercourse. The percentage of women and men who had sexual intercourse by exact ages is shown in Table 4.5. Overall, 15 percent of women age 20-49 had sex before age 15 and 42 percent before age 18. The proportion of women who first had sexual intercourse by the ages of 15 and 18 is notably higher among older age groups, peaking at 24 percent and 54 percent, respectively, among women age 45-49. The median age at first sexual intercourse for women age 25-49 years is 18.6 years, which is the same as the median age at first marriage of 18.6 years. This suggests that women in The Gambia generally begin sexual intercourse at the time of their first marriage. Women’s sexual debut occurs much earlier than that of men (18.6 years for women versus 23.1 years for men). 54 • Marriage and Sexual Activity Table 4.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had sexual intercourse, and median age at first sexual intercourse, according to current age, The Gambia 2013 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse15 18 20 22 25 WOMEN 15-19 5.7 na na na na 75.2 2,407 na 20-24 10.1 34.3 51.7 na na 32.3 2,125 19.8 25-29 13.2 38.5 55.5 67.8 80.2 9.1 1,822 19.3 30-34 15.3 40.4 58.4 70.7 81.3 2.9 1,504 18.9 35-39 20.0 49.8 65.3 75.0 83.5 0.7 1,056 18.0 40-44 23.2 53.5 67.5 77.4 86.4 0.0 761 17.6 45-49 23.9 54.4 71.9 79.1 85.5 0.0 559 17.6 20-49 15.4 41.8 58.7 na na 11.5 7,826 18.9 25-49 17.4 44.6 61.3 72.3 82.4 3.8 5,701 18.6 15-24 7.8 na na na na 55.1 4,532 a MEN 15-19 6.1 na na na na 77.3 836 a 20-24 3.0 22.2 38.9 na na 46.6 849 a 25-29 1.5 17.2 34.6 48.4 64.5 23.2 586 22.4 30-34 1.0 11.3 28.4 46.6 54.8 6.9 425 23.4 35-39 0.8 15.2 29.3 45.1 61.7 1.3 391 22.7 40-44 1.1 8.2 22.7 42.4 54.6 0.7 270 23.4 45-49 0.2 4.7 19.1 36.5 47.1 1.0 220 25.5 20-49 1.7 15.7 31.8 na na 20.8 2,741 a 25-49 1.1 12.7 28.6 45.1 58.3 9.2 1,892 23.1 15-24 4.6 na na na na 61.8 1,685 a 20-59 1.7 15.1 30.5 na na 19.1 2,985 a 25-59 1.1 12.2 27.2 43.6 57.2 8.2 2,136 23.3 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Differentials in median age at first sexual intercourse among women age 25-49 and men age 25-59 by background characteristics are shown in Table 4.6. Women in rural areas begin engaging in sexual activity about one and a half years earlier than their urban counterparts (17.7 versus 19.4). The median age at first sexual intercourse among women is youngest in Kuntaur (17.0) and oldest in Banjul (20.8). With respect to education, women with a secondary or higher education begin engaging in sexual activity almost four years later than those with no education (21.5 versus 17.5). Age at first sexual intercourse increases steadily with increasing wealth, from 17.4 years among the poorest women to 20.6 years among those in the highest quintile. The data for men show no major differences in median age at first sexual intercourse by urban-rural residence, LGA, education, or wealth. 4.5 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the frequency of intercourse. Thus, information on sexual activity can be used to refine measures of exposure to pregnancy. Tables 4.7.1 and 4.7.2 show the percent distribution of women and men age 15-49, respectively, by timing of last sexual intercourse, according to background characteristics. Table 4.6 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 25-49, and median age at first sexual intercourse among men age 25-59, according to background characteristics, The Gambia 2013 Background characteristic Women age 25-49 Men age 25-59 Residence Urban 19.4 23.4 Rural 17.7 23.3 Local Government Area Banjul 20.8 22.8 Kanifing 19.7 22.7 Brikama 18.9 23.5 Mansakonko 17.4 21.9 Kerewan 17.4 22.4 Kuntaur 17.0 a Janjanbureh 18.5 23.3 Basse 17.9 24.2 Education No education 17.5 23.8 Primary 18.2 21.0 Secondary or higher 21.5 23.1 Wealth quintile Lowest 17.4 23.1 Second 17.7 23.4 Middle 18.0 24.7 Fourth 19.0 23.4 Highest 20.6 22.7 Total 18.6 23.3 a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Marriage and Sexual Activity • 55 Table 4.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, The Gambia 2013 Timing of last sexual intercourse Never had sexual intercourse Total Number of women Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 12.6 9.5 2.6 0.0 75.2 100.0 2,407 20-24 33.1 22.5 11.9 0.3 32.3 100.0 2,125 25-29 49.5 29.1 12.1 0.2 9.1 100.0 1,822 30-34 56.4 24.3 16.3 0.1 2.9 100.0 1,504 35-39 60.7 24.3 14.3 0.0 0.7 100.0 1,056 40-44 58.6 23.2 17.9 0.4 0.0 100.0 761 45-49 65.3 15.9 18.7 0.0 0.0 100.0 559 Marital status Never married 1.7 5.0 5.3 0.2 87.8 100.0 2,963 Married or living together 60.9 27.1 10.4 0.1 1.5 100.0 6,791 Divorced/separated/widowed 4.8 27.9 65.6 0.4 1.3 100.0 478 Marital duration2 0-4 years 53.3 32.6 8.5 0.0 5.6 100.0 1,696 5-9 years 55.7 30.2 13.1 0.3 0.7 100.0 1,311 10-14 years 62.3 26.4 11.3 0.0 0.0 100.0 1,070 15-19 years 66.5 22.0 11.5 0.0 0.0 100.0 824 20-24 years 69.9 20.0 10.0 0.0 0.0 100.0 578 25+ years 67.5 21.8 10.4 0.2 0.0 100.0 541 Married more than once 67.0 25.4 7.4 0.2 0.0 100.0 771 Residence Urban 37.8 18.0 12.3 0.2 31.7 100.0 5,730 Rural 45.4 24.3 10.4 0.1 19.9 100.0 4,503 Local Government Area Banjul 31.5 18.1 15.6 0.7 34.1 100.0 225 Kanifing 32.3 19.0 13.8 0.2 34.7 100.0 2,342 Brikama 42.3 18.9 11.0 0.2 27.6 100.0 3,550 Mansakonko 43.2 23.6 9.8 0.1 23.4 100.0 490 Kerewan 51.3 19.5 5.4 0.0 23.7 100.0 1,107 Kuntaur 51.1 23.7 8.0 0.0 17.2 100.0 526 Janjanbureh 39.1 25.7 13.4 0.0 21.9 100.0 739 Basse 43.2 25.5 14.1 0.1 17.1 100.0 1,254 Education No education 54.8 23.9 12.8 0.1 8.4 100.0 4,757 Primary 38.3 24.4 8.8 0.3 28.1 100.0 1,405 Secondary or higher 26.1 15.8 10.8 0.1 47.1 100.0 4,071 Wealth quintile Lowest 45.9 24.5 10.0 0.1 19.5 100.0 1,745 Second 44.7 23.8 10.4 0.1 20.9 100.0 1,882 Middle 44.5 21.6 11.6 0.2 22.1 100.0 1,927 Fourth 40.8 19.5 11.3 0.2 28.3 100.0 2,135 Highest 32.9 16.3 13.4 0.2 37.3 100.0 2,545 Total 41.1 20.8 11.5 0.1 26.5 100.0 10,233 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married 56 • Marriage and Sexual Activity Table 4.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, The Gambia 2013 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 4.8 8.6 9.3 0.0 77.3 100.0 836 20-24 15.7 19.0 18.6 0.1 46.6 100.0 849 25-29 32.3 26.7 17.1 0.7 23.2 100.0 586 30-34 52.4 28.9 10.5 1.3 6.9 100.0 425 35-39 58.4 34.4 5.7 0.2 1.3 100.0 391 40-44 68.5 21.9 8.1 0.8 0.7 100.0 270 45-49 75.2 16.2 6.4 1.3 1.0 100.0 220 Marital status Never married 10.4 16.9 17.0 0.2 55.5 100.0 2,177 Married or living together 67.6 27.0 3.9 0.8 0.6 100.0 1,360 Divorced/separated/widowed (45.7) (17.5) (36.7) (0.0) (0.0) 100.0 40 Marital duration2 0-4 years 58.2 35.2 3.4 1.5 1.8 100.0 393 5-9 years 67.5 30.0 2.5 0.0 0.0 100.0 305 10-14 years 69.2 25.4 5.0 0.3 0.0 100.0 184 15-19 years 68.2 24.5 6.7 0.7 0.0 100.0 97 20-24 years (58.8) (25.7) (11.8) (3.8) (0.0) 100.0 39 25+ years * * * * * 100.0 8 Married more than once 79.4 15.8 3.8 0.8 0.3 100.0 334 Residence Urban 30.1 22.5 13.0 0.5 33.8 100.0 2,228 Rural 36.6 17.7 11.0 0.3 34.3 100.0 1,349 Local Government Area Banjul 33.4 25.3 14.7 1.1 25.5 100.0 85 Kanifing 31.8 22.9 12.5 1.2 31.5 100.0 858 Brikama 29.2 21.6 13.6 0.1 35.5 100.0 1,454 Mansakonko 33.1 23.7 9.4 0.8 33.1 100.0 141 Kerewan 38.1 16.8 8.8 0.4 35.8 100.0 323 Kuntaur 41.7 12.9 4.8 0.9 39.7 100.0 141 Janjanbureh 31.0 24.6 17.2 0.0 27.2 100.0 240 Basse 40.4 13.6 9.0 0.0 37.0 100.0 336 Education No education 45.1 21.2 9.7 0.5 23.6 100.0 1,090 Primary 28.6 16.0 11.0 0.3 44.2 100.0 493 Secondary or higher 26.7 21.7 14.0 0.5 37.2 100.0 1,994 Wealth quintile Lowest 37.1 18.7 9.8 0.0 34.5 100.0 517 Second 34.3 20.0 11.8 0.2 33.7 100.0 614 Middle 29.5 21.2 12.7 0.5 36.1 100.0 588 Fourth 28.1 23.4 14.2 0.6 33.7 100.0 940 Highest 35.4 19.4 11.7 0.7 32.8 100.0 919 Total 15-49 32.6 20.7 12.2 0.5 34.0 100.0 3,577 50-59 75.1 11.1 13.0 0.7 0.2 100.0 244 Total 15-59 35.3 20.1 12.3 0.5 31.8 100.0 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes men who had sexual intercourse within the last 4 weeks 2 Excludes men who are not currently married Twenty-seven percent of women and 34 percent of men age 15-49 have never had sexual intercourse. The percentages of respondents who have never had sexual intercourse are highest among those in the youngest age group, with three-quarters of women and men age 15-19 never having had sex. Marriage and Sexual Activity • 57 More than one in ten women and men age 15-49 (12 percent each) report that their last sexual encounter occurred more than one year before the survey, and 41 percent of women and 33 percent of men reported that it occurred in the past four weeks. Recent sexual activity is more common among currently married respondents, with 61 percent of women and 68 percent of men having had sex in the four weeks before the survey. Among never-married respondents, the proportion of men who report a recent sexual encounter is five times that of women (10 percent and 2 percent, respectively). Respondents who live in rural areas, those with no education, and the poorest respondents are most likely to report recent sexual activity. Fertility Levels, Trends, and Differentials • 59 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 5 5.1 INTRODUCTION his chapter focuses on a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women begin childbearing. Information on current and cumulative fertility is essential for monitoring population growth, which guides population policies and programmes. Birth intervals are important because short intervals are associated with high childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the mother and the child. To generate data on fertility, a birth history was collected from each woman interviewed in the 2013 GDHS. Women were asked to report the total number of sons and daughters to whom they had given birth in their lifetime. To ensure that all information was reported, women were asked separately about children still living at home, those living elsewhere, and those who had died. Data on the sex, date of birth, and survival status of each child were obtained, and age at death for children who had died was recorded.1 5.2 CURRENT FERTILITY Findings on measures of current fertility are presented in Table 5.1. These include the total fertility rate (TFR), general fertility rate (GFR), crude birth rate (CBR), and age-specific fertility rates (ASFRs) for women by five-year age groups. ASFRs are calculated by dividing the number of births to women in a specific age group by the number of woman-years lived during a given period.2 The TFR is defined as the average number of children a woman would have if she went through her entire reproductive period, from age 15 to 49, reproducing at the prevailing ASFRs. The GFR represents the annual number of births per 1,000 women age 15-44, and the CBR represents the annual number of births per 1,000 population. The CBR was estimated using birth history data in conjunction with the population data collected in the Household Questionnaire. 1 The survey results in this chapter are presented for the country as a whole, by urban-rural residence, and by Local Government Area. 2 Numerators for age-specific fertility rates are calculated by summing all births that occurred during the period 1 to 36 months preceding the survey, classified by the age of the mother at the time of the birth in five-year age groups. The denominators are the number of woman-years lived in each specific five-year age group during the 1 to 36 months preceding the survey. T Key Findings • The total fertility rate for the three years preceding the survey is 5.6 births per woman. • Childbearing begins early in The Gambia. Thirty-one percent of women age 25-49 have given birth by age 18 and 49 percent by age 20. • The median birth interval for women in The Gambia is 34.2 months; 15 percent of non-first births occur within 24 months following a previous birth. • The median age at first birth among women age 25-49 is 20.1 years. • Almost one in five (18 percent) adolescent women age 15-19 are already mothers or pregnant with their first child. 60 • Fertility Levels, Trends, and Differentials As shown in Table 5.1, the TFR was 5.6 births per woman for the three years preceding the survey. The TFR in rural areas was higher than in urban areas (6.8 and 4.7 births per woman, respectively). This pattern is reflected across each age group. Nationally and in both rural and urban areas, peak fertility occurs at age 25-29. Fertility rates fall drastically after age 39 in both rural and urban areas. Table 5.1 further shows a GFR of 185 live births per 1,000 women age 15-44 and a CBR of 40.5 births per 1,000 population. Both rates are higher in rural than in urban areas. The disparities in fertility among rural and urban women can be attributed to the significant role played by education in population growth. When women’s literacy improves, fertility rates tend to decrease. Similarly, fertility rates tend to be lower where women have access to formal jobs and good health care, which are more available in urban areas than in rural ones. Table 5.2 shows differentials in total fertility rates by residence, Local Government Area (LGA), education, and wealth quintile. Fertility is lowest in Banjul (3.9) and highest in Kuntaur (7.2). LGA differentials in fertility are closely associated with disparities in educational levels and in knowledge and use of family planning methods (see Chapter 7). Table 5.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49, by background characteristics, The Gambia 2013 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 4.7 6.6 5.3 Rural 6.8 10.0 6.7 Local Government Area Banjul 3.9 5.8 4.3 Kanifing 4.0 5.9 5.1 Brikama 5.6 7.7 5.9 Mansakonko 6.0 9.1 7.0 Kerewan 6.3 8.8 6.9 Kuntaur 7.2 11.5 6.6 Janjanbureh 6.8 9.2 6.5 Basse 7.0 10.9 6.2 Education No education 6.6 10.2 6.3 Primary 6.6 10.9 6.5 Secondary or higher 4.1 4.7 4.5 Wealth quintile Lowest 6.7 9.9 6.7 Second 6.8 9.2 6.8 Middle 6.2 10.4 6.4 Fourth 5.3 6.2 5.5 Highest 3.8 5.9 4.6 Total 5.6 8.1 6.0 Note: Total fertility rates are for the period 1-36 months prior to the interview. Table 5.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, The Gambia 2013 Age group Residence Total Urban Rural 15-19 63 119 88 20-24 171 281 215 25-29 242 312 271 30-34 212 269 237 35-39 167 207 185 40-44 71 131 99 45-49 5 42 24 TFR (15-49) 4.7 6.8 5.6 GFR 155 223 185 CBR 37.7 43.4 40.5 Note: Age-specific fertility rates are per 1,000 women. Rates for the 45-49 age group may be slightly biased due to truncation. Rates are for the period 1-36 months prior to the interview. TFR: Total fertility rate, expressed per woman GFR: General fertility rate, expressed per 1,000 women age 15-44 CBR: Crude birth rate, expressed per 1,000 population Fertility Levels, Trends, and Differentials • 61 Several studies have shown that educational level is inversely related to fertility. In the 2013 Gambia DHS, the difference in TFR between women with no education and women with a secondary education or higher is 2.5 births per woman (6.6 and 4.1, respectively). Fertility also decreases steadily as wealth increases. The lowest TFR is seen among women in the highest wealth quintile (3.8), and the highest is seen among women in the lowest two quintiles (6.7 and 6.8, respectively). Table 5.2 further shows that 8 percent of interviewed women were pregnant at the time of the survey. Differentials in pregnancy rates are generally consistent with the pattern of fertility depicted across the various subgroups. Kuntaur had the highest proportion of women who were pregnant (12 percent), while Banjul and Kanifing had the lowest (6 percent each). Women with no education or a primary education were twice as likely to be pregnant at the time of the survey (10 percent and 11 percent, respectively) as those with a secondary education or higher (5 percent). A comparison of the mean number of lifetime births to older women with the current TFR can provide insight into changes in fertility over the previous two decades or so. For example, the mean number of children ever born to women age 40-49 is 6.0, slightly higher than the TFR of 5.6 births per woman. On average, women age 40-49 in rural areas have given birth to 6.7 children, as compared with only 5.3 children among their urban counterparts. Differences by LGA show that women age 40-49 in Banjul have the lowest mean number of children ever born (4.3), while women in Mansakonko have the highest (7.0). Mean number of children ever born is inversely related to education and wealth. 5.3 FERTILITY TRENDS Table 5.3 uses information from the retrospective birth histories obtained in the 2013 GDHS to examine trends in age- specific fertility rates for successive five-year periods before the survey. To calculate these rates, births are classified according to the period of time in which the birth occurred and the mother’s age at the time of the birth. Because birth histories were not collected for women age 50 and older, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 45-49 for periods 5-9 years or more preceding the survey because women in that age group would have been age 50 or older at the time of the survey. The results in Table 5.3 show that age-specific fertility rates decreased between the two five-year periods prior to the survey for all age groups. The largest decrease in fertility over time occurred among women giving birth between age 15 and age 24. 5.4 CHILDREN EVER BORN AND CHILDREN SURVIVING The distributions of all women and currently married women age 15-49 by number of children ever born are presented in Table 5.4. Overall, 34 percent of all women age 15-49 have never given birth, and this percentage decreases substantially with age. As expected, a large proportion of women age 15-19 (86 percent) have never given birth. This indicates that the vast majority of women age 15-19 delay the onset of childbearing, with only 14 percent having already given birth. More than four in ten women age 20-24 (44 percent) and 16 percent of those age 25-29 have never given birth. However, this proportion declines rapidly to about 7 percent or even less among women age 30 and older, indicating that childbearing among women in The Gambia is nearly universal. Table 5.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, The Gambia 2013 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 87 109 115 146 20-24 212 239 232 262 25-29 261 276 268 257 30-34 230 247 235 [222] 35-39 182 184 [176] 40-44 93 [122] 45-49 [29] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of the interview. 62 • Fertility Levels, Trends, and Differentials Table 5.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, The Gambia 2013 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 85.7 12.5 1.6 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,407 0.17 0.15 20-24 44.0 25.8 19.2 7.4 2.3 1.0 0.2 0.1 0.0 0.0 0.0 100.0 2,125 1.02 0.96 25-29 16.0 15.2 22.2 22.2 13.4 7.3 2.6 0.9 0.2 0.0 0.0 100.0 1,822 2.40 2.27 30-34 7.1 10.6 13.2 16.5 16.6 15.5 11.5 5.0 2.5 1.4 0.2 100.0 1,504 3.69 3.43 35-39 1.9 3.9 6.8 9.7 15.2 17.4 17.0 13.1 8.2 4.3 2.4 100.0 1,056 5.18 4.74 40-44 2.5 3.4 5.0 5.5 9.9 15.2 17.0 14.1 14.5 7.0 6.0 100.0 761 5.88 5.28 45-49 2.6 1.4 4.0 10.3 9.0 11.4 12.3 18.3 10.4 9.1 11.1 100.0 559 6.19 5.44 Total 33.7 13.3 11.5 9.9 8.1 7.3 5.9 4.3 2.9 1.7 1.3 100.0 10,233 2.53 2.32 CURRENTLY MARRIED WOMEN 15-19 48.0 44.5 6.3 0.9 0.3 0.0 0.0 0.0 0.0 0.0 0.0 100.0 573 0.61 0.56 20-24 18.5 34.1 29.9 11.7 3.5 1.7 0.4 0.1 0.0 0.0 0.0 100.0 1,237 1.55 1.45 25-29 7.7 14.0 25.0 24.9 15.4 8.6 3.0 1.1 0.3 0.0 0.0 100.0 1,528 2.71 2.56 30-34 3.7 8.8 12.6 17.0 18.0 17.1 12.6 5.7 2.9 1.5 0.2 100.0 1,319 3.96 3.68 35-39 1.0 2.8 5.7 9.6 15.5 17.5 17.9 13.9 8.7 4.7 2.6 100.0 966 5.36 4.90 40-44 1.7 2.4 4.5 5.6 9.6 14.1 18.3 15.2 14.6 7.8 6.3 100.0 673 6.06 5.44 45-49 2.2 1.4 3.3 9.2 8.0 10.8 12.2 20.1 10.6 9.9 12.5 100.0 496 6.42 5.62 Total 10.4 15.6 15.5 13.7 11.4 10.2 8.4 6.3 4.1 2.4 2.0 100.0 6,791 3.54 3.25 The data further show that women age 45-49 have given birth to a mean of 6.2 children. This is 0.6 children higher than the TFR (5.6), a discrepancy that is attributable to the decline in fertility during the previous decades. Similar patterns are observed among currently married women. The only difference is that the percentage of currently married women age 15-19 and age 20-24 who have never given birth (48 percent and 19 percent, respectively) is much lower than that of all women in the same age groups (86 percent and 44 percent, respectively). Similar to all women, this proportion diminishes rapidly, to 8 percent or less among married women age 25 and older. These differences in childbearing can be explained by the presence in the “all women” category of unmarried women, who are less exposed to the risk of conception than married women and exhibit lower fertility. On average, currently married women age 45-49 have borne 6.4 children. As expected, currently married women age 40 and older have much higher parities, with substantial proportions having given birth to eight or more children. For example, 33 percent of currently married women age 45-49 have given birth to eight or more children. The mean number of children ever born and the mean number of living children increase with increasing age, as expected in a normal population. This indicates minimal or no recall bias, which heightens confidence in the birth history reports. Fertility Levels, Trends, and Differentials • 63 5.5 BIRTH INTERVALS The length of intervals between births contributes greatly to the level of fertility and also affects the health of both the mother and the child. Examining birth intervals provides insights into birth patterns and maternal and child health. Studies have shown that children born fewer than 24 months after a previous sibling are at greater risk of having poor health and that such births threaten maternal health. Table 5.5 shows the percent distribution of non-first births in the five years before the survey by the number of months since the preceding birth, according to background characteristics. Table 5.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, The Gambia 2013 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 5.9 19.4 56.0 13.5 2.3 2.9 100.0 51 30.6 20-29 6.2 12.4 45.5 20.3 7.8 7.8 100.0 2,682 32.2 30-39 3.2 8.4 40.1 21.7 12.6 13.9 100.0 2,764 35.4 40-49 1.9 7.4 27.8 26.1 12.3 24.4 100.0 683 41.1 Sex of preceding birth Male 4.9 10.8 40.1 22.1 9.3 12.8 100.0 3,107 34.2 Female 3.9 9.5 42.3 20.8 11.6 11.9 100.0 3,073 34.3 Survival of preceding birth Living 3.3 9.4 42.2 21.9 10.8 12.4 100.0 5,804 34.5 Dead 21.0 21.7 25.8 14.8 5.4 11.2 100.0 377 25.9 Birth order 2-3 4.7 10.1 40.4 22.1 9.3 13.4 100.0 2,693 34.4 4-6 4.1 11.1 41.7 19.7 11.2 12.3 100.0 2,504 34.0 7+ 4.1 8.1 42.3 24.4 11.6 9.6 100.0 983 34.4 Residence Urban 5.4 9.6 35.9 22.1 12.2 14.8 100.0 2,849 35.7 Rural 3.5 10.6 45.8 21.0 8.9 10.2 100.0 3,331 33.3 Local Government Area Banjul 4.5 7.0 28.1 25.3 15.8 19.4 100.0 92 40.0 Kanifing 5.1 10.4 33.7 20.6 15.2 15.0 100.0 1,028 36.2 Brikama 5.5 10.6 38.6 22.1 10.2 13.1 100.0 2,120 34.6 Mansakonko 2.9 11.1 44.0 19.5 9.6 12.8 100.0 317 33.1 Kerewan 2.9 10.8 45.6 22.0 9.4 9.4 100.0 710 33.2 Kuntaur 4.3 9.7 44.6 22.3 8.5 10.7 100.0 444 33.8 Janjanbureh 3.5 8.6 43.2 21.1 11.8 11.8 100.0 515 34.5 Basse 3.2 9.3 49.7 21.0 6.8 10.0 100.0 954 32.8 Education No education 3.5 9.5 43.3 21.6 11.0 11.1 100.0 3,995 34.2 Primary 5.6 11.1 42.4 18.8 8.1 14.0 100.0 872 33.7 Secondary or higher 6.1 11.6 34.1 22.9 10.4 14.9 100.0 1,313 35.1 Wealth quintile Lowest 3.0 10.4 45.0 21.4 10.2 10.0 100.0 1,311 33.7 Second 3.9 10.4 45.9 20.8 10.0 9.1 100.0 1,392 33.2 Middle 4.1 9.0 41.6 22.8 10.8 11.7 100.0 1,250 35.0 Fourth 5.1 10.1 40.2 22.1 9.9 12.5 100.0 1,246 34.0 Highest 6.3 11.0 30.3 20.1 11.7 20.6 100.0 981 36.8 Total 4.4 10.2 41.2 21.5 10.4 12.3 100.0 6,180 34.2 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. The median birth interval for women in The Gambia is 34.2 months. The median birth interval increases as women’s age increases. It is shorter among children whose preceding sibling died (25.9 months), children in rural areas (33.3 months), and children in Basse (32.8 months). It is highest among children born to women age 40-49 (41.1 months), children in Banjul (40.0 months), children born to women with a secondary education or higher (35.1 months), and children from the richest households (36.8 months). 64 • Fertility Levels, Trends, and Differentials The data show that 15 percent of children in The Gambia are born fewer than 24 months following a previous birth. A short birth interval may increase the risk to the health of both the mother and the child. The highest proportion of children with a short interval following a preceding birth are born to women age 15-19 (25 percent) and born after a preceding sibling died (43 percent). 5.6 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea is defined as the period between childbirth and the resumption of menstruation, which generally approximates the return of ovulation. This period is largely determined by the duration and intensity of breastfeeding. The risk of conception in this period is very low. The duration of postpartum amenorrhoea and sexual abstinence after childbirth determines the length of the insusceptibility period. Thus, women are considered insusceptible if they either are abstaining from sex after childbirth or are amenorrhoeic. In the 2013 GDHS, women who gave birth in the five years preceding the survey were asked about the duration of amenorrhoea and sexual abstinence after each birth. The results are presented in Table 5.6 for the three years before the survey. The results show that almost all women are insusceptible to pregnancy within the first two months after childbirth due to amenorrhoea and abstinence. After the second month, the proportion of women who are amenorrhoeic or abstaining steadily declines to 41 percent and 26 percent, respectively, in the period 12-13 months after the birth. By that same time period, insusceptibility among women has dropped to 55 percent. The overall median duration of postpartum insusceptibility is 14.0 months; the median duration of postpartum amenorrhoea is 11.7 months, and the median duration of postpartum abstinence is 6.0 months. Postpartum amenorrhoea is the most influential determinant in the length of the insusceptibility period. Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, The Gambia 2013 Months since birth Percentage of births for which the mother is: Number of births Amenorrhoeic Abstaining Insusceptible1 <2 96.7 96.3 99.6 240 2-3 83.2 79.2 92.2 371 4-5 76.4 59.5 88.5 327 6-7 67.7 39.4 80.6 332 8-9 61.2 37.6 75.5 244 10-11 66.5 30.1 73.1 261 12-13 41.3 26.4 54.5 357 14-15 37.7 16.9 47.4 355 16-17 24.7 19.6 38.2 272 18-19 27.5 15.9 37.7 232 20-21 11.2 10.9 17.8 204 22-23 8.2 12.0 19.1 257 24-25 2.1 6.6 8.4 244 26-27 1.7 4.2 5.5 269 28-29 1.3 3.4 3.8 265 30-31 3.3 6.0 8.1 273 32-33 1.8 5.4 7.2 209 34-35 0.6 4.3 5.0 215 Total 37.0 28.2 45.6 4,929 Median 11.7 6.0 14.0 na Mean 12.5 9.7 15.5 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth Fertility Levels, Trends, and Differentials • 65 Table 5.7 shows that the median duration of postpartum insusceptibility is longest among women age 30-49 (15.1 months), women in rural areas (15.7 months), those with no education (14.5 months), and those in the poorest households (16.4 months). 5.7 MENOPAUSE Infecundity is the inability to reproduce. One cause of infecundity in women is the onset of menopause. The 2013 GDHS defines menopausal women as women who are neither pregnant nor postpartum amenorrhoeic and who have not had a menstrual period in the six months before the survey. Women would also cease to have a menstrual period if they were sterilised. However, the rate of female sterilisation in The Gambia is very low (see Chapter 7). Table 5.8 shows the percentage of women age 30-49 who are menopausal. Overall, only 7 percent of women in this age group are menopausal. As expected, the proportion of women who are menopausal increases steadily with age, from less than 1 percent among women age 30-34 to 40 percent among women age 48-49. 5.8 AGE AT FIRST BIRTH Because the reproductive period is biologically limited, the onset of childbearing has a direct effect on fertility. Early initiation of childbearing lengthens the reproductive period and subsequently increases fertility, which is likely to pose a risk for socioeconomic disadvantages in later life—even for adolescent mothers from relatively comfortable backgrounds. Table 5.9 shows the percentage of women age 15-49 who have given birth by exact ages, the percentage who have never given birth, and the median age at first birth, according to their current age. The youngest women for whom median age at first birth can be calculated are those in the 25-29 age group. The medians for women age 15-19 and 20-24 cannot be determined because less than half of these women had given birth before reaching the beginning of the age group. Table 5.7 Median duration of amenorrhoea, postpartum abstinence, and postpartum insusceptibility Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, The Gambia 2013 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother’s age 15-29 10.9 6.0 13.3 30-49 13.1 5.8 15.1 Residence Urban 9.2 5.8 11.9 Rural 13.4 6.1 15.7 Local Government Area Banjul 7.3 * * Kanifing 6.1 6.6 13.6 Brikama 10.0 6.0 11.7 Mansakonko * (7.2) * Kerewan 14.7 3.9 15.2 Kuntaur (14.7) (4.2) * Janjanbureh (12.6) (9.2) (15.9) Basse 13.5 7.1 16.4 Education No education 12.8 5.7 14.5 Primary 9.9 7.9 14.1 Secondary or higher 8.8 5.7 12.2 Wealth quintile Lowest 13.6 6.0 16.4 Second 12.8 6.0 15.4 Middle 11.9 6.4 13.8 Fourth 9.1 6.8 11.7 Highest 8.6 4.1 11.0 Total 11.7 6.0 14.0 Note: Medians are based on status at the time of the survey (current status). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, The Gambia 2013 Age Percentage menopausal1 Number of women Age 30-34 0.8 1,504 35-39 1.9 1,056 40-41 3.7 376 42-43 9.8 292 44-45 19.9 283 46-47 30.1 190 48-49 40.1 180 Total 6.7 3,879 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred 6 or more months preceding the survey 66 • Fertility Levels, Trends, and Differentials Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, The Gambia 2013 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 Age 15-19 1.8 na na na na 85.7 2,407 a 20-24 4.1 19.4 38.4 na na 44.0 2,125 a 25-29 5.0 23.1 42.0 59.0 76.3 16.0 1,822 20.9 30-34 8.4 28.3 46.5 62.9 77.7 7.1 1,504 20.4 35-39 9.4 37.1 55.1 70.6 84.9 1.9 1,056 19.4 40-44 10.1 39.3 55.2 68.7 83.7 2.5 761 19.3 45-49 11.1 39.7 60.6 76.9 86.3 2.6 559 19.0 25-49 8.0 30.9 49.2 65.2 80.2 7.9 5,701 20.1 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group In The Gambia, 8 percent of women age 25-49 have given birth by age 15, 31 percent by age 18, and 49 percent by age 20. Comparing the proportions of women who have given birth by age 15 across age groups provides another way to view trends in age at first birth over time. The results indicate a decrease in early childbearing over time. The percentage of women who had given birth by age 15 is less than 2 percent among those age 15-19, as compared with 11 percent among those age 45-49. The decrease in the percentage of women giving birth early in life supports the finding that age at first childbirth has been increasing slowly in The Gambia. A younger median age at first birth usually has a positive effect on fertility levels because the exposure period is increased. Table 5.10 presents median age at first birth among women age 25-49 by background characteristics. As expected, women in urban areas have a higher median age at first birth than their rural counterparts (20.9 and 19.2 years, respectively). The highest median age at first birth is seen among women in Banjul and Kanifing (21.5 years each), women with a secondary education or higher (22.8 years), and women in the richest households (22.1 years). 5.9 TEENAGE FERTILITY Teenage pregnancy is a major health concern because of its association with higher morbidity and mortality for both the mother and the child. In addition, childbearing during the teenage years frequently has adverse social consequences, particularly regarding educational attainment, because women who become mothers in their teens are more likely to curtail their education. Table 5.11 shows the percentage of women age 15-19 who have had a live birth or who are pregnant with their first child. Table 5.10 Median age at first birth Median age at first birth among women age 25-49, according to background characteristics, The Gambia 2013 Background characteristic Women age 25-49 Residence Urban 20.9 Rural 19.2 Local Government Area Banjul 21.5 Kanifing 21.5 Brikama 20.2 Mansakonko 19.2 Kerewan 18.9 Kuntaur 19.4 Janjanbureh 19.6 Basse 19.3 Education No education 19.1 Primary 19.7 Secondary or higher 22.8 Wealth quintile Lowest 18.8 Second 19.4 Middle 19.6 Fourth 20.4 Highest 22.1 Total 20.1 Fertility Levels, Trends, and Differentials • 67 Table 5.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, The Gambia 2013 Background characteristic Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 1.3 1.8 3.1 476 16 6.1 2.8 8.8 449 17 15.7 5.6 21.3 399 18 18.3 3.8 22.1 625 19 29.3 2.3 31.6 459 Residence Urban 10.1 2.0 12.1 1,321 Rural 19.4 4.8 24.2 1,086 Local Government Area Banjul 7.9 0.5 8.4 48 Kanifing 7.8 1.2 9.0 516 Brikama 11.8 2.2 13.9 822 Mansakonko 13.5 6.7 20.2 119 Kerewan 14.0 3.9 17.9 283 Kuntaur 21.6 5.2 26.7 124 Janjanbureh 22.0 4.6 26.6 194 Basse 26.0 6.4 32.5 300 Education No education 29.2 6.8 36.1 575 Primary 15.9 5.2 21.1 509 Secondary or higher 7.2 0.9 8.2 1,323 Wealth quintile Lowest 20.1 4.8 24.8 428 Second 14.8 4.1 18.9 436 Middle 20.1 4.3 24.5 492 Fourth 13.9 2.2 16.2 481 Highest 5.0 1.3 6.3 571 Total 14.3 3.2 17.5 2,407 Overall, 18 percent of young women age 15-19 have begun childbearing; 14 percent have had a live birth, and 3 percent are pregnant with their first child. The percentage of teenagers who have begun childbearing increases with age. Furthermore, twice as many teenagers in rural areas as in urban areas have begun childbearing (24 percent versus 12 percent). At the LGA level, the percentage of teenagers who have started childbearing is highest in Basse (33 percent) and lowest in Banjul (8 percent). This percentage decreases drastically with increasing education, from 36 percent among young women with no education to only 8 percent among those with a secondary education or higher. Teenagers in the highest wealth quintile are less likely to have started childbearing (6 percent) than those in the other quintiles (16 percent to 25 percent). Fertility Preferences • 69 FERTILITY PREFERENCES 6 he underlying rationale of family planning programmes in The Gambia is to give couples sufficient freedom and ability to bear the number of children they want and achieve their desired spacing of births. These programmes are becoming increasingly universal in the country. This chapter is designed to address some fundamental questions that allow an assessment of family sizes: Does the respondent want more children? How long would she choose to wait before the next child? How many children would she want altogether? The 2013 Gambia DHS collected information from both women and men on their fertility preferences, including their desire to have a (another) child, their ideal number of children, and the length of time they would like to wait before their next birth. 6.1 DESIRE FOR MORE CHILDREN Many married couples in The Gambia have plans for the number of children they want to have. Information on married couples’ desire for children can provide an indication of their future reproductive behaviours. Table 6.1 shows the percent distribution of currently married women and married men age 15-49 by desire for children, according to number of living children. Overall, 16 percent of women and 3 percent of men want no more children or have been sterilised. Three in ten married women (30 percent) and married men (31 percent) want to have another child within two years. Almost half of married women (47 percent) and 58 percent of married men want to have another child in two or more years. The proportion of women wanting no more children increases steadily and sharply from 1 percent among those with one living child to 46 percent among those with six or more living children. On the other hand, the proportion of women wanting to have another child soon (within two years) decreases sharply from 89 percent among childless women to 9 percent among women with six or more living children. The desire for more children is much higher among men than among women. For instance, 9 percent of married women with six or more living children want to have a child soon, as compared with 23 percent of married men with the same number of living children. T Key Findings • Sixteen percent of currently married women and 3 percent of currently married men do not want to have more children. The percentage wanting no more children increases with the number of living children. • The ideal family size among currently married women age 15-49 is 6.5 children, as compared with 9.2 children among currently married men age 15-59. • The total wanted fertility rate is 4.7 children per woman, close to one child lower than the actual fertility rate (5.6 children per woman). 70 • Fertility Preferences Table 6.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, The Gambia 2013 Desire for children Number of living children Total 15-49 Total 15-59 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 89.0 36.2 30.8 29.8 24.2 18.1 9.4 30.4 na Have another later3 6.9 57.7 60.6 57.3 55.6 49.7 31.9 47.3 na Have another, undecided when 1.2 3.7 2.5 1.3 2.0 1.3 1.1 1.9 na Undecided 0.5 0.6 1.2 1.8 2.5 3.1 7.2 2.7 na Want no more 0.4 0.9 3.7 6.9 13.6 24.3 46.1 15.2 na Sterilised4 0.0 0.1 0.6 0.9 0.6 0.1 1.4 0.6 na Declared infecund 1.7 0.1 0.3 1.3 0.7 2.7 2.0 1.2 na Missing 0.4 0.9 0.3 0.7 0.8 0.7 1.0 0.7 na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 na Number of women 615 1,101 1,131 1,011 859 748 1,325 6,791 na MEN5 Have another soon2 81.9 34.4 23.7 26.0 26.8 21.5 22.5 30.7 31.6 Have another later3 11.5 61.0 71.0 62.7 59.6 62.8 54.8 57.5 52.5 Have another, undecided when 2.8 2.4 0.4 2.5 1.2 2.5 5.7 2.7 2.8 Undecided 1.0 0.0 3.4 4.9 4.8 8.4 10.3 4.9 6.4 Want no more 0.0 0.5 1.0 3.7 7.7 3.6 4.7 2.9 5.3 Missing 2.8 1.8 0.4 0.2 0.0 1.2 2.0 1.2 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 114 252 229 189 139 142 296 1,360 1,593 na = Not applicable 1 The number of living children includes the current pregnancy. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilisation 5 The number of living children includes one additional child if the respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 6.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS Tables 6.2.1 and 6.2.2 present information on desire to limit childbearing among currently married women and currently married men age 15-49, respectively, according to background characteristics. Table 6.2.1 shows that, overall, 16 percent of married women indicate no desire for more children. Urban women are slightly more likely than rural women to want to limit childbearing (17 percent and 15 percent, respectively). There are large variations in desire to limit childbearing across Local Government Areas (LGAs). Banjul, the capital and a major urban area, has the highest proportion of married women who want no more children (24 percent). Kuntaur, a predominantly rural area, has the lowest proportion (11 percent). Education has an impact on desire to limit childbearing. Namely, women with no education are almost twice as likely as women with any education to want to limit childbearing. On the other hand, wealth does not have a strong relationship with fertility preferences. Overall, however, women in the highest wealth quintile are much more likely than women in the lower quintiles to want no more children. Fertility Preferences • 71 Table 6.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, The Gambia 2013 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 0.4 1.0 5.9 10.1 18.8 31.9 51.5 16.5 Rural 0.4 0.9 2.4 4.9 10.0 18.1 44.9 15.2 Local Government Area Banjul (0.0) 0.8 13.5 18.1 41.7 40.8 65.0 23.6 Kanifing 0.8 1.8 7.2 13.0 18.2 42.8 56.5 17.7 Brikama 0.0 0.0 4.0 7.3 16.2 25.8 51.3 17.0 Mansakonko 0.0 1.2 1.1 6.8 8.7 10.1 38.8 13.2 Kerewan 1.2 1.6 1.5 6.1 10.4 16.8 47.4 16.9 Kuntaur 1.4 1.9 0.0 0.9 8.1 11.0 37.1 11.0 Janjanbureh 0.0 1.1 0.7 4.0 9.8 21.2 34.9 12.3 Basse 0.0 0.6 5.6 7.1 11.4 20.4 46.3 14.0 Education No education 0.9 1.5 4.2 7.9 12.8 23.1 48.0 19.2 Primary 0.0 0.6 2.4 7.5 7.2 15.9 40.5 10.8 Secondary or higher 0.0 0.4 5.2 7.8 23.5 40.3 52.3 10.5 Wealth quintile Lowest 0.0 1.5 0.9 5.0 7.0 19.7 41.0 14.6 Second 0.5 0.6 2.1 7.0 9.3 14.5 48.1 15.5 Middle 0.6 0.4 5.1 3.6 12.1 20.1 48.6 16.1 Fourth 1.0 0.6 2.6 6.6 15.3 35.6 51.4 16.0 Highest 0.0 1.4 9.4 14.7 30.2 36.4 51.9 17.0 Total 0.4 0.9 4.3 7.8 14.2 24.5 47.5 15.8 Note: Women who have been sterilised are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. 1 The number of living children includes the current pregnancy. Table 6.2.2 shows that 3 percent of married men indicate no desire to have more children. The table includes only total percentages because the unweighted number of men is too small to show desire to limit childbearing by number of living children. The desire to limit childbearing is similar among men in urban and rural areas but varies across LGAs, ranging from less than 1 percent in Kuntaur to 7 percent in Banjul. Desire to limit childbearing increases with increasing education, from 2 percent among men with no education to 5 percent among men with a secondary education or higher. There is no clear pattern in the relationship between wealth and desire to limit childbearing. However, men in the highest wealth quintile are most likely to desire no more children (5 percent). 6.3 IDEAL NUMBER OF CHILDREN Family planning programmes in The Gambia provide opportunities for women and men to decide on the number of children they would like to have. The 2013 GDHS ascertained ideal number of children by asking respondents to consider, abstractly and independently of their actual family size, the number of children they would like to have if they could start building their family again. There is usually a correlation between respondents’ actual and ideal Table 6.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children by background characteristics, The Gambia 2013 Background characteristic Total Residence Urban 3.3 Rural 2.5 Local Government Area Banjul 6.5 Kanifing 5.1 Brikama 2.5 Mansakonko 2.2 Kerewan 3.0 Kuntaur 0.3 Janjanbureh 0.8 Basse 2.4 Education No education 1.8 Primary 2.2 Secondary or higher 4.5 Wealth quintile Lowest 2.6 Second 3.3 Middle 0.9 Fourth 2.5 Highest 5.2 Total 15-49 2.9 50-59 19.0 Total 15-59 5.3 Note: Men who have been sterilised or who state in response to the question about desire for children that their wife has been sterilised are considered to want no more children. The table shows only the total column because the percentages of men who want no more children by number of living children are largely based on fewer than 25 unweighted cases and would have been suppressed. 1 The number of living children includes one additional child if the respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 72 • Fertility Preferences number of children. The reason is twofold. First, to the extent that respondents implement their preferences, those who want larger families will tend to achieve larger families. Second, respondents may adjust their ideal family size upward as their actual number of children increases. It is also possible that respondents with large families, being on average older than those with small families, have larger ideal family sizes because of attitudes they acquired 20 to 30 years ago. Despite the likelihood that some rationalisation occurs, however, it is common to find that many respondents state ideal sizes lower than their actual number of surviving children. Respondents fall into three categories: those whose ideal family size is greater than their actual family size, those whose ideal family size is less than their actual family size, and those whose ideal family size and actual family size are the same. The second category is of particular interest, because it is an indicator of surplus or unwanted fertility. Table 6.3 shows the distribution of respondents by their ideal number of children, according to number of living children. Fifty percent of women consider six or more children to be ideal, 21 percent consider five or more children to be ideal, and 17 percent consider four children to be ideal. Altogether, an overwhelming 88 percent of all women consider four or more children to be ideal. Table 6.3 Ideal number of children by number of living children Percent distribution of women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to the number of living children, The Gambia 2013 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN1 0 0.2 0.1 0.1 0.0 1.3 0.4 0.2 0.3 1 0.3 0.2 0.3 0.2 0.7 0.0 0.2 0.3 2 3.4 2.0 1.6 1.1 1.3 1.5 1.4 2.1 3 9.7 8.9 5.0 4.0 2.0 3.0 2.3 6.2 4 25.2 17.0 18.6 16.3 9.0 6.7 7.3 17.0 5 24.4 25.7 23.4 21.6 18.6 14.7 12.5 21.3 6+ 35.0 43.6 47.6 53.7 64.5 70.9 70.4 50.0 Non-numeric responses 1.9 2.4 3.4 3.1 2.6 2.8 5.7 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 3,363 1,406 1,267 1,094 916 810 1,377 10,233 Mean ideal number of children for:2 All women 5.3 5.7 5.9 6.1 6.6 6.9 7.3 6.0 Number of women 3,300 1,372 1,224 1,060 892 787 1,298 9,934 Currently married women 6.1 6.0 6.0 6.2 6.6 7.0 7.4 6.5 Number of currently married women 607 1,075 1,093 979 836 729 1,246 6,565 MEN3 0 0.2 0.0 0.0 0.1 2.6 1.6 0.8 0.3 1 0.4 0.3 0.0 0.0 0.0 0.0 0.0 0.3 2 2.0 0.9 2.3 0.0 0.0 2.4 0.7 1.6 3 9.0 7.4 4.7 7.1 1.9 0.0 1.4 7.2 4 16.4 15.9 17.1 9.9 7.0 3.3 2.0 14.0 5 19.8 16.4 18.7 16.9 8.5 8.2 1.8 16.9 6+ 49.1 52.0 52.1 57.8 71.4 74.4 84.9 54.9 Non-numeric responses 3.2 7.1 5.1 8.2 8.6 10.0 8.4 4.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 2,250 307 246 195 140 143 296 3,577 Mean ideal number of children for men age 15-49:2 All men 7.0 7.1 7.2 7.8 8.3 10.3 12.5 7.7 Number of men 2,179 285 234 179 128 129 271 3,405 Currently married men 6.7 7.5 7.3 7.9 7.9 10.4 12.5 8.9 Number of currently married men 102 230 216 175 127 128 271 1,249 Mean ideal number of children for men age 15-59:2 All men 7.0 7.1 7.1 7.9 8.0 10.0 12.7 7.9 Number of men 2,185 289 250 189 146 170 386 3,615 Currently married men 6.7 7.5 7.3 7.9 7.7 10.0 12.7 9.2 Number of currently married men 104 233 231 184 144 169 385 1,451 1 The number of living children includes the current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if the respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Fertility Preferences • 73 The mean ideal number of children is 6.0 among all women and 6.5 among currently married women. Mean ideal number of children increases with number of living children, from 5.3 among women with no children to 7.3 among women with six or more children. This indicates that women who have more living children have higher ideal family sizes than women with smaller families. In general, men want more children than women. The mean ideal number of children ranges from 7.0 among men with no children to 12.5 among men with six or more living children. There are no differences between all men and currently married men in ideal number of children. Overall, 55 percent of men consider six or more children to be ideal, 17 percent consider five or more children to be ideal, and 14 percent consider four children to be ideal. Eighty-six percent of all men consider four or more children to be ideal. 6.4 MEAN IDEAL NUMBER OF CHILDREN BY BACKGROUND CHARACTERISTICS There are variations in mean ideal number of children by background characteristics among all women age 15-49 (Table 6.4). The data show that the mean ideal number of children among women in The Gambia increases steadily with age, from 5.4 children among women age 15-19 to 6.9 children among those age 45-49. Urban women prefer to have fewer children than rural women (5.5 and 6.7 children, respectively). Among LGAs, the mean ideal number of children ranges from 4.5 for women in Banjul to 7.1 for women in Mansakonko. Desire for children decreases as education and wealth increase. For example, whereas women with no education want 6.8 children, those with a secondary education or higher want 5.1 children. Similarly, women in the lowest wealth quintile want 6.8 children on average, as compared with 5.0 children among women in the highest wealth quintile. 6.5 FERTILITY PLANNING STATUS The 2013 GDHS asked women with births in the five years preceding the survey whether the births were wanted at the time (planned), wanted at a later time (mistimed), or not wanted at all (unwanted). Table 6.5 shows the findings. The data show that almost nine in ten births in the five years preceding the survey (86 percent) were wanted at the time, 12 percent were mistimed, and only 1 percent were unwanted. The proportion of births wanted at the time of conception decreases slightly with increasing birth order and mother’s age, while the proportion of unwanted births increases with increasing birth order and mother’s age. Among women age 45-49, 19 percent of births in the five years before the survey were unwanted. Table 6.4 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, The Gambia 2013 Background characteristic Mean Number of women1 Age 15-19 5.4 2,364 20-24 5.7 2,068 25-29 6.0 1,767 30-34 6.4 1,466 35-39 6.5 1,012 40-44 6.7 725 45-49 6.9 532 Residence Urban 5.5 5,626 Rural 6.7 4,308 Local Government Area Banjul 4.5 219 Kanifing 5.1 2,314 Brikama 5.9 3,472 Mansakonko 7.1 485 Kerewan 6.4 957 Kuntaur 6.8 511 Janjanbureh 6.7 722 Basse 6.9 1,253 Education No education 6.8 4,541 Primary 6.2 1,376 Secondary or higher 5.1 4,016 Wealth quintile Lowest 6.8 1,662 Second 6.6 1,803 Middle 6.4 1,863 Fourth 5.8 2,092 Highest 5.0 2,514 Total 6.0 9,934 1 Number of women who gave a numeric response 74 • Fertility Preferences Table 6.5 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, The Gambia 2013 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 88.1 10.9 0.2 0.9 100.0 1,885 2 88.8 10.6 0.2 0.5 100.0 1,634 3 85.7 13.6 0.3 0.4 100.0 1,341 4+ 84.4 12.6 2.2 0.8 100.0 3,876 Mother’s age at birth <20 86.2 12.4 0.3 1.2 100.0 1,170 20-24 86.7 12.5 0.1 0.7 100.0 2,276 25-29 87.4 12.1 0.2 0.3 100.0 2,445 30-34 86.9 11.5 0.8 0.8 100.0 1,577 35-39 83.1 11.5 4.3 1.1 100.0 904 40-44 80.5 10.2 8.0 1.3 100.0 326 45-49 69.4 10.0 19.0 1.6 100.0 39 Total 86.2 12.0 1.1 0.7 100.0 8,736 6.6 WANTED FERTILITY RATES The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. A birth is considered wanted if the number of living children at the time of conception is lower than the ideal number of children reported by the respondent. The difference between wanted and actual fertility gives an indication of how successful women are in achieving their reproductive aspirations. Table 6.6 shows a comparison of the total wanted fertility rate with the total fertility rate for the three years preceding the survey by background characteristics. Overall, the total fertility rate in The Gambia (5.6 children per woman) is 0.9 children higher than the total wanted fertility rate (4.7 children per woman). Urban women are closer to achieving wanted fertility than rural women; the difference between wanted and actual fertility rates is 0.6 children among urban women and 1.2 children among rural women. Across LGAs, women in Kanifing are closest to achieving wanted fertility, with a difference in wanted and actual fertility rates of 0.6 children. Kerewan has the largest gap in wanted and actual fertility, with a difference of 1.8 children. The difference between total wanted and actual fertility rates decreases steadily with increasing education. In addition, women in the highest wealth quintile are much closer to achieving wanted fertility than those in the lower quintiles. For example, women in the lowest wealth quintile have a gap of 1.2 children, as compared with 0.5 children among those in the highest quintile. Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, The Gambia 2013 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 4.1 4.7 Rural 5.6 6.8 Local Government Area Banjul 3.1 3.9 Kanifing 3.4 4.0 Brikama 4.8 5.6 Mansakonko 5.0 6.0 Kerewan 4.5 6.3 Kuntaur 5.9 7.2 Janjanbureh 6.0 6.8 Basse 6.3 7.0 Education No education 5.6 6.6 Primary 5.5 6.6 Secondary or higher 3.5 4.1 Wealth quintile Lowest 5.5 6.7 Second 5.6 6.8 Middle 5.3 6.2 Fourth 4.6 5.3 Highest 3.3 3.8 Total 4.7 5.6 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 5.2. Family Planning • 75 FAMILY PLANNING 7 o attain a balance between resources and population, population policies in The Gambia promote family planning as an entitlement that is based on informed and voluntary choices. Couples are motivated to adopt a family planning method when they are offered access to high-quality reproductive health services. Adequate information about methods of contraception enables couples to develop a rational approach to planning their families. Therefore, a primary objective of this survey was to assess knowledge and use of contraceptive methods. This chapter covers women’s knowledge, history of use, and current use of contraceptive methods, as well as sources of modern methods and informed choice. In addition, exposure to family planning messages and level of contact with family planning providers are assessed. 7.1 KNOWLEDGE OF CONTRACEPTIVE METHODS One of the major objectives of the survey was to develop a profile concerning knowledge of family planning methods, since knowledge of at least one method is essential for making a decision to initiate contraceptive use. Broader knowledge of many methods can facilitate the choice of the most appropriate method. Information about knowledge of contraceptive methods was collected from both women and men by reading the name of each method of family planning and asking whether the respondent had ever heard of it. If necessary, the interviewer read a brief description of the method. Information was collected on 11 modern methods (female sterilisation, male sterilisation, the pill, the intrauterine device (IUD), injectables, implants, male condoms, female condoms, the lactational amenorrhoea method (LAM), diaphragm/foam/jelly, and emergency contraception). Two traditional methods were also included (rhythm/calendar method and withdrawal). In addition, provision was made in the questionnaire to record any other methods named spontaneously by the respondent. Table 7.1 shows the level of knowledge of contraceptive methods among all women and men age 15-49, as well as among those who are currently married and those who are unmarried but sexually active. T Key Findings • Almost all married women in The Gambia have heard of at least one method of family planning. • Only 9 percent of currently married women are using a method of contraception; 8 percent are using a modern method. • The methods most commonly used by married women are injectables and the pill. • The public sector serves 60 percent of contraceptive users, while the private sector serves one-quarter and nongovernmental groups serve 8 percent. Government health centres are the most important single source, serving 41 percent of users of modern family planning methods. • Overall, 28 percent of contraceptive users discontinued an episode within 12 months of starting its use, although 5 percent switched to another method following discontinuation. The main reasons for discontinuation are a desire to become pregnant and side effects/health concerns. • One-quarter of married women have an unmet need for family planning, mostly for spacing births. 76 • Family Planning Knowledge of any contraceptive method is generally high in The Gambia, with 96 percent of currently married women and 99 percent of currently married men knowing at least one method. Although women are the users of most of these methods, the mean number of methods known is higher among married men than women (7.3 and 6.1, respectively). Sexually active unmarried respondents are most likely to have heard of any method (100 percent of both women and men), followed by those who are currently married (96 percent of women and 99 percent of men) and all respondents (96 percent of women and 98 percent of men). Table 7.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who have heard of any contraceptive method, by specific method, The Gambia 2013 Method Women Men All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 95.6 96.3 100.0 98.2 98.9 100.0 Any modern method 95.3 95.8 100.0 97.9 98.1 100.0 Female sterilisation 69.0 73.7 80.0 57.0 67.2 64.9 Male sterilisation 11.6 11.8 21.9 27.0 31.1 35.3 Pill 89.1 91.9 95.4 82.4 87.7 91.4 IUD 39.5 44.3 54.6 26.3 33.1 31.6 Injectables 87.3 91.3 95.4 76.1 86.9 81.0 Implants 30.2 32.9 48.3 19.0 27.1 17.3 Male condom 86.5 85.5 99.2 97.1 96.9 99.9 Female condom 21.2 20.3 46.8 39.3 42.8 52.5 Diaphragm/foam/jelly 11.9 12.7 16.4 20.8 25.8 33.2 Lactational amenorrhoea (LAM) 11.6 13.2 13.2 20.8 25.8 33.2 Emergency contraception 14.5 15.0 33.1 33.4 39.8 46.1 Any traditional method 61.9 70.1 78.6 77.9 87.8 84.0 Rhythm 37.3 41.8 66.3 48.2 62.3 58.3 Withdrawal 48.9 56.5 69.3 72.1 82.5 78.7 Other 19.2 24.0 17.0 13.6 19.7 7.2 Mean number of methods known by respondents age 15-49 5.8 6.1 7.6 6.3 7.3 7.3 Number of respondents 10,233 6,791 73 3,577 1,360 245 Mean number of methods known by respondents age 15-59 na na na 6.4 7.3 7.3 Number of respondents na na na 3,821 1,593 246 na = Not applicable 1 Had last sexual intercourse within 30 days preceding the survey Among women, modern methods are more widely known than traditional methods; 96 percent of married women know at least one modern method, while only 70 percent know at least one traditional method. Married women are most likely to have heard of pills (92 percent), injectables (91 percent), and male condoms (86 percent). Among currently married women, more than seven in ten have heard of female sterilisation, more than four in ten have heard of the IUD, three in ten have heard about implants, and two in ten have heard of female condoms. The least known modern methods are male sterilisation, diaphragm/foam/jelly, lactational amenorrhoea, and emergency contraception, all of which are known by 15 percent or less of married women. With regard to traditional methods, over half of married women know about withdrawal, while only four in ten know about the rhythm method. As might be expected, married men are more likely than women to know about the male-oriented methods such as male sterilisation, male condoms, and withdrawal. However, they are also more likely than women to know about female condoms, diaphragm/foam/jelly, LAM, emergency contraception, and the rhythm method. Women are more likely than men to know about the pill, female sterilisation, the IUD, injectables, and implants. Family Planning • 77 7.2 KNOWLEDGE OF CONTRACEPTIVE METHODS BY BACKGROUND CHARACTERISTICS Table 7.2 presents data on the proportion of currently married women and men who have heard of at least one contraceptive method by background characteristics. The proportion of currently married women and men who have heard of at least one contraceptive method and at least one modern contraceptive method exceeds 90 percent in all categories by age, residence, Local Government Area (LGA), education, and wealth. Among women, there is a tendency for the proportions who have heard of any method or any modern method to rise slightly with age, education, and wealth. This correlation does not hold among men. Both women and men in urban areas are slightly more likely to have heard of a contraceptive method than those in rural areas. Currently married women and men in Brikama are slightly more likely to have heard of a method than those in other LGAs. Table 7.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method, by background characteristics, The Gambia 2013 Women Men Background characteristic Heard of any method Heard of any modern method1 Number of women Heard of any method Heard of any modern method1 Number of men Age 15-19 91.1 90.9 573 * * 2 20-24 95.8 95.4 1,237 100.0 100.0 57 25-29 97.1 96.6 1,528 97.5 95.8 197 30-34 96.4 95.9 1,319 99.7 99.4 307 35-39 97.3 97.1 966 99.3 98.7 344 40-44 97.0 96.3 673 98.5 97.6 245 45-49 98.0 97.2 496 98.8 97.3 208 Residence Urban 97.9 97.9 3,356 99.3 98.7 758 Rural 94.7 93.8 3,435 98.4 97.3 602 Local Government Area Banjul 96.8 96.6 114 97.6 97.2 30 Kanifing 97.8 97.8 1,258 98.5 97.3 286 Brikama 98.5 98.5 2,282 100.0 99.7 508 Mansakonko 95.5 95.1 344 97.9 94.5 59 Kerewan 95.8 93.2 801 99.2 97.4 143 Kuntaur 95.8 95.0 427 99.3 98.9 73 Janjanbureh 91.9 91.1 550 98.5 98.5 92 Basse 92.6 92.5 1,015 96.9 95.9 170 Education No education 94.8 94.1 4,125 98.2 96.7 649 Primary 98.0 98.0 912 99.8 99.5 161 Secondary or higher 98.8 98.7 1,754 99.5 99.3 550 Wealth quintile Lowest 93.6 92.8 1,303 98.1 96.4 247 Second 95.8 95.0 1,404 99.4 98.7 248 Middle 96.4 95.9 1,386 99.1 98.5 246 Fourth 96.3 96.3 1,344 99.2 97.8 330 Highest 99.2 99.1 1,354 98.9 98.9 289 Total 15-49 96.3 95.8 6,791 98.9 98.1 1,360 50-59 na na na 99.4 95.5 233 Total 15-59 na na na 99.0 97.7 1,593 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, diaphragm/foam/jelly, lactational amenorrhoea method (LAM), and emergency contraception 78 • Family Planning 7.3 CURRENT USE OF CONTRACEPTIVE METHODS Table 7.3 shows the percent distribution of all women, currently married women, and sexually active unmarried women age 15-49 by contraceptive method currently used, according to age. The data show that only 9 percent of currently married women in The Gambia are using a contraceptive method; 8 percent are using modern methods and 1 percent are using traditional methods. Injectables are the most commonly used method (4 percent) among married women, followed by the pill (2 percent). Contraceptive use differs according to age. Use among currently married women is lowest among those age 15-19 (3 percent), peaks among women age 35-39 (12 percent), and then declines among those age 45-49 (8 percent). Injectables are the most common method used by married women in all age groups up to age 40-49, at which point use of the pill becomes slightly higher. Contraceptive use is lower among all women than among currently married women (7 percent and 9 percent, respectively), but the patterns of use are similar in the two groups. Sexually active unmarried women are by far the most likely to be using contraception (44 percent), and male condoms are the most widely used method in this group. A comparison of the data from the 2013 GDHS with previous data shows that contraceptive use may be declining in The Gambia. The proportion of married women currently using any method declined from 13 percent in the 2010 Multiple Indicator Cluster Survey (GBoS and UNICEF, 2011) to 9 percent in 2013. However, most of the apparent decline is related to use of traditional methods; the proportion of married women using modern methods is virtually indistinguishable between the two surveys (9 percent in 2010 and 8 percent in 2013). Fa m ily P la nn in g • 7 9 Ta bl e 7. 3 C ur re nt u se o f c on tra ce pt io n by a ge Pe rc en t d is tri bu tio n of a ll w om en , c ur re nt ly m ar rie d w om en , a nd s ex ua lly a ct iv e un m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rre nt ly u se d, a cc or di ng to a ge , T he G am bi a 20 13 Ag e An y m et ho d An y m od er n m et ho d M od er n m et ho d A ny tr ad i- tio na l m et ho d Tr ad iti on al m et ho d N ot cu rre nt ly us in g To ta l N um be r of w om en Fe m al e st er ili- sa tio n P ill IU D In je ct - ab le s Im pl an ts M al e co nd om R hy th m W ith - dr aw al O th er AL L W O M EN 15 -1 9 1. 1 0. 8 0. 0 0. 1 0. 0 0. 3 0. 0 0. 4 0. 3 0. 0 0. 0 0. 3 98 .9 10 0. 0 2, 40 7 20 -2 4 5. 3 4. 8 0. 0 0. 6 0. 0 2. 9 0. 3 1. 0 0. 5 0. 0 0. 2 0. 2 94 .7 10 0. 0 2, 12 5 25 -2 9 8. 8 8. 5 0. 1 2. 4 0. 4 3. 6 0. 4 1. 5 0. 3 0. 1 0. 2 0. 1 91 .2 10 0. 0 1, 82 2 30 -3 4 11 .9 10 .6 0. 4 2. 3 0. 4 5. 3 1. 5 0. 7 1. 3 0. 3 0. 7 0. 3 88 .1 10 0. 0 1, 50 4 35 -3 9 12 .4 11 .9 0. 3 3. 1 0. 5 6. 8 0. 4 0. 7 0. 6 0. 1 0. 1 0. 4 87 .6 10 0. 0 1, 05 6 40 -4 4 10 .8 9. 4 1. 5 3. 3 1. 1 2. 7 0. 8 0. 0 1. 3 0. 5 0. 2 0. 6 89 .2 10 0. 0 76 1 45 -4 9 7. 0 5. 9 3. 4 1. 0 0. 2 1. 0 0. 0 0. 3 1. 0 0. 0 0. 0 1. 0 93 .0 10 0. 0 55 9 To ta l 7. 1 6. 5 0. 4 1. 5 0. 3 3. 0 0. 5 0. 8 0. 6 0. 1 0. 2 0. 3 92 .9 10 0. 0 10 ,2 33 C U R R E N TL Y M A R R IE D W O M EN 15 -1 9 3. 3 2. 2 0. 0 0. 1 0. 2 1. 1 0. 0 0. 8 1. 1 0. 0 0. 0 1. 1 96 .7 10 0. 0 57 3 20 -2 4 6. 4 5. 7 0. 0 1. 0 0. 0 3. 8 0. 1 0. 8 0. 7 0. 0 0. 4 0. 2 93 .6 10 0. 0 1, 23 7 25 -2 9 8. 4 8. 0 0. 1 2. 5 0. 4 3. 6 0. 4 0. 9 0. 4 0. 1 0. 2 0. 1 91 .6 10 0. 0 1, 52 8 30 -3 4 11 .6 10 .2 0. 4 2. 4 0. 4 5. 1 1. 6 0. 4 1. 3 0. 3 0. 6 0. 4 88 .4 10 0. 0 1, 31 9 35 -3 9 12 .1 11 .5 0. 3 3. 3 0. 4 6. 7 0. 5 0. 3 0. 6 0. 1 0. 1 0. 4 87 .9 10 0. 0 96 6 40 -4 4 11 .1 9. 6 1. 7 3. 2 0. 8 3. 0 0. 9 0. 0 1. 5 0. 6 0. 2 0. 7 88 .9 10 0. 0 67 3 45 -4 9 7. 7 6. 6 3. 8 1. 2 0. 2 1. 1 0. 0 0. 3 1. 2 0. 0 0. 0 1. 2 92 .3 10 0. 0 49 6 To ta l 9. 0 8. 1 0. 6 2. 1 0. 3 3. 9 0. 6 0. 6 0. 9 0. 2 0. 3 0. 4 91 .0 10 0. 0 6, 79 1 SE XU AL LY A C TI VE U N M A R R IE D W O M EN 1 To ta l 43 .8 42 .0 0. 0 6. 5 1. 9 10 .6 0. 0 23 .0 1. 8 0. 0 0. 0 1. 8 56 .2 10 0. 0 73 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. M et ho ds th at a re n ot c ur re nt ly u se d by a ny w om en a re n ot s ho w n. 1 W om en w ho h ad s ex ua l i nt er co ur se w ith in 3 0 da ys p re ce di ng th e su rv ey Family Planning • 79 80 • Family Planning 7.4 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS Current use of contraceptive methods also differs by background characteristics (Table 7.4). Use of contraception increases with increasing number of living children, from 1 percent among currently married women with no children to 11 percent among women with five or more children. Urban women are much more likely to use a contraceptive than rural women (13 percent and 5 percent, respectively). Contraceptive use is highest in the capital city of Banjul (21 percent), followed by Kanifing (15 percent) and Brikama (11 percent). Basse has the lowest contraceptive prevalence rate (1 percent). Current use of contraception increases steadily with increasing education, from 6 percent among married women with no education to 8 percent among women with only a primary education and 17 percent among women with a secondary education or higher. Similarly, use of any method of contraception increases with increasing wealth, from 5 percent among married women in the lowest wealth quintile to 17 percent among those in the highest quintile. Table 7.4 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, The Gambia 2013 Background characteristic Any method Any modern method Modern method Any tradi- tional method Traditional method Not currently using Total Number of women Female sterili- sation Pill IUD Inject- ables Implants Male condom Rhythm With- drawal Other Number of living children 0 1.1 1.0 0.0 0.0 0.0 0.0 0.0 1.0 0.1 0.0 0.1 0.0 98.9 100.0 771 1-2 8.6 7.6 0.3 1.5 0.4 4.0 0.5 0.8 1.0 0.0 0.5 0.4 91.4 100.0 2,212 3-4 10.3 9.3 0.8 2.6 0.2 4.4 0.8 0.5 1.0 0.5 0.2 0.3 89.7 100.0 1,818 5+ 11.3 10.3 1.0 3.1 0.5 4.9 0.6 0.2 0.9 0.0 0.1 0.8 88.7 100.0 1,990 Residence Urban 13.0 11.8 0.8 3.5 0.5 5.0 1.2 0.9 1.2 0.3 0.4 0.4 87.0 100.0 3,356 Rural 5.0 4.4 0.4 0.7 0.2 2.8 0.0 0.2 0.6 0.0 0.1 0.4 95.0 100.0 3,435 Local Government Area Banjul 21.1 20.7 0.8 8.1 0.9 9.9 0.2 0.6 0.4 0.4 0.0 0.0 78.9 100.0 114 Kanifing 14.6 13.4 0.6 4.2 0.5 5.4 1.6 1.1 1.3 0.4 0.7 0.1 85.4 100.0 1,258 Brikama 11.1 9.9 1.0 2.5 0.4 4.6 0.7 0.6 1.2 0.2 0.3 0.7 88.9 100.0 2,282 Mansakonko 8.0 7.0 0.7 0.6 0.3 4.1 0.0 1.3 0.9 0.4 0.0 0.5 92.0 100.0 344 Kerewan 7.1 6.4 0.6 0.8 0.3 4.2 0.1 0.3 0.7 0.0 0.1 0.5 92.9 100.0 801 Kuntaur 4.2 4.0 0.1 1.3 0.0 2.4 0.0 0.2 0.2 0.0 0.1 0.1 95.8 100.0 427 Janjanbureh 5.8 5.1 0.3 1.5 0.3 2.7 0.3 0.1 0.7 0.0 0.0 0.7 94.2 100.0 550 Basse 1.3 1.0 0.0 0.1 0.0 0.8 0.0 0.1 0.3 0.0 0.1 0.1 98.7 100.0 1,015 Education No education 6.0 5.5 0.5 1.4 0.1 3.1 0.2 0.2 0.5 0.0 0.1 0.4 94.0 100.0 4,125 Primary 7.7 6.4 0.6 1.4 0.2 3.7 0.2 0.4 1.2 0.2 0.5 0.5 92.3 100.0 912 Secondary or higher 16.7 15.0 0.8 4.1 1.0 6.0 1.6 1.6 1.7 0.5 0.6 0.6 83.3 100.0 1,754 Wealth quintile Lowest 4.7 4.2 0.2 0.5 0.0 3.2 0.0 0.2 0.4 0.0 0.2 0.2 95.3 100.0 1,303 Second 5.9 4.8 0.3 1.3 0.3 2.8 0.0 0.2 1.0 0.0 0.0 1.0 94.1 100.0 1,404 Middle 5.8 5.5 1.0 0.8 0.2 2.7 0.0 0.8 0.3 0.0 0.1 0.2 94.2 100.0 1,386 Fourth 12.1 10.8 0.2 3.4 0.6 4.8 1.2 0.5 1.3 0.6 0.4 0.3 87.9 100.0 1,344 Highest 16.5 15.1 1.3 4.3 0.6 6.1 1.7 1.2 1.4 0.2 0.7 0.5 83.5 100.0 1,354 Total 9.0 8.1 0.6 2.1 0.3 3.9 0.6 0.6 0.9 0.2 0.3 0.4 91.0 100.0 6,791 Note: If more than one method is used, only the most effective method is considered in this tabulation. Methods that are not currently used by any women are not shown. 7.5 SOURCE OF CONTRACEPTION Information on where women obtain their contraceptive methods is useful for family planning programme managers and implementers for logistics planning. In the 2013 GDHS, all women who reported that they were using a modern contraceptive method at the time of the survey were asked where they obtained the method the last time. Since women may not know exactly in which category the source falls (e.g., government or private, health centre or clinic), interviewers were instructed to write the full Family Planning • 81 name of the source or facility on the questionnaire to allow checking and possible recoding after the interview. Table 7.5 shows the percent distribution of users of modern contraceptive methods by the most recent method source. Sixty percent of users obtain their method from a public (government) facility, while 26 percent were supplied through private medical sources, 8 percent through the nongovernmental (NGO) medical sector, and 4 percent through other sources. The most common single source of contraceptives in The Gambia is government health centres, which supply about two-fifths (41 percent) of all users of modern methods. Private pharmacies supply about one-fifth (21 percent) of users, and government hospitals supply 16 percent. The sources of contraceptive methods vary by method used. Government hospitals are by far the predominant source for female sterilisations (93 percent). Public sector sources also supply 69 percent of injectable users, two-thirds of IUD users, and just over half of pill users, mainly through government health centres. Private pharmacies are the main suppliers of male condoms (48 percent), followed by friends and relatives (30 percent). Table 7.5 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, The Gambia 2013 Source Female sterilisation Pill IUD Injectables Male condom Total Public sector (93.3) 52.3 (65.5) 69.1 12.4 60.1 Government hospital (91.9) 9.8 (15.8) 10.8 1.8 15.6 Government health centre (0.0) 38.4 (49.7) 52.8 9.7 40.8 Government health post (1.4) 3.9 (0.0) 3.6 1.0 2.8 Government fieldworker (0.0) 0.2 (0.0) 1.9 0.0 0.9 Private medical sector (6.7) 38.9 (20.3) 20.0 47.6 25.5 Private hospital/clinic (6.7) 4.3 (14.2) 3.3 0.0 3.6 Private pharmacy (0.0) 31.1 (0.0) 16.2 47.6 20.6 Private doctor (0.0) 3.5 (6.1) 0.2 0.0 1.2 Private fieldworker (0.0) 0.0 (0.0) 0.3 0.0 0.1 NGO medical sector (0.0) 4.5 (14.3) 9.2 0.7 7.7 NGO hospital/clinic/mobile clinic (0.0) 0.5 (0.0) 1.5 0.0 0.8 Family planning clinic (0.0) 4.0 (14.3) 7.7 0.7 6.9 Other source (0.0) 1.6 (0.0) 0.0 30.2 3.9 Shop (0.0) 0.0 (0.0) 0.0 0.5 0.1 Friend/relative (0.0) 1.6 (0.0) 0.0 29.7 3.9 Other (0.0) 0.0 (0.0) 0.0 5.0 0.8 Missing (0.0) 2.7 (0.0) 1.6 4.0 1.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 42 158 29 312 78 666 Note: Total includes other modern methods, such as implants, but excludes lactational amenorrhoea method (LAM). Figures in parentheses are based on 25-49 unweighted cases. 7.6 BRANDS OF PILLS USED AND INFORMED CHOICE Women age 15-49 who were currently using oral contraceptives and condoms were asked for the brand name of the pills and condoms they last used. Among pill users, 75 percent use Microgynon and 25 percent use Microlut (data not shown). Users of contraceptive methods who are informed of potential side effects or problems associated with each method are best able to make an informed choice about the method they would like to use. In the 2013 GDHS, current users of various modern contraceptive methods who started the most recent episode of use within the five years preceding the survey were asked whether they were informed of possible side effects or problems with the methods they were using, whether they were told what to do if they experienced side effects, and whether they were informed about other methods of contraception they could use. Table 7.6 presents the results by method type and source of the method. 82 • Family Planning Table 7.6 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, the percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods they could use, by method and initial source, The Gambia 2013 Method/source Among women who started last episode of modern contraceptive method within five years preceding the survey: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if side effects experienced Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Pill 46.3 36.5 56.4 149 Injectables 44.2 38.5 55.0 296 Initial source of method1 Public sector 45.0 40.6 57.7 370 Government hospital 42.9 35.2 45.7 89 Government health centre 44.9 41.5 61.2 262 Private medical sector 42.3 33.1 43.5 103 Private pharmacy 33.7 25.2 42.1 73 NGO medical sector (47.0) (40.8) (67.2) 52 Family planning clinic (43.2) (36.6) (64.9) 48 Total 43.8 38.5 54.4 543 Note: Table includes users of only the methods listed individually and methods with 25 or more unweighted numbers of users. Figures in parentheses are based on 25-49 unweighted cases. 1 Source at start of current episode of use The results show that less than half (44 percent) of users were informed of the side effects of the method they were provided, and only 39 percent were informed of what to do if they experienced side effects. More than half (54 percent) of users of modern contraceptive methods were informed of other methods that could be used. Only two methods are used by numbers of women sufficiently large for tabulation (pill and injectables), and the results do not show any large differences in measures of informed choice between users of these methods. However, differences by the source of the method are larger. Women who obtained their method from a public (government) source were more likely than those who used a private medical source to be informed about side effects of the method, about what to do if they experienced side effects, and about other methods they could use. Levels of all three measures of informed choice were particularly low for private pharmacies. 7.7 CONTRACEPTIVE DISCONTINUATION Couples can realise their reproductive goals only when they use contraceptive methods continuously. A prominent concern for managers of family planning programmes is discontinuation of methods. All segments of contraceptive use between January 2008 and the date of the interview were recorded in the calendar section of the questionnaire, along with reasons for any discontinuations. Five- year contraceptive discontinuation rates based on the calendar data are presented in Table 7.7.1 1 The discontinuation rates presented here include only those segments of contraceptive use initiated since January 2008. The rates apply to the 3- to 62-month period prior to the survey; exposure during the month of the interview and the two months prior is excluded to avoid the biases that may be introduced by unrecognised pregnancies. These cumulative discontinuation rates represent the proportion of users discontinuing a method within 12 months after the start of use. The rates are calculated by dividing the number of women discontinuing a method by the number exposed at that duration. The single-month rates are then cumulated to produce a one-year rate. Family Planning • 83 Table 7.7 Twelve-month contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months, by reason for discontinuation and specific method, The Gambia 2013 Method Method failure Desire to become pregnant Other fertility- related reasons1 Side effects/ health concerns Wanted more effective method Other method- related reasons2 Other reasons Any reason3 Switched to another method4 Number of episodes of use5 Pill 2.2 7.0 3.2 6.9 1.9 6.1 9.6 36.7 6.7 289 Injectables 1.6 7.0 0.9 10.4 1.1 1.5 4.5 27.1 4.0 414 All methods 2.0 7.0 1.9 7.1 1.9 2.9 5.5 28.3 4.6 946 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months preceding the survey. 1 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation 2 Includes lack of access/too far, costs too much, and inconvenient to use 3 Reasons for discontinuation are mutually exclusive and add to the total given in this column. 4 The episodes of use included in this column are a subset of the discontinued episodes included in the discontinuation rate. A woman is considered to have switched to another method if she used a different method in the month following discontinuation or if she gave “wanted a more effective method” as the reason for discontinuation and started another method within 2 months of discontinuation. 5 Number of episodes of use includes both episodes of use that were discontinued during the period of observation and episodes of use that were not discontinued during the period of observation. Overall, more than one-quarter of women (28 percent) who start using a contraceptive method discontinue the method within 12 months. The main reasons for stopping use are side effects/health concerns (7 percent) and a desire to get pregnant (7 percent). Three percent of users stop because of method-related reasons such as lack of access, excessive costs, and inconvenience of the method. Two percent of women discontinue because the method failed (i.e., they became pregnant while using). Similar proportions stopped using because they wanted a more efficient method or for fertility-related reasons such as infrequent sexual exposure or menopause. It is encouraging to note that 5 percent of women discontinued a method but started using another method soon thereafter. As expected, discontinuation rates are much higher among pill users (37 percent) than among users of injectables (27 percent). For each reason presented, discontinuation rates are equal or higher for the pill than for injectables with the exception of side effects/health concerns, which is given as a reason for 10 percent of discontinuations of injectables. Table 7.8 provides information about women’s reasons for discontinuing contraception. The table includes all discontinuations in the five years preceding the survey, regardless of whether they occurred during the first 12 months of use or later. The reason given most frequently for discontinuation was the desire to get pregnant (40 percent), followed by side effects or health concerns (17 percent), method failure (8 percent), and desire for a more effective method (7 percent). The other reasons cited by women for discontinuation were husband’s disapproval (5 percent), infrequent sex or husband’s absence (4 percent), and inconvenience of use (3 percent). Only 2 percent of discontinuations were due to lack of access and to excessive cost. With regard to specific methods, discontinuations of the pill are somewhat more likely than discontinuations of injectables to be due to method failure or inconvenience of the method. Users of injectables are more likely than pill users to discontinue because of side effects or health concerns with the method and because of a desire to get pregnant. 84 • Family Planning Table 7.8 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method, The Gambia 2013 Reason Pill Injectables Male condom Other All methods Became pregnant while using 8.0 5.6 (0.3) (32.8) 7.5 Wanted to become pregnant 36.6 43.4 (37.5) (35.4) 39.6 Husband disapproved 6.8 3.2 (0.0) (0.0) 4.6 Wanted a more effective method 4.3 5.6 (21.4) (14.3) 6.6 Side effects/health concerns 16.5 21.5 (0.0) (0.0) 17.0 Lack of access/too far 3.4 2.3 (0.4) (0.0) 2.3 Cost too much 1.6 1.6 11.8) (0.0) 2.3 Inconvenient to use 4.9 0.8 (7.5) (0.0) 3.3 Up to God/fatalistic 0.0 0.1 (0.0) (0.0) 0.0 Infrequent sex/husband away 3.5 3.5 (8.8) (0.0) 3.6 Marital dissolution/separation 0.0 0.2 (0.0) (0.0) 0.1 Other 3.4 3.9 (0.0) (0.0) 3.0 Missing 10.9 8.3 (12.3) (17.5) 10.2 Total 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 216 251 46 23 577 Note: Table shows only methods with more 25 or more unweighted numbers of users. Figures in parentheses are based on 25-49 unweighted cases. 7.8 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for successful practice of coitus- associated methods such as withdrawal and condoms. Such knowledge is particularly critical in the use of the rhythm method. The 2013 GDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during her menstrual cycle. Respondents were asked “From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?” If the reply was yes, the respondent was further asked whether that time was just before a woman’s period begins, during her period, right after her period has ended, or halfway between two periods. The data show that women’s knowledge of the fertile period is generally low. Only 26 percent of women correctly identified a woman’s fertile period as occurring halfway between two menstrual periods (Table 7.9). One-third of women think that a woman is most fertile right after her period has ended, while 12 percent think that the fertile period occurs just before her period begins. Fourteen percent of women report that there is no specific time when a woman is more fertile, and 11 percent report that they do not know when a woman’s fertile period occurs (data not shown). 7.9 NEED FOR FAMILY PLANNING SERVICES This section focuses on the extent of need and potential demand for family planning services in The Gambia. Family planning methods can be used to either space or limit childbearing. The proportion of women who want to stop childbearing or who want to space their next birth is a crude measure of the extent of the need for family planning, given that not all of these women are exposed to the risk of pregnancy and some of them may already be using contraception. Table 7.9 Knowledge of fertile period Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, The Gambia 2013 Perceived fertile period All women Just before her menstrual period begins 11.9 During her menstrual period 4.5 Right after her menstrual period has ended 32.3 Halfway between two menstrual periods 25.9 No specific time 13.7 Don’t know 11.1 Missing 0.5 Total 100.0 Number of women 10,233 Family Planning • 85 Unmet need for family planning refers to fecund women who are not using contraception but who wish to postpone their next birth (spacing) or stop childbearing altogether (limiting). Specifically, women are considered to have an unmet need for spacing if they are: • At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years or are unsure if or when they want to become pregnant. • Pregnant with a mistimed pregnancy. • Postpartum amenorrhoeic for up to two years following a mistimed birth and not using contraception. Women are considered to have an unmet need for limiting if they are: • At risk of becoming pregnant, not using contraception, and want no (more) children. • Pregnant with an unwanted pregnancy. • Postpartum amenorrhoeic for up to two years following an unwanted birth and not using contraception. Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Women who are using contraception are considered to have a met need. Women using contraception who say they want no (more) children are considered to have a met need for limiting, and women who are using contraception and say they want to delay having a child or are unsure if or when they want a (another) child are considered to have a met need for spacing. Unmet need, total demand, percentage of demand satisfied, and percentage of demand satisfied by modern methods are defined as follows: • Unmet need: the sum of unmet need for spacing and unmet need for limiting • Total demand for family planning: the sum of unmet need and total contraceptive use • Percentage of demand satisfied: total contraceptive use divided by the sum of unmet need and total contraceptive use • Percentage of demand satisfied by modern methods: total modern contraceptive use divided by the sum of unmet need and total contraceptive use Table 7.10 presents information on unmet need, met need, total demand for family planning services among currently married women, and percentage of the demand for contraception that is satisfied, according to background characteristics. Overall, one in every four currently married women in The Gambia have an unmet need for family planning - 20 percent have an unmet need for spacing, and 5 percent have an unmet need for limiting births. Need for family planning varies by age group. Women in the youngest and oldest age groups have the lowest unmet need (17 percent and 19 percent, respectively), whereas unmet need is relatively high and stable among women age 20-44. Unmet need for spacing is highest among women age 25-29 (27 percent), while unmet need for limiting is highest in the 40-44 age group (17 percent). Up to age 39, the majority of unmet need for family planning is related to spacing, while for women age 40-49 unmet need mainly relates to limiting. 86 • Family Planning Unmet need for family planning is only slightly higher among rural women (25 percent) than urban women (24 percent). At the LGA level, total unmet need for family planning is highest in Janjanbureh (33 percent) and lowest in Mansakonko and Basse (21 percent each). Unmet need varies little by education or wealth quintile. Table 7.10 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, The Gambia 2013 Background characteristic Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Per- centage of demand satisfied2 Per- centage of demand satisfied by modern methods3 Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 16.8 0.0 16.9 3.3 0.0 3.3 20.1 0.0 20.2 16.4 10.9 573 20-24 23.3 0.2 23.5 6.3 0.0 6.4 29.6 0.3 29.9 21.3 19.1 1,237 25-29 27.4 0.7 28.2 8.2 0.2 8.4 35.6 1.0 36.6 23.0 21.9 1,528 30-34 22.4 3.2 25.6 9.6 2.0 11.6 32.0 5.2 37.2 31.1 27.5 1,319 35-39 16.6 9.9 26.4 5.6 6.5 12.1 22.1 16.4 38.5 31.3 29.7 966 40-44 11.2 16.6 27.8 3.5 7.6 11.1 14.8 24.2 38.9 28.6 24.7 673 45-49 4.7 14.3 18.9 0.9 6.8 7.7 5.5 21.1 26.6 29.0 24.6 496 Residence Urban 19.1 5.2 24.4 9.5 3.5 13.0 28.6 8.8 37.4 34.8 31.6 3,356 Rural 20.8 4.6 25.4 3.3 1.7 5.0 24.1 6.3 30.4 16.4 14.5 3,435 Local Government Area Banjul 19.4 6.8 26.2 14.1 7.0 21.1 33.5 13.8 47.3 44.7 43.8 114 Kanifing 20.1 5.7 25.8 11.2 3.5 14.6 31.2 9.2 40.4 36.2 33.1 1,258 Brikama 19.3 5.2 24.5 7.2 3.9 11.1 26.6 9.1 35.6 31.2 27.8 2,282 Mansakonko 16.9 3.7 20.6 6.1 1.9 8.0 22.9 5.7 28.6 27.9 24.6 344 Kerewan 22.4 4.8 27.2 4.8 2.3 7.1 27.2 7.1 34.3 20.6 18.7 801 Kuntaur 18.9 4.0 22.9 3.0 1.3 4.2 21.9 5.2 27.1 15.6 14.7 427 Janjanbureh 27.1 5.4 32.5 5.0 0.9 5.8 32.0 6.3 38.3 15.2 13.3 550 Basse 17.3 3.7 21.0 1.0 0.3 1.3 18.2 4.0 22.3 5.8 4.6 1,015 Education No education 18.5 6.2 24.7 3.7 2.3 6.0 22.2 8.4 30.7 19.5 17.9 4,125 Primary 24.2 3.3 27.5 5.5 2.2 7.7 29.7 5.4 35.1 21.8 18.3 912 Secondary or higher 21.2 2.9 24.1 13.0 3.7 16.7 34.2 6.6 40.8 40.9 36.9 1,754 Wealth quintile Lowest 19.9 4.5 24.3 3.4 1.2 4.7 23.3 5.7 29.0 16.1 14.6 1,303 Second 22.0 4.7 26.7 3.7 2.1 5.9 25.7 6.8 32.5 18.0 14.9 1,404 Middle 19.9 5.3 25.2 3.7 2.0 5.8 23.6 7.3 30.9 18.6 17.7 1,386 Fourth 19.9 4.9 24.8 9.0 3.1 12.1 28.9 8.0 36.9 32.8 29.3 1,344 Highest 18.3 5.3 23.5 11.8 4.7 16.5 30.1 10.0 40.0 41.2 37.7 1,354 Total 20.0 4.9 24.9 6.3 2.6 9.0 26.3 7.6 33.9 26.5 23.8 6,791 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilisation, pill, IUD, injectables, implants, and male condom. No currently married women report current use of the other modern methods. As mentioned above, 9 percent of currently married women are using contraception, so they are considered to have a met need for family planning. Six percent of these women are using contraception to space births and 3 percent to limit childbearing. The total demand for family planning (the sum of met and unmet need) among currently married women is 34 percent, 26 percent for spacing purposes and 8 percent for limiting births. Only 27 percent of the total demand is satisfied, with 24 percent satisfied by modern family planning methods. The total demand for family planning and the proportion of demand that is satisfied increase with increasing education and wealth, but this pattern is due entirely to the fact that current use (met need) increases with these two variables. Family Planning • 87 7.10 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which nonusers plan to use contraceptive methods in the future. In the 2013 GDHS, women age 15-49 who were not using any contraceptive method at the time of the survey were asked about their intention to use family planning in the future. Table 7.11 shows that 21 percent of currently married nonusers intend to use a method of contraception in the future, 6 percent are unsure of their intentions, and 73 percent have no intention of using any method in the future. Notably, intentions for future use of a contraceptive method vary only minimally according to number of living children. Nonetheless, the proportion of women who intend to use contraception increases slightly with increasing numbers of living children. Table 7.11 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, The Gambia 2013 Intention Number of living children1 Total 0 1 2 3 4+ Intends to use 17.1 19.8 20.6 21.7 21.0 20.5 Unsure 9.1 8.5 5.2 5.0 4.4 5.8 Does not intend to use 73.5 71.2 74.0 72.6 73.3 73.0 Missing 0.3 0.5 0.3 0.7 1.2 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 606 1,025 1,018 916 2,617 6,182 1 Includes current pregnancy 7.11 EXPOSURE TO FAMILY PLANNING MESSAGES IN THE MEDIA Exposure to family planning messages is a vital component in delivering family planning services to both urban and rural residents. Information on the level of public exposure to a particular type of media allows policymakers to use the most effective media for various target groups in the population. In order to assess the effectiveness of such media in disseminating family planning information, women and men interviewed in the 2013 GDHS were asked whether, in the few months before the survey, they had heard or seen family planning messages on the radio or television, in a newspaper or magazine, through peer health education, from friends or relatives, from traditional communicators, through the Internet, or from health personnel. Table 7.12 shows the percentage of women and men who were exposed to family planning messages through the various types of media. Friends and relatives are the most frequent source of family planning messages for both women (43 percent) and men (48 percent) age 15-49, followed by radio (34 percent of women and 43 percent of men) and television (22 percent of women and 29 percent of men). The Internet is the least common source of family planning messages among both women and men (2 percent and 8 percent, respectively). Men are more likely than women to be exposed to family planning messages; this is true for each specific type of source other than health personnel, who are slightly more likely to reach women than men. The sharpest difference by gender occurs for peer health education, which reaches 22 percent of men with a family planning message as opposed to only 8 percent of women. Women are more likely than men to have no exposure to any of the eight sources of family planning messages (41 percent and 32 percent, respectively). As expected, family planning media exposure varies by background characteristics for both women and men. Exposure to family planning messages is generally more common among those age 20- 44 and is more common in urban than rural areas. Among both women and men, exposure to family planning messages is highest in Kuntaur and lowest in Basse. The data also show that the higher a respondent’s educational level, the greater the likelihood that she or he has been exposed to a family planning message through at least one of the eight types of media. Media exposure also generally increases with increasing wealth. 88 • F am ily P la nn in g Ta bl e 7. 12 E xp os ur e to fa m ily p la nn in g m es sa ge s P er ce nt ag e of w om en a nd m en a ge 1 5- 49 w ho h ea rd o r s aw a fa m ily p la nn in g m es sa ge o n ra di o, o n te le vi si on , o r i n a ne w sp ap er o r m ag az in e, o r t hr ou gh p ee r h ea lth e du ca tio n, fr ie nd s or tr ad iti on al c om m un ic at or s, in th e pa st fe w m on th s, ac co rd in g to b ac kg ro un d ch ar ac te ris tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic W om en M en R ad io Te le vi si on N ew s- pa pe r/ m ag az in e P ee r he al th ed uc at io n Fr ie nd s/ re la tiv es Tr a- di tio na l co m m un i- ca to rs In te rn et H ea lth pe rs on - ne l/ w or ke r N on e of th es e ei gh t m ed ia so ur ce s N um be r of w om en R ad io Te le vi si on N ew s- pa pe r/ m ag az in e P ee r he al th ed uc at io n Fr ie nd s/ re la tiv es Tr a- di tio na l co m m un i- ca to rs In te rn et H ea lth pe rs on - ne l/ w or ke r N on e of th es e ei gh t m ed ia so ur ce s N um be r of m en A ge 15 -1 9 23 .3 15 .6 2. 7 13 .4 30 .0 8. 0 1. 6 6. 9 53 .5 2, 40 7 33 .1 19 .7 4. 8 28 .8 42 .4 11 .6 3. 4 6. 9 39 .3 83 6 20 -2 4 36 .4 23 .9 5. 1 9. 4 44 .6 13 .0 3. 3 17 .8 39 .0 2, 12 5 41 .5 28 .9 11 .5 23 .4 47 .9 17 .0 7. 6 12 .6 32 .2 84 9 25 -2 9 37 .1 24 .2 4. 6 6. 3 49 .5 13 .8 2. 4 23 .3 35 .1 1, 82 2 42 .8 31 .7 12 .4 23 .8 53 .7 18 .7 12 .8 20 .1 27 .1 58 6 30 -3 4 38 .4 25 .3 4. 5 6. 4 47 .6 15 .2 1. 6 22 .8 35 .7 1, 50 4 47 .7 38 .2 14 .1 22 .6 50 .7 20 .8 10 .9 23 .1 25 .4 42 5 35 -3 9 41 .7 25 .1 2. 9 4. 7 47 .0 13 .4 1. 1 23 .0 35 .7 1, 05 6 46 .2 30 .8 9. 5 12 .3 47 .1 17 .0 8. 1 20 .6 31 .7 39 1 40 -4 4 36 .8 24 .2 3. 3 4. 4 43 .0 16 .4 1. 2 20 .7 39 .0 76 1 55 .1 31 .4 16 .8 20 .6 51 .9 23 .3 8. 9 21 .0 28 .1 27 0 45 -4 9 36 .6 22 .0 4. 2 4. 4 42 .3 15 .7 1. 2 15 .8 42 .5 55 9 48 .6 28 .1 5. 9 10 .0 43 .4 17 .9 0. 8 17 .2 34 .7 22 0 R es id en ce U rb an 38 .4 32 .5 5. 7 10 .0 46 .4 12 .1 2. 8 14 .6 36 .7 5, 73 0 43 .3 34 .3 13 .7 25 .5 51 .6 15 .7 10 .7 16 .1 28 .4 2, 22 8 R ur al 29 .2 9. 3 1. 7 5. 9 37 .5 13 .5 1. 0 21 .4 46 .6 4, 50 3 41 .2 19 .3 4. 6 17 .2 41 .5 19 .1 2. 5 14 .6 38 .0 1, 34 9 Lo ca l G ov er nm en t A re a B an ju l 33 .2 38 .5 8. 8 18 .6 49 .4 15 .3 6. 5 16 .5 34 .3 22 5 35 .4 34 .8 13 .7 21 .4 43 .5 9. 0 12 .1 16 .6 34 .6 85 K an ifi ng 36 .5 35 .7 7. 4 11 .6 45 .2 11 .8 3. 8 15 .9 35 .7 2, 34 2 38 .8 33 .0 15 .9 19 .6 43 .3 10 .0 10 .0 14 .5 34 .0 85 8 B rik am a 37 .8 27 .4 4. 7 9. 4 49 .1 16 .7 2. 3 17 .8 36 .4 3, 55 0 43 .7 32 .0 11 .3 27 .7 55 .4 18 .5 10 .2 16 .3 27 .4 1, 45 4 M an sa ko nk o 30 .4 9. 1 1. 4 8. 6 40 .7 17 .6 0. 3 15 .8 46 .5 49 0 40 .9 19 .8 3. 0 12 .8 28 .9 13 .5 1. 9 11 .6 41 .5 14 1 K er ew an 28 .2 16 .4 2. 0 6. 0 36 .0 8. 1 0. 9 20 .8 43 .2 1, 10 7 50 .2 21 .4 5. 9 27 .7 59 .3 28 .8 2. 6 18 .9 19 .2 32 3 K un ta ur 48 .6 9. 2 0. 7 7. 0 58 .5 24 .4 0. 3 34 .0 24 .7 52 6 61 .5 29 .8 2. 0 26 .6 65 .6 35 .9 0. 4 36 .1 17 .6 14 1 Ja nj an bu re h 47 .0 8. 1 1. 6 5. 8 34 .1 5. 9 0. 9 15 .2 40 .7 73 9 38 .5 21 .7 8. 7 21 .4 38 .3 16 .7 5. 0 17 .6 38 .2 24 0 B as se 14 .2 3. 8 0. 2 0. 3 22 .1 4. 0 0. 0 12 .9 68 .7 1, 25 4 36 .5 16 .7 2. 0 4. 7 23 .8 12 .7 1. 0 2. 9 56 .0 33 6 Ed uc at io n N o ed uc at io n 32 .5 15 .2 0. 7 2. 2 38 .8 11 .8 0. 2 17 .0 45 .6 4, 75 7 45 .6 23 .1 1. 9 10 .1 43 .4 18 .2 0. 6 12 .1 37 .0 1, 09 0 P rim ar y 31 .5 18 .4 1. 2 5. 3 40 .2 12 .7 0. 8 17 .2 43 .3 1, 40 5 37 .7 22 .3 2. 6 12 .2 40 .2 14 .9 1. 2 6. 4 39 .4 49 3 S ec on da ry o r hi gh er 37 .4 31 .9 8. 8 16 .2 47 .6 13 .8 4. 5 18 .4 35 .0 4, 07 1 41 .9 33 .3 16 .7 31 .6 52 .1 16 .8 13 .0 19 .7 27 .4 1, 99 4 W ea lth q ui nt ile Lo w es t 30 .4 9. 0 1. 4 6. 0 40 .0 14 .7 0. 6 19 .5 44 .7 1, 74 5 40 .6 15 .1 5. 5 16 .5 43 .1 15 .4 2. 4 15 .4 36 .9 51 7 S ec on d 33 .2 11 .7 2. 5 6. 2 40 .4 14 .0 1. 1 22 .1 41 .5 1, 88 2 44 .6 20 .4 5. 7 19 .0 44 .4 19 .7 3. 8 13 .0 35 .5 61 4 M id dl e 30 .5 13 .3 1. 6 5. 8 37 .0 12 .3 0. 9 16 .8 48 .8 1, 92 7 42 .6 24 .7 4. 6 20 .3 42 .1 18 .0 3. 0 15 .3 38 .3 58 8 Fo ur th 36 .5 28 .6 4. 2 8. 1 44 .1 13 .2 1. 7 15 .1 38 .8 2, 13 5 43 .5 31 .9 10 .3 21 .9 50 .3 15 .8 6. 2 11 .0 29 .5 94 0 H ig he st 38 .9 40 .7 8. 3 13 .1 48 .5 10 .3 4. 8 15 .7 34 .4 2, 54 5 41 .0 41 .1 19 .5 29 .8 53 .9 16 .6 17 .5 22 .1 25 .4 91 9 To ta l 1 5- 49 34 .3 22 .3 4. 0 8. 2 42 .5 12 .7 2. 0 17 .6 41 .1 10 ,2 33 42 .5 28 .7 10 .2 22 .4 47 .8 17 .0 7. 6 15 .5 32 .0 3, 57 7 50 -5 9 na na na na na na na na na na 48 .9 26 .4 11 .7 8. 1 41 .5 19 .7 3. 5 15 .8 35 .3 24 4 To ta l 1 5- 59 na na na na na na na na na na 42 .9 28 .5 10 .3 21 .5 47 .4 17 .2 7. 3 15 .6 32 .2 3, 82 1 na = N ot a pp lic ab le \ 88 • Family Planning Family Planning • 89 7.12 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS In the 2013 GDHS, women were asked whether they had been visited by a health worker who talked with them about family planning in the 12 months preceding the survey. This information is useful for determining whether family planning outreach programmes are reaching nonusers. Women were also asked if they had visited a health facility in the past 12 months for any reason and, if so, whether any staff member at the facility had spoken to them about family planning. The results shown in Table 7.13 indicate that only a small proportion (3 percent) of nonusers are being reached by fieldworkers who discuss family planning issues. The proportion of women who were visited by a fieldworker varied minimally by background characteristics; however, women in Mansakonko (9 percent) and Janjanbureh (6 percent) were more likely than other women to be visited by a fieldworker who discussed family planning. Table 7.13 also shows that, overall, about nine in ten women who came into contact with family planning providers did not in fact discuss family planning with them. While almost two-thirds of women (65 percent) visited a health facility in the 12 months preceding the survey, only 6 percent said they discussed family planning during their visit. Table 7.13 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the past 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who did not discuss family planning either with a fieldworker or at a health facility, by background characteristics, The Gambia 2013 Percentage of women who were visited by fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who did not discuss family planning either with fieldworker or at a health facility Number of women Background characteristic Discussed family planning Did not discuss family planning Age 15-19 1.1 1.1 43.1 97.9 2,381 20-24 2.6 6.9 60.4 91.2 2,013 25-29 3.0 8.9 66.7 88.9 1,662 30-34 2.7 9.6 66.8 88.3 1,325 35-39 4.7 10.5 66.5 86.1 924 40-44 2.4 7.0 64.5 91.4 679 45-49 3.1 2.6 56.5 94.7 520 Residence Urban 1.8 4.9 57.1 93.6 5,193 Rural 3.4 7.9 60.7 89.5 4,311 Local Government Area Banjul 2.8 4.5 51.5 92.9 194 Kanifing 1.8 5.0 53.2 93.7 2,103 Brikama 2.0 6.7 60.4 91.8 3,251 Mansakonko 8.8 9.9 63.5 82.8 459 Kerewan 1.6 10.6 58.4 88.5 1,047 Kuntaur 3.2 12.4 58.1 85.8 506 Janjanbureh 6.0 3.8 60.5 91.1 704 Basse 1.1 1.6 62.7 97.2 1,241 Education No education 2.9 7.3 64.6 90.5 4,498 Primary 3.0 6.8 58.7 90.9 1,319 Secondary or higher 1.9 4.9 51.6 93.6 3,687 Wealth quintile Lowest 3.6 8.3 62.1 89.1 1,672 Second 2.9 8.1 60.5 89.9 1,791 Middle 3.4 6.5 58.4 90.9 1,828 Fourth 1.6 5.6 61.1 93.0 1,941 Highest 1.5 3.8 53.2 94.9 2,271 Total 2.5 6.3 58.7 91.8 9,504 90 • Family Planning Staff at health facilities are most likely to discuss family planning with women age 35-39. Similarly, women in rural areas are more likely than women in urban areas to visit a health facility and discuss family planning (8 percent versus 5 percent). The proportion of nonusers who visited a health facility and discussed family planning is higher in Kuntaur and Kerewan (12 percent and 11 percent, respectively) than in other LGAs. Women with less education and those in the lower wealth quintiles are more likely than their counterparts to visit a health facility and discuss family planning with a provider. Overall, a large majority of nonusers (92 percent) did not discuss family planning with a fieldworker or at a health facility during the 12 months prior to the survey. Infant and Child Mortality • 91 INFANT AND CHILD MORTALITY 8 his chapter describes levels of and trends and differentials in early childhood mortality in The Gambia. Infant and child mortality rates are important indicators of a country’s socioeconomic development and quality of life, as well as the population’s health status. Measures of childhood mortality also contribute to a better understanding of the progress of population and health programmes and policies. Analyses of mortality measures are useful in identifying promising directions for health and nutrition programmes and improving child survival efforts. Disaggregation of mortality measures by socioeconomic and demographic characteristics helps to identify differentials in population subgroups and target high-risk groups for effective programmes. Measures of childhood mortality are also useful for population projections. Childhood mortality in general and infant mortality in particular are often used as broad indicators of socioeconomic development or specific indicators of health status. Childhood mortality rates are used for monitoring a country’s progress toward Millennium Development Goal (MDG) 4, which aims for a two-thirds reduction in child mortality by the year 2015 (United Nations Development Programme, 2013). Results from the 2013 GDHS can be used to monitor the impact of major national neonatal and child health interventions, strategies, and policies. This chapter presents information on neonatal, postneonatal, infant, child, and under-5 mortality. In addition, it includes information on perinatal mortality and patterns of fertility related to mortality. Mortality estimates are disaggregated by socioeconomic characteristics, such as urban-rural residence, mother’s level of education, and household wealth, as well as selected demographic characteristics, such as child sex, mother’s age at birth, birth order, birth interval, and birth size. The data used to estimate infant and childhood mortality were collected in the birth history section of the Woman’s Questionnaire. The 2013 GDHS asked women age 15-49 to provide a complete history of their live births. The birth history section begins with questions about the respondent’s experience with childbearing (i.e., the number of sons and daughters living with the mother, the number who live elsewhere, and the number who have died). These questions are followed by a retrospective birth history in which each respondent is asked to list each of her births, starting with the first birth. For each birth, data were obtained on sex, month and year of birth, survivorship status, and current age or, if the child is dead, age at death. This information is used to directly estimate mortality rates. In this report, age-specific mortality rates are categorised and defined as follows: T Key Findings • One in every 29 children in The Gambia die before their first birthday, and one in every 19 children die before their fifth birthday. • Infant mortality declined by 32 percent over the 15-year period preceding the survey, from 50 deaths per 1,000 live births to 34 deaths per 1,000 live births. • Under-5 mortality declined by 39 percent over the 15-year period preceding the survey, from 89 deaths per 1,000 live births to 54 deaths per 1,000 live births. • Childhood mortality is higher in rural areas than in urban areas. • The neonatal mortality rate is 22 deaths per 1,000 live births, the postneonatal mortality rate is 12 deaths per 1,000 live births, and the perinatal mortality rate is 30 deaths per 1,000 pregnancies. 92 • Infant and Child Mortality • Neonatal mortality (NN): the probability of dying within the first month of life • Postneonatal mortality (PNN): the probability of dying after the first month of life but before the first birthday (the difference between infant and neonatal mortality) • Infant mortality (1q0): the probability of dying before the first birthday • Child mortality (4q1): the probability of dying between the first and fifth birthdays • Under-5 mortality (5q0): the probability of dying between birth and the fifth birthday All rates are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths between age 1 and age 4 per 1,000 children surviving to age 1. Information on stillbirths and deaths that occurred within seven days of birth is used to estimate perinatal mortality, which is the number of stillbirths and early neonatal deaths per 1,000 stillbirths and live births. 8.1 ASSESSMENT OF DATA QUALITY The quality of mortality estimates calculated from retrospective birth histories depends on the mother’s ability to recall all of the children she has given birth to, as well as their birth dates and ages at death. Potentially the most serious data quality problem is the selective omission from the birth histories of those births that did not survive. If the problem of omission is serious, it can result in underestimation of childhood mortality. If selective omission of childhood deaths occurs, it is usually most severe for deaths early in infancy. Generally, if deaths are substantially underreported, the result is a low ratio of early neonatal deaths (deaths within the first week of life) to all neonatal deaths and a low ratio of neonatal deaths to infant deaths. An examination of the proportion of early neonatal deaths (0-6 days) to all neonatal deaths (0-30 days) shows that early neonatal deaths represented 87 percent of all neonatal deaths for the five-year period prior to the 2013 GDHS (Appendix Table C.5).1 During the period 5-19 years preceding the survey, this proportion ranged between 79 percent and 88 percent. An examination of the proportion of neonatal deaths to infant deaths (Appendix Table C.6) shows that neonatal deaths represented 66 percent of infant deaths for the five-year period prior to the 2013 GDHS. This is similar to the proportion reported in the period 5-19 years before the survey, which ranged between 61 percent and 71 percent. Another potential data quality problem involves the displacement of birth dates, which may distort mortality trends. This can occur if an interviewer knowingly records a birth as occurring in a different year, which could happen if an interviewer were trying to cut down on his or her overall work load, because live births occurring during the five years preceding the interview are the subject of a lengthy set of additional questions. In the 2013 GDHS questionnaire, the cut-off year for these questions was 2008. Appendix Table C.4 shows evidence of transference of children from 2008 to earlier years. For example, there were 1,448 children born in 2007 compared with 1,299 born in 2008, an 11 percent increase. A third factor that affects childhood mortality estimates is the quality of reporting of age at death. Misreporting of the child’s age at death may distort the age pattern of mortality, especially if the net effect of the age misreporting is to transfer deaths from one age bracket to another. For example, a net transfer of deaths from under 1 month to a higher age will affect the estimates of neonatal and postneonatal mortality. To minimize errors in reporting age at death, GDHS interviewers were instructed to record age at death in 1 There are no models for mortality patterns during the neonatal period. However, one review of data from several developing countries concluded that, at neonatal mortality levels of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma, 1988). Infant and Child Mortality • 93 days if the death took place in the month following the birth, in months if the child died before age 2, and in years if the child was at least age 2. They also were asked to probe for deaths reported at age 1 to determine a more precise age at death in terms of months. Despite the emphasis during interviewer training and fieldwork monitoring on probing for accurate age at death, Appendix Table C.6 shows that, for the five years preceding the survey, there is considerable heaping of deaths at age 6 months and age 12 months. However, only the heaping at age 12 months can potentially bias the mortality rates reported in the tables in this chapter. Age heaping at 12 months is likely to result in some underestimation of infant mortality and some overestimation of child mortality, especially for the earlier five-year periods. Finally, any method of measuring childhood mortality that relies on mothers’ reports (e.g., birth histories) assumes that female adult mortality is not high, or if it is high, that there is little or no correlation between the mortality risks of the mothers and those of their children. In countries like The Gambia that have low rates of female adult mortality due to HIV (see Chapter 14), these assumptions are likely valid. 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY 8.2.1 Early Childhood Mortality Rates Table 8.1 shows neonatal, postneonatal, infant, child, and under-5 mortality rates for successive five-year periods before the survey. For the five years preceding the survey (2009-2013), the infant mortality rate was 34 per 1,000 live births, the child mortality rate was 20 per 1,000 children surviving to age 1, and the under-5 mortality rate was 54 per 1,000 live births. This implies that one in about 29 children in The Gambia die before their first birthday and that one in about 19 die before their fifth birthday. During the same five-year period, the neonatal mortality rate was 22 deaths per 1,000 live births, and the postneonatal mortality rate was 12 deaths per 1,000 live births. Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, The Gambia 2013 Years preceding the survey Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 22 12 34 20 54 5-9 32 14 46 27 72 10-14 31 19 50 41 89 1 Computed as the difference between the infant and neonatal mortality rates 8.2.2 Trends in Early Childhood Mortality Mortality trends can be examined by comparing mortality rates for the three five-year periods preceding the survey. The 2013 GDHS data show a steady decline in all levels of childhood mortality over the last 15 years. Infant mortality declined by 32 percent over the 15-year period preceding the survey, from 50 deaths per 1,000 live births to 34 deaths per 1,000 live births. Under-5 mortality declined by 39 percent over the same period, from 89 deaths per 1,000 live births to 54 deaths per 1,000 live births. Finally, neonatal mortality decreased by 29 percent, from 31 deaths per 1,000 live births to 22 deaths per 1,000 live births. Mortality trends can also be examined by comparing data from the 2013 GDHS with data from the 2010 Gambia Multiple Indicator Cluster Survey. The data show that between 2010 and 2013, infant mortality declined from 81 deaths per 1,000 live births to 34 deaths per 1,000 live births. During the same period, under-5 mortality declined from 109 deaths per 1,000 live births to 54 deaths per 1,000 live births. However, caution should be exercised when comparing rates from different surveys. In particular, 94 • Infant and Child Mortality sampling errors associated with early childhood mortality estimates are large and should be taken into account when examining trends between surveys. 8.3 EARLY CHILDHOOD MORTALITY RATES BY SOCIOECONOMIC CHARACTERISTICS Mortality differences by place of residence, Local Government Area (LGA), mother’s education, and household wealth are presented in Table 8.2. Mortality rates are presented for the 10-year period preceding the survey to ensure a sufficient number of births to study mortality differentials across population subgroups. The table shows that infant and child survival are strongly influenced by background characteristics. Mortality rates are consistently lower in urban areas than in rural areas, although the difference is quite small for neonatal and postneonatal mortality. Infant mortality is 44 deaths per 1,000 live births in rural areas, as compared with 35 deaths per 1,000 live births in urban areas. Similarly, there is an urban-rural difference in under-5 mortality (69 deaths per 1,000 live births in rural areas versus 53 deaths per 1,000 live births in urban areas). Wide differences in early childhood mortality are also observed by LGA. For example, under-5 mortality rates range from a low of 52 per 1,000 live births in Kanifing and Kerewan to a high of 92 per 1,000 live births in Basse. Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by background characteristics, The Gambia 2013 Background characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 24 11 35 19 53 Rural 29 15 44 27 69 Local Government Area Banjul 27 8 35 21 55 Kanifing 24 7 32 21 52 Brikama 27 17 43 18 61 Mansakonko 30 13 42 22 63 Kerewan 26 9 35 18 52 Kuntaur 33 12 45 26 70 Janjanbureh 12 10 22 16 38 Basse 35 18 52 42 92 Mother’s education No education 29 15 44 26 69 Primary 30 12 42 26 67 Secondary or higher 18 8 26 12 37 Wealth quintile Lowest 29 18 47 25 70 Second 30 13 43 26 68 Middle 32 14 45 26 70 Fourth 28 14 42 19 60 Highest 12 6 18 17 34 1 Computed as the difference between the infant and neonatal mortality rates As expected, mother’s education is inversely related to a child’s risk of dying. Under-5 mortality among children born to mothers with no education is 69 per 1,000 live births, as compared with 37 per 1,000 live births among children born to mothers with a secondary education or higher. The beneficial effect of educating mothers is evident for all childhood mortality categories. Also, childhood mortality generally decreases as wealth increases and is lowest among children in the highest wealth quintile. 8.4 DEMOGRAPHIC DIFFERENTIALS IN EARLY CHILDHOOD MORTALITY The demographic characteristics of both mothers and children have been found to play an important role in child survival. Table 8.3 presents childhood mortality rates according to sex of the child, mother’s age at birth, birth order, previous birth interval, and the infant’s size at birth. Infant and Child Mortality • 95 The data show that mortality rates are generally higher among male children than female children. This is true for all mortality categories with the exception of postneonatal mortality. Infant mortality is highest for mothers under age 20 (51 per 1,000 live births) and for first births (47 per 1,000 live births). Short birth intervals, especially intervals of less than two years, substantially reduce children’s chances of survival. For example, children born less than two years after the preceding birth are more than twice as likely to die within the first year of life and within the first five years of life as children born three years after the preceding birth. These findings are consistent with observations from other sources (Cecatti et al., 2008; Rutstein, 2005). Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by demographic characteristics, The Gambia 2013 Demographic characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 28 13 42 24 65 Female 25 13 38 22 59 Mother’s age at birth <20 31 19 51 20 70 20-29 25 11 36 24 59 30-39 27 15 43 23 64 40-49 26 (6) (33) * * Birth order 1 32 14 47 19 64 2-3 21 13 34 22 55 4-6 28 12 40 27 66 7+ 29 14 43 25 67 Previous birth interval2 <2 years 54 18 72 38 107 2 years 20 9 29 26 55 3 years 18 14 32 15 47 4+ years 16 13 30 14 44 Birth size3 Small/very small 29 13 41 na na Average or larger 19 12 30 na na Note: Figures in parentheses are based on 250-499 unweighted person-years of exposure to the risk of death. An asterisk indicates that a figure is based on fewer than 250 unweighted person-years of exposure to the risk of death and has been suppressed. na = Not available 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey In the 2013 GDHS, mothers were asked whether their children born in the past five years were very large, larger than average, average, smaller than average, or very small at birth, since this has been found to be a good proxy for a child’s weight. As expected, the size of the baby at birth and mortality are negatively associated. For example, the infant mortality rate among very small or small children is 41 per 1,000 live births, as compared with 30 per 1,000 live births among children regarded as average or large in size. 8.5 PERINATAL MORTALITY The 2013 GDHS asked women to report on any pregnancy losses that had occurred in the five years preceding the survey. For each pregnancy that did not end in a live birth, the duration of pregnancy was recorded. In this report, perinatal deaths include pregnancy losses of at least seven months’ gestation (stillbirths) and deaths to live births within the first seven days of life (early neonatal deaths). The perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the sum of all stillbirths and live births. Information on stillbirths and infant deaths within the first week of life is highly susceptible to omission and misreporting. Nevertheless, retrospective surveys in developing countries provide more 96 • Infant and Child Mortality representative and accurate perinatal death rates than do vital registration systems and hospital-based studies. The distinction between a stillbirth and an early neonatal death may be a fine one, depending often on the observed presence or absence of faint signs of life after delivery. Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, The Gambia 2013 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months’ duration Mother’s age at birth <20 13 22 32 1,077 20-29 38 84 28 4,333 30-39 26 39 29 2,245 40-49 12 6 55 341 Previous pregnancy interval in months4 First pregnancy 25 45 41 1,698 <15 7 7 65 216 15-26 10 31 27 1,574 27-38 18 20 16 2,376 39+ 28 48 36 2,131 Residence Urban 34 85 31 3,805 Rural 55 66 29 4,190 Local Government Area Banjul 2 3 36 128 Kanifing 19 37 40 1,394 Brikama 28 59 32 2,724 Mansakonko 6 5 27 403 Kerewan 9 9 19 915 Kuntaur 6 11 30 540 Janjanbureh 7 8 22 669 Basse 14 19 27 1,222 Mother’s education No education 49 87 29 4,757 Primary 11 33 38 1,142 Secondary or higher 29 31 28 2,096 Wealth quintile Lowest 16 23 24 1,607 Second 27 26 30 1,773 Middle 19 39 36 1,605 Fourth 13 43 35 1,606 Highest 14 20 24 1,405 Total 89 151 30 7,995 1 Stillbirths are foetal deaths in pregnancies lasting 7 or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of 7 or more months’ duration, expressed per 1,000 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. Table 8.4 shows that of the 7,995 reported pregnancies of at least seven months’ gestation in the five years preceding the survey, 89 were stillbirths and 151 were early neonatal deaths, yielding an overall perinatal mortality rate of 30 deaths per 1,000 pregnancies. Because the rate is subject to a high degree of sampling variation, differences by background characteristics should be interpreted with caution. The perinatal mortality rate is highest among mothers age 40-49 (55 deaths per 1,000 pregnancies) and among births that occur less than 15 months after the previous birth (65 deaths per 1,000 pregnancies). Also, perinatal mortality is higher in urban areas (31 deaths per 1,000 pregnancies) and in Kanifing (40 deaths per 1,000 pregnancies). There is no clear pattern in the relationship between perinatal mortality and mother’s education and household wealth. Infant and Child Mortality • 97 8.6 HIGH-RISK FERTILITY BEHAVIOUR The survival of infants and children depends in part on the demographic and biological characteristics of their mothers. Typically, the probability of dying in infancy is much greater among children born to mothers who are too young (under age 18) or too old (over age 34), children who are too closely spaced (children born less than 24 months after the preceding birth), and children born to mothers of high parity (more than three children). First births may be at increased risk of dying relative to births of other orders; however, this distinction is not included in the risk categories in Table 8.5 because it is not considered avoidable fertility behaviour. Also, for the short birth interval category, only children with a preceding interval of less than 24 months are included. Short succeeding birth intervals are not included, even though they can influence the survivorship of a child, because of the problem of reverse causal effect (i.e., a short succeeding birth interval can be the result of the death of a child rather than being the cause of the death of a child). The risk is elevated when a child is born to a mother who has a combination of these risk characteristics. Table 8.5 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality, the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, The Gambia 2013 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high risk category 27.7 1.00 17.0a Unavoidable risk category First-order births between ages 18 and 34 17.4 1.36 8.3 Single high-risk category Mother’s age <18 5.0 2.72 1.6 Mother’s age >34 0.7 2.70 2.7 Birth interval <24 months 4.8 0.92 11.6 Birth order >3 25.3 1.03 15.2 Subtotal 35.8 1.28 31.1 Multiple high-risk category Age <18 and birth interval <24 months2 (0.3) (2.46) 0.4 Age >34 and birth interval <24 months * * 0.4 Age >34 and birth order >3 12.5 1.14 23.2 Age >34 and birth interval <24 months and birth order >3 1.2 2.81 6.3 Birth interval <24 months and birth order >3 5.2 1.92 13.3 Subtotal 19.1 1.48 43.5 In any avoidable high-risk category 54.9 1.35 74.7 Total 100.0 na 100.0 Number of births/women 7,906 na 6,791 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Figures in parentheses are based on 25-49 unweighted births. An asterisk indicates that a figure is based on fewer than 25 unweighted births and has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilised women Table 8.5 shows the percentages of births occurring in the five years before the survey that fall into the various risk categories. A total of 55 percent of births in the last five years are in an avoidable high-risk category. In 36 percent of the cases, the risk is higher only because of a single high-risk category (mother’s age, birth order, or birth interval), and in 19 percent of cases the risk is higher because of 98 • Infant and Child Mortality multiple high-risk categories. The largest groups of children at risk are those who are of a high birth order (25 percent) and those who are of a high birth order and whose mothers are over age 34 (13 percent). Table 8.5 also shows the relative risk of dying for children born in the last five years by comparing the proportion dead in each risk category with the proportion dead among children with no risk factors. The most detrimental factors are young age at birth, older age at birth, and the combination of older age at birth, short birth interval, and high birth order. Children in these groups are 2.7 to 2.8 times more likely to die than children not in any risk category. Fortunately, only 7 percent of births fall into these categories. The last column of Table 8.5 shows the distribution of currently married women by the risk category into which a birth would fall if conceived at the time of the survey. The information in this column is purely hypothetical and does not take into consideration the protection provided by postpartum insusceptibility, prolonged abstinence, or family planning methods other than sterilisation. However, it provides insight into the potential magnitude of high-risk births. Overall, 75 percent of currently married women have the potential for a high-risk birth, with 31 percent falling into a single high-risk category and 44 percent falling into a multiple high-risk category. Reproductive Health • 99 REPRODUCTIVE HEALTH 9 he major objective of antenatal care (ANC) is to ensure optimal health outcomes for the mother and the baby. Antenatal care from a skilled provider is important to monitor the pregnancy and reduce morbidity risks for the mother and child during pregnancy and delivery. Antenatal care provided by a skilled provider enables (1) early detection of complications and prompt treatment (e.g., detection and treatment of sexually transmitted infections), (2) prevention of diseases through immunisation and micronutrient supplementation, (3) birth preparedness and complication readiness, and (4) health promotion and disease prevention through health messages and counselling of pregnant women. 9.1 ANTENATAL CARE Mothers who had a live birth in the five years preceding the survey were asked whether they had obtained antenatal care during the pregnancy for their most recent birth. Table 9.1 presents information on the source of antenatal care services for that pregnancy. The data show that among the 5,305 women age 15-49 who had a live birth in the five years preceding the survey, 86 percent received ANC from a skilled health provider, 11 percent from a doctor, 75 percent from a nurse or midwife, and 13 percent from an auxiliary nurse. There were no major variations in the percentage of women who received ANC from a skilled provider by most of the background characteristics, except for urban-rural residence and Local Government Areas (LGA). Rural women were somewhat less likely to receive antenatal care from a skilled provider (85 percent) than their urban counterparts (88 percent). By LGA, the percentage of women who received ANC from a skilled provider ranged from 63 percent in Janjanbureh to 96 percent in Kanifing. Women with a secondary education or higher are much more likely to receive antenatal care from a doctor than those with no education (17 percent versus 9 percent). Similarly, women in the highest wealth quintile are more likely to receive antenatal care from a doctor. T Key Findings • Eighty-six percent of women receive antenatal care from a skilled provider. • Seventy-eight percent of women make four or more antenatal care visits during their pregnancy. The median duration of pregnancy at the first antenatal visit is 4.5 months. • Seventy-one percent of mothers with a birth in the five years preceding the survey had their last birth protected against neonatal tetanus. • Fifty-seven percent of births in the past five years were assisted by a skilled provider. • Seventy-six percent of women giving birth in the two years preceding the survey received postnatal care for their most recent birth in the first two days after delivery. • Fifteen percent of infants born outside a health facility in the two years preceding the survey received a postnatal checkup in the first two days after birth. • Forty-three percent of women face at least one problem in seeking health care for themselves when they are sick. 100 • Reproductive Health Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, The Gambia 2013 Background characteristic Antenatal care provider No ANC Total Percentage receiving antenatal care from a skilled provider1 Number of women Doctor Nurse/ midwife Auxiliary nurse Com- munity/ village health worker Traditional birth attendant Missing Mother’s age at birth <20 9.7 74.7 15.4 0.0 0.0 0.1 0.2 100.0 84.3 697 20-34 11.9 74.6 12.3 0.1 0.1 0.2 0.9 100.0 86.5 3,704 35-49 9.5 77.0 12.2 0.1 0.2 0.6 0.5 100.0 86.4 905 Birth order 1 11.6 73.1 14.9 0.1 0.1 0.1 0.1 100.0 84.7 1,114 2-3 13.9 73.3 11.6 0.1 0.0 0.2 0.9 100.0 87.3 1,797 4-5 9.2 76.3 13.3 0.0 0.2 0.4 0.6 100.0 85.4 1,208 6+ 8.8 78.1 11.6 0.1 0.1 0.3 1.1 100.0 86.8 1,187 Residence Urban 16.0 71.5 11.1 0.0 0.0 0.2 1.2 100.0 87.5 2,643 Rural 6.5 78.5 14.2 0.1 0.2 0.3 0.2 100.0 84.9 2,663 Local Government Area Banjul 27.2 64.4 7.4 0.0 0.0 0.0 1.1 100.0 91.5 93 Kanifing 20.3 75.3 3.1 0.0 0.0 0.4 1.0 100.0 95.6 982 Brikama 11.8 76.0 11.0 0.0 0.0 0.1 1.1 100.0 87.8 1,820 Mansakonko 6.4 79.2 13.8 0.0 0.2 0.0 0.5 100.0 85.6 265 Kerewan 18.9 66.6 14.3 0.0 0.0 0.0 0.3 100.0 85.5 589 Kuntaur 3.7 86.2 9.4 0.0 0.0 0.1 0.7 100.0 89.9 336 Janjanbureh 3.0 60.4 34.5 0.9 0.3 0.6 0.3 100.0 63.4 451 Basse 0.2 82.2 16.6 0.0 0.3 0.7 0.0 100.0 82.4 769 Education No education 8.5 75.3 14.6 0.1 0.1 0.3 1.1 100.0 83.8 3,082 Primary 11.5 79.1 9.0 0.0 0.1 0.0 0.2 100.0 90.6 747 Secondary or higher 16.7 72.3 10.5 0.0 0.0 0.3 0.3 100.0 89.0 1,476 Wealth quintile Lowest 6.4 81.1 11.5 0.1 0.1 0.1 0.6 100.0 87.5 1,027 Second 7.3 77.3 14.3 0.2 0.0 0.6 0.3 100.0 84.6 1,114 Middle 5.8 76.3 16.7 0.0 0.3 0.1 0.9 100.0 82.1 1,074 Fourth 13.5 74.6 10.5 0.0 0.0 0.1 1.2 100.0 88.1 1,072 Highest 23.6 65.5 10.1 0.0 0.0 0.4 0.5 100.0 89.1 1,019 Total 11.2 75.0 12.7 0.1 0.1 0.3 0.7 100.0 86.2 5,305 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, or midwife. 9.1.1 Number and Timing of Antenatal Visits Prenatal care is more effective in preventing adverse pregnancy outcomes when it is sought early in the pregnancy and continued through delivery. Health professionals recommend that the first prenatal visit occur within the initial 12 to 16 weeks of the pregnancy. The second visit should occur at 28 weeks, the third visit at 32 weeks, and the fourth visit at 36 weeks. Under normal circumstances, the World Health Organization (WHO) recommends that a woman without complications have at least four visits. Women with complications, special needs, or conditions beyond the scope of basic care may require additional visits. In the 2013 GDHS, women with a live birth in the five years preceding the survey were asked how many prenatal care visits they made during the pregnancy for their most recent live birth and how many months pregnant they were at the time of the first visit. Table 9.2 shows that more than three-fourths of pregnant women (78 percent) make four or more antenatal visits, with no major difference between urban and rural women. Reproductive Health • 101 Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, The Gambia 2013 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 1.4 0.4 0.9 1 2.0 1.0 1.5 2-3 19.6 20.2 19.9 4+ 77.0 78.3 77.6 Don’t know/missing 0.1 0.2 0.1 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.4 0.4 0.9 <4 34.9 40.4 37.7 4-5 41.0 41.0 41.0 6-7 20.4 17.2 18.8 8+ 2.2 1.0 1.6 Don’t know/missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Number of women 2,643 2,663 5,305 Median months pregnant at first visit (for those with ANC) 4.6 4.4 4.5 Number of women with ANC 2,606 2,653 5,260 The data also show that most women do not receive antenatal care early in their pregnancy. Only 38 percent of women obtain antenatal care in the first trimester of pregnancy. Overall, the median length of pregnancy at the first visit is 4.5 months. 9.1.2 Components of Antenatal Care Measuring the content of antenatal care is essential for assessing the quality of antenatal care services, given that pregnancy complications are a primary source of maternal and child morbidity and mortality. Pregnant women should routinely receive information on the signs of complications and should be assessed for their risk of complications. Table 9.3 presents information on the percentage of women who took iron tablets or syrup during the pregnancy for their most recent birth in the last five years, along with the percentage who took medicine for intestinal parasites, who were informed of the signs of pregnancy complications, and who received selected services during antenatal care visits. Table 9.3 shows that almost all (97 percent) women with a live birth in the last five years took iron tablets or syrup during the pregnancy for their most recent live birth, and two-fifths (40 percent) took intestinal parasite drugs. Among women who received antenatal care for their most recent birth, 73 percent reported that they had been informed of the signs of pregnancy complications. Furthermore, 99 percent reported that they had their blood pressure measured, 95 percent had a urine sample taken, and 98 percent had a blood sample taken. 102 • Reproductive Health Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, The Gambia 2013 Background characteristic Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Number of women with a live birth in the past five years Among women who received antenatal care for their most recent birth in the past five years, the percentage with selected services Number of women with ANC for their most recent birth Took iron tablets or syrup Took intestinal parasite drugs Informed of signs of pregnancy complications Blood pressure measured Urine sample taken Blood sample taken Mother’s age at birth <20 97.5 41.4 697 66.0 98.6 92.8 97.5 695 20-34 96.7 40.5 3,704 73.6 99.1 95.6 98.3 3,669 35-49 95.7 38.5 905 74.6 99.3 95.9 99.0 895 Birth order 1 97.4 38.5 1,114 70.8 98.9 93.7 98.0 1,111 2-3 96.5 41.6 1,797 73.8 99.1 95.6 98.2 1,781 4-5 97.0 42.3 1,208 72.3 99.0 95.8 98.6 1,198 6+ 95.7 38.1 1,187 73.6 99.3 95.8 98.5 1,170 Residence Urban 95.2 36.0 2,643 73.6 99.5 97.2 98.8 2,606 Rural 98.0 44.6 2,663 72.0 98.7 93.4 97.8 2,653 Local Government Area Banjul 94.2 37.0 93 61.1 98.4 96.9 97.6 92 Kanifing 95.2 36.5 982 71.8 99.9 98.1 99.4 969 Brikama 95.7 34.1 1,820 76.4 99.6 96.9 98.9 1,798 Mansakonko 97.9 36.1 265 65.5 97.8 87.2 97.7 264 Kerewan 98.9 37.6 589 75.7 99.1 95.1 98.7 587 Kuntaur 98.6 31.7 336 79.4 98.3 89.4 97.1 334 Janjanbureh 97.2 68.8 451 78.7 97.5 96.4 97.2 447 Basse 97.5 50.9 769 60.8 98.7 92.7 96.7 769 Education No education 96.6 41.3 3,082 72.0 99.0 95.4 98.3 3,046 Primary 95.9 43.3 747 74.3 99.3 94.5 98.5 746 Secondary or higher 97.0 36.7 1,476 73.6 99.2 95.6 98.4 1,468 Wealth quintile Lowest 98.3 41.5 1,027 68.2 99.0 93.8 98.6 1,019 Second 98.0 42.7 1,114 76.2 98.9 95.5 98.4 1,108 Middle 95.2 46.5 1,074 74.0 98.7 93.1 96.7 1,064 Fourth 95.6 34.5 1,072 70.5 99.3 96.4 99.0 1,057 Highest 95.9 36.0 1,019 74.6 99.7 97.8 99.0 1,011 Total 96.6 40.3 5,305 72.8 99.1 95.3 98.3 5,260 9.1.3 Tetanus Toxoid Injections Neonatal tetanus is a leading cause of neonatal death in developing countries, where a high proportion of deliveries take place at home or in places where hygienic conditions do not exist. Tetanus toxoid (TT) immunisations are given to pregnant women to prevent neonatal tetanus. If a woman has received no previous TT injections, she needs two doses of TT during pregnancy for full protection. However, if a woman was immunised before she became pregnant, she may require one injection or may not require any TT injections during pregnancy, depending on the number of injections she has already received and the timing of the last injection. Five doses are required for lifetime protection. Table 9.4 shows that 42 percent of women received two or more doses of tetanus toxoid during the pregnancy for their most recent birth in the last five years. The percentage of women who received a TT injection decreases substantially with mother’s age at birth and with increasing birth order. Rural women are slightly more likely than urban women to have received two or more TT injections during their last pregnancy. Coverage with at least two doses ranges from 38 percent of women in Kanifing to 54 percent of women in Janjanbureh. Reproductive Health • 103 Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, The Gambia 2013 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 56.5 65.0 697 20-34 40.8 72.7 3,704 35-49 32.9 67.6 905 Birth order 1 57.8 59.2 1,114 2-3 40.5 77.0 1,797 4-5 38.2 76.9 1,208 6+ 31.2 66.2 1,187 Residence Urban 39.9 67.3 2,643 Rural 43.2 74.3 2,663 Local Government Area Banjul 39.6 65.8 93 Kanifing 37.9 67.8 982 Brikama 38.9 69.6 1,820 Mansakonko 52.9 87.4 265 Kerewan 40.4 72.3 589 Kuntaur 48.3 67.9 336 Janjanbureh 53.9 69.2 451 Basse 39.5 73.5 769 Education No education 41.2 71.6 3,082 Primary 40.5 75.1 747 Secondary or higher 42.7 67.0 1,476 Wealth quintile Lowest 42.9 71.4 1,027 Second 43.0 75.1 1,114 Middle 40.3 70.8 1,074 Fourth 40.8 70.4 1,072 Highest 40.7 65.9 1,019 Total 41.5 70.8 5,305 1 Includes mothers with 2 injections during the pregnancy of their last birth or 2 or more injections (the last within 3 years of the last live birth), 3 or more injections (the last within 5 years of the last birth), 4 or more injections (the last within 10 years of the last live birth), or 5 or more injections at any time prior to the last birth Seventy-one percent of women reported that their last live birth was protected against neonatal tetanus. First-order births (59 percent), births to women in urban areas (67 percent), births to women residing in Banjul (66 percent), births to women with a secondary education or higher (67 percent), and births to women in the highest wealth quintile (66 percent) are least likely to be protected against neonatal tetanus. 9.2 DELIVERY 9.2.1 Place of Delivery Delivery in a health facility is an important factor in reducing health risks to both the mother and the baby. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and infections. Table 9.5 presents the distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. The data show that 63 percent of births in The Gambia are delivered in a health facility and 37 percent take place at home. The majority of births (57 percent) take place in a public health facility. 104 • Reproductive Health Births to women less than age 20 (68 percent), first-order births (79 percent), and births to women with four or more ANC visits (67 percent) are more likely to be delivered at a health facility than other births. In addition, births in urban areas are substantially more likely to be delivered at a health facility that those in rural areas (83 percent versus 44 percent). The proportion of births delivered at a health facility ranges from 31 percent in Basse to 93 percent in Banjul. Health facility deliveries increase steadily with increases in mother’s education and wealth. For example, only 54 percent of births to mothers with no education occur at a health facility, as compared with 82 percent of births to mothers with a secondary education or higher. Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, The Gambia 2013 Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector NGO medical sector Mother’s age at birth <20 63.6 3.1 1.2 31.7 0.0 0.4 100.0 67.9 1,063 20-34 55.6 4.9 1.2 37.5 0.4 0.5 100.0 61.7 5,703 35-49 58.5 2.3 1.3 36.8 0.3 0.8 100.0 62.1 1,140 Birth order 1 70.7 5.9 2.3 20.3 0.2 0.6 100.0 78.9 1,726 2-3 56.1 5.7 0.9 36.5 0.2 0.5 100.0 62.8 2,693 4-5 53.1 2.4 1.1 42.8 0.3 0.4 100.0 56.5 1,849 6+ 48.9 2.4 0.7 46.9 0.5 0.4 100.0 52.1 1,638 Antenatal care visits1 None (7.5) (0.0) (0.0) (75.1) (0.0) (17.4) 100.0 (7.5) 46 1-3 55.7 2.1 0.9 41.2 0.1 0.1 100.0 58.6 1,133 4+ 60.5 5.5 1.4 32.1 0.3 0.1 100.0 67.4 4,119 Residence Urban 73.2 8.1 1.8 16.0 0.4 0.5 100.0 83.1 3,771 Rural 42.4 0.9 0.7 55.4 0.2 0.4 100.0 44.0 4,135 Local Government Area Banjul 88.1 4.1 1.2 5.2 0.0 1.3 100.0 93.4 126 Kanifing 73.7 11.7 2.3 10.8 0.3 1.1 100.0 87.7 1,376 Brikama 67.6 5.7 1.9 24.0 0.3 0.5 100.0 75.2 2,697 Mansakonko 51.3 1.4 0.9 46.2 0.1 0.1 100.0 53.6 397 Kerewan 51.9 0.7 0.0 46.7 0.6 0.1 100.0 52.6 906 Kuntaur 38.0 0.0 0.0 61.4 0.4 0.1 100.0 38.1 534 Janjanbureh 47.6 1.2 1.1 49.3 0.3 0.6 100.0 49.8 663 Basse 31.1 0.1 0.0 68.6 0.0 0.2 100.0 31.2 1,208 Mother’s education No education 51.5 2.2 0.5 45.2 0.2 0.4 100.0 54.2 4,708 Primary 58.1 4.2 0.7 36.2 0.6 0.1 100.0 63.0 1,131 Secondary or higher 69.4 9.1 3.0 17.3 0.4 0.8 100.0 81.5 2,067 Wealth quintile Lowest 47.3 0.7 0.9 50.1 0.3 0.6 100.0 48.9 1,591 Second 47.8 1.4 0.7 49.4 0.1 0.5 100.0 49.9 1,746 Middle 49.3 1.3 1.3 47.8 0.1 0.4 100.0 51.8 1,586 Fourth 71.7 4.6 0.5 22.7 0.2 0.3 100.0 76.7 1,593 Highest 72.1 15.2 3.1 8.1 0.8 0.6 100.0 90.4 1,391 Total 57.1 4.3 1.2 36.6 0.3 0.5 100.0 62.6 7,906 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 7 cases for whom information on number of ANC visits is missing. 1 Includes only the most recent birth in the 5 years preceding the survey 9.2.2 Assistance during Delivery In addition to place of birth, assistance during childbirth is an important variable that influences birth outcomes and the health of mothers and infants. The skills and performance of the birth attendant determine whether he or she can manage complications and observe hygiene practices. Table 9.6 shows the percent distribution of live births in the five years preceding the survey by the person providing assistance, according to background characteristics. The table also presents data on the prevalence of births delivered via caesarean section (C-section). The results show that 57 percent of births in The Gambia are delivered under the supervision of a skilled provider, mostly a nurse or midwife (50 Reproductive Health • 105 percent). Traditional birth attendants play a vital role, assisting in 27 percent of deliveries. Relatives and others assist with 7 percent of deliveries, and 2 percent of deliveries are not assisted by anyone. Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider, and percentage delivered via caesarean section, according to background characteristics, The Gambia 2013 Background characteristic Person providing assistance during delivery Percentage delivered by a skilled provider1 Percentage delivered by C-section Number of births Doctor Nurse/ midwife Auxiliary nurse Traditional birth attendant Relative/ other No one Don’t know/ missing Total Mother’s age at birth <20 7.2 54.3 7.4 25.7 4.8 0.3 0.5 100.0 61.5 1.9 1,063 20-34 7.0 49.2 7.0 27.4 7.2 1.8 0.4 100.0 56.2 1.9 5,703 35-49 7.2 50.8 5.9 26.0 6.5 2.9 0.8 100.0 58.0 2.7 1,140 Birth order 1 11.0 60.6 7.8 15.9 3.6 0.4 0.6 100.0 71.6 3.4 1,726 2-3 7.1 50.2 6.8 26.4 7.7 1.4 0.3 100.0 57.3 1.9 2,693 4-5 5.1 45.8 7.6 32.0 7.6 1.5 0.4 100.0 50.9 1.1 1,849 6+ 4.9 43.9 5.2 33.8 7.7 3.9 0.7 100.0 48.8 1.8 1,638 Antenatal care visits2 None (1.1) (0.6) (5.8) (30.9) (22.4) (21.8) (17.4) 100.0 (1.7) (0.0) 46 1-3 5.9 44.6 9.1 29.4 8.1 2.6 0.1 100.0 50.5 1.4 1,133 4+ 8.4 53.8 6.7 23.9 5.9 1.3 0.0 100.0 62.2 2.8 4,119 Place of delivery Health facility 11.0 78.6 10.1 0.1 0.1 0.0 0.1 100.0 89.6 3.2 4,950 Elsewhere 0.3 2.3 1.5 72.9 18.1 4.6 0.3 100.0 2.6 0.0 2,917 Residence Urban 11.7 63.6 8.8 8.8 5.0 1.6 0.5 100.0 75.3 2.9 3,771 Rural 2.8 37.8 5.1 43.5 8.4 1.8 0.5 100.0 40.6 1.1 4,135 Local Government Area Banjul 21.9 66.8 5.3 0.8 2.5 1.9 0.8 100.0 88.7 10.5 126 Kanifing 13.7 71.1 3.6 3.7 5.1 1.8 0.9 100.0 84.8 4.0 1,376 Brikama 8.5 59.8 8.0 15.4 6.5 1.4 0.4 100.0 68.3 1.6 2,697 Mansakonko 2.2 52.6 1.0 33.0 9.4 1.7 0.2 100.0 54.8 1.7 397 Kerewan 7.7 36.7 10.7 30.8 10.0 4.0 0.2 100.0 44.3 1.4 906 Kuntaur 2.6 30.7 4.8 52.0 9.5 0.3 0.1 100.0 33.3 0.5 534 Janjanbureh 2.0 32.6 21.1 33.3 7.4 2.5 1.1 100.0 34.6 1.3 663 Basse 0.4 30.5 0.4 62.6 5.0 0.7 0.4 100.0 30.9 1.3 1,208 Mother’s education No education 5.5 42.9 7.4 34.0 7.7 2.0 0.5 100.0 48.5 1.7 4,708 Primary 5.9 56.0 2.7 26.6 7.4 1.3 0.1 100.0 61.9 1.4 1,131 Secondary or higher 11.1 63.3 8.0 11.0 4.4 1.4 0.7 100.0 74.4 3.1 2,067 Wealth quintile Lowest 2.9 42.5 5.1 36.8 10.6 1.9 0.3 100.0 45.5 1.1 1,591 Second 3.4 42.3 6.5 37.6 7.2 2.1 0.9 100.0 45.7 0.8 1,746 Middle 3.6 43.4 6.1 36.7 7.3 2.4 0.5 100.0 47.0 1.7 1,586 Fourth 10.7 59.0 7.6 15.7 5.5 1.3 0.3 100.0 69.7 2.2 1,593 Highest 16.0 66.2 9.5 4.2 2.9 0.7 0.5 100.0 82.2 4.7 1,391 Total 7.0 50.1 6.9 27.0 6.8 1.7 0.5 100.0 57.2 2.0 7,906 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Figures in parentheses are based on 25-49 unweighted cases. Total includes 7 cases for whom information on number of ANC visits is missing and 39 cases for whom information on place of delivery is missing. 1 Skilled provider includes doctor, nurse, or midwife. 2 Includes only the most recent birth in the 5 years preceding the survey Births to women under age 20 (62 percent), first-order births (72 percent), and births to women with four or more ANC visits (62 percent) are more likely to be attended by a skilled provider than other births. As expected, births that occur in health facilities are much more likely to be attended by a skilled provider than those delivered elsewhere (90 percent versus 3 percent), and births to women in urban areas are much more likely to be assisted by a skilled provider than births to rural women (75 percent versus 41 percent). LGA differentials in type of assistance at delivery are also pronounced, with the lowest proportion of births assisted by a skilled provider occurring in Basse (31 percent) and the highest in Banjul (89 percent). The proportion of births assisted by a skilled provider increases notably with increasing education and wealth. 106 • Reproductive Health Overall, only 2 percent of births are delivered via caesarean section. There are no major variations by background characteristics other than the proportion of caesarean section deliveries being higher in Banjul (11 percent) than in other LGAs. Figure 9.1 presents data on mothers’ duration of stay in the health facility after giving birth, according to type of birth. The majority of women who had a vaginal delivery spent less than 12 hours at the health facility (69 percent); on the other hand, only 13 percent of women with a caesarean delivery spent less than 12 hours at the health facility. By contrast, 74 percent of women who had a Caesarean delivery spent three or more days at the health facility, as compared with only 5 percent of women who had a vaginal delivery. Figure 9.1 Mother’s duration of stay in the health facility after giving birth 44 8 25 56 1 20 12 5 74 Vaginal birth Caesarean section Percentage < 6 hours 6-11 hours 12-23 hours 1-2 days 3+ days GDHS 2013 9.3 POSTNATAL CARE A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Thus, postnatal care is important for both the mother and the child to treat complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. It is recommended that all women receive a health check within two days of delivery. To assess the extent of postnatal care utilisation, respondents were asked whether, for their most recent birth in the two years preceding the survey, they had received a health check after the delivery and, if so, the timing of the first checkup and the type of health provider performing it. 9.3.1 Timing of First Postnatal Checkup for the Mother Table 9.7 shows that, overall, 76 percent of women who gave birth in the two years preceding the survey received a postnatal checkup in the first two days after birth. About seven in ten women (69 percent) received postnatal care within 4 hours of delivery, 5 percent received care between 4 and 23 hours after delivery, and 2 percent a postnatal checkup 1-2 days following delivery. One percent of women received postnatal care 3-41 days following the delivery. The percentage of women who received postnatal care within the first two days after the delivery decreases with increasing birth order. As expected, women who give birth in a health facility (92 percent) are more likely to receive postnatal care in the first two days after birth than women who deliver elsewhere Reproductive Health • 107 (47 percent). Women in rural areas are less likely to receive postnatal care than urban women (68 percent and 85 percent, respectively). The percentage of women who receive timely postnatal care is lowest in Kerewan and Kuntaur (61 percent each) and highest in Banjul (84 percent). The percentage of women who receive postnatal care within two days of birth increases with increasing education and tends to increase with wealth, although not in a linear manner. Table 9.7 Timing of first postnatal checkup Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution of the mother’s first postnatal checkup for the last live birth by time after delivery, and the percentage of women with a live birth in the two years preceding the survey who received a postnatal checkup in the first two days after giving birth, according to background characteristics, The Gambia 2013 Background characteristic Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Mother’s age at birth <20 71.7 5.0 0.8 0.0 0.2 1.2 21.0 100.0 77.5 471 20-34 69.2 4.2 2.0 0.3 1.0 0.9 22.4 100.0 75.4 2,403 35-49 66.4 6.8 1.3 0.6 1.5 1.5 21.9 100.0 74.5 519 Birth order 1 76.4 4.5 0.9 0.3 0.5 1.3 16.0 100.0 81.9 736 2-3 68.0 5.2 2.3 0.1 0.7 1.1 22.7 100.0 75.5 1,138 4-5 67.9 4.1 2.0 0.2 1.7 1.0 23.2 100.0 73.9 781 6+ 65.0 4.9 1.2 0.7 1.0 0.9 26.2 100.0 71.1 737 Place of delivery Health facility 84.5 6.1 1.5 0.1 0.3 1.6 5.9 100.0 92.1 2,156 Elsewhere 42.5 2.4 2.0 0.7 2.2 0.1 50.1 100.0 46.9 1,232 Residence Urban 76.4 5.7 2.4 0.4 0.8 1.1 13.1 100.0 84.5 1,565 Rural 62.9 3.9 1.1 0.2 1.1 1.0 29.8 100.0 67.9 1,828 Local Government Area Banjul 65.0 13.4 5.5 0.9 1.1 2.4 11.8 100.0 83.9 51 Kanifing 70.4 9.6 3.1 0.3 1.0 2.4 13.1 100.0 83.1 517 Brikama 78.0 2.7 1.8 0.5 1.2 0.9 15.0 100.0 82.5 1,171 Mansakonko 68.1 7.1 0.9 0.5 2.0 0.0 21.2 100.0 76.2 169 Kerewan 55.0 5.3 0.4 0.3 0.6 1.3 37.1 100.0 60.7 419 Kuntaur 53.6 5.5 2.3 0.0 1.0 0.6 37.1 100.0 61.3 227 Janjanbureh 70.1 3.4 2.7 0.0 0.7 0.2 22.9 100.0 76.2 298 Basse 66.3 2.9 0.3 0.1 0.5 0.9 29.1 100.0 69.5 541 Education No education 64.6 4.2 1.9 0.3 1.1 1.3 26.6 100.0 70.7 1,951 Primary 68.8 5.6 1.8 0.3 1.1 0.7 21.7 100.0 76.2 502 Secondary or higher 78.7 5.5 1.3 0.3 0.7 0.7 12.9 100.0 85.5 940 Wealth quintile Lowest 66.1 3.6 1.7 0.5 1.4 1.3 25.4 100.0 71.4 703 Second 62.9 4.4 1.2 0.4 1.3 0.7 29.1 100.0 68.4 757 Middle 68.5 3.6 0.8 0.0 1.1 0.8 25.2 100.0 72.9 702 Fourth 70.6 6.3 3.1 0.2 0.7 1.5 17.7 100.0 79.9 681 Highest 80.6 6.2 1.8 0.4 0.1 1.1 9.8 100.0 88.7 549 Total 69.1 4.7 1.7 0.3 1.0 1.1 22.1 100.0 75.6 3,392 Note: Total includes 4 cases for whom information on place of delivery is missing. 1 Includes women who received a checkup after 41 days 9.3.2 Type of Provider of First Postnatal Checkup for the Mother Table 9.8 presents information on the type of provider of women’s first postnatal checkup. Fifty- five percent of women who gave birth in the two years preceding the survey received postnatal care from a skilled provider (i.e., a doctor, nurse, or midwife). Twelve percent of women received postnatal care from a traditional birth attendant, 7 percent from an auxiliary nurse, and 1 percent from a community or village health worker. Differentials in type of postnatal care provider show that women with first-order births (67 percent), women who deliver at a health facility (82 percent), and urban women (70 percent) are more 108 • Reproductive Health likely than other women to receive their first postnatal checkup from a skilled provider. LGA differentials in the percentage of women who receive a postnatal checkup from a skilled provider are notable, with Basse having the lowest proportion (33 percent) and Banjul the highest (77 percent). Overall, the proportion of women who received their first postnatal checkup from a skilled provider increases notably with increasing education and wealth. For example, 48 percent of women in the lowest wealth quintile received their first postnatal checkup from a doctor, nurse, or midwife, as compared with 78 percent of women in the highest quintile. Table 9.8 Type of provider of first postnatal checkup for the mother Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal health check in the two days after the last live birth, according to background characteristics, The Gambia 2013 Background characteristic Type of health provider of mother’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of women Doctor/ nurse/ midwife Auxiliary nurse Community/ village health worker Traditional birth attendant Mother’s age at birth <20 58.5 7.5 0.8 10.6 22.5 100.0 471 20-34 54.8 6.7 1.4 12.6 24.6 100.0 2,403 35-49 54.0 7.5 1.0 12.1 25.5 100.0 519 Birth order 1 67.1 7.0 0.7 7.1 18.1 100.0 736 2-3 56.2 6.6 1.0 11.6 24.5 100.0 1,138 4-5 50.9 8.1 2.2 12.7 26.1 100.0 781 6+ 46.2 6.1 1.1 17.8 28.9 100.0 737 Place of delivery Health facility 82.3 9.6 0.0 0.2 7.9 100.0 2,156 Elsewhere 7.9 2.4 3.4 33.2 53.1 100.0 1,232 Residence Urban 70.3 9.2 0.2 4.8 15.5 100.0 1,565 Rural 42.2 5.0 2.1 18.5 32.1 100.0 1,828 Local Government Area Banjul 76.6 6.8 0.5 0.0 16.1 100.0 51 Kanifing 76.2 5.5 0.0 1.4 16.9 100.0 517 Brikama 67.4 7.1 0.7 7.3 17.5 100.0 1,171 Mansakonko 60.1 3.1 1.1 11.9 23.8 100.0 169 Kerewan 43.7 8.1 0.4 8.5 39.3 100.0 419 Kuntaur 34.4 5.5 1.8 19.7 38.7 100.0 227 Janjanbureh 37.2 19.7 3.6 15.6 23.8 100.0 298 Basse 32.6 1.6 2.9 32.4 30.5 100.0 541 Education No education 45.9 7.6 1.5 15.6 29.3 100.0 1,951 Primary 59.1 4.0 1.5 11.5 23.8 100.0 502 Secondary or higher 72.3 7.1 0.5 5.6 14.5 100.0 940 Wealth quintile Lowest 47.8 4.7 1.3 17.6 28.6 100.0 703 Second 44.9 6.6 2.5 14.4 31.6 100.0 757 Middle 46.3 7.6 1.9 17.1 27.1 100.0 702 Fourth 64.8 7.7 0.1 7.3 20.1 100.0 681 Highest 78.1 8.4 0.0 2.1 11.3 100.0 549 Total 55.2 6.9 1.2 12.2 24.4 100.0 3,392 Note: Total includes 4 cases for whom information on place of delivery is missing. 9.3.3 Timing of First Postnatal Checkup for the Newborn Table 9.9 shows the timing of the first postnatal checkup for infants born outside a heath facility in the two years preceding the survey. Overall, only 15 percent of newborns delivered outside a health facility received a postnatal checkup in the first two days after birth. The percentage of non-institutional births with a postnatal checkup within the first two days after delivery is lowest among births to older women (age 35-49) and higher order births. Newborns in urban areas (22 percent) are more likely to receive postnatal care in the first two days after birth than newborns in rural areas (13 percent). The percentage of newborns who receive timely postnatal care is lowest in Basse Reproductive Health • 109 and Kuntaur (5 percent each) and highest in Mansakonko (35 percent). Newborn postnatal care within two days of birth increases steadily with increasing mother’s education and fluctuates with wealth. Table 9.9 Timing of first postnatal checkup for the newborn Percent distribution of last non-institutional births in the two years preceding the survey by time after birth of first postnatal checkup, and the percentage of non-institutional births with a postnatal checkup in the first two days after birth, according to background characteristics, The Gambia 2013 Background characteristic Time after birth of newborn’s first postnatal checkup No postnatal checkup1 Total Percentage of births with a postnatal checkup in the first two days after birth Number of non- institutional births Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don’t know/ missing Mother’s age at birth <20 3.0 4.4 1.8 4.3 2.0 0.1 84.3 100.0 13.5 127 20-34 2.3 7.0 2.6 4.1 3.5 0.2 80.2 100.0 16.0 913 35-49 2.8 2.3 1.4 3.1 3.8 0.0 86.6 100.0 9.6 192 Birth order 1 5.8 6.5 1.8 3.6 3.1 0.1 79.0 100.0 17.7 135 2-3 1.9 7.4 2.0 4.3 3.1 0.4 80.8 100.0 15.6 409 4-5 1.3 7.7 2.0 3.0 2.5 0.0 83.6 100.0 13.9 317 6+ 2.7 2.9 3.3 4.6 4.6 0.1 81.8 100.0 13.4 372 Residence Urban 1.1 11.3 3.0 6.6 1.9 0.6 75.5 100.0 22.0 257 Rural 2.8 4.6 2.2 3.2 3.8 0.1 83.3 100.0 12.8 976 Local Government Area Banjul * * * * * * * 100.0 * 3 Kanifing (0.0) (13.7) (6.7) (8.4) (0.0) (2.6) (68.6) 100.0 (28.9) 55 Brikama 6.0 10.9 3.0 6.4 2.9 0.0 70.7 100.0 26.4 278 Mansakonko 7.2 18.3 4.6 4.5 4.4 0.0 61.1 100.0 34.6 70 Kerewan 2.7 4.5 3.5 1.5 6.1 0.4 81.3 100.0 12.3 199 Kuntaur 0.0 1.6 1.4 2.3 2.4 0.0 92.3 100.0 5.3 133 Janjanbureh 1.9 4.4 1.7 6.7 1.8 0.0 83.5 100.0 14.7 136 Basse 0.0 1.6 0.7 2.2 3.7 0.0 91.8 100.0 4.5 358 Mother’s education No education 1.7 4.4 2.2 3.2 3.4 0.0 85.1 100.0 11.5 873 Primary 1.8 8.4 2.0 7.4 5.0 0.2 75.2 100.0 19.6 191 Secondary or higher 6.6 12.0 3.3 4.0 2.0 1.2 71.0 100.0 25.9 169 Wealth quintile Lowest 2.6 5.2 2.1 6.0 3.3 0.0 80.8 100.0 15.9 336 Second 3.0 4.7 3.6 1.2 4.8 0.1 82.6 100.0 12.5 369 Middle 2.3 4.7 0.5 2.5 3.3 0.1 86.6 100.0 9.9 320 Fourth 1.8 7.3 4.6 7.8 1.8 0.1 76.6 100.0 21.5 159 Highest (0.0) (25.8) (0.0) (7.3) (0.0) (2.8) (64.1) 100.0 (33.1) 50 Total 2.4 6.0 2.3 4.0 3.4 0.2 81.6 100.0 14.7 1,232 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes newborns who received a checkup after the first week 9.3.4 Type of Provider of First Postnatal Checkup for the Newborn Table 9.10 shows the type of provider of the first postnatal checkup for infants born outside a heath facility in the two years preceding the survey. The results indicate that 10 percent of newborns received their first postnatal checkup from a skilled provider (i.e., a doctor, nurse, or midwife). Two percent each received postnatal care from an auxiliary nurse or a traditional birth attendant, and less than 1 percent received care from a community health worker. Newborns of mothers age 20-34 (11 percent), those of birth order six or higher (10 percent), newborns in urban areas (17 percent), and those in Kanifing (19 percent) are more likely than other newborns to receive their first postnatal checkup from a skilled provider. The proportion of newborns who receive their first postnatal checkup from a skilled provider increases steadily with increasing mother’s education. However, there are no clear patterns according to wealth. 110 • Reproductive Health Table 9.10 Type of provider of first postnatal checkup for the newborn Percent distribution of last non-institutional births in the two years preceding the survey by type of provider of the newborn’s first postnatal health check during the two days after the last live birth, according to background characteristics, The Gambia 2013 Background characteristic Type of health provider of newborn’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of non- institutional births Doctor/ nurse/ midwife Auxiliary nurse Community health worker Other health worker Traditional birth atten- dant Mother’s age at birth <20 8.1 0.6 0.2 0.0 4.6 86.5 100.0 127 20-34 10.7 2.4 0.6 0.0 2.3 84.0 100.0 913 35-49 6.1 1.0 0.5 0.0 1.9 90.4 100.0 192 Birth order 1 9.7 1.8 0.0 0.0 6.2 82.3 100.0 135 2-3 9.4 2.8 0.5 0.0 2.9 84.4 100.0 409 4-5 9.7 2.0 1.1 0.0 1.1 86.1 100.0 317 6+ 10.1 1.2 0.4 0.0 1.7 86.6 100.0 372 Residence Urban 16.5 5.4 0.1 0.0 0.0 78.0 100.0 257 Rural 8.0 1.1 0.7 0.0 3.1 87.2 100.0 976 Local Government Area Banjul * * * * * * 100.0 3 Kanifing (19.4) (9.4) (0.0) (0.0) (0.0) (71.1) 100.0 55 Brikama 17.7 2.8 1.9 0.0 4.1 73.6 100.0 278 Mansakonko 14.4 2.7 0.7 0.0 16.7 65.4 100.0 70 Kerewan 9.0 2.6 0.0 0.0 0.6 87.7 100.0 199 Kuntaur 3.9 0.8 0.0 0.0 0.6 94.7 100.0 133 Janjanbureh 9.6 2.5 0.0 0.0 2.6 85.3 100.0 136 Basse 3.7 0.0 0.3 0.0 0.5 95.5 100.0 358 Mother’s education No education 8.2 1.1 0.2 0.0 2.1 88.5 100.0 873 Primary 12.2 2.3 1.9 0.0 3.1 80.4 100.0 191 Secondary or higher 15.0 6.3 1.0 0.0 3.6 74.1 100.0 169 Wealth quintile Lowest 10.9 0.5 0.4 0.0 4.1 84.1 100.0 336 Second 6.8 1.7 1.0 0.0 2.9 87.5 100.0 369 Middle 6.2 1.5 0.5 0.0 1.7 90.1 100.0 320 Fourth 18.8 2.6 0.2 0.0 0.0 78.5 100.0 159 Highest (17.6) (15.4) (0.0) (0.0) (0.0) (66.9) 100.0 50 Total 9.7 2.0 0.6 0.0 2.4 85.3 100.0 1,232 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 9.4 PROBLEMS IN ACCESSING HEALTH CARE Many factors prevent women from obtaining medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers that some women face in seeking care during pregnancy and at delivery. Women were asked whether each of the following factors would be a significant problem in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to a health facility, and not wanting to go alone. Forty-three percent of women age 15-49 reported that they have at least one problem in accessing health care (Table 9.11). Thirty percent of women reported getting money for treatment as a problem, and 28 percent noted that distance to a health facility is a concern. Furthermore, 10 percent of women cited not wanting to go alone for treatment as a problem in accessing health care, and 5 percent reported that getting permission for treatment is a hindrance. Reproductive Health • 111 Table 9.11 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, The Gambia 2013 Background characteristic Problems in accessing health care Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone At least one problem accessing health care Number of women Age 15-19 6.1 28.9 28.1 11.9 43.9 2,407 20-34 5.0 27.3 26.9 9.0 40.9 5,451 35-49 5.0 35.9 30.6 9.4 46.8 2,375 Number of living children 0 5.9 25.0 24.7 10.0 39.6 3,530 1-2 4.9 27.1 26.9 9.4 39.7 2,644 3-4 5.6 31.1 29.6 9.1 44.1 1,955 5+ 4.4 39.5 33.6 10.5 51.7 2,103 Marital status Never married 5.9 26.0 24.6 10.5 40.3 2,963 Married or living together 5.1 31.2 30.0 9.7 44.4 6,791 Divorced/separated/widowed 4.1 30.0 21.4 7.4 39.9 478 Employed in last 12 months Not employed 6.5 28.4 26.5 8.4 41.2 5,110 Employed for cash 4.2 29.9 28.4 10.9 43.7 4,668 Employed not for cash 2.5 42.0 41.8 13.8 56.1 431 Residence Urban 5.6 21.5 16.0 5.8 32.1 5,730 Rural 4.9 40.1 43.3 14.8 56.8 4,503 Local Government Area Banjul 3.9 17.8 11.4 7.4 26.9 225 Kanifing 4.3 20.2 12.8 6.8 30.8 2,342 Brikama 5.7 25.7 20.2 7.5 37.4 3,550 Mansakonko 4.1 27.2 32.2 12.8 42.7 490 Kerewan 13.5 37.2 42.0 13.9 53.7 1,107 Kuntaur 2.8 49.7 63.9 14.2 72.8 526 Janjanbureh 4.4 47.9 43.7 8.7 60.2 739 Basse 0.7 35.9 43.3 16.2 52.3 1,254 Education No education 5.0 37.5 35.0 10.4 50.3 4,757 Primary 4.7 30.9 28.5 11.3 44.5 1,405 Secondary or higher 5.8 20.1 19.7 8.5 33.9 4,071 Wealth quintile Lowest 5.4 45.3 43.9 14.0 59.3 1,745 Second 5.7 40.2 42.5 14.2 57.0 1,882 Middle 3.9 33.4 32.0 10.8 47.8 1,927 Fourth 4.9 25.1 20.2 6.5 35.6 2,135 Highest 6.1 12.1 10.0 5.5 24.0 2,545 Total 5.3 29.7 28.0 9.8 43.0 10,233 Note: Total includes 24 cases for whom information on employment in the last 12 months is missing. Child Health • 113 CHILD HEALTH 10 his chapter presents findings on several areas of importance relating to child health, including infant birth weight; childhood vaccination coverage by timing, source of information on coverage, and background characteristics; prevalence and treatment of symptoms of acute respiratory infections (ARIs) (a proxy for pneumonia); prevalence and treatment of fever; and prevalence and treatment of diarrhoea, feeding practices during diarrhoea, knowledge of oral rehydration salt (ORS) packets, and disposal of children’s stools. Information on birth weight or size at birth is important for the design and implementation of programmes aimed at reducing neonatal and infant mortality. Vaccination coverage information focuses on the 12- to 23-month age group (i.e., the typical age by which children should have received all basic vaccinations). Data on differences in vaccination coverage between subgroups of the population aid in programme planning. Data on treatment practices and contact with health services among children ill with the three most important childhood illnesses (acute respiratory infection, fever, and diarrhoea) help in the assessment of national programmes aimed at reducing the mortality impact of these illnesses. Information is provided on the prevalence and treatment of ARIs, including treatment with antibiotics, and the prevalence of fever and its treatment with antimalarial drugs and antibiotics. Data on the treatment of diarrhoeal disease with oral rehydration therapy and increased fluids help in the assessment of programmes that recommend such treatments. Because sanitary practices can help prevent and reduce the severity of diarrhoeal disease, information is also provided on disposal of children’s faecal matter. The information on child health presented in this chapter pertains only to children born during the five years preceding the survey unless otherwise specified. 10.1 CHILD’S SIZE AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to childhood illnesses and chance of survival. Children with a birth weight of less than 2.5 kilograms and children reported to be “very small” or “smaller than average” are considered to have a higher than average risk of early childhood death. T Key Findings • Fifty-nine percent of live births in the five years preceding the survey had a reported birth weight, and 12 percent of infants with a reported birth weight were of low birth weight (less than 2.5 kilograms). • Seventy-six percent of children age 12-23 months were fully vaccinated at the time of the survey. • Five percent of children under age 5 had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey; treatment was sought for 68 percent of symptomatic children, and 49 percent were given antibiotics. • Twelve percent of children under age 5 had a fever in the two weeks preceding the survey; treatment was sought for 61 percent, 7 percent took antimalarial drugs, and 40 percent took antibiotics. • Seventeen percent of children under age 5 had diarrhoea in the two weeks preceding the survey. Treatment was sought for 68 percent of these children, 79 percent received oral rehydration therapy (ORT) or increased fluids, and 27 percent received antibiotic drugs. 114 • Child Health Table 10.1 presents information on children’s weight and size at birth according to background characteristics. The results show that birth weight was reported for only 59 percent of the live births that occurred in the five years preceding the survey. This is not surprising given that about four in ten births do not take place in a health facility, and children are less likely to be weighed at birth in a non-institutional setting. Among children born in the five years before the survey with a reported birth weight, 12 percent were of low birth weight (less than 2.5 kg). There are slight variations in the percentage of children with low birth weights by most background characteristics. Children of young mothers (less than age 20), children of birth order one, children in Banjul, and children of women in the lowest wealth quintile are somewhat more likely than children in other groups to have low birth weights. In the absence of birth weight, a mother’s subjective assessment of the size of her baby at birth may be a useful proxy. Nine percent of children were reported to be very small at birth, 12 percent were reported to be smaller than average, and 78 percent were reported to be average or larger in size. Differences in children’s size by background characteristics follow a pattern similar to that observed for reported birth weight. Table 10.1 Child’s size and weight at birth Percent distribution of live births in the five years preceding the survey by mother’s estimate of baby’s size at birth, percentage of live births in the five years preceding the survey that have a reported birth weight, and among live births in the five years preceding the survey with a reported birth weight, percentage less than 2.5 kg, according to background characteristics, The Gambia 2013 Background characteristic Percent distribution of all live births by size of child at birth Percentage of all births that have a reported birth weight1 Number of births Births with a reported birth weight1 Very small Smaller than average Average or larger Don’t know/ missing Total Percentage less than 2.5 kg Number of births Mother’s age at birth <20 8.8 13.3 77.1 0.7 100.0 57.3 1,063 13.5 609 20-34 8.9 11.6 78.6 0.8 100.0 59.4 5,703 11.1 3,386 35-49 11.0 11.6 76.1 1.3 100.0 60.9 1,140 13.1 694 Birth order 1 9.5 13.1 76.2 1.2 100.0 66.8 1,726 13.6 1,154 2-3 8.0 13.0 78.3 0.6 100.0 61.4 2,693 9.6 1,655 4-5 10.5 8.8 80.0 0.7 100.0 55.2 1,849 12.2 1,021 6+ 9.4 12.1 77.5 1.0 100.0 52.5 1,638 12.8 860 Residence Urban 10.1 11.7 77.4 0.8 100.0 76.1 3,771 11.9 2,870 Rural 8.4 12.0 78.7 0.9 100.0 44.0 4,135 11.5 1,818 Local Government Area Banjul 12.2 12.8 73.7 1.3 100.0 85.8 126 14.3 108 Kanifing 12.6 11.9 74.3 1.1 100.0 83.0 1,376 13.4 1,141 Brikama 8.8 11.7 78.6 0.8 100.0 71.2 2,697 11.8 1,920 Mansakonko 5.7 11.4 82.1 0.8 100.0 59.7 397 9.6 237 Kerewan 11.3 14.2 73.9 0.5 100.0 40.9 906 12.1 370 Kuntaur 12.9 11.3 75.0 0.7 100.0 31.3 534 9.9 167 Janjanbureh 10.7 8.8 79.3 1.2 100.0 58.2 663 9.3 386 Basse 3.1 12.2 84.1 0.6 100.0 29.7 1,208 10.1 359 Mother’s education No education 10.4 11.8 77.1 0.7 100.0 50.3 4,708 12.6 2,366 Primary 7.6 13.8 78.2 0.4 100.0 59.7 1,131 11.8 675 Secondary or higher 7.4 11.0 80.3 1.3 100.0 79.7 2,067 10.5 1,647 Wealth quintile Lowest 10.1 12.0 77.0 0.9 100.0 47.4 1,591 14.0 754 Second 8.9 10.1 79.8 1.1 100.0 48.5 1,746 10.0 846 Middle 7.4 13.8 77.9 1.0 100.0 51.0 1,586 9.6 809 Fourth 10.3 11.6 77.8 0.4 100.0 68.6 1,593 12.7 1,093 Highest 9.5 12.0 77.7 0.8 100.0 85.3 1,391 12.1 1,187 Total 9.2 11.9 78.1 0.8 100.0 59.3 7,906 11.7 4,689 1 Based on either a written record or the mother’s recall Child Health • 115 10.2 VACCINATION COVERAGE Vaccination coverage is one of the indicators used to monitor progress toward the achievement of Millennium Development Goal 4 and the reduction of child morbidity and mortality, as it is one of the most cost-effective public health interventions for reaching these goals. Differences in vaccination coverage among subgroups of the population are useful for programme planning and targeting resources toward areas most in need. According to the guidelines developed by the World Health Organization (WHO) and adopted by The Gambia, children are considered fully vaccinated when they have received a vaccination against tuberculosis (also known as BCG), three doses each of the DPT-HepB-Hib (also called pentavalent; introduced in August 2009) and polio vaccines, and a vaccination against measles. The BCG vaccine is usually given at birth or at first clinical contact, while the DPT-HepB-Hib and polio vaccines are administered at approximately age 6, 10, and 14 weeks. The measles vaccine should be given at or soon after age 9 months. The GDHS collected information on vaccination coverage in two ways: from vaccination cards shown to the interviewer and from mothers’ verbal reports. If the cards were available, the interviewer copied the vaccination dates directly onto the questionnaire. When there was no vaccination card for the child or if a vaccine had not been recorded on the card as being given, the respondent was asked to recall the vaccines given to her child. Table 10.2 shows information on vaccination coverage among children age 12-23 months by source of information (i.e., vaccination record or mother’s report). This is the youngest cohort of children who have reached the age by which they should be fully immunised. Overall, 68 percent of children age 12-23 months were fully immunised by the time of the survey. With regard to specific vaccines, 99 percent of children had received the BCG immunisation, and 88 percent had been immunised against measles. Coverage of the first dose of the DPT/pentavalent and polio vaccines was relatively high (98 percent each). However, only 88 percent and 90 percent of these children, respectively, went on to receive the third doses of these vaccines, contributing to a dropout of 11 percent and 8 percent between the first and third doses of the DPT/pentavalent and polio vaccines, respectively. There are minimal differences between DPT and polio vaccine coverage, because these vaccines are administered at the same time. The findings show that only 1 percent of children age 12-23 months did not receive any vaccine at all. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother’s report), and percentage vaccinated by age 12 months, The Gambia 2013 Source of information BCG DPT/ penta- valent 1 DPT/ penta- valent 2 DPT/ penta- valent 3 Polio 01 Polio 1 Polio 2 Polio 3 Measles All basic vaccina- tions2 No vaccina- tions Number of children Vaccinated at any time before survey Vaccination card 90.0 89.7 87.4 82.1 89.9 89.5 88.2 87.3 79.3 73.7 0.0 1,496 Mother’s report 8.8 8.4 7.9 5.5 7.4 8.3 7.4 2.7 8.5 2.3 1.0 163 Either source 98.9 98.1 95.3 87.7 97.3 97.8 95.6 90.0 87.8 76.0 1.0 1,660 Vaccinated by age 12 months3 98.6 97.5 94.6 86.2 97.0 97.2 95.2 88.6 78.8 68.0 1.3 1,660 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and 3 doses each of DPT or pentavalent and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccination. 116 • Child Health 10.2.1 Vaccination Coverage by Background Characteristics Table 10.3 shows the percentage of children age 12-23 months who received specific vaccines at any time before the survey, according to background characteristics. Boys are slightly more likely than girls to be fully immunised (78 percent versus 74 percent). Birth order varies inversely with immunisation coverage; as birth order increases, immunisation coverage generally decreases. Sixty-eight percent of first- born children have been fully immunised, as compared with 81 percent of children of birth order six and above. Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report), and percentage with a vaccination card, by background characteristics, The Gambia 2013 Background characteristic BCG DPT/ penta- valent 1 DPT/ penta- valent 2 DPT/ penta- valent 3 Polio 01 Polio 1 Polio 2 Polio 3 Measles All basic vaccina- tions2 No vaccina- tions Percent- age with a vaccina- tion card seen Number of children Sex Male 99.4 98.2 95.5 89.1 98.0 98.7 96.3 91.8 87.6 78.0 0.5 92.5 853 Female 98.3 97.9 95.0 86.2 96.4 96.7 94.8 88.1 88.1 73.9 1.5 87.7 807 Birth order 1 98.1 96.9 94.3 85.1 96.8 97.8 96.8 88.3 81.6 67.6 1.9 87.6 368 2-3 99.1 98.2 95.4 88.6 96.6 98.2 95.9 90.2 90.4 78.4 0.7 89.9 570 4-5 99.3 98.5 95.8 88.1 97.5 97.2 95.6 91.6 87.8 75.6 0.2 90.5 360 6+ 98.8 98.5 95.6 88.3 98.5 97.6 93.9 89.8 90.2 81.2 1.2 92.7 363 Residence Urban 98.1 97.5 93.4 84.0 96.4 96.2 94.2 87.1 82.0 67.1 1.7 87.5 776 Rural 99.5 98.5 96.9 90.9 98.0 99.1 96.8 92.5 92.9 83.9 0.4 92.5 884 Local Government Area Banjul 93.7 92.7 91.1 76.1 91.7 91.3 87.6 76.2 81.8 58.8 5.5 75.9 21 Kanifing 95.1 94.7 89.3 82.7 91.9 91.9 88.9 83.4 84.3 70.9 4.9 83.0 240 Brikama 99.5 98.8 95.8 85.7 98.3 98.6 96.6 90.5 82.9 69.5 0.2 89.5 599 Mansakonko 99.2 98.0 97.4 94.5 98.8 98.0 96.8 92.2 92.4 85.5 0.8 92.0 80 Kerewan 99.4 98.5 96.0 88.3 97.5 98.0 95.6 89.2 93.3 78.9 0.6 92.6 214 Kuntaur 99.0 98.7 96.2 89.3 96.6 99.3 98.0 90.2 94.5 81.0 0.3 88.9 105 Janjanbureh 100.0 97.5 93.0 84.1 99.0 99.7 95.3 87.3 86.8 71.8 0.0 92.5 144 Basse 100.0 99.6 99.6 96.5 98.8 99.6 99.1 97.4 95.1 92.2 0.0 96.1 257 Mother’s education No education 99.0 98.5 95.7 89.6 98.1 97.8 95.9 90.5 89.1 78.3 0.7 91.5 943 Primary 99.0 96.2 91.7 85.6 96.0 97.0 92.3 89.5 92.5 81.8 0.9 90.2 247 Secondary or higher 98.4 98.1 96.3 84.9 96.3 98.0 96.7 89.1 82.9 68.2 1.6 87.5 470 Wealth quintile Lowest 99.0 98.2 95.5 90.0 98.1 98.5 95.8 91.9 93.0 83.7 0.5 93.2 333 Second 99.4 98.0 95.8 88.1 97.8 99.0 95.4 88.5 89.4 76.6 0.5 89.2 370 Middle 99.4 99.1 94.8 88.3 97.0 97.5 95.2 91.3 89.3 80.3 0.5 93.4 357 Fourth 98.5 97.2 92.9 88.5 98.0 96.9 95.6 90.2 89.4 76.8 1.5 89.7 319 Highest 97.7 97.7 97.7 82.7 95.0 96.5 96.1 87.7 76.2 59.7 2.2 84.3 281 Total 98.9 98.1 95.3 87.7 97.3 97.8 95.6 90.0 87.8 76.0 1.0 90.2 1,660 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and 3 doses each of DPT or pentavalent and polio vaccine (excluding polio vaccine given at birth) Urban-rural differences in immunisation coverage are substantial, with children residing in urban areas much less likely to be fully immunised (67 percent) than children in rural areas (84 percent). There are differences in coverage by Local Government Area (LGA), with 59 percent of children fully immunised in Banjul, compared with 92 percent in Basse. Immunisation coverage is notably higher among children born to uneducated women and women with a primary education (78-82 percent) than among children whose mothers have a secondary education or higher (68 percent). Children in households in the highest wealth quintile (60 percent) are much less likely to be fully immunised than those in households in the lower wealth quintiles (77-84 percent). Table 10.3 also shows that an immunisation card was seen for 90 percent of children age 12-23 months. Cards were somewhat less likely to have been seen for girls and for children living in urban areas Child Health • 117 (88 percent each), as well as for children living in Banjul (76 percent), children of mothers with a secondary education or higher (88 percent), and children of mothers in the highest wealth quintile (84 percent). 10.3 TRENDS IN VACCINATION COVERAGE One way of measuring trends in vaccination coverage is to compare coverage among children of different ages in the 2013 GDHS. Table 10.4 shows the percentage of children who received vaccinations during the first year of life by current age (12-59 months). These data provide information on trends in vaccination coverage over the past five years. The percentage of children who have received all basic vaccinations is inversely associated with age. Vaccination coverage is 68 percent among children age 12-23 months, as compared with 53 percent among those age 48-59 months. Similar trends are observed for individual vaccines. Younger children are substantially more likely to have a vaccination card than older children. Sixty-three percent of children age 48-59 months have a vaccination card, compared with 90 percent of those age 12-23 months. Table 10.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by age 12 months, and percentage with a vaccination card, by current age of child, The Gambia 2013 Age in months BCG DPT/ penta- valent 1 DPT/ penta- valent 2 DPT/ penta- valent 3 Polio 01 Polio 1 Polio 2 Polio 3 Measles All basic vaccina- tions2 No vaccina- tions Percent- age with a vaccina- tion card seen Number of children 12-23 98.6 97.5 94.6 86.2 97.0 97.2 95.2 88.6 78.8 68.0 1.3 90.2 1,660 24-35 96.9 94.9 91.4 83.0 94.2 96.4 92.3 80.7 78.9 63.8 2.8 79.9 1,426 36-47 97.1 93.7 90.5 79.0 92.8 94.9 90.3 74.0 78.7 58.7 2.3 69.9 1,396 48-59 95.9 91.5 87.7 74.9 88.9 94.1 88.2 70.9 74.8 53.1 3.1 62.9 1,369 12-59 97.2 94.6 91.4 81.4 93.4 95.8 91.8 79.4 78.3 61.7 2.3 76.4 5,850 Note: Information was obtained from the vaccination card or, if there was no written record, from the mother. For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and 3 doses each of DPT or pentavalent and polio vaccine (excluding polio vaccine given at birth) 10.4 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is one of the leading causes of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large number of deaths caused by ARI. In the 2013 GDHS, the prevalence of ARI was estimated by asking mothers whether their children under age 5 had been ill in the two weeks preceding the survey with a cough accompanied by short, rapid breathing that the mother considered to be chest related. These symptoms are compatible with pneumonia. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Table 10.5 shows that 5 percent of children under age 5 had a cough accompanied by short, rapid breathing in the two weeks before the survey. There are no major differences by most background characteristics. Among LGAs, Banjul and Kanifing have the highest prevalence of ARI symptoms at 7 percent each. Among children with the ARI symptoms, advice or treatment was sought from a health facility or a health care provider for 68 percent, and 49 percent received antibiotics. While advice or treatment from a health facility or provider was sought more for male than female children (72 percent versus 63 percent), a higher percentage of females than males received antibiotics (52 percent versus 47 percent). There are no 118 • Child Health clear patterns in the relationship between the percentage of children with ARI symptoms for whom advice or treatment was sought from a health facility or provider and mother’s education or household wealth. Children of mothers with a secondary education or higher (57 percent) were more likely to receive antibiotics for their ARI symptoms than children of mothers with a primary education or no education (42-46 percent). There does not appear to be an association between wealth quintile and the percentage of children with ARI symptoms who received antibiotics. Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age 5, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey and among children with symptoms of ARI, the percentage for whom advice or treatment was sought from a health facility or provider and the percentage who received antibiotics as treatment, according to background characteristics, The Gambia 2013 Background characteristic Among children under age 5: Among children under age 5 with symptoms of ARI: Percentage for whom advice or treatment was sought from a health facility or provider2 Percentage who received antibiotics Number of children Percentage with symptoms of ARI1 Number of children Age in months <6 3.0 931 (46.7) (23.9) 28 6-11 5.8 805 63.6 48.5 46 12-23 4.8 1,660 71.0 50.8 80 24-35 6.4 1,426 64.4 54.5 91 36-47 3.6 1,396 75.4 49.4 50 48-59 3.9 1,369 (78.0) (48.1) 54 Sex Male 5.3 3,846 72.0 46.5 204 Female 3.9 3,740 62.5 51.7 145 Cooking fuel Electricity or gas * 19 * * 1 Kerosene * 15 * * 0 Charcoal 5.4 1,444 69.5 47.9 78 Wood/straw3 4.4 6,097 67.7 48.9 268 No food cooked in household * 5 * * 0 Residence Urban 4.8 3,605 68.1 46.4 173 Rural 4.4 3,981 68.0 51.0 175 Local Government Area Banjul 7.1 121 (54.6) (41.8) 9 Kanifing 6.5 1,317 (68.6) (43.3) 86 Brikama 4.6 2,566 69.8 56.3 118 Mansakonko 3.1 385 * * 12 Kerewan 5.7 890 71.2 67.7 51 Kuntaur 3.7 514 (54.6) (26.7) 19 Janjanbureh 6.3 644 66.6 21.7 41 Basse 1.2 1,151 * * 14 Mother’s education No education 3.8 4,504 71.4 45.6 171 Primary 5.5 1,071 55.2 41.5 59 Secondary or higher 5.9 2,011 69.6 56.7 118 Wealth quintile Lowest 4.5 1,525 69.7 47.7 69 Second 4.1 1,686 70.1 51.2 70 Middle 4.5 1,512 70.8 61.9 67 Fourth 4.5 1,509 62.4 27.0 69 Highest 5.5 1,354 67.3 55.4 74 Total 4.6 7,586 68.0 48.7 349 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related and/or by difficult breathing that is chest-related) are considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 3 Includes grass, shrubs, and crop residues Child Health • 119 10.5 FEVER Fever is a major manifestation of malaria and other acute infections in children. Malaria and fever contribute to high levels of malnutrition and morbidity. While fever can occur year-round, malaria is more prevalent following the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Since malaria is a major contributory cause of death in infancy and childhood in many developing countries, presumptive treatment of fever with antimalarial medication is advocated in a number of countries where malaria is endemic. The 2013 GDHS fieldwork was carried out from early February to the end of April 2013, which is outside the malaria season. In the 2013 GDHS, mothers were asked whether their children under age 5 had a fever in the two weeks preceding the survey and, if so, whether any treatment was sought. Table 10.6 shows that 12 percent of children were reported to have had a fever in the two weeks preceding the survey. Fever was least common among children age 48-59 months (7 percent) and most common among those age 6-11 months (17 percent). Fever prevalence varied little by sex or residence. The proportion of children with fever was highest in Banjul (19 percent) and Kuntaur (16 percent) and lowest in Basse (8 percent) and Janjanbureh (7 percent). Table 10.6 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey, and among children with fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who received antibiotics as treatment, by background characteristics, The Gambia 2013 Background characteristic Among children under age 5: Among children under age 5 with fever: Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children Percentage with fever Number of children Age in months <6 11.2 931 52.3 0.4 32.8 104 6-11 17.0 805 52.1 2.9 46.5 137 12-23 15.1 1,660 59.7 7.8 35.0 250 24-35 12.6 1,426 67.5 10.1 40.6 180 36-47 9.5 1,396 74.2 9.4 42.2 132 48-59 7.0 1,369 58.4 5.9 42.9 96 Sex Male 12.3 3,846 59.9 7.4 37.4 473 Female 11.4 3,740 62.7 5.9 41.9 425 Residence Urban 10.6 3,605 62.9 7.4 37.6 380 Rural 13.0 3,981 60.0 6.1 40.9 518 Local Government Area Banjul 19.4 121 58.1 1.6 39.8 23 Kanifing 14.6 1,317 57.2 9.1 34.4 192 Brikama 12.1 2,566 68.6 8.9 41.0 309 Mansakonko 9.1 385 54.8 8.0 34.7 35 Kerewan 12.6 890 67.6 4.9 56.7 112 Kuntaur 16.4 514 57.1 2.3 25.4 84 Janjanbureh 6.9 644 49.0 4.7 30.3 44 Basse 8.4 1,151 50.5 2.3 43.2 97 Mother’s education No education 10.8 4,504 59.6 6.4 38.2 484 Primary 13.3 1,071 60.8 9.3 37.1 142 Secondary or higher 13.5 2,011 64.4 5.8 43.1 272 Wealth quintile Lowest 12.4 1,525 63.9 4.9 39.9 189 Second 13.7 1,686 57.3 7.9 40.9 232 Middle 11.0 1,512 60.8 5.2 40.8 166 Fourth 9.9 1,509 62.8 7.1 41.1 149 Highest 11.9 1,354 62.6 8.2 34.3 162 Total 11.8 7,586 61.2 6.7 39.5 898 1 Excludes pharmacy, shop, market, and traditional practitioner 120 • Child Health Sixty-one percent of children with a fever were taken to a health facility or provider for treatment. Children age 36-47 months, female children, those living in urban areas, and those living in Brikama were more likely than other children to receive treatment from a health facility or provider. The percentage of children with fever taken to a health facility or provider increases with increasing mother’s education and it is highest for children in the richest households. Table 10.6 also shows that 7 percent of children with fever took antimalarial drugs and 40 percent received antibiotics. Younger children (under age 6 months), male children, urban children and those living in Kuntaur, children of mothers with a primary or no education, and children in the wealthiest households were less likely than other children to receive treatment with antibiotics. Malaria is discussed in detail in Chapter 12. 10.6 DIARRHOEAL DISEASE Dehydration from diarrhoea is a major cause of death in infancy and childhood. This is unfortunate since the condition is easily treated with oral rehydration therapy (ORT). The combination of high cause-specific mortality and the existence of effective treatment makes diarrhoea and its treatment a priority concern for health services. Exposure to diarrhoea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. Diarrhoea with blood in the stool is indicative of specific diseases and needs to be treated somewhat differently than diarrhoea without blood. In the 2013 GDHS, mothers were asked whether any of their children under age 5 had diarrhoea at any time during the two- week period preceding the survey. If the child had diarrhoea, the mother was asked about feeding practices during the diarrhoeal episode. The validity of this indicator is affected by the mother’s perception of diarrhoea as an illness and her capacity to recall the events. Moreover, the prevalence of diarrhoea varies seasonally. 10.6.1 Prevalence of Diarrhoea Table 10.7 shows the percentage of children under age 5 with diarrhoea in the two weeks preceding the survey, by selected background characteristics. Seventeen percent of children had a diarrhoeal episode in the two weeks preceding the survey, and 1 percent had blood in their stools. Table 10.7 Prevalence of diarrhoea Percentage of children under age 5 who had diarrhoea in the two weeks preceding the survey, by background characteristics, The Gambia 2013 Background characteristic Diarrhoea in the two weeks preceding the survey Number of children All diarrhoea Diarrhoea with blood Age in months <6 12.7 0.4 931 6-11 27.9 1.5 805 12-23 26.8 2.7 1,660 24-35 22.3 1.6 1,426 36-47 8.5 0.8 1,396 48-59 6.9 0.7 1,369 Sex Male 18.7 1.4 3,846 Female 16.0 1.3 3,740 Source of drinking water1 Improved 17.5 1.4 6,759 Not improved 16.6 1.0 817 Toilet facility2 Improved, not shared 17.5 1.5 2,906 Shared3 20.7 1.5 1,424 Non-improved 15.8 1.2 3,242 Residence Urban 18.4 1.3 3,605 Rural 16.4 1.5 3,981 Local Government Area Banjul 26.0 1.2 121 Kanifing 22.3 1.6 1,317 Brikama 19.0 1.4 2,566 Mansakonko 14.4 0.9 385 Kerewan 12.9 1.8 890 Kuntaur 20.3 1.9 514 Janjanbureh 14.4 1.4 644 Basse 12.0 0.5 1,151 Mother’s education No education 16.1 1.4 4,504 Primary 21.0 2.2 1,071 Secondary or higher 18.3 0.9 2,011 Wealth quintile Lowest 16.1 1.3 1,525 Second 17.2 1.5 1,686 Middle 16.7 1.3 1,512 Fourth 18.3 1.5 1,509 Highest 18.7 1.3 1,354 Total 17.4 1.4 7,586 Note: Total includes 9 cases for whom information on source of drinking water is missing and 13 cases for whom information on the toilet facility is missing. 1 See Table 2.1 for definition of categories. 2 See Table 2.2 for definition of categories. 3 Facilities that would be considered improved if they were not shared by 2 or more households Child Health • 121 The prevalence of diarrhoea varies by the age of the child. Children age 6-11 months had a higher prevalence of diarrhoea than children in other age groups. Diarrhoea is more prevalent among children whose household shares a toilet facility with other households (21 percent) than among children in households that have an improved, non-shared toilet facility (18 percent) or a non-improved facility (16 percent). The prevalence of diarrhoea varies by LGA, with children in Banjul having the highest prevalence (26 percent) and children in Basse the lowest (12 percent). There is no clear pattern in diarrhoea prevalence by mother’s education or household wealth. 10.6.2 Treatment of Diarrhoea In the 2013 NDHS, mothers of children who had diarrhoea were asked about what was done to treat the illness. Table 10.8 shows the percentage of children with diarrhoea who received specific treatments, according to background characteristics. Sixty-eight percent of children with diarrhoea were taken to a health care facility or provider for advice or treatment. This proportion was highest for children age 6-11 months (74 percent) and lowest for children under age 6 months (48 percent). Treatment was sought from a health facility or health provider for a slightly higher percentage of male than female children (69 percent versus 66 percent). Treatment and advice were sought more often for children in rural areas (69 percent) than their urban counterparts (66 percent). With respect to other characteristics, children with blood in their stools (83 percent), children in Kerewan (74 percent), and children of mothers with no education (69 percent) were more likely than other children to be taken to a health care facility or provider for advice or treatment. Table 10.8 also includes information on oral rehydration therapy and other treatments. Seventy- nine percent of children with diarrhoea in the last two weeks were treated with ORT or increased fluids, 59 percent were treated with ORS (a mixture prepared from a packet of oral rehydration solution), and 46 percent received increased fluids. Children age 24-35 months (87 percent), children with bloody diarrhoea (84 percent), children living in Kerewan (92 percent), children of mothers with a primary education or no education (80-81 percent), and children in the fourth wealth quintile (83 percent) were most likely to receive ORT or increased fluids. Twenty-seven percent of children were given antibiotic drugs, and 26 percent received home remedies or other treatments. Twelve percent of children with diarrhoea received no treatment. 12 2 • C hi ld H ea lth Ta bl e 10 .8 D ia rrh oe a tre at m en t A m on g ch ild re n un de r ag e 5 w ho h ad d ia rr ho ea in th e tw o w ee ks p re ce di ng th e su rv ey , t he p er ce nt ag e fo r w ho m a dv ic e or tr ea tm en t w as s ou gh t f ro m a h ea lth fa ci lit y or p ro vi de r, th e pe rc en ta ge gi ve n or al r eh yd ra tio n th er ap y (O R T) , th e pe rc en ta ge g iv en i nc re as ed f lu id s, t he p er ce nt ag e gi ve n O R T or i nc re as ed f lu id s, a nd t he p er ce nt ag e gi ve n ot he r tre at m en ts , by b ac kg ro un d ch ar ac te ris tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic P er ce nt ag e of ch ild re n w ith di ar rh oe a fo r w ho m ad vi ce o r t re at m en t w as s ou gh t f ro m a he al th fa ci lit y or pr ov id er 1 O ra l r eh yd ra tio n th er ap y (O R T) In cr ea se d flu id s O R T or in cr ea se d flu id s O th er tr ea tm en ts N o tre at m en t N um be r o f ch ild re n w ith di ar rh oe a Fl ui d fro m O R S p ac ke ts or p re - pa ck ag ed liq ui d R ec om m en d ed h om e flu id s (R H F) E ith er O R S or R H F A nt ib io tic dr ug s A nt im ot ili ty dr ug s H om e re m ed y/ ot he r A ge in m on th s <6 48 .0 32 .0 4. 5 35 .0 24 .4 47 .7 17 .0 0. 0 19 .0 35 .7 11 8 6- 11 73 .9 60 .3 9. 2 64 .1 43 .5 78 .5 37 .7 1. 1 29 .0 11 .9 22 4 12 -2 3 72 .2 60 .9 13 .4 67 .5 48 .7 81 .0 30 .7 0. 0 26 .3 9. 0 44 5 24 -3 5 63 .9 64 .0 18 .4 70 .6 50 .8 86 .7 15 .8 1. 6 25 .9 9. 9 31 7 36 -4 7 63 .7 60 .2 10 .8 66 .7 48 .4 83 .9 30 .8 0. 0 26 .5 9. 8 11 8 48 -5 9 70 .9 64 .7 14 .4 71 .0 49 .3 81 .3 25 .0 0. 0 21 .3 12 .4 94 Se x M al e 68 .9 59 .2 15 .1 66 .1 48 .0 80 .0 28 .5 0. 6 25 .9 11 .7 71 8 Fe m al e 65 .7 59 .1 10 .3 63 .6 44 .0 78 .3 24 .5 0. 6 25 .5 13 .3 59 9 Ty pe o f d ia rr ho ea N on -b lo od y 65 .8 58 .1 12 .6 64 .1 45 .0 78 .6 25 .9 0. 5 24 .3 13 .4 1, 18 0 B lo od y 83 .4 67 .6 14 .7 71 .5 59 .1 84 .4 35 .7 1. 5 35 .3 3. 9 10 4 R es id en ce U rb an 65 .9 61 .5 10 .5 65 .7 43 .8 78 .7 28 .1 1. 1 20 .9 13 .8 66 5 R ur al 69 .0 56 .8 15 .4 64 .2 48 .5 79 .8 25 .3 0. 1 30 .5 11 .0 65 3 Lo ca l G ov er nm en t A re a B an ju l 63 .5 60 .5 9. 3 63 .5 46 .8 75 .1 15 .9 0. 0 22 .7 19 .3 31 K an ifi ng 64 .8 57 .2 13 .4 63 .8 42 .0 75 .6 28 .3 1. 1 21 .6 14 .8 29 3 B rik am a 68 .8 62 .3 12 .2 66 .7 47 .5 81 .2 30 .0 0. 8 26 .1 10 .7 48 8 M an sa ko nk o 68 .4 57 .9 14 .8 66 .4 38 .9 75 .7 21 .0 0. 8 14 .5 15 .8 55 K er ew an 73 .6 63 .9 22 .0 72 .7 68 .9 91 .7 18 .0 0. 0 40 .3 6. 0 11 5 K un ta ur 64 .7 55 .0 8. 1 59 .4 58 .3 84 .0 12 .1 0. 0 35 .6 11 .2 10 4 Ja nj an bu re h 68 .3 59 .0 19 .8 67 .6 24 .6 76 .6 33 .2 0. 0 9. 3 13 .5 93 B as se 65 .2 52 .0 5. 9 57 .1 39 .5 70 .3 30 .3 0. 0 29 .4 15 .9 13 8 M ot he r’s e du ca tio n N o ed uc at io n 69 .0 60 .6 12 .1 65 .8 44 .7 80 .8 27 .0 0. 2 24 .4 9. 6 72 4 P rim ar y 65 .3 63 .5 13 .6 69 .0 51 .5 80 .4 26 .5 1. 3 26 .0 14 .5 22 5 S ec on da ry o r h ig he r 65 .6 53 .7 14 .0 60 .9 45 .8 75 .4 26 .2 0. 8 28 .1 16 .6 36 8 W ea lth q ui nt ile Lo w es t 67 .0 55 .8 16 .7 62 .0 45 .7 78 .6 24 .3 0. 0 20 .9 14 .7 24 5 S ec on d 71 .0 56 .8 9. 8 61 .3 43 .6 74 .6 28 .3 0. 2 30 .7 10 .1 29 0 M id dl e 67 .2 60 .7 14 .4 67 .7 48 .9 81 .0 30 .0 1. 0 34 .2 10 .1 25 2 Fo ur th 65 .6 64 .4 13 .1 68 .9 48 .9 82 .7 25 .9 0. 0 17 .4 13 .8 27 6 H ig he st 66 .1 57 .9 11 .2 64 .9 43 .8 79 .7 24 .7 1. 8 25 .1 13 .5 25 4 To ta l 67 .5 59 .2 12 .9 65 .0 46 .2 79 .2 26 .7 0. 6 25 .7 12 .4 1, 31 8 N ot e: O R T in cl ud es fl ui d pr ep ar ed fr om o ra l r eh yd ra tio n sa lt (O R S) p ac ke ts , p re -p ac ka ge d O R S fl ui d, a nd re co m m en de d ho m e flu id s (R H F) . 1 E xc lu de s ph ar m ac y, s ho p, a nd tr ad iti on al p ra ct iti on er 122 • Child Health Child Health • 123 10.6.3 Feeding Practices during Diarrhoea When a child has diarrhoea, mothers are encouraged to continue feeding the child the same amount of food as they would if the child did not have diarrhoea. Mothers are also encouraged to increase the child’s fluid intake. These practices help to reduce dehydration and minimise the adverse consequences of diarrhoea for the child’s nutritional status. In the 2013 GDHS, mothers were asked whether they gave their child with diarrhoea less, the same amount, or more fluids and food than usual. Table 10.9 shows the percent distribution of children under age 5 who had diarrhoea in the two weeks preceding the survey by feeding practices, according to background characteristics. Forty-six percent of children with diarrhoea were given more liquids than usual, and 24 percent were given the same amount. It is of concern that 15 percent of children were given somewhat less to drink than usual, 13 percent were given much less to drink, and 2 percent were given nothing to drink during the diarrhoea episode. In terms of food, 12 percent of children were given more than usual and 27 percent were given the same amount. On the other hand, 27 percent of children were given somewhat less to eat, 23 percent were given much less, and 4 percent were given no food at all. Overall, only 30 percent of children continued feeding and were given increased fluids, and 51 percent continued feeding and were given ORT and/or increased fluids. 12 4 • C hi ld H ea lth Ta bl e 10 .9 F ee di ng p ra ct ic es d ur in g di ar rh oe a P er ce nt d is tri bu tio n of c hi ld re n un de r ag e 5 w ho h ad d ia rr ho ea in t he tw o w ee ks p re ce di ng t he s ur ve y by a m ou nt o f liq ui ds a nd fo od o ffe re d co m pa re d w ith n or m al p ra ct ic e, t he p er ce nt ag e of c hi ld re n gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g du rin g th e di ar rh oe a ep is od e, a nd th e pe rc en ta ge w ho c on tin ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s du rin g th e ep is od e of d ia rrh oe a, b y ba ck gr ou nd c ha ra ct er is tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic A m ou nt o f l iq ui ds g iv en A m ou nt o f f oo d gi ve n P er ce nt ag e gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g1 P er ce nt ag e w ho co nt in ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s1 N um be r of ch ild re n w ith di ar rh oe a M or e S am e as us ua l S om e- w ha t l es s M uc h le ss N on e D on ’t kn ow / m is si ng To ta l M or e S am e as us ua l S om e- w ha t l es s M uc h le ss N on e N ev er ga ve fo od D on ’t kn ow / m is si ng To ta l A ge in m on th s <6 24 .4 35 .6 19 .2 9. 6 11 .2 0. 0 10 0. 0 1. 4 28 .4 6. 4 7. 9 2. 1 47 .5 6. 2 10 0. 0 5. 8 14 .7 11 8 6- 11 43 .5 19 .3 22 .0 13 .0 2. 3 0. 0 10 0. 0 9. 1 25 .4 25 .8 21 .5 6. 9 11 .3 0. 0 10 0. 0 25 .5 45 .9 22 4 12 -2 3 48 .7 19 .6 13 .7 15 .9 1. 4 0. 7 10 0. 0 11 .7 21 .8 30 .4 27 .2 5. 7 2. 6 0. 7 10 0. 0 31 .5 50 .0 44 5 24 -3 5 50 .8 27 .8 12 .2 9. 0 0. 2 0. 0 10 0. 0 14 .8 35 .7 26 .5 21 .6 1. 5 0. 0 0. 0 10 0. 0 38 .1 65 .5 31 7 36 -4 7 48 .4 25 .2 12 .7 12 .4 0. 0 1. 3 10 0. 0 15 .1 27 .5 27 .8 27 .6 0. 9 0. 0 1. 1 10 0. 0 32 .3 58 .0 11 8 48 -5 9 49 .3 21 .9 15 .6 10 .9 0. 0 2. 3 10 0. 0 12 .9 19 .4 35 .6 28 .9 0. 9 0. 0 2. 3 10 0. 0 33 .2 53 .6 94 Se x M al e 48 .0 22 .8 15 .3 12 .0 1. 8 0. 1 10 0. 0 11 .4 26 .2 28 .7 24 .4 3. 0 5. 4 0. 8 10 0. 0 31 .0 51 .9 71 8 Fe m al e 44 .0 24 .6 15 .3 13 .0 2. 1 1. 0 10 0. 0 11 .6 27 .2 24 .3 21 .9 4. 7 9. 1 1. 3 10 0. 0 28 .8 49 .5 59 9 Ty pe o f d ia rr ho ea N on -b lo od y 45 .0 24 .8 15 .4 12 .5 2. 0 0. 3 10 0. 0 11 .7 27 .9 25 .8 22 .6 3. 6 7. 5 0. 9 10 0. 0 29 .6 51 .1 1, 18 0 B lo od y 59 .1 14 .8 11 .3 13 .1 1. 7 0. 0 10 0. 0 8. 2 13 .8 32 .6 34 .5 7. 1 3. 8 0. 0 10 0. 0 31 .7 43 .2 10 4 R es id en ce U rb an 43 .8 24 .9 15 .2 14 .9 1. 1 0. 0 10 0. 0 8. 6 28 .4 29 .3 26 .0 2. 5 4. 7 0. 5 10 0. 0 27 .3 50 .4 66 5 R ur al 48 .5 22 .3 15 .4 10 .0 2. 8 1. 0 10 0. 0 14 .4 24 .9 24 .0 20 .5 5. 1 9. 5 1. 6 10 0. 0 32 .6 51 .3 65 3 Lo ca l G ov er nm en t A re a B an ju l 46 .8 33 .5 8. 8 9. 7 0. 8 0. 4 10 0. 0 9. 0 24 .8 24 .9 34 .6 1. 1 5. 1 0. 4 10 0. 0 19 .8 41 .7 31 K an ifi ng 42 .0 24 .1 17 .4 15 .5 1. 1 0. 0 10 0. 0 11 .0 29 .3 30 .9 23 .7 2. 2 2. 9 0. 0 10 0. 0 27 .8 51 .8 29 3 B rik am a 47 .5 25 .8 12 .4 13 .1 0. 5 0. 7 10 0. 0 9. 6 28 .9 24 .2 27 .6 3. 0 5. 4 1. 3 10 0. 0 28 .9 49 .7 48 8 M an sa ko nk o 38 .9 31 .1 10 .6 12 .2 3. 8 3. 4 10 0. 0 14 .3 39 .8 19 .7 16 .4 1. 6 5. 3 2. 9 10 0. 0 29 .5 57 .3 55 K er ew an 68 .9 10 .0 7. 5 10 .0 3. 7 0. 0 10 0. 0 20 .1 18 .8 18 .1 24 .2 6. 3 12 .6 0. 0 10 0. 0 42 .1 54 .0 11 5 K un ta ur 58 .3 19 .8 13 .5 6. 8 1. 0 0. 7 10 0. 0 5. 3 24 .6 33 .0 25 .0 3. 2 8. 2 0. 7 10 0. 0 35 .0 52 .2 10 4 Ja nj an bu re h 24 .6 18 .4 26 .4 20 .9 9. 1 0. 6 10 0. 0 10 .6 20 .3 23 .0 22 .0 16 .2 7. 4 0. 6 10 0. 0 19 .9 40 .2 93 B as se 39 .5 27 .2 24 .8 5. 7 2. 8 0. 0 10 0. 0 16 .4 20 .9 34 .5 6. 2 1. 5 17 .3 3. 2 10 0. 0 33 .7 55 .8 13 8 M ot he r’s e du ca tio n N o ed uc at io n 44 .7 24 .1 16 .2 12 .3 2. 1 0. 6 10 0. 0 10 .5 27 .8 28 .1 20 .2 5. 0 7. 2 1. 2 10 0. 0 30 .5 53 .3 72 4 P rim ar y 51 .5 23 .2 13 .0 11 .3 1. 0 0. 0 10 0. 0 13 .5 20 .9 22 .9 29 .0 3. 5 9. 1 1. 1 10 0. 0 30 .1 46 .4 22 5 S ec on da ry o r h ig he r 45 .8 22 .8 14 .9 13 .6 2. 2 0. 7 10 0. 0 12 .0 28 .0 26 .3 26 .0 1. 6 5. 6 0. 6 10 0. 0 28 .8 48 .7 36 8 W ea lth q ui nt ile Lo w es t 45 .7 22 .1 17 .2 10 .9 3. 2 0. 8 10 0. 0 11 .8 25 .3 20 .0 25 .9 4. 4 10 .2 2. 4 10 0. 0 27 .5 45 .5 24 5 S ec on d 43 .6 25 .1 14 .7 13 .1 2. 0 1. 6 10 0. 0 14 .3 24 .9 23 .8 18 .7 7. 7 8. 8 1. 8 10 0. 0 30 .3 48 .8 29 0 M id dl e 48 .9 21 .0 20 .9 7. 2 2. 0 0. 0 10 0. 0 13 .0 22 .7 34 .6 18 .4 3. 4 6. 9 1. 0 10 0. 0 34 .1 54 .8 25 2 Fo ur th 48 .9 25 .3 9. 2 14 .7 1. 9 0. 0 10 0. 0 11 .1 31 .6 27 .2 23 .0 1. 0 6. 1 0. 0 10 0. 0 33 .9 56 .8 27 6 H ig he st 43 .8 24 .1 15 .1 16 .3 0. 6 0. 0 10 0. 0 6. 7 28 .8 27 .8 31 .3 2. 1 3. 3 0. 0 10 0. 0 23 .5 48 .0 25 4 To ta l 46 .2 23 .6 15 .3 12 .5 1. 9 0. 5 10 0. 0 11 .5 26 .7 26 .7 23 .3 3. 8 7. 1 1. 0 10 0. 0 30 .0 50 .8 1, 31 8 N ot e: It is re co m m en de d th at c hi ld re n be g iv en m or e liq ui ds to d rin k du rin g di ar rh oe a an d th at fo od n ot b e re du ce d. T ot al in cl ud es 3 2 ca se s fo r w ho m in fo rm at io n on ty pe o f d ia rr ho ea is m is si ng . 1 C on tin ue d fe ed in g pr ac tic es in cl ud es c hi ld re n w ho w er e gi ve n m or e, th e sa m e as u su al , o r s om ew ha t l es s fo od d ur in g th e di ar rh oe a ep is od e. 124 • Child Health Child Health • 125 10.7 KNOWLEDGE OF ORS PACKETS To ascertain respondents’ knowledge of ORS in The Gambia, women were asked whether they knew about ORS packets. Table 10.10 presents information on the percentage of mothers with a birth in the five years preceding the survey who had heard about ORS packets. Ninety-four percent of women age 15-49 have heard about ORS. Knowledge is somewhat higher among women age 35-49 (96 percent), women in rural areas (95 percent), and women living in Basse (97 percent). 10.8 STOOL DISPOSAL If human faeces are left uncontained, disease may spread by direct contact or by animal contact with the faeces. Proper disposal of children’s stools is extremely important in preventing the spread of disease. Table 10.11 presents information on disposal of children’s stools by background characteristics. The stools of 82 percent of children are disposed of safely; 6 percent of children under age 5 use a toilet or latrine, the stools of 75 percent of children are disposed of in a toilet or latrine, and the stools of 1 percent of children are buried. On the other hand, the stools of 6 percent of children are put or rinsed into a drain or ditch, the stools of 12 percent are thrown into the garbage, and the stools of 1 percent are left in the open. Safe stool disposal varies by background characteristics. A higher proportion of stools are disposed of safely in rural areas (89 percent) than in urban areas (74 percent). By LGA, Basse has the highest proportion of safe stool disposal (95 percent) and Banjul the lowest (70 percent). For the most part, safe stool disposal is inversely associated with increasing mother’s education and household wealth. The stools of 84 percent of children of mothers with a primary or no education are disposed of safely, as compared with 76 percent among children whose mothers have a secondary education or higher. Among children in the lowest wealth quintile, 86 percent of stools are disposed of safely, compared with 69 percent among those in the highest wealth quintile. Table 10.10 Knowledge of ORS packets or pre-packaged liquids Percentage of women age 15-49 with a live birth in the five years preceding the survey who know about ORS packets or ORS pre- packaged liquids for treatment of diarrhoea, by background characteristics, The Gambia 2013 Background characteristic Percentage of women who know about ORS packets or ORS pre- packaged liquids Number of women Age 15-19 88.4 339 20-24 92.5 1,147 25-34 94.5 2,544 35-49 96.2 1,275 Residence Urban 93.2 2,643 Rural 94.9 2,663 Local Government Area Banjul 91.6 93 Kanifing 92.1 982 Brikama 95.4 1,820 Mansakonko 96.1 265 Kerewan 88.8 589 Kuntaur 96.2 336 Janjanbureh 93.4 451 Basse 96.6 769 Education No education 93.8 3,082 Primary 93.7 747 Secondary or higher 94.8 1,476 Wealth quintile Lowest 93.9 1,027 Second 94.8 1,114 Middle 93.1 1,074 Fourth 94.0 1,072 Highest 94.4 1,019 Total 94.1 5,305 ORS = Oral rehydration salts 126 • Child Health Table 10.11 Disposal of children’s stools Percent distribution of youngest children under age 5 living with their mother by the manner of disposal of the child’s last faecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, The Gambia 2013 Background characteristic Manner of disposal of children’s stools Percentage of children whose stools are disposed of safely1 Number of children Child used toilet or latrine Put/ rinsed into toilet or latrine Buried Put/ rinsed into drain or ditch Thrown into garbage Left in the open Missing Total Age in months <6 2.2 70.8 0.4 5.9 19.3 1.0 0.3 100.0 73.4 913 6-11 1.0 76.2 0.4 5.4 15.3 0.8 0.8 100.0 77.6 795 12-23 1.3 77.5 0.8 5.7 13.4 0.7 0.5 100.0 79.6 1,568 24-35 7.6 80.6 0.5 4.1 5.9 0.7 0.6 100.0 88.7 961 36-47 13.9 75.4 1.3 5.9 2.5 0.6 0.5 100.0 90.5 513 48-59 28.4 58.9 0.5 6.8 2.2 0.4 2.6 100.0 87.8 338 Toilet facility2 Improved, not shared 7.0 72.2 0.7 6.6 12.3 0.3 0.8 100.0 80.0 1,966 Shared3 4.6 74.7 0.1 6.2 14.0 0.1 0.3 100.0 79.4 980 Non-improved or shared 4.9 78.3 0.8 4.0 9.7 1.4 0.7 100.0 84.1 2,134 Residence Urban 6.1 67.8 0.5 9.4 15.4 0.2 0.7 100.0 74.4 2,499 Rural 5.2 82.4 0.8 1.7 7.8 1.3 0.6 100.0 88.5 2,589 Local Government Area Banjul 6.5 63.9 0.0 7.5 21.3 0.0 0.8 100.0 70.4 87 Kanifing 6.9 71.3 0.5 6.7 13.2 0.0 1.4 100.0 78.7 921 Brikama 4.9 68.9 0.4 10.0 14.6 0.8 0.3 100.0 74.3 1,740 Mansakonko 2.1 86.8 0.4 2.2 6.3 2.0 0.2 100.0 89.4 257 Kerewan 4.1 80.3 0.0 2.9 12.0 0.1 0.7 100.0 84.4 575 Kuntaur 3.1 81.0 0.9 1.6 10.6 2.2 0.6 100.0 85.0 326 Janjanbureh 4.9 76.5 4.0 0.8 11.8 1.1 0.4 100.0 85.4 433 Basse 9.7 85.0 0.0 0.8 2.9 0.7 0.8 100.0 94.7 748 Mother’s education No education 5.9 77.5 0.5 3.6 10.7 0.9 0.9 100.0 83.9 2,957 Primary 4.7 77.7 1.7 7.1 7.4 0.6 0.8 100.0 84.1 715 Secondary or higher 5.6 69.4 0.5 8.6 15.3 0.4 0.2 100.0 75.5 1,417 Wealth quintile Lowest 5.1 79.9 1.1 1.4 9.8 2.0 0.6 100.0 86.1 992 Second 4.9 82.7 0.7 2.0 8.5 0.8 0.5 100.0 88.2 1,080 Middle 5.5 80.8 0.2 2.5 9.0 0.5 1.3 100.0 86.5 1,030 Fourth 3.9 72.6 0.9 9.6 12.4 0.2 0.4 100.0 77.3 1,023 Highest 9.2 59.0 0.4 12.4 18.5 0.0 0.6 100.0 68.6 963 Total 5.7 75.2 0.7 5.5 11.5 0.7 0.7 100.0 81.6 5,088 Note: Total includes 8 cases for whom information on type of facility is missing. 1 Children’s stools are considered to be disposed of safely if the child used a toilet or latrine, if the faecal matter was put/rinsed into a toilet or latrine, or if it was buried. 2 See Table 2.2 for definition of categories. 3 Facilities that would be considered improved if they were not shared by 2 or more households Nutrition of Women and Children • 127 NUTRITION OF WOMEN AND CHILDREN 11 his chapter presents findings on the nutritional status of women and children. A specific focus is infant and young child feeding practices, including early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding until at least age 2, timely introduction of complementary foods at age 6 months (with increasing frequency of feeding solid and semisolid foods), and diet diversity. Data on nutritional status, diversity of foods consumed, micronutrient intake, vitamin A supplementation and iron deficiency anaemia are presented for women and for children under age 5, along with the results of household testing of salt for adequate levels of iodine. A summary indicator that describes the quality of infant and young child feeding (IYCF) practices for infants age 6-23 months is included. Good nutrition is a basic building block of human capital and, as such, contributes to economic development. Adequate nutrition is critical to child development, with the period from birth to age 2, referred to as the critical window of opportunity, being important for optimal growth, health, and development. Unfortunately, this period is often marked by growth faltering, micronutrient deficiencies, and common childhood illnesses such as malaria, diarrhoea, and acute respiratory infections. A woman’s nutritional status has important implications for her health as well as the health of her children. Malnutrition in women results in reduced productivity, an increased susceptibility to infections, slow recovery from illness, and heightened risks of adverse pregnancy outcomes. For example, a woman who has poor nutritional status, as indicated by a low body mass index (BMI), short stature, anaemia, or other micronutrient deficiencies, has a greater risk of obstructed labour, of having a baby with a low birth weight, of producing lower quality breast milk, of mortality due to postpartum haemorrhage, and of morbidity for both herself and her baby. T Key Findings • Twenty-five percent of children under age 5 in The Gambia are stunted (short for their age), 12 percent are wasted (thin for their height), and 16 percent are underweight (thin for their age). Only 3 percent of children are overweight (heavy for their height). • Almost all (99 percent) last-born children under age 2 were breastfed at some point in their life. Forty-seven percent of children under age 6 months are exclusively breastfed, and 54 percent of children age 6-8 months are breastfeeding and consuming complementary foods. • Only 8 percent of children age 6-23 months are fed in accordance with the three core infant and young child feeding (IYCF) practices. • Sixty-nine percent of children age 6-59 months received vitamin A supplements in the past six months, 17 percent received iron supplements in the past seven days, 34 percent received deworming medication in the past six months, and 76 percent live in households with iodised salt. • Overall, 61 percent of women have a body mass index (BMI) in the normal range. Almost one in four women are overweight or obese. • Among women age 15-49 with a child born in the past five years, 85 percent received a vitamin A dose postpartum. • Forty-five percent of women took iron tablets for the recommended period of 90 or more days, and 40 percent took deworming medication during the pregnancy of their last birth. 128 • Nutrition of Women and Children 11.1 NUTRITIONAL STATUS OF CHILDREN The anthropometric data on height and weight collected in the 2013 GDHS permit the measurement and evaluation of the nutritional status of young children in The Gambia. This evaluation allows identification of subgroups of the child population that are at increased risk of growth faltering, diseases, impaired mental development, and death. Marked differences, especially with regard to height- for-age, weight-for-height, and weight-for-age, are often seen among different subgroups of children within the country. 11.1.1 Measurement of Nutritional Status among Young Children The 2013 GDHS collected data on the nutritional status of children by measuring the height and weight of all children under age 5. Data were collected with the aim of calculating three indices—namely, weight-for-age, height-for-age, and weight-for-height—all of which take age and sex into consideration. Weight measurements were obtained using lightweight, bathroom-type scales with a digital screen designed and manufactured under the guidance of UNICEF. Height measurements were carried out using a measuring board. Children younger than age 24 months were measured lying down (recumbent length) on the board, while standing height was measured for older children. For this report, indicators of the nutritional status of children were calculated using growth standards published by WHO in 2006. These growth standards were generated through data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). That study, whose sample included 8,440 children in six countries, was designed to provide a description of how children should grow under optimal conditions. The WHO child growth standards can therefore be used to assess children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. The three nutritional status indicators described below are expressed in standard deviation units from the median of the Multicentre Growth Reference Study sample. Each of these indices provides different information about growth and body composition. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the WHO reference population are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the reference median are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to height or length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) from the reference median are considered thin (wasted) and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) from the reference median are considered severely wasted. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the reference median are classified as underweight. Children whose weight-for- age is below minus three standard deviations (-3 SD) from the reference median are considered severely underweight. Nutrition of Women and Children • 129 11.1.2 Data Collection Height and weight measurements were obtained for 3,372 children under age 5 who were present in the households selected for the GDHS at the time of the survey. The following analysis focuses on children for whom complete and credible anthropometric data and valid age data were collected. Table 11.1 shows the percentage of children under age 5 classified as malnourished according to the three anthropometric indices of nutritional status (height-for-age, weight-for-height, and weight-for-age). Although data were collected for all children under age 5, for purposes of comparability, the analysis is limited to children under age 5. Height and weight measurements were obtained for 81 percent of the 4,312 eligible children (unweighted). Height and weight were missing for 11 percent of children, the data for 7 percent were flagged (out-of-range), and 1 percent had incomplete information on age in months. 11.1.3 Levels of Child Malnutrition Table 11.1 indicates the nutritional status of children under age 5 as measured by stunting (low height-for-age) and various background characteristics. Nationally, 25 percent of children under age 5 are stunted, and 8 percent are severely stunted. Analysis by age groups shows that stunting is highest (34 percent) among children age 24-35 months and lowest (9 percent) among children age 6-8 months (Figure 11.1). Severe stunting shows a similar trend, with children age 24-35 months having the highest proportion of severe stunting (12 percent) and those age 6-8 months having the lowest proportion (3 percent). More than one-quarter (26 percent) of male children are stunted, as compared with 23 percent of female children. There is an inverse relationship between the length of the preceding birth interval and the proportion of children who are stunted. The longer the interval, the less likely the child is to be stunted. For example, 26 percent of non-first-born children with a preceding birth interval of less than 24 months are stunted, compared with 21 percent with a birth interval of 48 months or more. The mother’s body mass index tends to have an inverse relationship with severe stunting levels. For example, 10 percent of children of mothers who are thin (BMI less than 18.5) are severely stunted, as compared with 7 percent of children whose mothers are overweight or obese (BMI of 25 or above). Children in rural areas are more likely than those in urban areas to be moderately stunted (29 percent and 19 percent, respectively) and severely stunted (10 percent and 6 percent, respectively). At the Local Government Area (LGA) level, Janjanbureh (35 percent) and Basse (32 percent) have the highest proportion of stunted children, while Banjul has the lowest (12 percent). Mother’s level of education generally has an inverse relationship with stunting levels. For example, children of mothers with a secondary education or higher are less likely to be stunted (15 percent) than children whose mothers have a primary education or no education (27-30 percent). A similar inverse relationship is observed between household wealth and stunting, with children living in households in the lowest wealth quintile most likely to be moderately and severely stunted (30 percent and 11 percent, respectively). Table 11.1 also shows the nutritional status of children under age 5 as measured by wasting (low weight-for-height). Overall, 12 percent of children are wasted and 4 percent are severely wasted. Basse and Kuntaur have the highest levels of wasting (17 percent and 16 percent, respectively). These levels may reflect food stress in these regions, which traditionally encounter food deficits. Children whose mothers have a primary education are most likely to be wasted and severely wasted (15 percent and 7 percent, respectively). 130 • Nutrition of Women and Children Table 11.1 Nutritional status of children Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for- height, and weight-for-age, by background characteristics, The Gambia 2013 Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children Percent- age below -3 SD Percent- age below -2 SD2 Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Age in months <6 7.7 13.9 -0.0 9.7 18.8 9.5 -0.5 3.4 8.5 1.1 -0.4 365 6-8 2.5 9.0 -0.2 8.3 16.5 2.9 -0.8 5.3 11.9 1.2 -0.7 202 9-11 7.3 17.4 -0.5 6.1 14.2 3.6 -0.7 3.6 17.8 1.0 -0.9 174 12-17 9.7 23.5 -1.0 5.7 18.0 1.7 -0.8 5.8 17.8 0.4 -1.0 413 18-23 11.1 32.3 -1.5 2.4 10.4 1.4 -0.6 3.7 19.7 0.4 -1.1 310 24-35 12.4 34.2 -1.4 2.5 7.7 1.2 -0.4 4.8 18.4 0.9 -1.1 630 36-47 7.0 25.5 -1.2 2.3 8.3 2.5 -0.6 3.1 16.3 0.6 -1.1 662 48-59 5.6 23.5 -1.2 2.8 8.1 1.6 -0.7 2.7 16.6 0.0 -1.2 616 Sex Male 9.5 26.2 -1.1 4.7 12.7 2.6 -0.6 4.1 17.5 0.5 -1.0 1,731 Female 6.9 22.7 -1.0 3.7 10.2 2.9 -0.6 3.8 14.9 0.7 -0.9 1,641 Birth interval in months3 First birth4 8.7 24.4 -1.1 3.2 11.8 2.8 -0.6 3.8 16.6 0.2 -1.1 616 <24 5.1 26.1 -0.9 6.3 11.1 2.4 -0.6 3.6 14.8 1.1 -0.9 330 24-47 8.5 25.1 -1.0 4.6 12.5 2.5 -0.6 4.2 17.8 0.5 -1.0 1,473 48+ 8.5 20.6 -0.8 5.9 12.8 3.5 -0.6 3.9 12.8 0.8 -0.9 536 Size at birth3 Very small 10.3 32.5 -1.3 5.7 22.2 3.3 -1.1 7.1 34.0 0.2 -1.5 254 Small 9.4 23.4 -1.2 4.5 13.1 2.4 -0.7 3.9 19.0 1.1 -1.2 349 Average or larger 7.7 23.4 -0.9 4.7 10.9 2.7 -0.5 3.7 13.9 0.5 -0.9 2,330 Mother’s interview status Interviewed 8.2 24.3 -1.0 4.7 12.2 2.7 -0.6 4.0 16.3 0.5 -1.0 2,955 Not interviewed but in household 10.1 27.7 -1.1 0.5 7.7 2.7 -0.6 4.3 16.7 2.1 -1.1 223 Not interviewed and not in the household5 7.8 24.3 -1.2 0.3 4.0 2.9 -0.3 2.1 14.7 0.3 -0.9 194 Mother’s nutritional status6 Thin (BMI <18.5) 10.4 23.8 -1.1 4.6 17.7 3.8 -0.9 7.4 22.0 0.9 -1.3 311 Normal (BMI 18.5-24.9) 8.1 24.4 -1.0 4.7 12.6 2.4 -0.6 4.1 16.1 0.4 -1.0 1,647 Overweight/ obese (BMI ≥25) 7.4 22.2 -0.9 2.9 8.4 2.9 -0.4 2.3 12.5 0.7 -0.8 525 Residence Urban 5.6 19.2 -0.7 4.0 10.3 3.2 -0.5 2.5 10.6 0.9 -0.8 1,470 Rural 10.3 28.5 -1.2 4.3 12.4 2.4 -0.7 5.0 20.6 0.4 -1.2 1,902 Local Government Area Banjul 3.4 12.2 -0.6 3.1 9.2 1.7 -0.6 2.6 12.2 1.4 -0.7 47 Kanifing 6.7 23.3 -0.8 3.1 11.3 3.5 -0.5 3.5 11.7 2.0 -0.8 499 Brikama 5.6 17.8 -0.7 3.8 9.0 2.9 -0.5 1.6 10.2 0.4 -0.8 1,140 Mansakonko 7.4 27.3 -1.2 4.1 10.5 3.3 -0.7 3.8 18.5 0.5 -1.1 211 Kerewan 8.8 24.9 -1.2 2.5 9.5 2.9 -0.5 3.4 15.9 0.2 -1.0 420 Kuntaur 9.9 29.3 -1.2 6.0 16.1 1.6 -0.9 6.4 25.6 0.6 -1.3 233 Janjanbureh 14.7 34.5 -1.4 3.2 11.4 2.6 -0.7 6.2 26.9 0.2 -1.3 275 Basse 11.6 32.1 -1.3 7.1 16.9 2.0 -0.8 7.4 23.2 0.4 -1.3 546 Mother’s education7 No education 9.5 27.0 -1.2 4.6 11.8 2.1 -0.7 4.9 18.9 0.6 -1.1 1,931 Primary 8.2 30.3 -1.1 6.9 14.9 3.5 -0.7 5.9 19.6 0.4 -1.1 444 Secondary or higher 5.4 15.3 -0.5 2.7 10.5 3.8 -0.5 0.8 8.4 1.0 -0.6 802 Wealth quintile Lowest 10.7 29.5 -1.2 3.4 11.0 2.2 -0.6 4.4 21.8 0.4 -1.1 725 Second 9.4 27.2 -1.2 4.3 12.0 3.3 -0.6 4.6 17.8 0.5 -1.1 822 Middle 8.8 25.2 -1.0 5.8 13.6 2.6 -0.7 4.0 17.9 1.0 -1.1 636 Fourth 7.4 22.4 -1.0 4.1 9.6 3.4 -0.5 3.9 11.8 0.0 -0.9 652 Highest 3.7 15.2 -0.5 3.5 11.0 1.9 -0.6 2.1 9.7 1.4 -0.7 537 Total 8.3 24.5 -1.0 4.2 11.5 2.7 -0.6 3.9 16.2 0.6 -1.0 3,372 Note: Table is based on children who stayed in the household on the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO child growth standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 19 cases for whom information on size at birth is missing and 1 case for whom information on mother’s education is missing. 1 Recumbent length is measured for children under age 2 and in the few cases when the age of the child is unknown and the child is less than 85 cm; standing height is measured for all other children. 2 Includes children who are below -3 standard deviations (SD) from the WHO child growth standards population median 3 Excludes children whose mothers were not interviewed 4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 5 Includes children whose mothers are deceased 6 Excludes children whose mothers were not weighed and measured, children whose mothers were not interviewed, and children whose mothers are pregnant or gave birth within the preceding two months. Mother’s nutritional status in terms of BMI (body mass index) is presented in Table 11.10. 7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. Nutrition of Women and Children • 131 Figure 11.1 Nutritional status of children by age 0 5 10 15 20 25 30 35 40 45 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Percent Age (months) Stunted Wasted Underweight Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a five- month moving average. GDHS 2013 Finally, 16 percent of children under age 5 are underweight (low weight-for-age) and 4 percent are severely underweight (Table 11.1). The proportion of underweight children is highest (20 percent) among those age 18-23 months, which might be explained by the fact that this is the period when breastfeeding frequency is reduced and consumption of adult foods increased. It also typify the period when children are more exposed to the environment, thus increasing their exposure to infections and susceptibility to illness. Coupled with inappropriate and/or inadequate feeding practices, this tendency may contribute to faltering nutritional status among children in this group. Female children (15 percent) are slightly less likely to be underweight than male children (18 percent). Similar to stunting, the percentage of underweight children decreases as the preceding birth interval lengthens. Rural children are more likely to be underweight (21 percent) than urban children (11 percent). At the LGA level, Janjanbureh has the highest proportion of underweight children (27 percent), while Brikama has the lowest proportion (10 percent). The proportion of underweight children is inversely associated with mother’s level of education and household wealth. 11.2 INITIATION OF BREASTFEEDING Early breastfeeding practices determine the successful establishment and duration of breastfeeding. Moreover, during the first three days after delivery, colostrum, an important source of nutrition and protection for the newborn, is produced and should be given to the newborn while awaiting the let-down of regular/mature breast milk. Thus, it is recommended that children be put to the breast immediately or within one hour after birth and that prelacteal feeding (i.e., feeding newborns anything other than breast milk before breast milk is initiated) be discouraged. Table 11.2 shows the percentage of children born in the five years before the survey by breastfeeding status and the timing of initial breastfeeding, according to background characteristics. The results indicate that 99 percent of children are breastfed at some point. Overall, 52 percent of children are breastfed within one hour of birth and 94 percent within one day after delivery. The practice of giving prelacteal feeds limits the frequency of suckling by the infant and exposes the baby to the risk of infection. Seventeen percent of children are given a prelacteal feed before initiating breastfeeding. Prelacteal feeding is most common in Banjul and Kanifing (27 percent and 25 percent, respectively) and least common in Kerewan (9 percent). Children delivered at home are slightly more 132 • Nutrition of Women and Children likely to be given a prelacteal feed (18 percent) than those delivered at a health facility (16 percent). Children whose delivery was assisted by someone other than a health professional, an auxiliary nurse, or a traditional birth attendant are more likely to receive a prelacteal feed (29 percent) than other children. Contrary to expectations, the proportion of children who receive a prelacteal feed does not have a clear correlation with mother’s education. Children whose mothers have no education are less likely to receive a prelacteal feed (15 percent) than those whose mothers have some education (17-20 percent). The proportion of children who receive a prelacteal feed is somewhat higher among those in the wealthiest households (21 percent). Table 11.2 Initial breastfeeding Among last-born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth, and among last-born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, The Gambia 2013 Background characteristic Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 98.7 51.4 94.1 1,685 16.6 1,663 Female 98.7 51.6 93.8 1,708 16.6 1,686 Assistance at delivery Health professional3 98.6 48.0 93.4 1,944 16.6 1,917 Auxiliary nurse 99.2 63.4 95.7 253 9.5 251 Traditional birth attendant 99.3 56.4 95.2 910 15.3 903 Other 99.2 51.6 93.7 214 28.5 212 No one 97.9 45.9 90.7 66 24.3 65 Place of delivery Health facility 98.6 49.6 93.5 2,156 15.7 2,126 At home 99.2 55.3 94.9 1,223 18.4 1,214 Residence Urban 98.1 47.2 91.9 1,565 18.6 1,535 Rural 99.2 55.2 95.6 1,828 15.0 1,814 Local Government Area Banjul 98.7 40.6 82.6 51 26.6 50 Kanifing 97.8 45.6 89.6 517 25.2 506 Brikama 98.3 44.8 92.2 1,171 18.2 1,151 Mansakonko 100.0 56.8 95.9 169 10.6 169 Kerewan 100.0 50.7 99.3 419 9.4 419 Kuntaur 99.4 51.3 95.9 227 11.4 225 Janjanbureh 97.7 60.2 93.5 298 15.1 291 Basse 99.3 66.9 97.3 541 14.9 537 Mother’s education No education 98.9 55.1 94.9 1,951 15.4 1,930 Primary 99.2 46.8 93.4 502 20.3 498 Secondary or higher 98.1 46.6 92.2 940 17.3 921 Wealth quintile Lowest 99.1 54.8 95.1 703 15.1 697 Second 99.2 54.0 95.6 757 16.0 751 Middle 99.5 55.6 94.7 702 13.8 699 Fourth 97.3 48.3 91.5 681 18.3 663 Highest 98.4 42.6 92.1 549 21.1 540 Total 98.7 51.5 93.9 3,392 16.6 3,349 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children were living or dead at the time of the interview. Total includes 6 cases for whom information on type of assistance at delivery is missing and 4 cases for whom information on place of delivery is missing. 1 Includes children who started breastfeeding within 1 hour of birth 2 Children given something other than breast milk during the first 3 days of life 3 Doctor, nurse, or midwife Nutrition of Women and Children • 133 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first six months of life and that they be given age-appropriate solid or semisolid complementary food in addition to continued breastfeeding from age 6 months to at least age 24 months. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all of the nutrients necessary for children in the first few months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease or infections. Early supplementation is discouraged for several reasons. First, it exposes infants to pathogens and increases their risk of infection. Second, it decreases infants’ intake of breast milk and therefore suckling, which reduces breast milk production. Third, in low-resource settings, supplementary food is often nutritionally inferior. Information on complementary feeding was obtained by asking mothers about the current breastfeeding status of all children under age 5 and, for the youngest child born in the three-year period before the survey and living with the mother, the foods and liquids given to the child the day and night before the survey. Table 11.3 shows breastfeeding practices by child age. Only 47 percent of infants under age 6 months are exclusively breastfed. Contrary to the recommendation that children under age 6 months be exclusively breastfed, 35 percent of infants consume plain water, 4 percent consume non-milk liquids, 3 percent consume other milk, and 11 percent consume complementary foods in addition to breast milk. Fifty-four percent of children age 6-8 months receive timely complementary foods, and nearly half of children age 18-23 months have been weaned. Feeding children using a bottle with a nipple is discouraged and remains a relatively uncommon practice in The Gambia; 8 percent of children below age 6 months are fed using a bottle with a nipple. The prevalence of bottle-feeding is highest among children age 6-8 months (14 percent). Table 11.3 Breastfeeding status by age Percent distribution of youngest children under age 2 who are living with their mother by breastfeeding status and the percentage currently breastfeeding, and the percentage of all children under age 2 using a bottle with a nipple, according to age in months, The Gambia 2013 Age in months Not breast- feeding Breastfeeding status Total Percentage currently breast- feeding Number of youngest children under age 2 living with their mother Percentage using a bottle with a nipple Number of all children under age 2 Exclusively breastfed Breast- feeding and consu- ming plain water only Breast- feeding and consu- ming non- milk liquids1 Breast- feeding and consu- ming other milk Breast- feeding and consu- ming comple- mentary foods 0-1 0.8 70.2 25.2 2.5 0.1 1.2 100.0 99.2 238 4.4 244 2-3 0.6 53.9 33.8 5.5 2.6 3.6 100.0 99.4 356 8.7 361 4-5 0.9 21.3 42.7 3.7 5.1 26.3 100.0 99.1 319 11.1 325 6-8 1.5 6.1 26.5 4.4 7.4 54.2 100.0 98.5 428 14.1 432 9-11 2.4 1.9 9.2 5.5 2.5 78.4 100.0 97.6 367 6.2 373 12-17 5.3 0.1 1.9 1.6 1.7 89.4 100.0 94.7 941 4.7 973 18-23 45.8 0.3 0.9 0.6 0.1 52.3 100.0 54.2 627 4.9 686 0-3 0.7 60.4 30.3 4.3 1.6 2.6 100.0 99.3 594 7.0 606 0-5 0.8 46.8 34.6 4.1 2.8 10.9 100.0 99.2 913 8.4 931 6-9 1.6 4.9 23.3 5.7 6.7 57.9 100.0 98.4 549 13.4 558 12-15 2.2 0.1 1.8 2.0 1.1 92.8 100.0 97.8 682 5.0 702 12-23 21.5 0.2 1.5 1.2 1.0 74.6 100.0 78.5 1,568 4.8 1,660 20-23 57.8 0.5 0.4 0.6 0.0 40.7 100.0 42.2 403 5.2 458 Note: Breastfeeding status refers to a “24-hour” period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, and breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semisolids) are hierarchical and mutually exclusive, and their percentages sum to 100 percent. Thus, children who receive breast milk and non-milk liquids and who do not receive other milk and do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Non-milk liquids include juice, juice drinks, clear broth, or other liquids. 134 • Nutrition of Women and Children Figure 11.2 depicts the transition of feeding practices among children up to age 2. The rapid drop in exclusive breastfeeding from 70 percent among infants under age 2 months to 21 percent among children age 4 to 5 months demands attention. Figure 11.2 Infant feeding practices by age 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months Not breastfeeding Complementary foods Other milk Non-milk liquids/juice Plain water only Exclusively breastfed GDHS 2013 Figure 11.3 presents the 2013 GDHS results on infant and young child feeding (IYCF) indicators related to breastfeeding status. Detailed descriptions of these indicators can be found in various WHO publications (WHO, 2008; WHO, 2010). As noted above, 47 percent of children under age 6 months are exclusively breastfed, and 55 percent of children age 6-8 months (both breastfed and nonbreastfed) are introduced to complementary foods at an appropriate time. Ninety-eight percent of all children are still breastfeeding at age 1, and 42 percent are still breastfeeding at age 2. Sixty-five percent of children age 0-23 months are breastfed appropriately for their age. This includes exclusive breastfeeding for children age 0-5 months and continued breastfeeding along with complementary foods for children age 6-23 months. Almost nine in ten children under age 6 months (86 percent) are predominantly breastfed. This percentage includes children who are exclusively breastfed and those who receive breast milk and only plain water or non-milk liquids such as juice. Finally, 7 percent of children under age 2 are bottle fed. Nutrition of Women and Children • 135 Figure 11.3 IYCF indicators on breastfeeding status 47 21 98 55 42 65 86 7 Exclusive breastfeeding at age 6 months Exclusive breastfeeding at age 4-5 months Continued breastfeeding at 1 year Introduction of solid, semisolid, or soft foods (6-8 months) Continued breastfeeding at 2 years Age-appropriate breastfeeding (0-23 months) Predominant breastfeeding (0-5 months) Bottle feeding (0-23 months) Percentage of children GDHS 2013 11.4 DURATION OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding (i.e., the length of time in months for whom information on half of children are breastfed) by selected background characteristics. Estimates of median and mean durations of breastfeeding are based on current status data, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. Overall, the median duration of any breastfeeding among children in The Gambia is 20 months, which is similar to the duration documented in the 2010 MICS (Gambia Bureau of Statistics [GboS], 2011), implying that there has been little change in breastfeeding patterns over time. The median duration of exclusive breastfeeding is 2 months, with a mean duration of 4 months. Median duration of any breastfeeding varies only minimally by background characteristics. 11.5 TYPES OF COMPLEMENTARY FOODS UNICEF and WHO recommend the introduction of solid food to infants after age 6 months because by that age breast milk alone is no longer sufficient to maintain a Table 11.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, by background characteristics, The Gambia 2013 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breast- feeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 20.5 2.0 5.8 Female 20.2 2.2 6.1 Residence Urban 19.5 1.8 5.2 Rural 21.1 2.5 6.5 Local Government Area Banjul * * (5.4) Kanifing * (1.6) 4.3 Brikama 19.7 2.0 5.6 Mansakonko * (3.1) (5.5) Kerewan (20.6) 1.8 (7.0) Kuntaur (22.0) (0.9) 6.4 Janjanbureh (22.4) 2.3 6.0 Basse (21.1) (2.9) (7.1) Mother’s education No education 21.0 1.9 6.2 Primary (18.8) 2.3 6.5 Secondary or higher 19.8 2.2 5.3 Wealth quintile Lowest 20.6 2.7 6.4 Second 21.4 2.7 6.8 Middle 20.7 1.7 6.0 Fourth 20.1 1.3 5.3 Highest 18.4 2.2 (4.9) Total 20.4 2.1 5.9 Mean for all children 20.4 3.5 7.1 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 It is assumed that non-last-born children and last-born children not currently living with their mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water and/or non-milk liquids only 136 • Nutrition of Women and Children child’s optimal growth. Appropriate nutrition includes feeding children a variety of foods to ensure that nutrient requirements are met. Fruits and vegetables rich in minerals and vitamins, especially in vitamin A, should be consumed daily. Although eating a range of fruits and vegetables, especially those rich in vitamin A, is important, studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients. Therefore, it has been recommended that meat, poultry, fish, or eggs be eaten daily or as often as possible (WHO, 1998). Table 11.5 is based on information from mothers about the foods and liquids consumed by their youngest child during the day or night preceding the interview. As expected, the proportions of children consuming foods or liquids included in the various food groups generally increase with age. Children who are still breastfed are less likely than children who are not being breastfed to consume other types of liquids and solid/semisolid foods. For example, 92 percent of nonbreastfeeding children age 6-23 months consumed foods made from grains the day or night preceding the interview, compared with 72 percent of breastfeeding children in that age group. Similarly, 31 percent of nonbreastfeeding children age 6-23 months consumed foods rich in vitamin A, as compared with 14 percent of breastfeeding children in the same age group. Sixty-one percent of nonbreastfeeding children and 36 percent of breastfeeding children age 6-23 months consumed meat, fish, and poultry. Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age 2 who are living with their mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, The Gambia 2013 Age in months Liquids Solid or semisolid foods Any solid or semi- solid food Number of children Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry Eggs Cheese, yogurt, other milk products Infant formula Other milk1 Other liquids2 BREASTFEEDING CHILDREN 0-1 0.3 0.1 2.7 0.7 0.4 0.1 0.1 0.1 0.1 0.1 0.1 0.1 1.2 236 2-3 2.3 1.1 6.1 1.7 2.4 0.0 0.6 0.0 0.0 1.3 0.9 0.2 3.6 354 4-5 3.6 4.7 9.3 12.7 10.3 1.7 0.0 0.7 0.3 0.4 0.7 1.5 26.5 316 6-8 7.6 7.8 16.0 23.0 31.5 3.5 3.4 2.9 1.5 6.1 0.5 2.1 55.0 421 9-11 5.8 7.8 36.3 24.2 65.2 9.2 10.1 8.0 8.0 29.1 6.4 8.1 80.3 358 12-17 4.4 10.8 35.7 18.7 86.0 18.1 11.7 9.8 10.8 46.7 9.0 8.1 94.4 891 18-23 2.0 13.7 40.1 9.4 91.6 22.0 15.1 11.4 15.2 53.5 11.7 11.8 96.4 340 6-23 4.9 10.1 32.4 19.0 71.8 14.1 10.2 8.3 9.1 36.2 7.2 7.5 84.0 2,011 Total 4.1 7.6 24.3 14.7 50.9 9.9 7.1 5.8 6.3 25.2 5.2 5.3 61.3 2,917 NONBREASTFEEDING CHILDREN 6-23 2.6 16.7 48.5 7.7 92.4 31.4 22.7 25.7 13.8 61.0 14.4 13.0 97.7 352 Total 2.7 16.3 47.7 7.5 90.7 30.8 22.3 25.7 13.6 59.8 14.1 12.8 96.4 359 Note: Breastfeeding status and food consumed refer to a “24-hour” period (yesterday and last night). 1 Other milk includes fresh, tinned, and powdered cow or other animal milk. 2 Does not include plain water 3 Includes fortified baby food 4 Includes pumpkins, carrots, squash, sweet potatoes, dark green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A 11.6 INFANT AND YOUNG CHILD FEEDING PRACTICES Appropriate IYCF practices include breastfeeding through age 2, introduction of solid and semisolid foods at age 6 months, and gradual increases in the amount of food given and frequency of feeding as the child gets older. The minimum frequencies for feeding children in developing countries are defined according to the energy output of complementary foods. Energy needs of children are based on age-specific total daily energy requirements plus two standard deviations (to cover almost all children), minus the average energy intake from breast milk. Infants with low breast milk intake need to be fed more frequently than those with high intake. However, care should be taken that feeding frequencies do not Nutrition of Women and Children • 137 exceed the recommended input from complementary foods because excessive feeding can result in displacement of breast milk (PAHO/WHO, 2003). According to recommendations, breastfed children age 6-23 months should receive animal-source foods and vitamin A-rich fruits and vegetables daily (PAHO/WHO, 2003). Because first foods almost always include a grain- or tuber-based staple, it is unlikely that young children who eat food from less than three groups will receive both an animal-source food and a vitamin A-rich fruit or vegetable. Therefore, three food groups are considered the minimum number appropriate for breastfed children (Arimond and Ruel, 2004). Breastfed infants age 6-8 months should receive complementary foods two to three times a day with one or two snacks; breastfed children age 9-23 months should receive meals three to four times a day with one or two snacks (PAHO/WHO, 2003; WHO, 2008; WHO, 2010). Nonbreastfed children age 6-23 months should receive milk or milk products two or more times a day to ensure that their calcium needs are met. In addition, they need animal-source foods and vitamin A- rich fruits and vegetables. Four food groups are considered the minimum number appropriate for nonbreastfed young children. Nonbreastfed children age 12-23 months should be fed meals four to five times each day, with one or two snacks (WHO, 2005; WHO, 2008; and WHO, 2010). Table 11.6 presents summary indicators of IYCF practices. The indicators take into account the percentages of children for whom feeding practices meet minimum standards with respect to food diversity (i.e., the number of food groups consumed) and feeding frequency (i.e., the number of times the child was fed), as well as consumption of breast milk or other milks or milk products. Breastfed children are considered as being fed in accordance with the minimum standards if they consume at least four food groups and receive foods other than breast milk at least twice per day in the case of infants age 6-8 months and at least three times per day in the case of children age 9-23 months. Nonbreastfed children are considered to be fed in accordance with the minimum standards if they consume milk or milk products, consume food from four or more food groups (including milk products), and are fed at least four times per day. Only 8 percent of children age 6-23 months are fed in accordance with all IYCF practices (Table 11.6). Although 87 percent of children receive either breast milk or other milk products and 58 percent are fed the minimum number of times, only 13 percent are fed from the required number of food groups. Nonbreastfed children are much more likely to consume a diverse diet (27 percent) than breastfed children (11 percent). By contrast, breastfed children seem to be more likely than nonbreastfed children to consume solid or semisolid foods the recommended number of times. An analysis by background characteristics indicates apparent differences in feeding practices by place of residence and mother’s education. Children residing in urban areas are more likely to be fed according to the three IYCF practices (11 percent) than rural children (6 percent). At the LGA level, the proportion of children who are fed according to the IYCF recommendations is lowest in Kuntaur (3 percent) and highest in Banjul (14 percent) and Kanifing (12 percent). Seven percent of children whose mothers have no education are fed according to the recommended practices, as compared with 9 percent of children whose mothers have a primary education and 12 percent of those whose mothers have a secondary education or higher. Overall, these findings suggest that feeding practices in The Gambia are poor across the board, and there is an urgent need to accelerate awareness about optimum feeding practices for infants and young children. 13 8 • N ut rit io n of W om en a nd C hi ld re n Ta bl e 11 .6 I nf an t a nd y ou ng c hi ld fe ed in g (IY C F) p ra ct ic es P er ce nt ag e of y ou ng es t c hi ld re n ag e 6- 23 m on th s liv in g w ith th ei r m ot he r w ho a re fe d ac co rd in g to th re e IY C F fe ed in g pr ac tic es b as ed o n br ea st fe ed in g st at us , n um be r o f f oo d gr ou ps , a nd ti m es th ey a re fe d du rin g th e da y or n ig ht pr ec ed in g th e su rv ey , b y ba ck gr ou nd c ha ra ct er is tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic A m on g br ea st fe d ch ild re n 6- 23 m on th s, p er ce nt ag e fe d: A m on g no nb re as tfe d ch ild re n 6- 23 m on th s, p er ce nt ag e fe d: A m on g al l c hi ld re n 6- 23 m on th s, p er ce nt ag e fe d: 4+ fo od gr ou ps 1 M in im um m ea l fre qu en cy 2 B ot h 4+ fo od gr ou ps a nd m in im um m ea l fre qu en cy N um be r o f br ea st fe d ch ild re n 6- 23 m on th s M ilk o r m ilk pr od uc ts 3 4+ fo od gr ou ps 1 M in im um m ea l fre qu en cy 4 W ith 3 IY C F pr ac tic es 5 N um be r o f no nb re as tfe d ch ild re n 6- 23 m on th s B re as t m ilk , m ilk , o r m ilk pr od uc ts 6 4+ fo od gr ou ps 1 M in im um m ea l fre qu en cy 7 W ith 3 IY C F pr ac tic es N um be r o f a ll ch ild re n 6- 23 m on th s A ge in m on th s 6- 8 2. 2 46 .7 2. 2 42 1 * * * * 6 98 .6 2. 2 46 .0 2. 2 42 8 9- 11 9. 0 44 .3 6. 3 35 8 * * * * 9 97 .6 8. 8 43 .7 6. 2 36 7 12 -1 7 12 .6 65 .5 11 .7 89 1 (1 4. 1) (3 2. 8) (5 1. 7) (8 .9 ) 50 95 .4 13 .6 64 .7 11 .6 94 1 18 -2 3 17 .8 68 .2 15 .3 34 0 11 .3 27 .3 56 .1 1. 3 28 7 59 .4 22 .1 62 .7 8. 9 62 7 Se x M al e 10 .4 57 .6 8. 4 1, 04 1 11 .2 25 .7 53 .9 3. 7 17 5 87 .2 12 .6 57 .0 7. 7 1, 21 6 Fe m al e 10 .9 58 .9 10 .4 97 0 11 .5 28 .2 53 .3 1. 0 17 7 86 .3 13 .6 58 .1 8. 9 1, 14 8 R es id en ce U rb an 14 .6 58 .3 12 .7 88 3 13 .4 32 .3 59 .3 3. 6 18 6 84 .9 17 .7 58 .5 11 .1 1, 06 9 R ur al 7. 5 58 .2 6. 8 1, 12 8 9. 1 20 .9 47 .3 0. 9 16 6 88 .3 9. 2 56 .8 6. 0 1, 29 4 Lo ca l G ov er nm en t A re a B an ju l 20 .1 53 .7 14 .3 24 (1 5. 7) (2 2. 5) (3 3. 6) (1 1. 9) 7 81 .9 20 .6 49 .4 13 .8 31 K an ifi n g 16 .0 55 .6 14 .6 27 3 (8 .4 ) (4 0. 1) (4 2. 9) (1 .2 ) 58 83 .9 20 .2 53 .3 12 .2 33 1 B rik am a 14 .5 61 .6 12 .2 68 9 16 .9 32 .8 62 .6 4. 5 14 1 85 .9 17 .6 61 .8 10 .9 83 0 M an sa ko nk o 11 .5 53 .7 8. 5 10 3 (7 .2 ) 21 .5 ) 34 .2 ) (0 .0 ) 13 89 .3 12 .7 51 .4 7. 6 11 7 K er ew an 5. 8 60 .7 5. 5 26 9 (3 .7 ) 26 .1 ) 68 .3 ) (0 .0 ) 32 89 .7 8. 0 61 .5 4. 9 30 1 K un ta ur 3. 5 48 .9 3. 5 14 8 (8 .1 ) (5 .6 ) 30 .8 ) (2 .5 ) 22 88 .3 3. 8 46 .6 3. 4 16 9 Ja nj an bu re h 5. 5 49 .8 5. 5 18 3 (5 .4 ) (9 .1 ) 41 .2 ) (0 .0 ) 24 89 .2 5. 9 48 .9 4. 9 20 7 B as se 7. 0 61 .9 7. 0 32 2 9. 0 16 .5 54 .8 0. 0 55 86 .6 8. 4 60 .9 6. 0 37 8 M ot he r’s e du ca tio n N o ed uc at io n 8. 3 56 .7 7. 5 1, 23 4 7. 6 17 .4 53 .4 0. 3 17 6 88 .5 9. 4 56 .3 6. 6 1, 41 0 P rim ar y 13 .1 57 .4 10 .6 24 6 7. 0 26 .0 46 .3 2. 8 74 78 .5 16 .0 54 .8 8. 8 32 0 S ec on da r y o r h ig he r 15 .0 62 .0 13 .2 53 1 21 .0 44 .1 59 .3 5. 5 10 2 87 .2 19 .7 61 .6 11 .9 63 3 W ea lth q ui nt ile Lo w es t 7. 5 55 .8 6. 2 43 2 8. 0 21 .3 45 .5 0. 0 64 88 .1 9. 3 54 .5 5. 4 49 6 S ec on d 8. 7 57 .7 8. 2 46 7 12 .5 16 .0 48 .2 0. 0 69 88 .8 9. 6 56 .5 7. 1 53 6 M id dl e 9. 3 58 .3 9. 2 43 1 6. 0 22 .3 56 .3 1. 5 66 87 .5 11 .0 58 .0 8. 1 49 8 Fo ur th 16 .0 64 .6 13 .9 37 2 (8 .0 ) (3 1. 0) (5 7. 2) (4 .0 ) 70 85 .4 18 .3 63 .5 12 .4 44 1 H ig he st 13 .4 54 .5 10 .5 30 9 20 .0 40 .7 59 .2 5. 4 83 83 .0 19 .2 55 .5 9. 4 39 2 To ta l 10 .6 58 .2 9. 4 2, 01 1 11 .3 27 .0 53 .6 2. 4 35 2 86 .8 13 .1 57 .5 8. 3 2, 36 3 N ot e: F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. 1 Fo od g ro up s: a . i nf an t f or m ul a, m ilk o th er th an b re as t m ilk , c he es e or y og ur t o r ot he r m ilk p ro du ct s; b . f oo ds m ad e fro m g ra in s, ro ot s, a nd tu be rs , i nc lu di ng p or rid ge a nd fo rti fie d ba by fo od fr om g ra in s; c . v ita m in A -r ic h fru its a nd ve ge ta bl es (a nd re d pa lm o il) ; d . o th er fr ui ts a nd v eg et ab le s; e . e gg s; f. m ea t, po ul try , f is h, a nd s he llf is h (a nd o rg an m ea ts ); g. le gu m es a nd n ut s. 2 F or b re as tfe d ch ild re n, m in im um m ea l f re qu en cy is re ce iv in g so lid o r s em is ol id fo od a t l ea st tw ic e a da y fo r i nf an ts a ge 6 -8 m on th s an d at le as t 3 ti m es a d ay fo r c hi ld re n ag e 9- 23 m on th s. 3 I nc lu de s 2 or m or e fe ed in gs o f c om m er ci al in fa nt fo rm ul a; fr es h, ti nn ed , a nd p ow de re d an im al m ilk ; a nd y og ur t 4 F or n on br ea st fe d ch ild re n ag e 6- 23 m on th s, m in im um m ea l f re qu en cy is re ce iv in g so lid o r s em is ol id fo od o r m ilk fe ed s at le as t 4 ti m es a d ay . 5 N on br ea st fe d ch ild re n ag e 6- 23 m on th s ar e co ns id er ed to b e fe d w ith a m in im um s ta nd ar d of 3 IY C F pr ac tic es if th ey re ce iv e ot he r m ilk o r m ilk p ro du ct s at le as t t w ic e a da y, re ce iv e th e m in im um m ea l f re qu en cy , a nd re ce iv e so lid or s em is ol id fo od s fro m a t l ea st 4 fo od g ro up s no t i nc lu di ng th e m ilk o r m ilk p ro du ct s fo od g ro up . 6 B re as tfe ed in g, o r n ot b re as tfe ed in g an d re ce iv in g 2 or m or e fe ed in gs o f c om m er ci al in fa nt fo rm ul a; fr es h, ti nn ed , a nd p ow de re d an im al m ilk ; a nd y og ur t 7 C hi ld re n ar e fe d th e m in im um re co m m en de d nu m be r o f t im es p er d ay a cc or di ng to th ei r a ge a nd b re as tfe ed in g st at us a s de sc rib ed in n ot es 2 a nd 4 . 138 • Nutrition of Women and Children Nutrition of Women and Children • 139 11.7 PREVALENCE OF ANAEMIA IN CHILDREN Anaemia, characterised by a low level of haemoglobin in the blood, is a major health problem in The Gambia, especially among young children and pregnant women. Anaemia may be an underlying cause of maternal mortality, spontaneous abortions, premature births, and low birth weight. The most common cause of anaemia is inadequate dietary intake of nutrients necessary for synthesis of haemoglobin, such as iron, folic acid, and vitamin B12. Anaemia also results from sickle cell disease, malaria, and parasitic infections. A number of interventions have been put in place to address anaemia in children. These include expanded distribution of multi-micronutrient powders; deworming of children age 1 to 5 every six months, along with vitamin A distribution; and promotion of environmental sanitation and the use of insecticide- treated mosquito nets for children under age 5 in malaria-endemic areas. In the 2013 GDHS, the HemoCue rapid testing methodology was used to determine anaemia levels among women age 15-49 and children under age 5. Table 11.7 presents anaemia levels among children age 6-59 months according to selected background characteristics. The results are based on children who stayed in the household the night before the interview. Haemoglobin was measured in 3,238 children. Unadjusted (i.e., measured) haemoglobin values were obtained using the HemoCue instrument. Given that haemoglobin requirements differ substantially depending on altitude, an adjustment to sea-level equivalents was made using CDC formulas before classifying children according to level of anaemia (CDC, 1998). Overall, 73 percent of children suffer from some level of anaemia, with 26 percent, 43 percent, and 4 percent being mildly, moderately, and severely anaemic, respectively (Table 11.7). Male children (74 percent) are slightly more likely to be anaemic than female children (72 percent). The prevalence of anaemia is higher among children in rural areas than among urban children (78 percent versus 67 percent). Kuntaur has the highest proportion of children with anaemia (85 percent), while Banjul has the lowest proportion (61 percent). There is an inverse relationship between anaemia prevalence by mother’s level of education. Wealth quintile is also inversely related to the prevalence of anaemia among children. Seventy- eight percent of children in households in the lowest wealth quintile are anaemic, as compared with 63 percent of those in households in the highest quintile. 140 • Nutrition of Women and Children Table 11.7 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteristics, The Gambia 2013 Background characteristic Anaemia status by haemoglobin level Any anaemia (<11.0 g/dl) Mild anaemia (10.0-10.9 g/dl) Moderate anaemia (7.0-9.9 g/dl) Severe anaemia (<7.0 g/dl) Number of children Age in months 6-8 82.1 29.0 51.5 1.6 189 9-11 90.4 25.1 61.5 3.7 188 12-17 85.2 23.9 54.3 7.0 442 18-23 88.3 25.8 56.8 5.6 351 24-35 78.5 22.6 50.5 5.4 677 36-47 60.7 27.0 31.3 2.5 717 48-59 56.3 26.7 27.4 2.2 673 Sex Male 73.7 25.0 44.8 4.0 1,687 Female 71.8 26.0 41.8 4.0 1,551 Mother’s interview status Interviewed 73.5 25.3 44.0 4.2 2,769 Not interviewed but in household 70.2 27.1 40.3 2.8 238 Not interviewed and not in the household1 67.3 25.7 38.6 3.0 231 Residence Urban 66.7 27.5 36.6 2.6 1,433 Rural 77.6 23.8 48.7 5.1 1,805 Local Government Area Banjul 61.3 27.7 31.3 2.2 41 Kanifing 63.1 24.6 34.6 3.9 482 Brikama 67.7 29.6 36.0 2.1 1,127 Mansakonko 79.2 27.1 49.0 3.0 186 Kerewan 73.3 25.6 44.2 3.6 432 Kuntaur 84.5 18.8 57.6 8.1 225 Janjanbureh 81.4 24.3 51.1 6.0 255 Basse 82.5 19.6 56.4 6.5 491 Mother’s education2 No education 75.5 23.1 47.6 4.8 1,846 Primary 73.3 25.8 44.7 2.9 405 Secondary or higher 67.8 31.0 33.9 2.9 755 Wealth quintile Lowest 77.8 22.9 49.8 5.0 704 Second 76.6 25.2 48.8 2.6 778 Middle 75.7 24.8 44.2 6.7 601 Fourth 68.3 27.2 37.9 3.2 632 Highest 62.6 27.9 32.2 2.5 525 Total 72.8 25.5 43.4 4.0 3,238 Note: Table is based on children who stayed in the household on the night before the interview and who were tested for anaemia. Prevalence of anaemia, based on haemoglobin levels, is adjusted for altitude using formulas in CDC, 1998. Haemoglobin is in grams per decilitre (g/dl). Total includes 1 case for whom information on mother’s education is missing. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 11.8 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is a major contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, fortified foods, and direct supplementation. The 2013 GDHS collected information on consumption of foods rich in vitamin A and iron and the status of children receiving vitamin A capsules, iron supplements, and deworming during national campaigns. Vitamin A is an essential micronutrient for the immune system that plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency (VAD) can cause eye damage. VAD can also increase the severity of infections, such as measles and diarrhoeal diseases in children, and slow recovery from illness. Vitamin A is found in breast milk, other milk, liver, eggs, fish, butter, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Table 11.8 presents data on intake of key micronutrients among children by background characteristics. The table shows the percentage of youngest children age 6-23 months living with their mother who consumed foods rich in vitamin A and iron in the day or night preceding the survey, the Nutrition of Women and Children • 141 percentage of all children age 6-59 months who were given vitamin A supplements in the six months preceding the survey and who were given iron supplements in the past seven days, the percentage of children age 12-59 months who were given deworming medication in the six months preceding the survey, and, among all children age 6-59 months living in households that were tested for the presence of iodised salt, the percentage who lived in households with iodised salt. Table 11.8 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey; among all children age 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, who were given iron supplements in the past seven days, and who were given deworming medication in the six months preceding the survey; and among all children age 6-59 months who live in households that were tested for iodised salt, the percentage who live in households with iodised salt, by background characteristics, The Gambia 2013 Background characteristic Among youngest children age 6-23 months living with their mother: Among all children age 6-59 months: Among children age 6-59 months living in households tested for iodised salt Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supple- ments in last 6 months Percentage given iron supple- ments in last 7 days Percent- age given dewor- ming medica- tion in last 6 months3 Number of children Percentage living in house- holds with iodised salt4 Number of children Age in months 6-8 8.4 6.4 428 63.3 18.1 16.1 432 73.8 407 9-11 33.4 30.6 367 82.0 15.4 27.7 373 71.0 353 12-17 56.9 50.0 941 87.0 18.6 37.6 973 77.1 914 18-23 68.8 62.1 627 83.1 15.6 36.5 686 75.3 648 24-35 na na na 71.6 18.4 38.2 1,426 74.8 1,328 36-47 na na na 60.5 15.9 35.9 1,396 77.5 1,317 48-59 na na na 51.9 14.1 30.6 1,369 76.5 1,269 Sex Male 47.5 41.1 1,216 68.1 17.0 33.9 3,417 75.8 3,202 Female 47.8 43.6 1,148 69.3 16.1 33.9 3,238 75.9 3,034 Breastfeeding status Breastfeeding 43.1 38.3 2,011 80.8 17.5 31.8 2,109 74.2 1,982 Not breastfeeding 73.7 65.3 352 63.2 16.2 34.9 4,471 76.6 4,184 Mother’s age at birth 15-19 44.2 40.0 156 71.2 15.2 32.4 246 68.1 230 20-29 46.1 40.8 1,236 67.5 15.6 32.2 3,322 77.3 3,112 30-39 51.0 44.6 798 69.5 17.8 35.4 2,488 75.4 2,329 40-49 46.3 44.9 173 70.9 17.1 37.2 599 72.7 564 Residence Urban 49.6 44.8 1,069 65.7 16.5 31.9 3,169 90.7 2,943 Rural 46.1 40.2 1,294 71.5 16.6 35.7 3,486 62.6 3,292 Local Government Area Banjul 41.9 40.1 31 72.1 14.4 40.0 103 87.5 34 Kanifing 47.0 40.9 331 69.9 21.8 38.1 1,147 91.4 1,106 Brikama 53.0 48.7 830 66.8 15.6 32.3 2,272 85.4 2,173 Mansakonko 39.4 37.7 117 76.6 18.6 38.4 334 50.3 326 Kerewan 59.2 55.7 301 70.8 16.2 32.5 777 46.6 763 Kuntaur 35.4 30.3 169 79.1 8.4 34.3 460 64.2 431 Janjanbureh 31.0 22.8 207 74.9 25.5 46.4 562 78.4 438 Basse 44.8 36.5 378 58.8 11.2 24.3 1,001 71.8 966 Mother’s education No education 44.0 39.4 1,410 68.6 16.7 33.3 4,015 72.6 3,778 Primary 55.7 45.4 320 66.6 16.6 33.9 910 75.7 846 Secondary or higher 51.7 47.2 633 70.0 16.2 35.3 1,731 83.4 1,612 Wealth quintile Lowest 45.9 41.6 496 69.4 20.7 36.2 1,340 64.4 1,257 Second 45.7 40.8 536 70.9 14.8 34.5 1,476 62.1 1,403 Middle 47.3 39.5 498 69.5 15.3 32.3 1,327 77.8 1,248 Fourth 51.4 46.2 441 65.8 14.3 32.9 1,294 84.5 1,210 Highest 48.8 44.4 392 67.4 17.7 33.4 1,218 94.3 1,117 Total 47.7 42.3 2,363 68.7 16.5 33.9 6,655 75.8 6,236 Note: Information on vitamin A is based on both mother’s recall and the immunisation card (where available). Information on iron supplements and deworming medication is based on mother’s recall. Total includes 69 cases for whom information on breastfeeding status is missing. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mango, papaya, and other locally grown fruits and vegetables that are rich in vitamin A 2 Includes meat (and organ meat), fish, poultry, and eggs 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 4 Any level of iodine present in the salt. Excludes children in households in which salt was not tested. 142 • Nutrition of Women and Children Forty-eight percent of children age 6-23 months consumed foods rich in vitamin A the day or night preceding the survey. There is no difference in the consumption of vitamin A-rich foods between boys and girls, but consumption of such foods is considerably higher among nonbreastfeeding (74 percent) than breastfeeding (43 percent) children. Children living in urban areas are somewhat more likely than children in rural areas to consume foods rich in vitamin A (50 percent versus 46 percent). At LGA level, children in Kerewan (59 percent) are most likely to consume vitamin A-rich foods, and those in Janjanbureh are least likely to do so (31 percent). Forty-two percent of children age 6-23 months consumed iron-rich foods in the day and night preceding the survey. Consumption of iron-rich foods is slightly higher among girls (44 percent) than boys (41 percent), and it is substantially higher among nonbreastfeeding than breastfeeding children (65 percent versus 38 percent). Urban children (45 percent) are more likely than rural children (40 percent) to consume iron-rich foods. Children in Kerewan (56 percent) are most likely to consume iron-rich foods, and those in Janjanbureh (23 percent) are least likely to do so. The percentage of children who consume iron-rich foods increases with increasing mother’s education, from 39 percent among children whose mothers have no education to 47 percent among those whose mothers have a secondary education or higher. The 2013 GDHS also collected data on vitamin A supplementation and iron supplementation among children under age 5. According to Table 11.8, 69 percent of children age 6-59 months were given vitamin A supplements in the six months before the survey. The proportion of children receiving vitamin A supplementation is highest among those age 12-17 months (87 percent). Children who are still breastfeeding (81 percent) are more likely to receive vitamin A supplements than those who are not breastfeeding (63 percent). At the LGA level, the proportion of children receiving vitamin A supplements is highest in Kuntaur (79 percent) and lowest in Basse (59 percent). Survey data on iron supplementation indicate that 17 percent of children received supplements in the seven days preceding the survey. There are no major variations by most background characteristics, except at the LGA level. Children in Janjanbureh (26 percent) are three times as likely to be given iron supplements as children in Kuntaur (8 percent). Certain types of intestinal parasites can cause anaemia. Periodic deworming for organisms such as helminthes and schistosomiasis (bilharzia) can improve children’s micronutrient status. Table 11.8 shows that about one- third of children age 6-59 months (34 percent) received deworming medication in the six months before the survey. Older children, those living in rural areas, and those living in Janjanbureh were more likely than other children to have been given deworming medication. Inadequate amounts of iodine in the diet are related to serious health risks for young children. Salt is used for several purposes in a household. It plays a role in cooking and food preservation. In line with 2006 Food Fortification and Salt Iodisation Regulations for The Gambia, household salt should be fortified with iodine (as potassium iodate) to at least 34 - 66 parts per million (ppm), with 50 – 80ppm at the point of entry and at production site. The 2013 GDHS tested for the presence of iodine in household salt. Overall, salt was tested in 84 percent of households (Table 11.9). Slightly less than eight in ten households (78 percent) have iodised salt. Urban households are more likely to have iodised salt (91 percent) than those in rural areas (62 percent). The presence of iodised salt is highest among households in Kanifing (93 percent) and lowest among households in Kerewan (50percent). The presence of iodised salt is positively correlated with wealth. Nutrition of Women and Children • 143 Table 11.9 Presence of iodised salt in household Among all households, the percentage with salt tested for iodine content and the percentage with no salt in the household, and among households with salt tested, the percentage with iodised salt, according to background characteristics, The Gambia 2013 Background characteristic Among all households, the percentage: Among households with tested salt: With salt tested With no salt in the household Number of households Percentage with iodised salt Number of households Residence Urban 78.6 21.4 3,671 90.5 2,884 Rural 91.3 8.7 2,546 61.7 2,326 Local Government Area Banjul 26.8 73.2 188 83.6 50 Kanifing 79.4 20.6 1,520 92.9 1,207 Brikama 87.6 12.4 2,160 84.5 1,893 Mansakonko 90.4 9.6 356 52.5 322 Kerewan 91.1 8.9 721 49.9 657 Kuntaur 93.2 6.8 296 64.9 276 Janjanbureh 68.9 31.1 410 77.6 283 Basse 92.2 7.8 566 73.8 522 Wealth quintile Lowest 88.2 11.8 1,423 63.3 1,255 Second 92.6 7.4 995 63.4 922 Middle 82.2 17.8 1,053 80.5 865 Fourth 74.9 25.1 1,404 87.6 1,051 Highest 83.2 16.8 1,342 93.8 1,116 Total 83.8 16.2 6,217 77.6 5,210 11.9 NUTRITIONAL STATUS OF WOMEN Anthropometric data on height and weight were collected for women age 15-49 interviewed in the survey. In this report, two indicators of nutritional status based on these data are presented: body mass index (BMI) and the percentage of women of very short stature (less than 145 cm). The body mass index, or the Quetelet index, is used to measure thinness or obesity. BMI is expressed as weight in kilograms divided by height squared in meters (kg/m2). A cutoff point of 18.5 is used to define thinness or acute undernutrition, and a BMI of 25.0 or above usually indicates overweight or obesity. The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. Low pre- pregnancy BMI and short stature are risk factors for poor birth outcomes and obstetric complications. In developing countries, maternal underweight is a leading risk factor for preventable death and diseases. Table 11.10 presents mean BMI values and the proportions of women falling into various BMI categories, according to background characteristics. Respondents for whom there was no information on height and/or weight and for whom a BMI could not be estimated were excluded from this analysis. Overall, less than 1 percent of women fall below the 145-cm cutoff point for height. The mean BMI for women age 15-49 is 22.5. At the national level, 17 percent of women are thin (BMI below 18.5) and 23 percent are overweight or obese. Being thin, overweight, or obese is inversely related to age. Women age 15-19 are nearly three times as likely as those age 40-49 to be thin (27 percent versus 10 percent), while the opposite is true for women who are overweight or obese. Women living in rural areas are more likely to be thin (20 percent) than those living in urban areas (14 percent), while urban women are more likely to be overweight or obese than rural women (27 percent versus 17 percent). At the LGA level, the proportion of thin women is highest in Janjanbureh (24 percent) and lowest in Kanifing (11 percent). The percentage of women who are thin tends to decrease with increasing wealth. As one would expect, overweight and obesity show a positive relationship with wealth. 144 • Nutrition of Women and Children Table 11.10 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, The Gambia 2013 Background characteristic Height Body mass index1 Percent- age below 145 cm Number of women Mean BMI 18.5-24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moder- ately and severely thin) ≥25.0 (total over- weight or obese) 25.0-29.9 (over- weight) ≥30.0 (obese) Number of women Age 15-19 0.9 1,031 20.6 63.9 27.0 18.6 8.5 9.1 6.9 2.2 962 20-29 0.0 1,753 22.1 64.0 16.3 10.4 5.9 19.7 14.6 5.1 1,524 30-39 0.1 1,120 23.7 59.2 11.1 8.7 2.4 29.7 19.3 10.4 992 40-49 0.1 572 24.9 48.4 9.7 6.5 3.3 41.9 24.9 17.0 546 Residence Urban 0.1 2,414 23.3 58.4 14.4 10.2 4.3 27.2 17.0 10.2 2,232 Rural 0.4 2,061 21.6 63.6 19.5 12.9 6.6 16.9 13.2 3.8 1,792 Local Government Area Banjul 0.5 97 24.4 47.9 12.0 7.6 4.4 40.1 23.9 16.2 90 Kanifing 0.0 997 24.1 55.3 10.9 7.2 3.7 33.7 21.3 12.4 930 Brikama 0.0 1,484 22.5 62.2 16.5 12.3 4.2 21.3 13.4 7.9 1,346 Mansakonko 0.4 223 21.6 60.7 21.5 14.3 7.2 17.8 14.1 3.7 197 Kerewan 0.8 528 21.4 63.0 21.4 13.4 8.0 15.6 11.7 3.9 465 Kuntaur 1.2 239 21.5 66.2 18.8 11.7 7.1 15.0 11.6 3.4 204 Janjanbureh 0.3 334 21.8 56.4 23.8 15.4 8.4 19.8 14.5 5.2 301 Basse 0.2 572 21.6 67.1 17.2 11.7 5.5 15.7 13.6 2.1 492 Education No education 0.2 2,114 22.6 60.7 15.5 10.5 5.1 23.8 17.3 6.5 1,859 Primary 0.6 621 22.5 64.3 14.5 9.6 4.9 21.2 15.1 6.2 545 Secondary or higher 0.2 1,740 22.5 59.4 18.8 13.1 5.7 21.8 13.1 8.7 1,620 Wealth quintile Lowest 0.6 776 21.7 66.1 18.5 11.5 7.0 15.4 11.3 4.1 674 Second 0.2 913 21.5 62.6 21.7 15.9 5.8 15.7 12.8 3.0 796 Middle 0.3 783 22.0 59.7 19.3 12.8 6.5 21.0 15.3 5.7 677 Fourth 0.1 940 23.3 58.0 14.2 8.9 5.3 27.8 17.5 10.3 874 Highest 0.0 1,064 23.6 58.4 11.9 9.0 2.9 29.6 18.1 11.6 1,003 Total 0.2 4,475 22.5 60.7 16.7 11.4 5.3 22.6 15.3 7.3 4,024 Note: Body mass index is expressed as the ratio of weight in kilograms to the square of height in metres (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding two months As is the case with many developing countries, The Gambia is facing the emergence of a number of diet-related noncommunicable diseases such as diabetes, hypertension, coronary heart disease, obesity, and some forms of cancer. The prevalence of noncommunicable diseases is increasing in The Gambia, especially in urban areas. Factors such as changes in diets and lifestyles, specifically among the affluent, have contributed to the increased occurrence of these diseases. With infectious diseases a major public health burden, the increase in the prevalence of diet-related noncommunicable diseases poses challenges with respect to allocation of scarce resources and is exerting immense pressure on an already overstretched health budget. The results from the GDHS indicate that, among women, overweight and obesity are more of a concern than underweight. 11.10 PREVALENCE OF ANAEMIA IN WOMEN Table 11.11 shows the prevalence of anaemia among women age 15-–49 by background characteristics. Overall, 60 percent of women are anaemic, with 41 percent, 17 percent, and 2 percent being mildly, moderately, and severely anaemic, respectively. The prevalence of anaemia is highest among women age 20-29 (63 percent), women who have given birth to six or more children (64 percent), and pregnant women (68 percent). All forms of anaemia (mild, moderate, and severe) are more prevalent among women living in rural areas than among women in urban areas. Overall, 68 percent of rural women are anaemic, as compared with 53 percent of urban women. At the LGA level, anaemia prevalence ranges from 51 percent in Kanifing to 74 percent each in Janjanbureh and Kuntaur. The prevalence of anaemia among women is Nutrition of Women and Children • 145 inversely correlated with education and tends to decrease with wealth. For example, 67 percent of women in the lowest wealth quintile are anaemic, as compared with 49 percent in the highest quintile. Table 11.11 Prevalence of anaemia in women Percentage of women age 15-49 with anaemia, by background characteristics, The Gambia 2013 Background characteristic Anaemia status by haemoglobin level Number of women Any Mild Moderate Severe Not pregnant <12.0 g/dl 10.0-11.9 g/dl 7.0-9.9 g/dl <7.0 g/dl Pregnant <11.0 g/dl 10.0-10.9 g/dl 7.0-9.9 g/dl <7.0 g/dl Age 15-19 58.2 43.5 13.2 1.5 1,008 20-29 62.7 42.1 19.3 1.4 1,718 30-39 59.3 40.5 16.5 2.3 1,110 40-49 58.2 37.1 18.4 2.7 557 Number of children ever born 0 56.9 42.5 13.2 1.3 1,408 1 61.1 43.4 15.9 1.8 609 2-3 60.7 40.1 18.9 1.6 957 4-5 61.6 36.2 23.3 2.1 673 6+ 64.1 44.0 17.2 2.8 745 Maternity status Pregnant 67.9 25.6 36.8 5.5 347 Breastfeeding 62.5 44.4 16.4 1.7 1,343 Neither 58.2 41.9 14.9 1.4 2,702 Residence Urban 53.3 38.9 13.4 1.1 2,362 Rural 68.4 44.3 21.4 2.7 2,030 Local Government Area Banjul 52.7 39.6 11.8 1.3 96 Kanifing 50.5 38.5 9.9 2.0 976 Brikama 56.3 40.0 15.5 0.8 1,451 Mansakonko 67.1 40.2 26.2 0.8 221 Kerewan 59.6 41.3 16.8 1.5 517 Kuntaur 73.5 41.1 28.5 3.9 238 Janjanbureh 74.3 42.7 27.4 4.2 331 Basse 72.7 50.1 20.0 2.6 561 Education No education 64.6 41.7 20.6 2.3 2,078 Primary 62.8 46.5 14.2 2.1 610 Secondary or higher 54.0 39.1 13.7 1.2 1,704 Wealth quintile Lowest 67.3 44.5 20.3 2.5 768 Second 66.0 42.4 21.4 2.2 902 Middle 67.1 45.1 20.6 1.5 768 Fourth 55.6 38.8 14.8 2.1 925 Highest 49.0 37.8 10.2 1.0 1,029 Total 60.3 41.4 17.1 1.8 4,393 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC, 1998. 11.11 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects the mother and infant against anaemia, which is considered a major cause of perinatal and maternal mortality. Anaemia also results in an increased risk of premature delivery and low birth weight. Finally, iodine deficiency is related to a number of adverse pregnancy outcomes including abortion, faetal brain damage and congenital malformation, stillbirth, low intelligent quotient (IQ) and prenatal death. The 2013 GDHS collected data on use of vitamin A and iron-folic acid supplements among women age 15-49 with a child born in the past five years, use of deworming medication during the last pregnancy, and the percentage of women living in households with iodised salt. 146 • Nutrition of Women and Children A single dose of vitamin A is typically given to women within 45 days of childbirth, aimed at increasing the mother’s vitamin A level and the content of the vitamin in her breast milk for the benefit of her child. Because of the risk of teratogenesis (abnormal development of the foetus) resulting from high doses of vitamin A during pregnancy, the dose should not be given to pregnant women. Table 11.12 includes measures that are useful in assessing micronutrient intake by women during pregnancy and the two months after birth (postpartum period). The results show that, overall, 85 percent of women age 15–49 years received vitamin A supplementation within the first two months after the birth of their last child. Intake of vitamin A is higher among women in rural than urban areas (88 percent versus 82 percent). The proportion of women receiving postpartum vitamin A is lowest among those age 15–19 (76 percent). In terms of LGAs, the proportion of women receiving postpartum vitamin A is highest in Kerewan and Mansakonko (92 percent each) and lowest in Banjul (81 percent). The percentage of women receiving postpartum vitamin A decreases with increasing education and wealth. With regard to iron supplementation during pregnancy, 45 percent of women reported taking iron tablets or syrup for 90 or more days during the pregnancy of their most recent birth. Only 3 percent did not take any iron supplements during pregnancy. Almost half of women age 15-19 (49 percent) consumed iron tablets or syrup 90 or more days. Rural women (49 percent) were more likely than urban women (40 percent) to take iron tablets or syrup for 90 or more days during their most recent pregnancy. Kerewan has the highest proportion of women who consumed iron supplements for 90 or more days (67 percent). Forty percent of women reported having taken deworming medication during the pregnancy of their most recent birth. Women residing in rural areas (45 percent) and those living in Janjanbureh (69 percent) are most likely to take deworming medicine. Seventy-six percent of women with a child born in the last five years live in households with iodised salt. The percentage of women who live in households with iodised salt is higher in urban areas (91 percent) than in rural areas (62 percent). Kerewan has the lowest proportion of women living in households with iodised salt (46 percent), and Kanifing has the highest proportion (92 percent). Consumption of iodised salt is inversely associated with women’s education and household wealth. N ut rit io n of W om en a nd C hi ld re n • 1 29 Ta bl e 11 .1 2 M ic ro nu tri en t i nt ak e am on g m ot he rs A m on g w om en a ge 1 5- 49 w ith a c hi ld b or n in th e pa st fi ve y ea rs , t he p er ce nt ag e w ho re ce iv ed a v ita m in A d os e in th e fir st tw o m on th s af te r t he b irt h of th e la st c hi ld , t he p er ce nt d is tri bu tio n by n um be r o f da ys th ey to ok ir on ta bl et s or s yr up d ur in g th e pr eg na nc y of th e la st c hi ld , a nd th e pe rc en ta ge w ho to ok d ew or m in g m ed ic at io n du rin g th e pr eg na nc y of th e la st c hi ld , a nd a m on g w om en a ge 1 5- 49 w ith a ch ild b or n in th e pa st fi ve y ea rs a nd w ho li ve in h ou se ho ld s th at w er e te st ed fo r i od is ed s al t, th e pe rc en ta ge w ho li ve in h ou se ho ld s w ith io di se d sa lt, b y ba ck gr ou nd c ha ra ct er is tic s, T he G am bi a 20 13 P er ce nt ag e w ho re ce iv ed vi ta m in A d os e po st pa rtu m 1 N um be r o f d ay s w om en to ok ir on ta bl et s or s yr up d ur in g pr eg na nc y of la st b irt h P er ce nt ag e of w om en w ho to ok d ew or m - in g m ed i- ca tio n du rin g pr eg na nc y of la st b irt h N um be r o f w om en A m on g w om en w ith a c hi ld bo rn in th e la st fi ve y ea rs w ho liv e in h ou se ho ld s th at w er e te st ed fo r i od is ed s al t B ac kg ro un d ch ar ac te ris tic N on e <6 0 60 -8 9 90 + D on ’t kn ow / m is si ng To ta l P er ce nt ag e liv in g in ho us eh ol ds w ith s al t w ith an y io di ne 2 N um be r o f w om en A ge 15 -1 9 75 .8 2. 2 34 .8 11 .5 48 .8 2. 7 10 0. 0 42 .0 33 9 72 .0 31 2 20 -2 9 84 .8 3. 0 32 .7 15 .5 43 .5 5. 3 10 0. 0 40 .5 2, 54 5 77 .2 2, 37 8 30 -3 9 86 .7 3. 6 30 .2 14 .5 45 .8 5. 9 10 0. 0 39 .5 1, 91 0 75 .9 1, 78 0 40 -4 9 84 .6 3. 6 30 .8 16 .9 42 .8 5. 9 10 0. 0 41 .0 51 1 75 .3 48 2 R es id en ce U rb an 81 .8 4. 6 35 .0 12 .6 40 .1 7. 7 10 0. 0 36 .0 2, 64 3 90 .6 2, 43 7 R ur al 88 .0 1. 9 28 .5 17 .5 49 .0 3. 1 10 0. 0 44 .6 2, 66 3 62 .3 2, 51 6 Lo ca l G ov er nm en t A re a B an ju l 80 .8 5. 6 34 .3 12 .4 37 .6 10 .1 10 0. 0 37 .0 93 87 .8 32 K an ifi ng 79 .7 4. 5 37 .2 17 .5 33 .9 7. 0 10 0. 0 36 .5 98 2 91 .7 93 5 B rik am a 82 .2 4. 2 35 .0 11 .8 43 .9 5. 1 10 0. 0 34 .1 1, 82 0 84 .8 1, 74 6 M an sa ko nk o 91 .9 2. 1 22 .7 36 .5 36 .6 2. 1 10 0. 0 36 .1 26 5 51 .2 25 9 K er ew an 92 .2 1. 1 11 .8 12 .3 66 .7 8. 0 10 0. 0 37 .6 58 9 46 .3 57 8 K un ta ur 91 .3 1. 3 44 .8 9. 7 41 .6 2. 7 10 0. 0 31 .7 33 6 63 .5 31 7 Ja nj an bu re h 89 .5 2. 2 20 .3 18 .9 50 .2 8. 4 10 0. 0 68 .8 45 1 78 .1 34 3 B as se 84 .9 2. 5 36 .0 14 .7 44 .6 2. 2 10 0. 0 50 .9 76 9 72 .8 74 3 Ed uc at io n N o ed uc at io n 85 .4 3. 3 30 .3 16 .3 44 .6 5. 6 10 0. 0 41 .3 3, 08 2 72 .8 2, 88 7 P rim ar y 86 .7 4. 1 37 .2 15 .3 40 .8 2. 7 10 0. 0 43 .3 74 7 76 .8 70 2 S ec on da ry o r h ig he r 83 .1 2. 7 32 .0 12 .3 46 .6 6. 3 10 0. 0 36 .7 1, 47 6 83 .1 1, 36 3 W ea lth q ui nt ile Lo w es t 90 .1 1. 6 29 .1 22 .7 44 .1 2. 5 10 0. 0 41 .5 1, 02 7 64 .8 95 7 S ec on d 86 .8 1. 8 29 .9 15 .6 48 .9 3. 8 10 0. 0 42 .7 1, 11 4 61 .5 1, 06 2 M id dl e 86 .1 4. 8 33 .1 11 .6 45 .3 5. 2 10 0. 0 46 .5 1, 07 4 78 .0 1, 00 5 Fo ur th 81 .2 4. 2 37 .3 12 .9 37 .8 7. 8 10 0. 0 34 .5 1, 07 2 84 .2 1, 00 2 H ig he st 80 .2 3. 8 29 .1 12 .5 46 .8 7. 8 10 0. 0 36 .0 1, 01 9 94 .3 92 7 To ta l 84 .9 3. 2 31 .7 15 .0 44 .6 5. 4 10 0. 0 40 .3 5, 30 5 76 .2 4, 95 3 1 I n th e fir st tw o m on th s af te r d el iv er y of la st b irt h 2 A ny le ve l o f i od in e pr es en t i n th e sa lt. E xc lu de s w om en in h ou se ho ld s w he re s al t w as n ot te st ed . Nutrition of Women and Children • 147 Malaria • 149 MALARIA 12 alaria remains a disease of public health importance in The Gambia. According to the country’s National Malaria Strategic Plan 2013-2020, malaria is a leading cause of morbidity and mortality, especially among children under age 5 (MoH&SW, 2013a). The endemic nature of the disease is influenced by ecological factors that favour breeding of the malarial vectors. Malaria is meso-endemic in The Gambia and has a marked seasonal variation; about 90 percent of cases occur in the rainy season, which usually lasts from June to October. The most common malaria parasite in The Gambia is Plasmodium falciparum, which accounts for more than 95 percent of all reported malaria cases. Plasmodium malariae and Plasmodium ovale account for the remainder of cases. The distribution of malaria vectors is well defined in the country. Members of the Anopheles gambiae species complex are the main vectors. These include Anopheles gambiae senso stricto, Anopheles arabiensis, and Anopheles melas. Although they are found throughout The Gambia, Anopheles gambiae senso stricto and Anopheles arabiensis are concentrated in the middle parts of the country. Anopheles melas can be found only in Brikama (Jawara et al., 2008). A malaria-free Gambia is the vision of the National Malaria Control Program (NMCP), with the goal of eliminating malaria infections in the country by 2020. To achieve this goal, the National Malaria Control Policy outlines seven key intervention strategies: • Programme management and partnership building • Malaria case management • Malaria control during pregnancy • Seasonal malaria chemoprevention • Integrated vector management M Key Findings • Seventy-two percent of households have at least one mosquito net; 69 percent have at least one insecticide-treated mosquito net (ITN), the majority of which are long-lasting insecticidal nets. • Thirty percent of households reported that they had received indoor residual spraying during the past 12 months. • On the night before the survey, 47 percent of children under age 5 slept under an ITN. Among households with at least one ITN, 59 percent of children under age 5 slept under an ITN. • Overall, 46 percent of pregnant women slept under an ITN the night before the survey. Among pregnant women living in households that possess an ITN, 61 percent slept under an ITN the night before the survey. • Sixty-two percent of women who had their last birth in the two years preceding the survey received intermittent preventive treatment during their pregnancy; that is, they took two or more doses of SP/Fansidar and received at least one during an antenatal care visit. • Twelve percent of children age 6-59 months had a low haemoglobin level (less than 8.0 g/dl), indicating possible malarial infection. • Two percent of children age 6-59 months have malaria according to rapid diagnostic testing (RDT) in the field, and 1 percent have malaria based on microscopy of thick blood smear slides. 150 • Malaria • Procurement supply management • Advocacy and behaviour change communication • Malaria surveillance, monitoring, evaluation, and operational research Specific objectives of the NMCP strategic interventions include the following. Prevention • Consistent use of long-lasting insecticidal nets (LLINs) by 85 percent of the population at risk by 2015 and maintained through 2020 • 80 percent coverage for indoor residual spraying (IRS) in all regions of the country by 2015 and maintained through 2020 • Use of intermittent preventive treatment during pregnancy (IPTp) by 85 percent of pregnant women with two doses by 2015, and 95 percent use of IPTp with four doses by 2020 • 80 percent coverage of complete treatment courses of sulphadoxine-pyrimethamine (SP) and amodiaquine for all infected children between age 3 months and age 10 during the peak transmission season by 2015 Case management • Achieve 85 percent malaria case management according to the national standard treatment guidelines by 2015, maintained through 2020 Advocacy, social mobilization, behavioural change, and communication • Malaria prevention and treatment messages to reach all households by 2015 • Proportion of households that adopt recommended malaria prevention and control behaviours to reach 80 percent by 2015 and 90 percent by 2020 Surveillance, monitoring and evaluation, and operational research • Conduct stratification and risk mapping by 2015, updated in 2017 • Establish a malaria information system capable of providing accurate, reliable, and timely information on malaria by 2015 12.1 OWNERSHIP OF MOSQUITO NETS The use of insecticide-treated mosquito nets (ITNs) is a primary health intervention designed to reduce malaria transmission in The Gambia. An ITN is a factory-treated net that does not require any further treatment or a net that has been soaked with insecticide within the past 12 months. Long-lasting insecticidal nets (LLINs) are factory-treated mosquito nets made with netting material that has insecticide incorporated within or bound around the fibres. The current generation of LLINs lasts three to five years, after which the net should be replaced. All households in the 2013 GDHS were asked whether they owned mosquito nets and, if so, how many. Table 12.1 shows household ownership of nets by type (any type, ITN, or LLIN) and average number of nets per household, by background characteristics. Overall, 72 percent of households in The Gambia own at least one net, regardless of type. Nearly seven in ten (69 percent) households own at least one net that meets one of the ITN criteria (i.e., a factory-treated net that does not require retreatment, a pretreated net obtained within the previous 12 months, or a net soaked in insecticide at some time within the 12 months prior to the survey). The majority of these ITNs are long-lasting insecticidal nets; 68 percent of households own at least one LLIN. Malaria • 151 Ownership of ITNs is higher in rural than in urban households (80 percent and 61 percent, respectively). Among Local Government Areas (LGAs), ownership of an ITN is lowest in Banjul (55 percent) and highest in Kuntaur, Janjanbureh, and Basse (88 percent each). Households in the lowest three wealth quintiles are more likely than those in the highest two quintiles to own an ITN. Although mosquito net ownership is a key indicator of the success of malaria control measures, it is also important to determine if a household has a sufficient number of nets for those sleeping within the home. Households in The Gambia own, on average, 2 ITNs, nearly all of which are LLINs. Universal net coverage within the population can be measured by assuming that each net is shared by two people in the household. Table 12.1 also shows the percentage of households with at least one mosquito net for every two persons who stayed in the household the night before the interview. One in four (25 percent) households in The Gambia had at least one mosquito net of any type for every two persons who stayed in the household the night before the survey. A similar percentage, 23 percent, had at least one ITN for every two people. 15 2 • M al ar ia T ab le 1 2. 1 H ou se ho ld p os se ss io n of m os qu ito n et s P er ce nt ag e of h ou se ho ld s w ith a t l ea st o ne m os qu ito n et (t re at ed o r u nt re at ed ), in se ct ic id e- tre at ed n et (I TN ), an d lo ng -la st in g in se ct ic id al n et (L LI N ); av er ag e nu m be r o f n et s, IT N s, a nd L LI N s pe r h ou se ho ld ; a nd pe rc en ta ge o f h ou se ho ld s w ith a t l ea st o ne n et , I TN , a nd L LI N p er tw o pe rs on s w ho s ta ye d in th e ho us eh ol d th e ni gh t b ef or e th e su rv ey , b y ba ck gr ou nd c ha ra ct er is tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic P er ce nt ag e of h ou se ho ld s w ith a t l ea st o ne m os qu ito n et A ve ra ge n um be r o f n et s pe r h ou se ho ld N um be r o f ho us eh ol ds P er ce nt ag e of h ou se ho ld s w ith a t l ea st o ne n et fo r e ve ry tw o pe rs on s w ho s ta ye d in th e ho us eh ol d th e ni gh t b ef or e th e su rv ey 1 N um be r o f ho us eh ol ds w ith a t l ea st on e pe rs on w ho s ta ye d in th e ho us eh ol d th e ni gh t b ef or e th e su rv ey A ny m os qu ito ne t In se ct ic id e- tre at ed m os qu ito n et (IT N )2 Lo ng -la st in g in se ct ic id al n et (L LI N ) A ny m os qu ito ne t In se ct ic id e- tre at ed m os qu ito n et (IT N )2 Lo ng -la st in g in se ct ic id al n et (L LI N ) A ny m os qu ito ne t In se ct ic id e- tre at ed m os qu ito n et (IT N )2 Lo ng -la st in g in se ct ic id al n et (L LI N ) R es id en ce U rb an 65 .1 61 .1 60 .5 1. 5 1. 4 1. 4 3, 67 1 20 .6 18 .2 17 .9 3, 65 8 R ur al 82 .4 80 .2 79 .7 2. 9 2. 7 2. 7 2, 54 6 32 .1 29 .0 28 .5 2, 54 1 Lo ca l G ov er nm en t A re a B an ju l 63 .0 55 .3 53 .1 1. 1 1. 0 0. 9 18 8 24 .9 19 .2 18 .2 18 7 K an ifi ng 62 .6 57 .7 56 .8 1. 3 1. 2 1. 1 1, 52 0 19 .8 16 .8 16 .5 1, 51 1 B rik am a 67 .2 63 .5 63 .1 1. 8 1. 7 1. 7 2, 16 0 17 .8 15 .8 15 .3 2, 15 5 M an sa ko nk o 80 .5 78 .6 77 .9 2. 4 2. 3 2. 2 35 6 38 .1 35 .2 34 .8 35 5 K er ew an 75 .8 73 .8 73 .5 2. 5 2. 3 2. 3 72 1 34 .6 31 .4 31 .1 72 1 K un ta ur 89 .1 88 .3 88 .3 3. 3 3. 2 3. 2 29 6 37 .1 34 .6 34 .6 29 6 Ja nj an bu re h 89 .3 88 .4 88 .4 3. 3 3. 1 3. 1 41 0 41 .9 38 .6 38 .6 40 9 B as se 89 .0 87 .6 86 .9 3. 3 3. 2 3. 2 56 6 30 .4 28 .7 27 .9 56 6 W ea lth q ui nt ile Lo w es t 79 .5 76 .7 76 .2 2. 2 2. 1 2. 1 1, 42 3 36 .4 32 .9 32 .3 1, 41 8 S ec on d 82 .4 80 .1 79 .7 3. 0 2. 8 2. 8 99 5 28 .9 26 .0 25 .6 99 5 M id dl e 76 .8 74 .9 74 .3 2. 5 2. 4 2. 4 1, 05 3 22 .8 20 .6 20 .0 1, 05 2 Fo ur th 66 .7 62 .4 61 .7 1. 6 1. 5 1. 5 1, 40 4 20 .7 18 .5 18 .1 1, 39 3 H ig he st 59 .0 54 .6 53 .8 1. 4 1. 3 1. 3 1, 34 2 17 .6 15 .3 15 .1 1, 34 2 To ta l 72 .2 68 .9 68 .3 2. 1 1. 9 1. 9 6, 21 7 25 .3 22 .7 22 .2 6, 19 9 1 D e fa ct o ho us eh ol d m em be rs 2 A n in se ct ic id e- tre at ed n et ( IT N ) is ( 1) a fa ct or y- tre at ed n et th at d oe s no t r eq ui re a ny fu rth er tr ea tm en t (L LI N ), (2 ) a pr et re at ed n et o bt ai ne d w ith in th e pa st 1 2 m on th s, o r (3 ) a ne t t ha t ha s be en s oa ke d w ith in se ct ic id e w ith in th e pa st 1 2 m on th s. 152 • Malaria Malaria • 153 12.2 INDOOR RESIDUAL SPRAYING In The Gambia, indoor residual spraying (IRS) is part of the integrated vector management strategy, which is a key component of malaria prevention. IRS has a significant impact on the mosquito population and therefore can lead to rapid reductions in malaria transmission and subsequent mortality. IRS involves spraying of the interior walls with insecticide with the goal of killing mosquitoes when they rest on the sprayed wall. In addition to reducing the mosquito population and, in turn, human-vector contact, IRS decreases the population of other insects of public health importance, thus reducing overall morbidity and saving costs. Due to financial challenges, IRS in The Gambia has not been implemented nationally since 2012. It has been conducted in three out of seven health regions in past years with support from the Global Fund. The Malaria Global Fund Phase 2 also provides support for IRS national scaling up between 2013 and 2015. To obtain information on the prevalence of indoor residual spraying, all households interviewed in the 2013 GDHS were asked whether the interior walls of their dwelling had been sprayed to protect against mosquitoes during the 12-month period before the survey and, if so, who had sprayed the dwelling. Table 12.2 shows that 30 percent of households had been sprayed in the past 12 months. There is a dramatic difference in IRS by residence, with rural households nearly five times more likely than urban households to report receiving IRS (57 percent and 12 percent, respectively). Table 12.2 Indoor residual spraying against mosquitoes Percentage of households in which someone has come into the dwelling to spray the interior walls against mosquitoes (IRS) in the past 12 months, the percentage of households with at least one ITN and/or IRS in the past 12 months, and the percentage of households with at least one ITN for every two persons and/or IRS in the past 12 months, by background characteristics, The Gambia 2013 Background characteristic Percentage of households with IRS1 in the past 12 months Percentage of households with at least one ITN2 and/or IRS in the past 12 months Percentage of households with at least one ITN2 for every two persons and/or IRS in the past 12 months Number of households Residence Urban 11.8 63.7 26.7 3,671 Rural 57.2 88.7 68.6 2,546 Local Government Area Banjul 4.7 56.4 22.6 188 Kanifing 7.9 60.1 23.4 1,520 Brikama 8.9 65.3 23.4 2,160 Mansakonko 75.4 94.4 85.5 356 Kerewan 45.9 85.0 64.5 721 Kuntaur 91.8 98.2 93.7 296 Janjanbureh 84.9 95.2 89.2 410 Basse 61.9 94.6 72.6 566 Wealth quintile Lowest 52.2 84.9 65.6 1,423 Second 52.4 88.1 63.6 995 Middle 32.7 79.7 46.5 1,053 Fourth 13.7 65.2 28.3 1,404 Highest 6.9 56.3 20.3 1,342 Total 30.4 73.9 43.8 6,217 1 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation (NGO). 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. Low urban coverage is also observed at the LGA level. Only 5-9 percent of households in Banjul, Brikama, and Kanifing, which are predominantly urban LGAs, reported having been sprayed. Wealthier households are also less likely to have been sprayed. For example, only 7 percent of households in the highest wealth quintile have been sprayed, as compared with 52 percent of households in the lowest quintile. 154 • Malaria The combination of IRS and use of an ITN offers the greatest protection against malaria. Overall, 74 percent of households are protected by owning at least one ITN and/or by having received IRS in the past 12 months. However, ITNs must be available in sufficient quantities for use by household members. Less than half (44 percent) of all households have at least one ITN for every two persons and/or have been sprayed in the past 12 months. Differences by residence, LGA, and wealth are similar to those observed for IRS. 12.3 ACCESS TO AN INSECTICIDE-TREATED NET (ITN) The 2013 GDHS gathered data on the proportion of the population that could sleep under an ITN if each ITN in the household were used by up to two people. This population is referred to as having access to an ITN. Coupled with mosquito net usage, ITN access can provide useful information on the magnitude of the gap between ITN ownership and use (in other words, the population with access to an ITN but not using it). If the difference between these indicators is substantial, the programme may need to focus on behaviour change and how to identify the main drivers of and barriers to ITN use in order to design an appropriate intervention. Such an analysis would help ITN programmes determine whether they need to achieve higher ITN coverage, promote ITN use, or both. Table 12.3 shows the percent distribution of the de facto household population by the number of ITNs owned by the household, according to the number of persons who stayed in the household the night before the survey. Nationally, 45 percent of the population in The Gambia has access to an ITN. Access to ITNs fluctuates as household size increases. It is higher among households with two to six persons who stayed in the household the night before the survey (50-55 percent) than for households with one person or seven or more persons (43-47 percent). Table 12.3 Access to an insecticide-treated net (ITN) Percent distribution of the de facto household population by number of ITNs the household owns, according to number of persons who stayed in the household the night before the survey, The Gambia 2013 Number of ITNs Number of persons who stayed in the household the night before the survey Total 1 2 3 4 5 6 7 8+ 0 56.1 45.1 37.4 30.6 28.0 31.2 30.6 22.0 25.2 1 38.3 36.8 35.2 30.8 21.8 16.4 14.7 7.5 12.0 2 4.6 14.5 19.8 27.0 33.6 22.4 22.8 9.9 14.1 3 0.5 2.2 6.2 7.9 10.1 18.6 18.2 12.8 12.7 4 0.4 0.8 1.5 3.5 4.7 8.4 11.3 15.2 12.6 5 0.0 0.6 0.0 0.1 1.0 2.5 1.1 8.2 6.1 6 0.0 0.0 0.0 0.1 0.7 0.4 1.0 7.5 5.4 7+ 0.1 0.0 0.0 0.0 0.2 0.1 0.3 16.9 12.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 554 761 1,416 1,937 3,007 3,519 3,496 34,862 49,553 Percentage with access to an ITN1 43.9 54.9 50.9 54.0 52.3 50.4 46.5 43.1 45.3 1 Percentage of the de facto household population that could sleep under an ITN if each ITN in the household were used by up to 2 people Figure 12.1 shows the percentage of the household population with access to an ITN, by selected background characteristics. A lower percentage of urban than rural households have access to an ITN (39 percent and 52 percent, respectively). Among LGAs, the percentage of the population with access to an ITN is highest in Janjanbureh (59 percent) and lowest in Banjul and Kanifing (35 percent each). The percentage of the household population with access to an ITN decreases as wealth increases, from 54 percent of the population in the lowest quintile to 33 percent in the highest quintile. Malaria • 155 Figure 12.1 Percentage of the de facto population with access to an ITN in the household 12.4 USE OF MOSQUITO NETS Community-level protection against malaria helps reduce the spread of the disease and offers an additional level of protection for those most vulnerable: children under age 5 and pregnant women. This section describes use of mosquito nets among all persons in the household, among children under age 5, and among pregnant women. 12.4.1 Use of Mosquito Nets by Persons in the Household Mosquito net coverage of the entire population is necessary to accomplish large reductions in the malaria burden. Although vulnerable groups (e.g., children under age 5 and pregnant women) should still be prioritised, the communal benefits of wide-scale ITN use by older children and adults should be promoted and evaluated by national malaria control programmes (Killeen et al., 2007). Table 12.4 shows that, overall, 39 percent of the household population slept under a net the night before the survey; 37 percent slept under ITNs, nearly all of which are LLINs. Children under age 5 are most likely to use ITNs (47 percent). Females are more likely than males to sleep under an ITN (41 percent versus 33 percent). Substantial differences are observed by LGA, with Basse having the lowest percentage of household members who slept under an ITN the night before the survey (28 percent) and Mansakonko having the highest percentage (50 percent). The percentage of the population sleeping under an ITN decreases steadily from 44 percent among households in the lowest wealth quintile to 30 percent among those in the highest quintile. Over half (58 percent) of the household population slept under an ITN the night before the survey or in a dwelling that was sprayed during the 12 months preceding the survey. Differences in the percentage 45 39 52 35 35 40 56 52 57 59 53 54 53 47 40 33 TOTAL RESIDENCE Urban Rural LGA Banjul Kanifing Brikama Mansakonko Kerewan Kuntaur Janjanbureh Basse WEALTH QUINTILE Lowest Second Middle Fourth Highest Percent GDHS 2013 156 • Malaria of the household population protected in this way by background characteristics are similar to those observed for the percentage of household members who slept under an ITN the night before the survey. The urban-rural difference is especially pronounced (74 percent and 44 percent, respectively). In households that own at least one ITN, 49 percent of household members slept under an ITN the night before the survey, with children under age 5 (59 percent), female household members and those living in urban areas (54 percent each), those living in Mansakonko (63 percent), and those in the poorest households (57 percent) being most likely to do so. Table 12.4 Use of mosquito nets by persons in the household Percentage of the de facto household population that slept the night before the survey under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months, and among the de facto household population in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, The Gambia 2013 Background characteristic Household population Household population in households with at least one ITN1 Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number Percentage who slept under an ITN1 the night before the survey Number Age <5 49.3 47.0 46.6 67.4 8,705 58.7 6,962 5-14 35.4 33.6 33.3 59.3 14,088 44.1 10,723 15-34 33.9 32.0 31.7 51.7 16,120 44.5 11,593 35-39 44.0 41.0 40.3 59.1 5,340 55.9 3,910 50+ 44.6 40.5 40.1 61.7 5,288 55.1 3,892 Sex Male 34.7 32.5 32.2 55.1 23,904 43.9 17,691 Female 43.5 41.1 40.7 61.5 25,649 54.3 19,399 Residence Urban 39.5 36.6 36.2 43.8 25,352 54.2 17,138 Rural 39.0 37.2 37.0 73.8 24,201 45.2 19,952 Local Government Area Banjul 40.3 35.5 34.2 38.0 966 57.0 601 Kanifing 37.7 34.6 33.9 41.3 9,681 54.1 6,191 Brikama 37.7 34.9 34.5 41.3 17,197 49.7 12,079 Mansakonko 51.1 49.7 49.0 89.3 2,594 63.0 2,046 Kerewan 41.7 39.8 39.7 70.4 5,858 52.0 4,484 Kuntaur 43.8 41.9 41.8 95.2 2,983 48.2 2,591 Janjanbureh 53.3 51.0 51.0 91.3 3,904 58.8 3,385 Basse 28.0 27.5 27.4 73.1 6,370 30.6 5,713 Wealth quintile Lowest 46.1 44.0 43.6 70.5 9,718 56.8 7,530 Second 41.4 39.4 39.2 73.8 9,860 47.7 8,135 Middle 37.1 35.4 35.1 65.1 9,927 43.0 8,181 Fourth 39.1 36.2 35.8 48.3 9,972 50.2 7,190 Highest 32.8 29.9 29.5 35.4 10,076 49.8 6,055 Total 39.3 36.9 36.6 58.4 49,553 49.4 37,090 Note: Total includes 24 cases with missing information on age. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation. Figure 12.2 presents data on ownership and coverage of, access to, and use of ITNs in The Gambia. Although 72 percent of households own at least one ITN, only 23 percent have enough ITNs to cover their entire household population (assuming that one ITN is used by two persons). Forty-five percent of household members have access to an ITN, and 37 percent slept under an ITN the night before the survey. A comparison of the first two columns indicates that households in The Gambia do not have a sufficient number of ITNs to cover the population sleeping in the household. A comparison of the second two columns, on the other hand, suggests that ITN access is generally similar to usage. Malaria • 157 Figure 12.2 Ownership of, access to, and use of ITNs 12.4.2 Use of Existing Mosquito Nets Table 12.5 presents data on use of existing ITNs. Overall, 74 percent of ITNs were used by someone in the household the night before the survey. Sixty-eight percent of ITNs were used in rural areas, as compared with 82 percent in urban areas. This pattern is also evident in the distribution by LGA, with the predominantly urban areas of Banjul and Kanifing having higher levels of usage (87 percent and 86 percent, respectively) than rural Basse (50 percent). There is little variation in use of nets by wealth. Table 12.5 Use of existing ITNs Percentage of insecticide-treated nets (ITNs) that were used by anyone the night before the survey, by background characteristics, The Gambia 2013 Background characteristic Percentage of existing ITNs1 used last night Number of ITNs1 Residence Urban 82.4 5,211 Rural 68.2 6,897 Local Government Area Banjul 87.1 183 Kanifing 85.7 1,769 Brikama 75.7 3,652 Mansakonko 82.0 812 Kerewan 72.8 1,680 Kuntaur 73.3 937 Janjanbureh 84.8 1,275 Basse 50.2 1,800 Wealth quintile Lowest 75.3 2,954 Second 69.4 2,835 Middle 69.9 2,499 Fourth 77.8 2,094 Highest 82.9 1,725 Total 74.3 12,108 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 72 23 45 37 Percentage of households with at least one ITN Percentage of households with at least one ITN for every two persons who stayed in the household the night before the interview* Percentage of the household population with access to an ITN within their household Percentage of the household population who slept under an ITN Percentage GDHS 2013*Assuming one ITN covers two persons. 158 • Malaria 12.4.3 Use of Mosquito Nets by Children Under Age 5 Malaria is endemic in The Gambia. Those living in areas of high malaria transmission acquire immunity to the disease over time (Doolan et al., 2009). Acquired immunity is not the same as sterile immunity; that is, acquired immunity does not prevent infection but rather protects against severe disease and death. Age is an important factor in determining levels of acquired immunity to malaria. For about six months following birth, antibodies acquired from the mother during pregnancy protect children born in areas of endemic malaria. This immunity gradually disappears, and children start to develop their own immunity. The pace at which immunity develops depends on the level of exposure to malarial infection; in highly malaria-endemic areas, children are thought to attain a high level of immunity by their fifth birthday. Such children may experience episodes of illness but usually do not suffer from severe, life- threatening malaria. Immunity in areas of low malaria transmission is acquired more slowly. Malaria affects all age groups of the population. Prevention of children under age 5 and pregnant women from malaria is a primary area of intervention for both the government and through NMCP. As such, the use of nets and other malaria prevention strategies is a major concern. Table 12.6 shows the use of mosquito nets by children under age 5. Almost half of all children (49 percent) slept under a mosquito net the night before the survey; 47 percent slept under an ITN nearly all of which are LLIN. Additionally, 67 percent of children either slept under an ITN the night before the survey or slept within a dwelling that had been sprayed in the past 12 months. Among households with at least one ITN, about six in ten children (59 percent) slept under an ITN the night before the survey. Female and male children have the same likelihood of sleeping under an ITN (47 percent each). Children age 23 months or younger (50 percent) are more likely than older children to have slept under an ITN the night before the survey. Urban children (50 percent), those residing in Mansakonko (58 percent), and those in the poorest households (52 percent) are most likely to sleep under an ITN. A comparison of data from the 2010 MICS and the 2013 GDHS shows that there has been an increase in the use of ITNs by children under age 5 over the past few years (from 33 percent to 47 percent) (Gambia Bureau of Statistics [GBoS], 2011). Malaria • 159 Table 12.6 Use of mosquito nets by children Percentage of children under age 5 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months, and among children under age 5 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, The Gambia 2013 Background characteristic Children under age 5 in all households Children under age 5 in households with at least one ITN1 Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number of children Percentage who slept under an ITN1 the night before the survey Number of children Age (in months) <12 52.1 50.0 49.7 70.0 1,872 60.3 1,551 12-23 52.2 50.2 49.8 69.3 1,845 61.8 1,499 24-35 47.2 44.5 43.8 65.3 1,636 57.1 1,274 36-47 47.3 44.4 44.1 64.3 1,718 56.8 1,341 48-59 47.0 45.0 44.8 67.4 1,635 56.7 1,298 Sex Male 49.6 47.3 47.0 68.0 4,458 58.8 3,588 Female 49.0 46.6 46.2 66.6 4,247 58.7 3,375 Residence Urban 53.5 50.1 49.5 55.6 4,014 67.3 2,985 Rural 45.7 44.3 44.1 77.4 4,691 52.2 3,977 Local Government Area Banjul 55.5 50.3 48.7 52.3 127 68.8 93 Kanifing 50.9 47.6 46.7 53.1 1,473 65.1 1,077 Brikama 50.1 46.9 46.4 51.9 2,932 62.0 2,216 Mansakonko 59.6 58.2 57.6 90.8 454 71.7 369 Kerewan 49.6 47.9 47.7 77.1 1,047 60.6 827 Kuntaur 52.1 50.1 50.1 95.8 594 56.3 528 Janjanbureh 59.1 57.3 57.3 91.6 757 65.4 664 Basse 34.4 34.2 34.2 76.4 1,321 38.0 1,188 Wealth quintile Lowest 54.1 52.3 51.8 75.7 1,831 65.2 1,468 Second 49.6 47.8 47.8 78.5 1,935 56.1 1,648 Middle 45.3 43.7 43.4 71.0 1,796 50.8 1,546 Fourth 49.3 45.6 45.2 57.5 1,668 59.2 1,284 Highest 47.8 44.7 44.1 49.1 1,475 64.9 1,017 Total 49.3 47.0 46.6 67.4 8,705 58.7 6,962 Note: Table is based on children who stayed in the household the night before the interview. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation. 12.4.4 Use of Mosquito Nets by Pregnant Women In malaria-endemic areas, adults usually have acquired some degree of immunity to severe, life- threatening malaria. However, pregnancy leads to suppression of the immune system, and thus pregnant women, especially those in their first pregnancy, have a higher risk of malarial infection. Moreover, malaria among pregnant women may be asymptomatic. Malaria during pregnancy is a major contributor to low birth weight, maternal anaemia, infant mortality, spontaneous abortion, and stillbirth. Pregnant women can reduce the risk of these adverse effects of malaria by sleeping under insecticide-treated mosquito nets. Table 12.7 shows the use of mosquito nets by pregnant women, according to background characteristics. Overall, 47 percent of pregnant women age 15-49 slept under any net the night before the survey; 46 percent slept under an ITN, and 45 percent slept under an LLIN. Furthermore, 66 percent of pregnant women either slept under an ITN the night before the survey or slept in a dwelling that had been sprayed during the 12 months preceding the survey. Among households with at least one ITN, 61 percent of pregnant women slept under an ITN the night before the survey. There are no major variations in use of ITNs among pregnant women by residence or education. By LGA, the percentage of women sleeping under an ITN ranges from 40 percent in Kerewan to 55 percent each in Banjul, Mansakonko, and Janjanbureh. ITN use decreases with increasing wealth, from 50 160 • Malaria percent among pregnant women in the poorest households to 38 percent among those in the wealthiest households. Table 12.7 Use of mosquito nets by pregnant women Percentages of pregnant women age 15-49 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months, and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, The Gambia 2013 Background characteristic Among pregnant women age 15-49 in all households Among pregnant women age 15-49 in households with at least one ITN1 Percentage who slept under any net the night before the survey Percentage who slept under an ITN1 the night before the survey Percentage who slept under an LLIN the night before the survey Percentage who slept under an ITN1 the night before the survey or in a dwelling sprayed with IRS2 in the past 12 months Number of women Percentage who slept under an ITN1 the night before the survey Number of women Residence Urban 47.7 45.9 45.0 50.4 376 67.2 257 Rural 47.0 45.6 45.5 79.0 465 56.7 375 Local Government Area Banjul 57.8 54.7 53.7 54.7 13 (73.6) 10 Kanifing 43.5 42.5 42.5 46.8 132 67.4 84 Brikama 47.7 45.5 44.4 49.4 276 65.0 193 Mansakonko 56.5 55.1 53.0 95.7 47 74.2 35 Kerewan 43.2 40.3 40.3 70.2 101 54.3 75 Kuntaur 51.7 48.9 48.9 95.0 61 55.1 54 Janjanbureh 54.5 54.5 54.5 94.7 69 63.7 59 Basse 43.8 43.8 43.8 79.1 142 50.6 123 Education No education 46.5 45.0 44.3 69.6 494 58.5 381 Primary 47.1 45.4 45.1 65.4 155 62.5 112 Secondary or higher 49.7 47.9 47.9 58.3 193 66.5 139 Wealth quintile Lowest 51.1 49.8 49.8 71.3 178 66.6 134 Second 50.4 49.1 48.8 81.0 178 61.6 142 Middle 48.0 46.9 45.4 73.5 204 57.4 167 Fourth 42.8 42.7 42.3 54.7 133 53.8 106 Highest 42.2 38.2 38.2 42.5 148 67.0 84 Total 47.3 45.8 45.3 66.2 842 60.9 632 Note: Table is based on women who stayed in the household the night before the interview. Figures in parentheses are based on 25-49 unweighted cases. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or nongovernmental organisation. The use of ITNs by pregnant women has increased since the 2010 MICS, from 26 percent to 46 percent (GBoS, 2011). 12.5 USE OF INTERMITTENT PREVENTIVE TREATMENT OF MALARIA DURING PREGNANCY Malaria prevention and control during pregnancy is another key intervention strategy. The primary aim is to improve pregnancy outcomes through prevention of malaria-related complications among pregnant women. Malaria poses major risks to pregnant women and newborns in The Gambia. It contributes to maternal anaemia, abortion, and low birth weight and increases the chances of perinatal and maternal death. Intermittent preventive treatment during pregnancy (IPTp) is one of the three components of preventing malaria in pregnancy. The provision of at least two doses of sulfadoxine-pyrimethamine (SP)/Fansidar protects the mother and her child from malaria and is given during routine antenatal care visits in the second and third trimesters of pregnancy. During antenatal care (ANC) visits, pregnant women are given the required dose of SP/Fansidar and urged to consume it immediately. Women in the 2013 GDHS who had a live birth in the two years preceding the survey were asked whether they took any antimalarial medications during the pregnancy leading to their most recent birth and, if so, which ones. Women were also asked whether the drugs they took were received during an antenatal care visit. It should be noted that obtaining information about drugs Malaria • 161 can be difficult because some respondents may not know or remember the name or the type of drug that they received. More than nine in ten pregnant women with a live birth in the two years preceding the survey (92 percent) reported taking at least one dose of SP/Fansidar during an ANC visit, and more than six in ten (62 percent) reported taking two or more doses, at least one of which was received during an ANC visit (Table 12.8). Sixty percent of pregnant women in urban areas took two or more doses of SP/Fansidar and received at least one dose during an ANC visit, as compared with 65 percent of women in rural areas. By LGA, this percentage ranges from 51 percent of women in Banjul to 70 percent of those residing in Basse. Similar to use of mosquito nets, pregnant women in the highest wealth quintile are least likely to use IPTp (57 percent). Table 12.8 Use of Intermittent Preventive Treatment (IPTp) by women during pregnancy Percentage of women age 15-49 with a live birth in the two years preceding the survey who, during the pregnancy preceding the last birth, received any SP/Fansidar during an ANC visit and who took at least two doses of SP/Fansidar and received at least one dose during an ANC visit, by background characteristics, The Gambia 2013 Background characteristic Percentage who received any SP/Fansidar during an ANC visit Percentage who took 2+ doses of SP/Fansidar and received at least one during ANC visit Number of women with a live birth in the two years preceding the survey Residence Urban 90.2 59.5 1,565 Rural 94.0 64.6 1,828 Local Government Area Banjul 89.0 50.8 51 Kanifing 89.7 52.0 517 Brikama 89.6 59.8 1,171 Mansakonko 94.6 60.4 169 Kerewan 93.8 68.5 419 Kuntaur 95.3 65.0 227 Janjanbureh 94.4 67.9 298 Basse 96.4 70.1 541 Education No education 92.2 63.1 1,951 Primary 93.3 61.6 502 Secondary or higher 91.7 60.9 940 Wealth quintile Lowest 93.3 61.6 703 Second 92.6 62.6 757 Middle 94.5 69.8 702 Fourth 93.9 59.6 681 Highest 85.5 56.5 549 Total 92.3 62.3 3,392 12.6 PREVALENCE, DIAGNOSIS, AND PROMPT TREATMENT OF CHILDREN WITH FEVER Fever is one of the most prominent symptoms of malaria, and prompt and effective malaria treatment is essential to prevent the disease from becoming severe. Important policy and strategic changes have been made with regard to the management of fever, including a change in the guidelines recommending confirmatory diagnosis of all fevers at all levels of care. The 2010 Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines were adapted to include confirmation of malaria before treatment. Malaria case management is a key intervention area, and the NMCP goal is to reduce case severity and the rate of deaths due to malaria through effective case management. As mentioned above, one of the main objectives of the malaria case management intervention is to ensure that, by 2015, at least 85 percent of suspected malaria cases are correctly diagnosed and that all diagnosed patients receive prompt and effective treatment in accordance with the standard guidelines within 24 hours of symptom onset. The timeliness and quality of treatment and diagnosis have major impacts on determining whether those suffering from malaria recover and on the duration of the illness. Currently, the programme’s main 162 • Malaria strategies are to expand laboratory diagnostic capacity and to improve the quality of laboratory diagnosis and malaria treatment at the health facility and community levels (MoH&SW, 2013b). Malaria case management, one of the most fundamental strategic areas of malaria control, is the identification, diagnosis, and prompt treatment of all malaria cases with appropriate and effective antimalarial drugs. As almost all treatment of malarial fevers occurs at home, caregivers are often trained in providing prompt and effective management to prevent the fever from becoming severe, thus preventing severe malaria-related morbidity and mortality. In the 2013 GDHS, mothers were asked if their children under age 5 had experienced an episode of fever in the two weeks preceding the survey and, if so, whether treatment and advice were sought. Information was also collected on the type and timing of the treatment given. Table 12.9 shows the percentage of children under age 5 who had a fever in the two weeks preceding the survey and, among those with a fever, the percentage for whom advice or treatment was sought from a health facility, provider, or pharmacy; the percentage of who had a drop of blood taken from a finger or heel (presumably for a malaria test); the percentage who took artemisinin-based combination therapy (ACT) or any antimalarial drugs; and the percentage who took drugs on the same or next day. Table 12.9 Prevalence, diagnosis, and prompt treatment of children with fever Percentage of children under age 5 with a fever in the two weeks preceding the survey, and among children under age 5 with fever, the percentage for whom advice or treatment was sought, the percentage who had blood taken from a finger or heel, the percentage who took any artemisinin-based combination therapy (ACT), the percentage who took ACT the same or next day following the onset of fever, the percentage who took antimalarial drugs, and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, The Gambia 2013 Background characteristic Among children under age 5: Among children under age 5 with fever: Percentage with fever in the two weeks preceding the survey Number of children Percentage for whom advice or treatment was sought1 Percentage who had blood taken from a finger or heel for testing Percentage who took any ACT Percentage who took any ACT the same or next day Percentage who took antimalarial drugs Percentage who took antimalarial drugs the same or next day Number of children Age (in months) <12 13.8 1,736 55.6 26.1 0.0 0.0 1.8 1.7 240 12-23 15.1 1,660 62.7 41.7 2.4 2.4 7.8 7.5 250 24-35 12.6 1,426 71.4 36.0 5.6 2.1 10.1 6.5 180 36-47 9.5 1,396 76.7 45.0 2.7 1.9 9.4 6.5 132 48-59 7.0 1,369 62.7 37.5 3.4 2.6 5.9 5.1 96 Sex Male 12.3 3,846 63.5 35.9 1.9 1.6 7.4 6.5 473 Female 11.4 3,740 65.8 37.0 3.2 1.7 5.9 4.0 425 Residence Urban 10.6 3,605 68.0 40.7 0.7 0.3 7.4 6.3 380 Rural 13.0 3,981 62.1 33.2 3.9 2.6 6.1 4.6 518 Local Government Area Banjul 19.4 121 65.2 36.7 0.8 0.8 1.6 1.2 23 Kanifing 14.6 1,317 62.7 42.0 0.7 0.0 9.1 6.9 192 Brikama 12.1 2,566 71.4 37.7 3.2 2.7 8.9 8.4 309 Mansakonko 9.1 385 57.6 21.5 5.7 1.9 8.0 4.1 35 Kerewan 12.6 890 70.4 30.8 4.6 3.7 4.9 3.7 112 Kuntaur 16.4 514 59.5 34.7 0.7 0.7 2.3 2.3 84 Janjanbureh 6.9 644 52.4 27.4 3.1 1.6 4.7 1.6 44 Basse 8.4 1,151 52.5 38.6 2.3 0.0 2.3 0.0 97 Mother’s education No education 10.8 4,504 63.2 33.3 3.4 2.3 6.4 5.1 484 Primary 13.3 1,071 66.1 32.4 0.5 0.5 9.3 7.5 142 Secondary or higher 13.5 2,011 66.4 44.0 2.0 0.9 5.8 4.6 272 Wealth quintile Lowest 12.4 1,525 66.3 30.0 2.3 1.4 4.9 3.6 189 Second 13.7 1,686 60.0 33.5 5.0 3.3 7.9 6.0 232 Middle 11.0 1,512 62.5 34.8 2.5 1.9 5.2 4.6 166 Fourth 9.9 1,509 66.7 37.6 0.6 0.6 7.1 5.1 149 Highest 11.9 1,354 69.5 48.6 1.0 0.1 8.2 7.3 162 Total 11.8 7,586 64.6 36.4 2.5 1.6 6.7 5.3 898 1 Excludes market and traditional practitioner Malaria • 163 Twelve percent of children under age 5 had a fever during the two weeks preceding the survey. The prevalence of fever is higher among children age 12-23 months (15 percent), rural children (13 percent), children in Banjul (19 percent), and children whose mothers have a primary education or higher (13-14 percent). There is no clear pattern in the relationship between fever prevalence and wealth. Advice or treatment was sought for 65 percent of children with a fever, and 36 percent had blood taken from a finger or heel for testing. Three percent of children who had a fever took ACT, and 2 percent took ACT the same or the next day. Seven percent of children with a fever took antimalarial drugs. The differentials in treatment patterns in Table 12.9 must be interpreted with caution because of the comparatively small number of children with fever in some subgroups and the small percentage who took antimalarial drugs. Table 12.10 shows the sources of advice or treatment for children with fever in the two weeks preceding the survey. The public sector was the principal source for advice or treatment (85 percent), followed by the private sector (17 percent). Other sources account only for 1 percent of the cases. Government health centres (60 percent) and government hospitals (15 percent) were the primary public sources of advice or treatment, and private hospitals (9 percent) and pharmacies (7 percent) were the primary private sources. NGO hospitals or clinics were the source of advice or treatment in 2 percent of the cases. Table 12.10 Source of advice or treatment for children with fever Percentage of children under age 5 with a fever in the two weeks preceding the survey for whom advice or treatment was sought from specific sources, and among children under age 5 with fever in the two weeks preceding the survey for whom advice or treatment was sought, the percentage for whom advice or treatment was sought from specific sources, by background characteristics, The Gambia 2013 Source Percentage for whom advice or treatment was sought from each source: Among children with fever Among children with fever for whom advice or treatment was sought Any public sector source 55.2 85.1 Government hospital 10.0 15.4 Government health centre 39.2 60.4 Government health post 5.8 9.0 Fieldworker 0.2 0.3 Any private sector source 11.2 17.2 Private hospital/clinic 5.6 8.7 Pharmacy 4.4 6.8 Private doctor 0.1 0.2 Fieldworker 0.0 0.1 NGO hospital/clinic 1.0 1.5 Any other source 0.8 1.2 Shop 0.2 0.4 Traditional practitioner 0.3 0.5 Other 0.2 0.4 Number of children 898 582 Nearly four in ten children under age 5 with a fever (38 percent) took ACT, 24 percent took chloroquine, 19 percent took SP/Fansidar, and 11 percent each took quinine or other antimalarials (data not shown due to the small numbers of children who had a fever and who took antimalarials). 164 • Malaria 12.7 PREVALENCE OF LOW HAEMOGLOBIN IN CHILDREN One of the objectives of the 2013 GHDS was to assess the prevalence of anaemia among children age 6-59 months. Table 11.7 in the chapter on nutrition presents the percentage of children who are anaemic (children are classified as anaemic if their haemoglobin level is below 11.0 g/dl and as severely anaemic if their haemoglobin level is below 7.0 g/dl). However, poor dietary intake of iron is only one of numerous causes of anaemia; malaria infection can also result in a person becoming anaemic. A haemoglobin concentration of less than 8.0 g/dl is considered low and may be an indication that an individual has malaria (Korenromp et al., 2004). Overall, 12 percent of children age 6-59 months have a haemoglobin level less than 8.0 g/dl (Table 12.11). Children age 12-17 months (22 percent); those residing in rural areas (16 percent); those in Basse (22 percent), Kuntaur (21 percent), and Janjanbureh (19 percent); those whose mothers have no education (14 percent); and those in the poorest households (16 percent) are most likely to have low haemoglobin levels. 12.8 PREVALENCE OF MALARIA IN CHILDREN One of the objectives of the 2013 GHDS was to test children age 6-59 months for malaria. Field health technicians collected capillary blood samples from children in this age group in half of the households surveyed. Testing for malaria was done in the field using a rapid diagnostic test (RDT). The SD Bioline Malaria Ag P.f/Pan is a high-sensitivity and high-specificity test that detects malaria antigens from capillary blood samples.1 Thick blood smear samples were prepared and sent to the National Public Health Laboratories to be read. Table 12.12 shows that 85 percent of the 3,816 eligible children age 6-59 months had their blood tested for malaria with RDT and 86 percent had their blood tested with microscopy. There are no major variations by background characteristics, except for children whose mothers were in the household but were not interviewed (56 percent coverage with each test). 1 Sensitivity is estimated at 99.7 percent for Plasmodium falciparum and at 95.5 percent for non-Plasmodium falciparum; specificity is estimated at 99.5 percent (http://www.pantech.co.za/products/details/sd_bioline_malaria_ antigen_pf_pan_test). Table 12.11 Haemoglobin <8.0 g/dl in children Percentage of children age 6-59 months with haemoglobin lower than 8.0 g/dl, by background characteristics, The Gambia 2013 Background characteristic Haemoglobin <8.0 g/dl Number of children Age (in months) 6-8 5.5 189 9-11 10.8 188 12-17 21.5 442 18-23 16.2 351 24-35 16.5 677 36-47 7.5 717 48-59 6.1 673 Sex Male 12.4 1,687 Female 11.6 1,551 Mother’s interview status Interviewed 12.1 2,769 Not interviewed but in household 12.9 238 Not interviewed and not in the household1 10.2 231 Residence Urban 7.2 1,433 Rural 15.9 1,805 Local Government Area Banjul 4.1 41 Kanifing 9.3 482 Brikama 5.5 1,127 Mansakonko 10.1 186 Kerewan 13.0 432 Kuntaur 21.2 225 Janjanbureh 18.8 255 Basse 22.4 491 Mother’s education2 No education 14.0 1,846 Primary 9.3 405 Secondary or higher 9.2 755 Wealth quintile Lowest 15.7 704 Second 13.2 778 Middle 14.8 601 Fourth 9.6 632 Highest 5.0 525 Total 12.0 3,238 Note: Table is based on children who stayed in the household the night before the interview. Prevalence of anaemia is based on haemoglobin levels. Haemoglobin is measured in grams per decilitre (g/dl). Total includes 1 case with missing information on mother’s education. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Children whose mothers are not listed in the Household Questionnaire are excluded. Malaria • 165 Table 12.12 Coverage of malaria testing among children by background characteristics Percentage of children age 6-59 months eligible for the rapid diagnostic test (RDT) and for microscopy, according to background characteristics (unweighted), The Gambia 2013 Percentage by type of test Background characteristic Rapid Diagnostic Test (RDT) Microscopy Number of children Age (in months) 6-8 80.1 79.4 272 9-11 88.4 88.4 225 12-17 84.5 85.7 477 18-23 89.2 90.0 381 24-35 85.2 86.3 831 36-47 86.2 87.3 818 48-59 84.6 85.1 812 Sex Male 85.8 86.4 1,975 Female 85.1 85.9 1,841 Mother's interview status Interviewed 89.4 90.3 3,144 Not interviewed but in household 56.4 56.4 374 Not interviewed and not in the household1 79.9 80.2 298 Residence Urban 82.3 83.1 1,237 Rural 86.9 87.7 2,579 Region Banjul 81.3 81.7 230 Kanifing 77.9 77.9 393 Brikama 87.9 88.5 688 Mansakonko 85.6 92.7 409 Kerewan 92.8 93.6 597 Kuntaur 81.7 82.3 530 Janjanbureh 80.0 80.5 436 Basse 89.3 86.5 533 Mother's education2 No education 86.9 87.4 2,299 Primary 87.0 87.0 471 Secondary or higher 82.4 84.4 744 Wealth quintile Lowest 88.6 90.6 971 Second 86.0 86.2 1,060 Middle 85.8 86.4 711 Fourth 85.3 85.4 597 Highest 77.4 77.8 477 Total 85.4 86.2 3,816 Note: Table is based on children who stayed in the household the night before the interview. Total includes 1 case for whom information on mother’s education is missing. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. Table 12.13 shows the prevalence of malaria among children age 6-59 months by background characteristics. Overall, according to rapid diagnostic testing performed in the field, the malaria prevalence among children is 2 percent. Additionally, only 1 percent of the thick blood smear samples were found to be positive for malaria based on microscopic reading of the slides at the laboratory. The malaria prevalence based on RDT may be higher than that according to microscopy because the antigens may still be present in the child’s blood after the parasites have disappeared. Children age 9-11 months, those whose mothers were not in the household and not interviewed, and those living in Basse are somewhat more likely to have malaria than other children. One reason for the low malaria prevalence among children age 6-59 months in the 2013 GDHS is that fieldwork was conducted between February and April, which falls in the dry, low-malaria season. 166 • Malaria Table 12.13 Prevalence of malaria in children Percentage of children age 6-59 months classified as having malaria by type of test, according to background characteristics, The Gambia 2013 RDT Microscopy Background characteristic Percentage positive Number Percentage positive Number Age (in months) 6-8 0.0 189 0.0 187 9-11 4.6 187 0.0 186 12-17 1.2 434 0.0 439 18-23 0.3 344 0.2 347 24-35 2.0 673 1.8 679 36-47 4.0 706 1.1 710 48-59 2.5 666 0.5 667 Sex Male 2.4 1,668 0.9 1,676 Female 2.2 1,531 0.6 1,540 Mother's interview status Interviewed 2.2 2,731 0.7 2,749 Not interviewed but in household 0.6 239 0.0 239 Not interviewed and not in the household1 5.4 229 1.8 229 Residence Urban 2.4 1,421 1.1 1,432 Rural 2.2 1,779 0.5 1,784 Region Banjul 0.0 40 0.0 40 Kanifing 3.2 482 1.2 483 Brikama 2.6 1,110 1.1 1,117 Mansakonko 0.5 179 0.0 189 Kerewan 0.2 423 0.1 428 Kuntaur 0.7 224 0.2 225 Janjanbureh 1.7 255 0.3 257 Basse 4.5 487 1.0 478 Mother's education2 No education 2.6 1,824 1.1 1,834 Primary 0.6 402 0.0 401 Secondary or higher 1.4 741 0.1 750 Wealth quintile Lowest 2.7 687 0.8 699 Second 1.5 770 0.5 769 Middle 3.9 592 0.7 594 Fourth 2.7 628 1.7 631 Highest 0.6 522 0.0 523 Total 2.3 3,199 0.8 3,216 Note: Table is based on children who stayed in the household the night before the interview. Total includes 1 case for whom information on mother’s education is missing. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 167 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 he data obtained in the 2013 GDHS provide an opportunity to assess some of the factors contributing to the spread of HIV/AIDS and sexually transmitted infections (STIs). The key objective of this chapter is to present information on HIV/AIDS-related knowledge, perceptions, and behaviours at the national and regional levels. This information can be used to develop strategies to target groups that are most in need of information and services and most vulnerable to the risk of HIV. Many of the indicators reported are included among the United Nations General Assembly Special Session (UNGASS) indicators. 13.1 KNOWLEDGE OF AIDS AND OF HIV PREVENTION METHODS The 2013 GDHS respondents were asked whether they had ever heard of HIV/AIDS. Table 13.1 shows that knowledge of AIDS in The Gambia is almost universal; 98 percent of women and men age 15-49 say that they have heard of AIDS. This percentage varies little across subgroups of women and men. HIV in adults is mainly transmitted through heterosexual contact between an HIV-positive partner and an HIV-negative partner. Consequently, HIV prevention programmes focus their messages and efforts on three important aspects of behaviour: use of condoms, limiting the number of sexual partners or staying faithful to one uninfected partner, and delaying young people’s sexual debut (abstinence). To ascertain whether programmes have effectively communicated these messages, GDHS respondents were asked specific questions about whether it is possible to reduce the chances of getting HIV by using a condom during every sexual encounter and limiting sexual intercourse to one partner. T Key Findings • Almost all women and men age 15-49 in The Gambia have heard of AIDS. • Knowledge of HIV transmission is limited, and men are better informed about AIDS transmission than women. Overall, only 27 percent of women and 36 percent of men age 15-49 have comprehensive knowledge about AIDS. • Fifty-six percent of women and 33 percent of men know that HIV can be transmitted through breastfeeding and that the risk can be reduced by taking drugs. • Ten percent of men and 5 percent of women express accepting attitudes in four situations related to HIV/AIDS stigma. • Eight percent of sexually active women and 3 percent of sexually active men reported having had a sexually transmitted infection (STI) and/or STI symptoms in the 12 months prior to the survey. • About one-quarter of young women (26 percent) and one-third of young men age 15-24 (32 percent) have comprehensive knowledge of AIDS. 168 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, The Gambia 2013 Women Men Background characteristic Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-24 97.8 4,532 96.9 1,685 15-19 97.0 2,407 95.6 836 20-24 98.7 2,125 98.1 849 25-29 98.8 1,822 98.8 586 30-39 98.8 2,559 99.1 816 40-49 98.9 1,320 98.9 490 Marital status Never married 98.2 2,963 97.4 2,177 Ever had sex 98.7 359 99.4 966 Never had sex 98.1 2,604 95.9 1,211 Married/living together 98.3 6,791 98.8 1,360 Divorced/separated/widowed 99.7 478 (100.0) 40 Residence Urban 99.3 5,730 99.2 2,228 Rural 97.1 4,503 96.0 1,349 Local Government Area Banjul 98.8 225 99.1 85 Kanifing 99.0 2,342 99.5 858 Brikama 99.5 3,550 98.3 1,454 Mansakonko 98.8 490 99.1 141 Kerewan 98.3 1,107 99.2 323 Kuntaur 93.6 526 97.7 141 Janjanbureh 95.1 739 91.5 240 Basse 97.8 1,254 95.5 336 Education No education 97.4 4,757 96.0 1,090 Primary 97.8 1,405 96.5 493 Secondary or higher 99.7 4,071 99.4 1,994 Wealth quintile Lowest 97.2 1,745 96.3 517 Second 97.6 1,882 96.0 614 Middle 98.3 1,927 97.3 588 Fourth 98.5 2,135 99.1 940 Highest 99.7 2,545 99.5 919 Total 15-49 98.4 10,233 98.0 3,577 50-59 na na 99.5 244 Total 15-59 na na 98.1 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable Table 13.2 shows that, overall, 71 percent of women and 78 percent of men age 15-49 know that using condoms during every sexual encounter can reduce the risk of HIV transmission; 86 percent and 87 percent of women and men, respectively, know that limiting sexual intercourse to one partner who has no other partners can reduce the chances of contracting HIV; and 68 percent of women and 72 percent of men say that using condoms during every sexual encounter and limiting sexual intercourse to one partner can reduce the risk of HIV infection. Knowledge of HIV prevention methods (using condoms and limiting sexual intercourse to one partner) among women and men shows no clear pattern by age or marital status. Knowledge of HIV prevention methods is higher among women and men in urban than in rural areas. For example, 73 percent of women in urban areas know about using condoms and limiting sexual intercourse to one partner, as compared with 60 percent in rural areas. Knowledge of HIV prevention methods increases with increasing education and wealth. HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 169 Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse and by having one sex partner who is not infected and has no other partners, by background characteristics, The Gambia 2013 Women Men Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of men Age 15-24 69.1 84.1 65.6 4,532 74.9 83.5 68.7 1,685 15-19 65.6 80.6 61.5 2,407 71.2 78.7 63.6 836 20-24 73.0 88.1 70.2 2,125 78.6 88.2 73.7 849 25-29 73.6 87.8 70.0 1,822 82.1 88.7 77.2 586 30-39 73.1 87.9 69.8 2,559 80.6 90.0 76.2 816 40-49 69.4 89.1 67.2 1,320 76.5 89.9 72.9 490 Marital status Never married 71.9 85.6 68.4 2,963 76.4 84.7 70.6 2,177 Ever had sex 79.6 88.3 76.8 359 81.7 89.6 76.5 966 Never had sex 70.8 85.3 67.2 2,604 72.1 80.8 65.8 1,211 Married/living together 70.1 86.4 67.0 6,791 79.7 90.2 75.6 1,360 Divorced/separated/widowed 77.1 91.0 72.9 478 (73.1) (77.4) (59.7) 40 Residence Urban 76.0 90.2 73.3 5,730 80.4 88.2 75.4 2,228 Rural 64.4 81.5 60.4 4,503 72.9 84.3 67.4 1,349 Local Government Area Banjul 79.4 91.6 74.9 225 80.9 87.2 75.7 85 Kanifing 75.0 92.0 72.3 2,342 81.6 86.9 76.4 858 Brikama 74.3 88.5 71.5 3,550 77.1 86.6 70.8 1,454 Mansakonko 80.8 94.5 79.5 490 81.1 89.5 76.5 141 Kerewan 75.1 90.9 73.2 1,107 73.7 89.7 69.8 323 Kuntaur 42.5 57.0 30.8 526 90.6 88.6 82.9 141 Janjanbureh 43.7 59.2 37.5 739 68.3 79.0 62.2 240 Basse 72.4 90.0 70.3 1,254 72.4 87.5 71.4 336 Education No education 65.4 83.3 62.0 4,757 72.4 85.3 68.2 1,090 Primary 68.6 85.9 65.7 1,405 73.6 81.8 67.0 493 Secondary or higher 78.1 90.1 74.9 4,071 81.4 88.7 76.0 1,994 Wealth quintile Lowest 66.5 81.3 62.6 1,745 72.1 80.0 63.9 517 Second 64.8 82.4 61.0 1,882 74.6 85.0 70.3 614 Middle 69.5 84.5 66.1 1,927 77.7 88.7 74.1 588 Fourth 70.8 88.1 68.0 2,135 79.1 86.6 73.7 940 Highest 79.7 92.6 76.9 2,545 81.1 90.4 76.1 919 Total 15-49 70.9 86.4 67.6 10,233 77.6 86.7 72.4 3,577 50-59 na na na na 70.3 80.9 65.9 244 Total 15-59 na na na na 77.1 86.3 72.0 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 13.2 COMPREHENSIVE KNOWLEDGE ABOUT AIDS As part of the effort to assess HIV and AIDS knowledge, the 2013 GDHS collected information on common misconceptions about HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have HIV and whether they believe HIV is transmitted through mosquito bites, supernatural means, or sharing food with a person who has HIV or AIDS. Comprehensive knowledge is defined as knowing that consistent condom use and having just one faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV transmission in The Gambia: that HIV can be transmitted by mosquito bites and that HIV can be transmitted by sharing food with a person who has AIDS. 170 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Tables 13.3.1 and 13.3.2 present data on knowledge about the ways in which the AIDS virus is transmitted. Men are better informed about AIDS transmission than women. About six in ten women (58 percent) and seven in ten men age 15-49 (71 percent) know that a healthy-looking person can have HIV. Sixty-five percent of women and 61 percent of men know that HIV cannot be transmitted by mosquito bites. Three-fourths of women 15-49 (75 percent) and about eight in ten men 15-49 (81 percent) know that HIV cannot be transmitted by supernatural means, and 72 percent of women and 76 percent of men know that a person cannot be infected by sharing food with someone who is infected with HIV. Overall, only 27 percent of women and 36 percent of men age 15-49 have comprehensive knowledge about AIDS. Table 13.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of the AIDS virus, and the percentage with comprehensive knowledge about AIDS, by background characteristics, The Gambia 2013 Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local miscon- ceptions1 Percentage with comprehensive knowledge about AIDS2 Number of women Background characteristic A healthy- looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has the AIDS virus Age 15-24 55.8 65.0 74.2 70.0 31.7 25.8 4,532 15-19 51.1 62.3 71.0 65.9 28.0 21.9 2,407 20-24 61.0 68.0 77.9 74.6 35.9 30.4 2,125 25-29 61.4 67.6 75.5 74.4 36.8 29.6 1,822 30-39 60.4 65.0 75.0 74.7 34.7 29.1 2,559 40-49 59.6 58.6 74.4 71.1 29.4 23.7 1,320 Marital status Never married 57.2 70.1 77.8 73.1 35.3 29.0 2,963 Ever had sex 60.0 68.3 76.0 69.6 33.6 30.5 359 Never had sex 56.8 70.3 78.1 73.6 35.5 28.8 2,604 Married/living together 58.6 61.7 72.9 71.3 31.7 25.9 6,791 Divorced/separated/widowed 63.1 71.8 80.0 77.4 39.3 31.4 478 Residence Urban 61.9 73.6 81.4 79.2 40.0 33.5 5,730 Rural 54.0 53.2 66.0 63.0 24.3 18.9 4,503 Local Government Area Banjul 58.1 72.7 82.2 79.5 37.1 30.4 225 Kanifing 65.8 74.2 84.4 80.4 45.2 36.9 2,342 Brikama 62.0 67.7 76.5 73.2 34.9 29.5 3,550 Mansakonko 75.3 65.3 67.0 70.2 40.2 36.2 490 Kerewan 39.5 60.4 78.9 64.5 19.6 17.0 1,107 Kuntaur 38.3 37.1 62.8 54.8 14.3 8.5 526 Janjanbureh 47.9 60.7 56.6 69.3 22.9 14.0 739 Basse 59.1 53.8 64.7 68.4 27.5 22.0 1,254 Education No education 53.2 54.8 66.9 66.1 23.9 18.9 4,757 Primary 58.2 59.2 68.9 65.7 28.6 23.2 1,405 Secondary or higher 64.6 78.0 85.8 81.3 45.3 38.0 4,071 Wealth quintile Lowest 54.9 53.1 60.7 60.4 23.3 19.1 1,745 Second 54.5 55.1 71.1 65.1 25.8 20.3 1,882 Middle 53.0 56.4 70.7 69.7 24.8 19.6 1,927 Fourth 57.1 70.2 79.4 77.7 35.2 28.5 2,135 Highest 68.9 81.1 86.0 82.4 49.7 42.0 2,545 Total 15-49 58.4 64.6 74.7 72.1 33.1 27.1 10,233 1 Two most common local misconceptions: that the AIDS virus can be transmitted by mosquito bites and that a person can become infected by sharing food with a person who has the AIDS virus 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention (that the AIDS virus can be transmitted by mosquito bites and that a person can become infected by sharing food with a person who has the AIDS virus). HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 171 Table 13.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of the AIDS virus, and the percentage with comprehensive knowledge about AIDS, by background characteristics, The Gambia 2013 Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local miscon- ceptions1 Percentage with compre- hensive knowledge about AIDS2 Number of men Background characteristic A healthy- looking person can have the AIDS virus The AIDS virus cannot be trans- mitted by mosquito bites The AIDS virus cannot be trans- mitted by supernatural means A person cannot become infected by sharing food with a person who has the AIDS virus Age 15-24 63.6 61.3 78.2 71.9 39.4 32.3 1,685 15-19 55.3 57.0 74.7 66.6 33.1 26.5 836 20-24 71.7 65.5 81.6 77.2 45.7 38.0 849 25-29 77.2 62.2 83.0 78.3 45.7 39.0 586 30-39 78.8 63.9 85.1 82.6 49.6 41.0 816 40-49 77.1 56.2 83.3 77.7 43.3 35.5 490 Marital status Never married 66.3 61.9 79.7 74.0 40.8 33.7 2,177 Ever had sex 72.9 64.1 84.9 78.6 43.6 36.0 966 Never had sex 61.1 60.2 75.5 70.4 38.6 31.8 1,211 Married/living together 79.0 60.6 83.6 79.4 47.4 39.5 1,360 Divorced/separated/widowed (66.4) (52.3) (85.8) (82.9) (38.4) (27.1) 40 Residence Urban 73.3 67.4 86.7 83.7 49.5 41.6 2,228 Rural 67.5 51.3 72.2 63.8 33.1 26.2 1,349 Local Government Area Banjul 68.4 68.3 85.8 82.0 45.7 38.5 85 Kanifing 73.1 69.8 84.4 83.3 48.9 41.5 858 Brikama 71.4 63.5 83.7 80.5 46.3 37.9 1,454 Mansakonko 65.8 50.8 74.3 68.3 32.5 29.9 141 Kerewan 78.7 75.6 86.0 83.3 56.4 42.1 323 Kuntaur 63.5 33.8 64.7 56.7 19.2 18.1 141 Janjanbureh 57.8 43.5 62.5 57.6 22.2 15.8 240 Basse 73.5 43.6 80.0 56.0 32.8 29.4 336 Education No education 65.8 50.0 73.4 67.0 32.9 27.7 1,090 Primary 62.9 46.3 74.4 68.6 30.6 23.1 493 Secondary or higher 76.1 71.3 87.2 83.1 52.2 43.4 1,994 Wealth quintile Lowest 66.2 48.6 69.3 65.3 30.5 22.7 517 Second 65.9 54.6 74.0 64.6 33.4 26.7 614 Middle 70.8 49.6 78.2 72.2 35.6 31.6 588 Fourth 73.3 67.8 85.6 80.2 48.0 40.2 940 Highest 75.4 73.8 90.3 88.4 57.3 47.4 919 Total 15-49 71.1 61.3 81.2 76.2 43.3 35.8 3,577 50-59 69.8 61.3 78.4 83.3 45.4 32.8 244 Total 15-59 71.1 61.3 81.1 76.6 43.4 35.6 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Two most common local misconceptions: that the AIDS virus can be transmitted by mosquito bites and that a person can become infected by sharing food with a person who has the AIDS virus 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention (that the AIDS virus can be transmitted by mosquito bites and that a person can become infected by sharing food with a person who has the AIDS virus). 172 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour 13.3 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing knowledge about prevention of mother-to-child transmission (PMTCT) of HIV to reduce transmission is critical. To assess PMTCT knowledge, respondents in the 2013 GDHS were asked whether HIV can be transmitted from a mother to a child during pregnancy, during delivery, and through breastfeeding. Table 13.4 shows that among respondents age 15-49, women are more likely than men to know about HIV transmission from mother to child by breastfeeding (72 percent versus 54 percent). Knowledge about special drugs that can be taken during pregnancy to reduce the risk of contracting HIV is also higher among women than among men (66 percent and 49 percent, respectively). While more than half (56 percent) of women know that HIV can be transmitted through breastfeeding and that the risk can be reduced by taking drugs, only 33 percent of men have this knowledge. There are notable variations across subgroups of women and men. Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, The Gambia 2013 Women Men Background characteristic HIV can be transmitted by breast- feeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breast- feeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 68.2 59.7 50.2 4,532 50.7 45.7 30.0 1,685 15-19 64.8 53.9 45.3 2,407 49.3 41.7 29.4 836 20-24 72.1 66.4 55.7 2,125 52.1 49.7 30.6 849 25-29 73.7 69.7 59.0 1,822 57.5 48.6 35.1 586 30-39 75.6 72.7 61.1 2,559 54.3 53.7 35.2 816 40-49 75.2 66.9 58.3 1,320 56.9 55.4 37.3 490 Marital status Never married 66.4 56.9 47.1 2,963 52.3 47.7 31.7 2,177 Ever had sex 71.1 66.3 51.1 359 56.3 54.4 34.8 966 Never had sex 65.7 55.6 46.5 2,604 49.1 42.4 29.3 1,211 Married/living together 74.5 69.1 59.2 6,791 55.0 52.1 35.4 1,360 Divorced/separated/widowed 70.5 71.3 56.1 478 (68.9) (42.8) (24.8) 40 Residence Urban 73.0 67.8 56.9 5,730 52.2 51.1 32.5 2,228 Rural 70.6 62.9 53.8 4,503 55.7 46.5 34.0 1,349 Local Government Area Banjul 66.4 64.1 48.9 225 45.0 45.5 26.2 85 Kanifing 69.4 68.1 54.9 2,342 51.5 52.3 32.8 858 Brikama 76.5 68.6 59.7 3,550 51.3 48.8 31.1 1,454 Mansakonko 84.1 79.6 72.1 490 60.7 47.0 33.6 141 Kerewan 78.5 62.3 59.0 1,107 53.4 70.1 45.8 323 Kuntaur 69.6 51.2 46.8 526 75.4 50.9 45.7 141 Janjanbureh 68.0 66.9 51.7 739 58.8 32.2 25.7 240 Basse 57.7 56.0 42.3 1,254 54.5 37.8 31.0 336 Education No education 70.8 64.2 54.9 4,757 51.2 46.6 31.2 1,090 Primary 70.8 63.3 53.9 1,405 48.5 40.0 27.9 493 Secondary or higher 73.7 68.3 56.7 4,071 56.0 53.1 35.3 1,994 Wealth quintile Lowest 73.2 66.3 57.2 1,745 55.3 41.1 30.0 517 Second 72.0 64.2 55.1 1,882 55.1 43.9 30.1 614 Middle 67.8 63.6 51.6 1,927 53.5 49.4 32.7 588 Fourth 72.8 63.7 54.4 2,135 54.0 49.4 33.7 940 Highest 73.5 69.6 58.6 2,545 51.0 57.4 36.2 919 Total 15-49 72.0 65.7 55.5 10,233 53.5 49.3 33.0 3,577 50-59 na na na na 48.6 53.3 31.0 244 Total 15-59 na na na na 53.2 49.6 32.9 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 173 13.4 ATTITUDES TOWARDS THOSE LIVING WITH HIV AND AIDS The HIV/AIDS epidemic has generated fear, anxiety, and prejudice against people living with HIV and AIDS, and people who are HIV positive face widespread stigma and discrimination. These societal attitudes can adversely affect both people’s willingness to be tested for HIV and their initiation of and adherence to antiretroviral therapy. Thus, reduction of stigma and discrimination is an important indicator of the success of programmes targeting HIV and AIDS prevention and control. To assess levels of stigma, 2013 GDHS respondents who had heard of AIDS were asked if they would be willing to care for a family member sick with AIDS in their own households, if they would be willing to buy fresh vegetables from a market vendor who had the AIDS virus, if they thought a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching, and if they would want to keep a family member’s HIV status secret. Tables 13.5.1 and 13.5.2 show the results for women and men, respectively. Overall, a small percentage of women and men age 15-49 (5 percent and 10 percent, respectively) express acceptance on all four measures. With respect to individual indicators, 88 percent of women and 95 percent of men are willing to care for a family member with AIDS in their own home. Accepting attitudes are generally more common among women and men in urban than in rural areas and increase with increasing education and wealth. Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, The Gambia 2013 Percentage of women who: Percentage expressing accepting attitudes on all four indicators Number of women who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 87.2 44.1 49.7 27.0 4.5 4,432 15-19 85.4 39.9 44.0 28.6 4.2 2,334 20-24 89.2 48.8 56.1 25.3 4.9 2,098 25-29 87.7 47.4 54.8 27.5 4.7 1,801 30-39 88.5 49.7 53.4 26.9 5.4 2,527 40-49 89.1 47.9 49.9 31.1 7.3 1,306 Marital status Never married 88.3 46.5 54.0 27.1 5.0 2,911 Ever had sex 86.8 44.7 52.1 25.1 4.5 355 Never had sex 88.5 46.7 54.2 27.4 5.1 2,556 Married/living together 87.3 46.1 50.1 28.0 5.1 6,679 Divorced/separated/widowed 93.1 53.9 58.3 25.7 6.8 477 Residence Urban 92.4 53.3 62.5 24.6 6.2 5,691 Rural 82.0 37.9 37.3 31.5 3.8 4,375 Local Government Area Banjul 91.7 58.1 68.4 32.5 13.5 223 Kanifing 91.2 54.5 65.8 27.8 7.9 2,319 Brikama 90.8 47.8 56.0 27.0 6.0 3,531 Mansakonko 81.1 50.6 39.2 50.3 8.2 484 Kerewan 94.0 43.2 40.8 14.2 1.2 1,088 Kuntaur 80.5 17.9 18.1 47.2 1.4 492 Janjanbureh 59.5 31.2 29.6 48.2 2.7 703 Basse 88.8 48.0 49.4 11.3 1.3 1,227 Education No education 84.7 40.9 41.9 27.9 3.5 4,633 Primary 87.3 39.8 45.9 25.9 3.0 1,374 Secondary or higher 91.6 55.4 64.6 27.9 7.7 4,059 Wealth quintile Lowest 84.0 38.2 33.5 31.4 4.2 1,696 Second 83.5 38.9 41.0 30.8 4.1 1,836 Middle 83.6 40.6 44.1 27.0 3.1 1,895 Fourth 90.9 49.0 58.9 26.1 5.8 2,103 Highest 94.2 60.3 70.9 24.5 7.6 2,536 Total 15-49 87.8 46.6 51.6 27.6 5.2 10,066 174 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, The Gambia 2013 Percentage of men who: Percentage expressing accepting attitudes on all four indicators Number of men who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 92.8 45.8 56.3 26.8 8.5 1,632 15-19 91.5 40.2 48.3 22.8 7.1 799 20-24 94.1 51.1 63.9 30.6 9.8 833 25-29 98.7 55.1 61.8 29.6 13.6 579 30-39 96.4 62.2 65.8 25.9 10.2 809 40-49 95.5 59.2 64.2 26.0 12.3 485 Marital status Never married 94.0 49.0 59.0 28.6 9.6 2,121 Ever had sex 96.7 52.9 62.5 27.8 9.4 960 Never had sex 91.8 45.8 56.1 29.2 9.7 1,161 Married/living together 96.5 59.2 63.1 24.7 11.5 1,344 Divorced/separated/widowed (94.5) (54.1) (54.4) (13.0) (4.8) 40 Residence Urban 95.6 58.3 68.0 28.9 12.7 2,210 Rural 93.9 43.9 47.7 23.6 6.2 1,295 Local Government Area Banjul 96.3 58.1 67.9 26.7 11.4 84 Kanifing 96.0 60.8 72.7 23.3 11.1 853 Brikama 95.2 56.6 63.9 31.5 13.1 1,429 Mansakonko 97.6 44.2 50.8 15.4 5.1 139 Kerewan 90.0 54.2 55.6 44.0 15.7 320 Kuntaur 94.9 57.9 67.8 21.9 3.1 138 Janjanbureh 94.1 33.0 40.5 20.2 2.0 220 Basse 95.5 28.7 30.8 10.9 1.1 321 Education No education 94.1 48.3 50.2 24.5 8.3 1,046 Primary 95.1 40.8 43.0 23.6 5.3 476 Secondary or higher 95.5 58.4 70.2 29.0 12.5 1,983 Wealth quintile Lowest 94.7 42.4 45.1 24.3 4.1 498 Second 94.6 46.4 51.3 24.8 8.5 589 Middle 95.9 48.9 55.4 22.5 8.1 571 Fourth 94.0 55.2 63.9 30.6 11.6 932 Highest 95.9 63.2 74.6 28.8 14.8 915 Total 15-49 95.0 53.0 60.5 26.9 10.3 3,505 50-59 98.3 60.7 74.1 27.2 18.3 243 Total 15-59 95.2 53.5 61.4 27.0 10.8 3,747 Note: Figures in parentheses are based on 25-49 unweighted cases. Men age 15-49 are also more likely than women of the same age range to say that they would buy fresh vegetables from a shopkeeper who has HIV (53 percent versus 47 percent) and to think that a female teacher with HIV should be allowed to continue teaching (61 percent versus 52 percent). Similar proportions of men and women report that they would not to want to keep secret a family member’s infection with HIV (27 percent and 28 percent, respectively). The proportion of women and men who express accepting attitudes toward people infected with HIV/AIDS on all four measures generally increases with age. By Local Government Area (LGA), accepting attitudes toward HIV-infected people on all measures are least common in Kuntaur, Janjanbureh, and Basse (1-3 percent). Education has no clear relationship with positive attitudes toward those who are HIV positive. However, the proportion of respondents who express accepting attitudes on all four measures is highest among those with a secondary education or higher. HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 175 Socioeconomic status is strongly related to accepting attitudes toward people infected with HIV, especially among men. For example, men in the highest wealth quintile are almost four times as likely as those in the lowest quintile to express accepting attitudes on all four measures (15 percent and 4 percent, respectively). 13.5 ATTITUDES TOWARDS NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent transmission is less useful if people feel powerless to negotiate safer sex with their partners. To assess attitudes toward safer sex, GDHS respondents were asked if they think a wife is justified in refusing to have sex with her husband and in asking that they use a condom if she knows he has an infection that can be transmitted through sexual intercourse. Table 13.6 shows that 52 percent of women and 61 percent of men in The Gambia believe that if a wife knows that her husband has sex with other women, she is justified in refusing to have sexual intercourse with him. Additionally, 84 percent of women and 89 percent of men believe that if a wife knows that her husband has a sexually transmitted infection, she is justified in asking him to use a condom. Table 13.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with other women, and percentage who believe that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI), by background characteristics, The Gambia 2013 Women Men Background characteristic Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of women Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of men Age 15-24 50.9 81.2 4,532 59.7 83.9 1,685 15-19 49.1 76.9 2,407 59.4 81.9 836 20-24 52.9 86.0 2,125 60.1 85.9 849 25-29 51.5 85.9 1,822 60.2 89.2 586 30-39 52.2 86.2 2,559 60.5 93.9 816 40-49 53.1 83.4 1,320 63.3 94.1 490 Marital status Never married 53.6 82.0 2,963 59.6 85.3 2,177 Ever had sex 60.4 87.7 359 61.6 91.3 966 Never had sex 52.6 81.2 2,604 58.0 80.6 1,211 Married/living together 50.5 83.8 6,791 61.5 93.1 1,360 Divorced/separated/widowed 54.7 89.5 478 (75.6) (99.3) 40 Residence Urban 54.3 88.2 5,730 62.0 90.9 2,228 Rural 48.1 77.6 4,503 57.9 84.4 1,349 Local Government Area Banjul 60.0 84.7 225 59.7 90.5 85 Kanifing 58.0 84.3 2,342 63.1 89.4 858 Brikama 54.2 88.8 3,550 58.4 89.2 1,454 Mansakonko 51.3 84.9 490 54.8 89.3 141 Kerewan 48.5 87.5 1,107 51.6 87.9 323 Kuntaur 35.3 58.0 526 76.9 95.0 141 Janjanbureh 43.9 59.3 739 64.4 78.4 240 Basse 45.2 88.0 1,254 64.1 87.2 336 Education No education 47.1 80.8 4,757 56.2 86.5 1,090 Primary 51.0 79.4 1,405 63.6 85.3 493 Secondary or higher 57.1 88.2 4,071 62.1 90.3 1,994 Wealth quintile Lowest 49.0 78.6 1,745 55.4 82.8 517 Second 50.0 79.8 1,882 58.9 85.8 614 Middle 48.9 80.7 1,927 66.0 87.8 588 Fourth 52.9 87.0 2,135 56.9 89.7 940 Highest 55.5 89.0 2,545 64.5 92.6 919 Total 15-49 51.6 83.5 10,233 60.5 88.5 3,577 50-59 na na 0 67.5 87.8 244 Total 15-59 na na 0 60.9 88.4 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 176 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Residents in rural areas have less favourable attitudes toward a wife negotiating safer sex with her husband. For example, 78 percent of women in rural areas have a favourable attitude toward safer sex, as compared with 88 percent of women in urban areas. Among men, the corresponding figures are 84 percent and 91 percent. Agreement with a wife’s ability to negotiate safer sex with her husband increases with increasing age, education, and wealth quintile. 13.6 ADULT SUPPORT FOR EDUCATION ABOUT CONDOM USE Condom use is one of the main strategies for combating the spread of HIV. However, educating youths about condoms is sometimes controversial, with some believing that it promotes early sexual experimentation. To assess attitudes toward condom education, GDHS respondents were asked if they thought that children age 12-14 should be taught about using condoms to avoid getting AIDS. Because the data focus on adult opinions, results are tabulated for respondents age 18-49. Table 13.7 shows that 31 percent of women and 37 percent of men agree that children age 12-14 should be taught about using condoms to avoid AIDS. Women and men in the oldest age group (40-49 years) are less likely than younger respondents to agree with teaching children age 12-14 about using condoms to avoid AIDS. Respondents who are married or living together with a partner are less likely to agree with condom education for youths than those who have never been married and those who are divorced, separated, or widowed. Support for educating children about condom use for protection against AIDS is stronger in urban areas than in rural areas. Among women, approval of educating children on condom use ranges from 18-19 percent in Kuntaur and Janjanbureh to 36 percent in Banjul and Kanifing. Among men, approval ranges from 27 percent in Kerewan to 64 percent in Kuntaur. In general, support for teaching children about using condoms to avoid AIDS increases with increasing education and wealth. Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 should be taught about using a condom to avoid AIDS, by background characteristics, The Gambia 2013 Women Men Background characteristic Percentage who agree Number of women Percentage who agree Number of men Age 18-24 31.2 3,209 38.0 1,236 18-19 30.1 1,084 31.1 386 20-24 31.7 2,125 41.2 849 25-29 32.3 1,822 37.1 586 30-39 31.0 2,559 38.6 816 40-49 26.5 1,320 30.1 490 Marital status Never married 35.6 1,872 39.1 1,727 Married/living together 28.9 6,563 33.5 1,360 Divorced/separated/widowed 36.1 475 (46.2) 40 Residence Urban 34.2 5,032 38.5 1,986 Rural 26.0 3,878 33.8 1,142 Local Government Area Banjul 35.8 199 37.0 76 Kanifing 35.8 2,070 38.0 783 Brikama 34.5 3,133 35.7 1,265 Mansakonko 32.5 417 33.9 113 Kerewan 25.1 959 26.7 275 Kuntaur 18.2 450 64.3 120 Janjanbureh 19.3 622 45.6 216 Basse 24.8 1,060 30.0 280 Education No education 24.5 4,436 31.5 1,015 Primary 33.4 1,083 32.5 366 Secondary or higher 37.9 3,392 40.7 1,746 Wealth quintile Lowest 24.5 1,503 32.9 437 Second 27.6 1,631 34.5 525 Middle 26.3 1,641 32.5 503 Fourth 32.3 1,883 38.1 833 Highest 38.8 2,252 41.4 829 Total 18-49 30.7 8,910 36.8 3,128 50-59 na 0 29.9 244 Total 18-59 na 0 36.3 3,371 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 177 13.7 HIGHER-RISK SEX Information on sexual behaviour is important in designing and monitoring intervention programmes to control the spread of HIV. The 2013 GDHS included questions on respondents’ sexual partners over the 12 months preceding the survey and during their lifetime. For male respondents, an additional question asked whether they had paid for sex during the 12 months preceding the interview. Information was collected from both women and men on use of condoms during their most recent sexual intercourse. These questions are sensitive, and it is recognised that some respondents may have been reluctant to provide information on recent sexual behaviours. 13.7.1 Multiple Sexual Partners Tables 13.8.1 and 13.8.2 show the proportion of women and men age 15-49 who had sexual intercourse with more than one partner in the preceding 12 months by background characteristics. Very few women had sex with two or more partners in the past 12 months. The average number of lifetime sexual partners among women is 1.2. There is little variation in these figures across subgroups of women. Table 13.8.1 Multiple sexual partners: Women Among all women age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months and the mean number of sexual partners during their lifetime for women who ever had sexual intercourse, by background characteristics, The Gambia 2013 All women Among women who ever had sexual intercourse1: Background characteristic Percentage who had 2+ partners in the past 12 months Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 0.1 4,532 1.1 2,026 15-19 0.1 2,407 1.1 594 20-24 0.1 2,125 1.1 1,432 25-29 0.3 1,822 1.2 1,643 30-39 0.3 2,559 1.3 2,496 40-49 0.6 1,320 1.4 1,309 Marital status Never married 0.2 2,963 1.6 355 Married/living together 0.2 6,791 1.2 6,652 Divorced/separated/widowed 1.4 478 1.6 467 Residence Urban 0.4 5,730 1.3 3,888 Rural 0.1 4,503 1.2 3,587 Local Government Area Banjul 0.4 225 1.4 147 Kanifing 0.6 2,342 1.3 1,525 Brikama 0.2 3,550 1.3 2,550 Mansakonko 0.2 490 1.2 372 Kerewan 0.0 1,107 1.2 840 Kuntaur 0.0 526 1.1 434 Janjanbureh 0.0 739 1.2 575 Basse 0.1 1,254 1.1 1,032 Education No education 0.2 4,757 1.2 4,338 Primary 0.3 1,405 1.3 1,002 Secondary or higher 0.3 4,071 1.3 2,135 Wealth quintile Lowest 0.1 1,745 1.2 1,400 Second 0.0 1,882 1.2 1,478 Middle 0.2 1,927 1.3 1,494 Fourth 0.4 2,135 1.3 1,522 Highest 0.4 2,545 1.3 1,581 Total 15-49 0.2 10,233 1.2 7,475 1 Means are calculated excluding respondents who gave non-numeric responses. 178 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.8.2 shows that 8 percent of men age 15-49 had two or more sexual partners in the past 12 months. The proportion of men with multiple sexual partners varies widely by background characteristics. Men age 40-49, ever-married men, and those with no education are more likely than other men to have multiple sexual partners. As expected, men in polygynous unions are most likely to have multiple partners (82 percent). Across LGAs, men in Brikama (6 percent) are least likely to have two or more partners, and men in Basse and Kuntaur are most likely to have multiple partners (13-14 percent). Table 13.8.2 Multiple sexual partners: Men Among all men age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for men who ever had sexual intercourse, by background characteristics, The Gambia 2013 All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Background characteristic Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 2.4 1,685 (51.1) 40 2.8 640 15-19 1.4 836 * 12 2.2 190 20-24 3.3 849 56.8) 28 3.1 450 25-29 4.7 586 40.3) 27 2.7 442 30-39 11.3 816 23.9 92 2.9 759 40-49 27.5 490 1.4 135 3.1 468 Marital status Never married 3.1 2,177 59.2 68 3.1 957 Married/living together 16.1 1,360 5.4 219 2.7 1,314 Divorced/separated/widowed (18.8) 40 * 8 (3.8) 38 Type of union In polygynous union 82.0 240 1.5 197 3.2 235 In non-polygynous union 1.9 1,120 * 21 2.6 1,079 Not currently in union 3.4 2,217 57.6 76 3.1 995 Residence Urban 6.6 2,228 29.2 147 3.2 1,437 Rural 10.9 1,349 8.4 147 2.4 873 Local Government Area Banjul 9.1 85 (48.2) 8 3.7 59 Kanifing 7.9 858 (35.9) 68 3.5 566 Brikama 5.7 1,454 17.0) 82 2.9 920 Mansakonko 10.1 141 (14.5) 14 2.5 92 Kerewan 10.6 323 (10.8) 34 2.6 206 Kuntaur 13.1 141 (3.9) 19 1.7 85 Janjanbureh 9.5 240 (21.2) 23 3.0 171 Basse 13.8 336 (4.0) 46 1.9 210 Education No education 13.7 1,090 4.8 149 2.3 817 Primary 5.8 493 (21.0) 28 3.1 267 Secondary or higher 5.9 1,994 36.0 117 3.2 1,225 Wealth quintile Lowest 9.3 517 10.4 48 2.4 332 Second 11.3 614 21.4 69 2.6 402 Middle 6.9 588 11.5 41 2.4 369 Fourth 6.7 940 5.8 63 2.9 612 Highest 8.0 919 37.2 73 3.6 595 Total 15-49 8.2 3,577 18.8 294 2.9 2,310 50-59 25.3 244 2.0 62 2.7 230 Total 15-59 9.3 3,821 15.9 356 2.9 2,540 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses. HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 179 The average number of lifetime sexual partners among men is 2.9. Unlike the proportion of men who have multiple partners, lifetime average number of partners varies little across subgroups of men. Interestingly, men who are most likely to have multiple partners do not necessarily have the largest number of sexual partners. 13.7.2 Point Prevalence UNAIDS defines concurrent sexual partnerships as “overlapping sexual partnerships where intercourse with one partner occurs between two acts of intercourse with another partner” (UNAIDS, 2009). Moreover, according to UNAIDS, concurrent sexual partnerships (as compared with serial monogamous partnerships) can increase the spread of HIV by reducing the time between which HIV is acquired and passed along to an uninfected individual, as well as by creating more connected sexual networks. The 2013 GDHS collected information on the time since the first and most recent sexual intercourse with each sexual partner in the past 12 months. This information is used to determine if sexual intercourse with one partner occurred between two acts of intercourse with another partner (i.e., whether two partnerships are concurrent). Two indicators are used to measure concurrent sexual partnerships. The point prevalence of concurrent sexual partnerships is defined as the proportion of women and men age 15-49 with more than one ongoing sexual partnership at the point in time six months before the survey. The cumulative prevalence of concurrent sexual partnerships is defined as the proportion of women and men age 15-49 who had any overlapping sexual partnerships in the 12 months preceding the survey (UNAIDS, 2009). A partnership that consists of a single sexual encounter is considered overlapping if it occurs during another ongoing partnership. The point prevalence is generally lower than the cumulative prevalence because the point prevalence includes only relationships ongoing on a particular day rather than over an entire year. In the case of male respondents, overlapping polygynous unions are considered concurrent partnerships in both the point prevalence and cumulative prevalence concurrency indicators. Data for women are not presented because very few women had concurrent sexual partners. Table 13.9 shows that among men age 15-49, 6 percent had concurrent sexual partnerships according to the point prevalence indicator and 7 percent had concurrent sexual partnerships according to the cumulative prevalence indicator. Point prevalence is substantially higher among men age 40-49 (21 percent), men who are married or living together with a partner (12 percent), and men in polygynous unions (65 percent) than among other men. Differences across subgroups of men according to the cumulative prevalence indicator are the same as those observed for point prevalence. 180 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners Percentage of all men age 15-49 who had concurrent sexual partners six months before the survey (point prevalence1), percentage of all men age 15-49 who had any concurrent sexual partners during the 12 months before the survey (cumulative prevalence2), and among men age 15-49 who had multiple sexual partners during the 12 months before the survey, percentage who had concurrent sexual partners, by background characteristics, The Gambia 2013 Among all men: Among all men who had multiple partners during the 12 months before the survey: Background characteristic Point prevalence of concurrent sexual partners1 Cumulative prevalence of concurrent sexual partners2 Number of men Percentage who had concurrent sexual partners2 Number of men Age 15-24 0.8 1.3 1,685 (53.2) 40 15-19 0.5 0.8 836 * 12 20-24 1.1 1.7 849 (52.7) 28 25-29 1.9 3.7 586 (79.4) 27 30-39 8.4 10.3 816 91.0 92 40-49 21.0 26.9 490 97.8 135 Marital status Never married 1.3 2.0 2,177 64.4 68 Married/living together 12.2 15.3 1,360 94.9 219 Divorced/separated/widowed (7.5) (18.4) 40 * 8 Type of union In polygynous union 65.0 80.1 240 97.7 197 In non-polygynous union 0.9 1.3 1,120 * 21 Not currently in union 1.4 2.3 2,217 67.7 76 Residence Urban 4.0 5.5 2,228 83.1 147 Rural 7.9 10.1 1,349 92.7 147 Total 15-49 5.5 7.2 3,577 87.9 294 50-59 22.5 25.2 244 99.6 62 Total 15-59 6.6 8.4 3,821 89.9 356 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Two sexual partners are considered to be concurrent if the date of the most recent sexual intercourse with the earlier partner is after the date of the first sexual intercourse with the later partner. 1 The percentage of men who had 2 (or more) sexual partners that were concurrent at the point in time 6 months before the survey 2 The percentage of men who had 2 (or more) sexual partners that were concurrent at any time during the 12 months preceding the survey HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 181 13.7.3 Payment for Sex Transactional sex is the exchange of money, favours, or gifts for sexual intercourse. This type of sexual intercourse is associated with a greater risk of contracting HIV and other STIs because of compromised power relations and the likelihood of multiple partners. Male respondents in the 2013 GDHS were asked if they had ever paid anyone in exchange for sex. Men who had sexual intercourse in the 12 months preceding the survey were asked if they had paid anyone for sexual intercourse during that time. Furthermore, men who had engaged in paid sexual intercourse in the past 12 months were asked if they had used a condom the last time they paid for sex. The results are shown in Table 13.10. Overall, 2 percent of men age 15-49 reported that they had paid someone in exchange for sex. By LGA, 5 percent of men in Banjul have paid for sex, as compared with less than 1 percent of men in Basse, Mansakonko, and Brikama. Less than 1 percent of men reported paying for sex at least once in the 12 months before the survey. 13.8 COVERAGE OF HIV TESTING AND COUNSELLING Knowledge of HIV status enables HIV- negative individuals to make specific decisions that can reduce their risk of contracting HIV. For those who are HIV positive, knowledge of their HIV status allows them to take actions to protect their sexual partners, to access treatment, and to plan for the future. To assess awareness and coverage of HIV testing services, GDHS respondents were asked whether they had ever been tested for HIV. Respondents who had had an HIV test were asked how long ago their most recent test occurred, whether they had received the results of their most recent test, and where they had been tested. Respondents who had never been tested were asked if they know a place they can go to get tested. Tables 13.11.1 and 13.11.2 present the results for women and men, respectively. Among respondents age 15-49, 69 percent of women and 76 percent of men know a place where people can go to get tested for HIV. Young women and men age 15-19 and those who have never had sex are least likely to know of a place to get an HIV test. Knowledge of a place for HIV testing is higher among women and men in urban areas than among those in rural areas. Women in Kuntaur (57 percent) and men in Mansakonko (59 percent) are least likely to know a place for HIV testing. Knowledge of a place to obtain an HIV test is most prevalent among respondents with a secondary education or higher and those in the highest wealth quintile. Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse Percentage of men age 15-49 who ever paid for sexual intercourse and percentage reporting payment for sexual intercourse in the past 12 months, by background characteristics, The Gambia 2013 Background characteristic Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Age 15-24 0.7 0.5 1,685 15-19 0.4 0.3 836 20-24 1.0 0.6 849 25-29 2.4 1.6 586 30-39 1.9 0.9 816 40-49 2.8 0.3 490 Marital status Never married 1.1 0.8 2,177 Married/living together 2.2 0.5 1,360 Divorced/separated/ widowed (5.1) (4.6) 40 Residence Urban 1.6 0.6 2,228 Rural 1.6 0.8 1,349 Local Government Area Banjul 5.4 2.1 85 Kanifing 2.6 1.4 858 Brikama 0.8 0.2 1,454 Mansakonko 0.6 0.2 141 Kerewan 1.9 0.4 323 Kuntaur 1.8 0.5 141 Janjanbureh 2.7 1.8 240 Basse 0.4 0.4 336 Education No education 2.1 0.7 1,090 Primary 2.2 1.5 493 Secondary or higher 1.2 0.5 1,994 Wealth quintile Lowest 1.2 0.8 517 Second 1.8 0.8 614 Middle 0.9 0.4 588 Fourth 2.0 0.8 940 Highest 1.6 0.8 919 Total 15-49 1.6 0.7 3,577 50-59 3.6 0.8 244 Total 15-59 1.7 0.7 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. 182 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Overall, women are more likely than men to have been tested for HIV. However, despite the high level of knowledge of sources for HIV testing, only 39 percent of women and 19 percent of men have ever been tested. The majority of those who had been tested reported that they had received their results. Younger women and men age 15-19 are least likely to have ever been tested (11 percent and 4 percent, respectively). HIV testing is more common among urban residents. Across LGAs, women in Kerewan and men in Kanifing are most likely to have been tested for HIV and to have received the results (43 percent and 29 percent, respectively). On the other hand, women and men in Kuntaur are least likely to have been tested for HIV (24 percent and 5 percent, respectively). Coverage of HIV testing does not have a linear relationship with education or wealth. Tables 13.11.1 and 13.11.2 also show coverage with respect to recent HIV testing. Fourteen percent of women and 7 percent of men age 15-49 were tested for HIV and received their results in the 12 months before the survey. Recent testing is higher among urban residents. Table 13.11.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, The Gambia 2013 Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Background characteristic Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 58.9 23.9 3.5 72.6 100.0 27.4 10.1 4,532 15-19 48.8 11.4 1.7 86.9 100.0 13.1 5.9 2,407 20-24 70.3 38.1 5.5 56.4 100.0 43.6 14.8 2,125 25-29 78.4 54.1 4.0 41.9 100.0 58.1 20.8 1,822 30-39 78.2 54.7 5.1 40.2 100.0 59.8 16.5 2,559 40-49 69.0 37.9 3.9 58.2 100.0 41.8 12.0 1,320 Marital status Never married 51.8 10.4 1.3 88.2 100.0 11.8 3.8 2,963 Ever had sex 69.0 36.6 2.6 60.8 100.0 39.2 16.2 359 Never had sex 49.4 6.8 1.1 92.0 100.0 8.0 2.0 2,604 Married/living together 75.2 51.0 5.4 43.7 100.0 56.3 18.5 6,791 Divorced/separated/widowed 76.6 41.8 2.3 55.9 100.0 44.1 10.1 478 Residence Urban 70.7 39.6 3.5 56.9 100.0 43.1 14.5 5,730 Rural 65.7 37.7 4.8 57.5 100.0 42.5 13.0 4,503 Local Government Area Banjul 74.8 38.3 3.0 58.7 100.0 41.3 17.2 225 Kanifing 69.4 36.7 3.1 60.2 100.0 39.8 14.6 2,342 Brikama 73.2 42.8 3.6 53.6 100.0 46.4 15.5 3,550 Mansakonko 68.8 31.1 3.4 65.4 100.0 34.6 9.5 490 Kerewan 65.6 43.4 3.7 53.0 100.0 47.0 14.0 1,107 Kuntaur 56.5 23.5 6.8 69.7 100.0 30.3 8.2 526 Janjanbureh 59.1 35.6 11.6 52.8 100.0 47.2 13.4 739 Basse 65.4 38.8 2.2 59.0 100.0 41.0 11.6 1,254 Education No education 67.3 42.7 5.0 52.3 100.0 47.7 14.2 4,757 Primary 66.1 39.2 4.2 56.7 100.0 43.3 15.7 1,405 Secondary or higher 70.7 34.1 2.9 63.0 100.0 37.0 12.8 4,071 Wealth quintile Lowest 65.2 37.4 5.7 56.9 100.0 43.1 13.9 1,745 Second 66.4 38.4 4.4 57.3 100.0 42.7 13.9 1,882 Middle 65.5 39.0 3.8 57.2 100.0 42.8 12.8 1,927 Fourth 69.6 40.9 3.4 55.7 100.0 44.3 14.8 2,135 Highest 73.5 38.2 3.4 58.4 100.0 41.6 13.8 2,545 Total 15-49 68.5 38.8 4.0 57.2 100.0 42.8 13.9 10,233 1 Includes “don’t know/missing” HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 183 Table 13.11.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, The Gambia 2013 Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Background characteristic Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 67.8 8.8 1.3 89.8 100.0 10.2 3.8 1,685 15-19 62.0 4.0 1.4 94.6 100.0 5.4 1.9 836 20-24 73.6 13.6 1.3 85.1 100.0 14.9 5.6 849 25-29 81.5 25.0 2.3 72.7 100.0 27.3 9.0 586 30-39 86.7 29.4 1.3 69.4 100.0 30.6 11.0 816 40-49 81.5 27.9 2.8 69.4 100.0 30.6 10.3 490 Marital status Never married 71.8 13.4 1.4 85.2 100.0 14.8 5.0 2,177 Ever had sex 77.8 21.3 1.6 77.1 100.0 22.9 8.1 966 Never had sex 67.1 7.1 1.2 91.7 100.0 8.3 2.5 1,211 Married/living together 82.8 27.2 1.9 70.9 100.0 29.1 10.9 1,360 Divorced/separated/widowed (92.4) (26.5) (7.9) (65.6) 100.0 (34.4) (1.2) 40 Residence Urban 80.7 22.1 1.8 76.0 100.0 24.0 8.4 2,228 Rural 68.8 13.3 1.4 85.3 100.0 14.7 5.1 1,349 Local Government Area Banjul 77.0 25.9 3.6 70.5 100.0 29.5 10.2 85 Kanifing 79.7 28.9 0.8 70.4 100.0 29.6 11.9 858 Brikama 78.2 17.5 2.1 80.4 100.0 19.6 6.0 1,454 Mansakonko 59.0 16.3 1.1 82.6 100.0 17.4 4.2 141 Kerewan 87.1 14.2 2.3 83.5 100.0 16.5 6.1 323 Kuntaur 78.0 5.2 0.4 94.5 100.0 5.5 2.7 141 Janjanbureh 61.8 14.6 2.7 82.6 100.0 17.4 5.7 240 Basse 64.8 11.1 1.1 87.8 100.0 12.2 4.8 336 Education No education 70.4 14.8 1.5 83.7 100.0 16.3 4.8 1,090 Primary 65.8 12.5 2.6 85.0 100.0 15.0 5.5 493 Secondary or higher 82.0 22.5 1.5 75.9 100.0 24.1 8.9 1,994 Wealth quintile Lowest 65.0 13.6 1.3 85.1 100.0 14.9 5.4 517 Second 69.6 12.0 1.6 86.5 100.0 13.5 4.2 614 Middle 75.7 17.4 1.5 81.1 100.0 18.9 7.6 588 Fourth 78.0 19.0 1.7 79.4 100.0 20.6 7.3 940 Highest 85.5 27.0 2.1 71.0 100.0 29.0 9.8 919 Total 15-49 76.2 18.8 1.7 79.5 100.0 20.5 7.2 3,577 50-59 82.7 26.2 3.0 70.9 100.0 29.1 9.3 244 Total 15-59 76.7 19.3 1.8 79.0 100.0 21.0 7.3 3,821 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes “don’t know/missing” 13.9 HIV TESTING DURING ANTENATAL CARE Screening is an important tool in reducing mother-to-child transmission of HIV. Table 13.12 presents information on HIV screening of pregnant women age 15-49 who gave birth in the two years preceding the survey. Sixty-five percent of women who gave birth in the two years before the survey received HIV counselling during antenatal care (ANC). More than half of women who were tested for HIV during an antenatal care visit (52 percent) received the test results and post-test counselling, while 10 percent received the results but did not receive post-test counselling. Five percent of women were tested for HIV during an ANC visit but did not receive the results. Overall, 54 percent of women received HIV counselling, an HIV test, and the test results during ANC for their most recent birth in the two years preceding the survey. Women age 25-39 (56–57 percent) were most likely to have been counselled and tested and to have received their HIV test result during ANC. Women were more likely to have been counselled and tested and to have received the test result if they 184 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour were married or living together with a partner (54 percent), lived in an urban area (60 percent), and lived in Brikama or Kerewan (63-64 percent). The proportion of women who were counselled and tested and received the results is highest among those with a primary education (59 percent), those with a secondary education or higher (58 percent), and those in the highest two wealth quintiles (59-60 percent). Table 13.12 Pregnant women counselled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received HIV pretest counselling, the percentage who received an HIV test during antenatal care (ANC) for their most recent birth by whether they received their results and post-test counselling, and the percentage who received an HIV test at the time of ANC or labour for their most recent birth by whether they received their test results, according to background characteristics, The Gambia 2013 Percentage who received counselling on HIV during antenatal care1 Percentage who were tested for HIV during antenatal care and who: Percentage who received counselling on HIV and an HIV test during ANC, and the results Percentage who had an HIV test during ANC or labour and who:2 Number of women who gave birth in the past two years3 Background characteristic Received results and: Did not receive results Received post-test counselling Did not receive post-test counselling Received results Did not receive results Age 15-24 61.0 48.1 10.2 6.2 49.7 58.5 6.3 1,106 15-19 56.4 45.6 7.2 7.9 45.3 52.9 7.9 280 20-24 62.6 48.9 11.2 5.6 51.2 60.4 5.8 826 25-29 66.0 55.5 9.2 4.0 57.1 64.7 4.1 924 30-39 67.2 53.3 10.5 5.3 55.7 64.2 5.3 1,132 40-49 64.8 56.1 7.8 4.6 52.1 63.9 4.6 230 Marital status Never married 56.8 41.8 12.1 5.5 44.7 54.1 5.5 118 Married/living together 65.0 52.9 9.8 5.3 54.4 62.9 5.3 3,201 Divorced/separated/widowed 66.2 45.8 8.5 1.7 46.4 60.0 1.7 73 Residence Urban 71.1 59.0 9.4 4.2 60.4 68.8 4.2 1,565 Rural 59.3 46.8 10.2 6.0 48.3 57.1 6.1 1,828 Local Government Area Banjul 52.4 55.5 11.7 3.7 47.1 68.0 3.7 51 Kanifing 64.5 52.5 14.9 4.3 54.0 68.7 4.3 517 Brikama 75.4 63.6 6.6 3.2 64.4 70.2 3.3 1,171 Mansakonko 54.8 26.1 18.1 5.8 34.4 44.7 5.8 169 Kerewan 69.8 48.0 22.7 3.7 62.9 70.6 3.8 419 Kuntaur 45.1 27.7 6.4 8.0 30.5 34.3 8.3 227 Janjanbureh 67.7 43.8 6.7 19.0 44.4 50.5 19.0 298 Basse 48.5 54.4 2.4 2.6 45.7 56.9 2.6 541 Education No education 61.1 49.4 9.5 5.8 50.5 59.0 5.8 1,951 Primary 68.3 57.0 10.6 4.9 59.3 67.7 5.0 502 Secondary or higher 70.3 56.2 10.1 4.1 58.0 67.0 4.2 940 Wealth quintile Lowest 63.7 46.9 9.3 7.1 50.5 56.4 7.1 703 Second 58.5 45.7 13.6 5.3 48.3 59.8 5.6 757 Middle 64.1 52.0 8.8 5.3 53.2 60.8 5.3 702 Fourth 67.5 59.0 8.3 4.9 59.7 67.3 4.9 681 Highest 71.9 61.1 8.6 2.7 59.4 70.2 2.7 549 Total 15-49 64.7 52.4 9.8 5.2 53.9 62.5 5.3 3,392 1 In this context, “pretest counselling” means that someone talked with the respondent about all 3 of the following topics: (1) babies getting the AIDS virus from their mother, (2) preventing the virus, and (3) getting tested for the virus. 2 Women were asked whether they received an HIV test during labour only if they were not tested for HIV during ANC. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past 2 years. Sixty-three percent of women who gave birth in the two years before the survey were tested for HIV during ANC or labour. Only 5 percent did not receive the results. Differentials by background characteristics are similar to those observed for HIV counselling, testing, and receipt of results during ANC. HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 185 13.10 SELF-REPORTED SEXUALLY TRANSMITTED INFECTIONS In the 2013 GDHS, respondents who had ever had sexual intercourse were asked if in the past 12 months they experienced an infection acquired through sexual contact or if they experienced either of two symptoms associated with STIs: a bad-smelling, abnormal discharge from the vagina or penis or a genital sore or ulcer. Table 13.13 shows the self-reported prevalence of STIs and STI symptoms among women and men. The self-reported prevalence of STIs and STI symptoms is higher among women than among men. Overall, 8 percent of women and 3 percent of men reported having had an STI or experiencing STI symptoms during the 12 months preceding the survey. Two percent of women and 1 percent of men reported having an STI, 4 percent of women and 2 percent of men had a bad-smelling or abnormal genital discharge, and 4 percent of women and 1 percent of men reported having had a genital sore or ulcer in the 12 months before the survey. Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, The Gambia 2013 Women Men Percentage of women who reported having in the past 12 months: Percentage of men who reported having in the past 12 months: Background characteristic STI Bad- smelling/ abnormal genital discharge Genital sore/ ulcer STI/genital discharge/ sore or ulcer Number of women who ever had sexual intercourse STI Bad- smelling/ abnormal discharge from penis Genital sore/ ulcer STI/ abnormal discharge from penis/ sore or ulcer Number of men who ever had sexual intercourse Age 15-24 1.8 4.5 4.7 7.8 2,032 1.0 1.6 2.4 4.2 644 15-19 1.0 4.5 3.3 6.4 596 1.3 0.6 3.9 4.7 190 20-24 2.1 4.5 5.3 8.4 1,437 0.9 2.0 1.7 4.0 453 25-29 2.7 4.7 5.3 9.2 1,653 1.7 1.8 1.4 4.1 449 30-39 2.2 3.6 4.1 7.6 2,508 0.6 1.3 0.4 1.9 776 40-49 1.4 2.4 3.1 5.6 1,318 2.4 1.9 0.8 3.1 480 Marital status Never married 4.5 9.6 4.9 12.0 359 1.2 1.5 2.1 3.9 966 Married/living together 1.9 3.4 4.3 7.3 6,680 1.4 1.7 0.5 2.7 1,343 Divorced/separated/widowed 2.1 6.2 5.7 9.8 472 (0.0) (0.4) (2.4) (2.8) 40 Residence Urban 2.4 4.2 4.9 8.3 3,907 1.3 1.4 0.9 2.7 1,466 Rural 1.7 3.5 3.8 6.9 3,605 1.3 2.0 1.6 4.0 883 Local Government Area Banjul 2.0 5.2 4.7 9.3 148 1.1 3.9 0.5 4.8 62 Kanifing 3.1 6.4 6.4 10.7 1,528 1.4 1.0 1.4 2.8 579 Brikama 2.0 3.5 4.3 7.4 2,568 1.4 1.7 1.4 3.7 936 Mansakonko 2.2 2.8 2.0 4.9 375 3.4 1.8 1.9 4.4 94 Kerewan 1.4 1.1 5.2 7.1 844 1.3 3.6 0.9 4.2 207 Kuntaur 1.3 3.0 3.2 6.3 435 0.9 1.6 0.6 2.3 85 Janjanbureh 3.8 2.6 2.2 5.1 577 0.8 1.6 0.7 2.6 175 Basse 0.5 4.7 3.5 6.8 1,036 0.4 0.2 0.3 1.0 211 Education No education 1.4 2.7 3.7 6.3 4,355 0.9 1.1 0.5 1.8 828 Primary 1.5 3.7 4.4 7.4 1,005 1.0 1.6 1.2 3.1 275 Secondary or higher 3.6 6.2 5.7 10.6 2,152 1.6 1.9 1.6 4.2 1,246 Wealth quintile Lowest 1.6 3.0 3.8 6.3 1,404 1.6 2.0 1.8 4.0 339 Second 1.8 3.7 4.0 7.5 1,485 1.3 1.6 0.9 3.3 405 Middle 1.8 3.7 3.4 6.4 1,497 0.4 1.3 1.0 2.2 375 Fourth 1.7 3.6 5.1 7.6 1,529 1.3 1.0 1.5 3.1 620 Highest 3.3 5.2 5.5 10.2 1,596 1.7 2.2 0.8 3.5 611 Total 15-49 2.1 3.9 4.4 7.7 7,512 1.3 1.6 1.2 3.2 2,349 50-59 na na na na 0 0.3 0.0 0.3 0.6 243 Total 15-59 na na na na 0 1.2 1.5 1.1 3.0 2,591 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 186 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour Women who have never been married have a higher prevalence of STIs and STI symptoms (12 percent) than those currently or previously married (7-10 percent). By LGA, the highest prevalence of STIs and STI symptoms is reported among women in Kanifing (11 percent) and the lowest among those in Mansakonko and Janjanbureh (5 percent each). The prevalence of STIs and STI symptoms among women increases with increasing education and wealth. Sixty-five percent of women and 42 percent of men sought advice or treatment from a clinic, hospital, private doctor, or other health professional for an STI or STI symptoms in the past 12 months. Twenty-seven percent of women and 26 percent of men did not seek any treatment or advice (Figure 13.1). Figure 13.1 Women and men seeking treatment for STIs 13.11 PREVALENCE OF MEDICAL INJECTIONS Use of nonsterile injections in a health care setting can contribute to the transmission of blood- borne pathogens. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2013 GDHS were asked whether they had received an injection in the past 12 months; if so, they were asked how many injections they had received and whether their last injection was given with a syringe from a newly opened package. Table 13.14 shows the reported prevalence of injections. Thirty-two percent of women and men reported receiving a medical injection from a health worker during the 12-month period preceding the survey. Generally, women and men received an average of one medical injection during that period. The vast majority of women (97 percent) and men (98 percent) reported that the last injection was given with a syringe from a newly opened package. 65 6 5 27 42 9 11 26 Clinic/hospital/private doctor/other health professional Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment Percentage Women Men GDHS 2013 HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 187 Table 13.14 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the last 12 months, the average number of medical injections per person in the last 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, The Gambia 2013 Women Men Background characteristic Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respon- dents For last injection, syringe and needle taken from a new, unopened package Number of respon- dents receiving medical injections in the last 12 months Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respon- dents For last injection, syringe and needle taken from a new, unopened package Number of respon- dents receiving medical injections in the last 12 months Age 15-24 28.1 0.7 4,532 96.9 1,271 30.6 0.9 1,685 97.8 515 15-19 22.6 0.5 2,407 96.1 544 30.9 0.9 836 97.4 259 20-24 34.2 0.8 2,125 97.5 727 30.2 0.9 849 98.3 256 25-29 37.0 0.9 1,822 97.2 674 31.6 0.9 586 98.4 185 30-39 36.1 0.8 2,559 97.1 924 33.5 1.0 816 98.4 273 40-49 27.6 0.9 1,320 94.7 365 32.5 1.0 490 98.0 159 Marital status Never married 20.7 0.6 2,963 96.8 613 31.2 0.9 2,177 97.9 679 Ever had sex 32.6 0.8 359 95.2 117 33.8 1.1 966 97.6 327 Never had sex 19.1 0.5 2,604 97.2 496 29.1 0.8 1,211 98.2 352 Married/living together 36.7 0.9 6,791 96.7 2,496 32.0 0.9 1,360 98.3 435 Divorced/separated/ widowed 26.0 0.7 478 97.4 125 (45.5) (1.5) 40 * 18 Residence Urban 30.0 0.8 5,730 97.4 1,718 32.4 1.0 2,228 99.1 722 Rural 33.6 0.8 4,503 96.0 1,515 30.4 0.8 1,349 96.2 411 Local Government Area Banjul 26.1 0.8 225 99.0 59 33.0 1.0 85 98.8 28 Kanifing 30.1 0.9 2,342 97.2 706 29.3 0.9 858 98.6 251 Brikama 31.9 0.8 3,550 97.0 1,132 35.3 1.1 1,454 99.0 513 Mansakonko 34.0 0.8 490 96.6 167 26.8 0.7 141 95.9 38 Kerewan 26.7 0.5 1,107 98.0 295 21.4 0.6 323 99.4 69 Kuntaur 32.3 0.7 526 96.5 170 22.4 0.5 141 93.6 32 Janjanbureh 28.8 0.7 739 92.7 212 28.1 0.7 240 93.8 68 Basse 39.3 0.9 1,254 96.6 493 39.9 1.0 336 96.7 134 Education No education 33.0 0.7 4,757 96.1 1,570 31.7 0.9 1,090 97.2 345 Primary 35.5 0.8 1,405 96.5 499 31.6 0.9 493 96.2 156 Secondary or higher 28.6 0.8 4,071 97.8 1,165 31.7 1.0 1,994 99.0 631 Wealth quintile Lowest 32.8 0.7 1,745 96.8 573 27.8 0.7 517 97.0 144 Second 33.0 0.8 1,882 95.7 621 28.8 0.8 614 98.2 177 Middle 33.7 0.8 1,927 95.7 650 32.5 0.9 588 96.1 191 Fourth 31.0 0.7 2,135 97.7 661 32.3 1.0 940 98.9 303 Highest 28.6 0.9 2,545 97.7 729 34.5 1.2 919 98.9 317 Total 15-49 31.6 0.8 10,233 96.8 3,234 31.7 0.9 3,577 98.1 1,132 50-59 na na 0 na 0 29.4 1.1 244 98.8 72 Total 15-59 na na 0 na 0 31.5 1.0 3,821 98.1 1,204 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 13.12 HIV- AND AIDS-RELATED KNOWLEDGE AND BEHAVIOUR AMONG YOUTH This section addresses HIV/AIDS-related knowledge and sexual behaviour among youth age 15- 24. In addition to knowledge of HIV transmission, data are presented on age at first sex, condom use, and age differences between sexual partners. Younger people are often at a higher risk of contracting STIs, as they are more likely to experiment with sex before marriage. Therefore, condom use among young adults plays an important role in preventing the transmission of HIV and other sexually transmitted infections, as well as in the 188 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour prevention of unwanted pregnancies. Likewise, knowledge of where to get condoms is an important prerequisite to their use. 13.12.1 Knowledge about HIV and AIDS and of Sources for Condoms Knowledge of how HIV is transmitted is crucial for people to avoid contracting HIV. Young people are often at greater risk because they have short relationships with more partners or engage in other risky behaviours. Table 13.15 shows the level of comprehensive knowledge of HIV and AIDS among youth and the percentage of youth who know of a source where they can obtain condoms. As noted earlier, comprehensive knowledge of HIV and AIDS is defined as knowing that condom use and having just one HIV-negative faithful partner can reduce the chances of contracting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common misconceptions about HIV transmission in The Gambia (that HIV can be transmitted by mosquito bites and by sharing food with someone who has AIDS). Table 13.15 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, The Gambia 2013 Women age 15-24 Men age 15-24 Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source1 Number of women Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of men Age 15-19 21.9 20.9 2,407 26.5 57.9 836 15-17 19.2 16.8 1,323 21.5 49.0 450 18-19 25.1 26.0 1,084 32.4 68.3 386 20-24 30.4 36.4 2,125 38.0 78.5 849 20-22 27.4 33.3 1,337 36.6 78.1 556 23-24 35.4 41.7 788 40.6 79.5 293 Marital status Never married 27.5 27.9 2,646 32.4 68.8 1,624 Ever had sex 30.2 51.1 245 35.0 83.3 588 Never had sex 27.3 25.5 2,401 30.8 60.6 1,036 Ever married 23.5 28.6 1,886 30.5 55.1 62 Residence Urban 32.1 35.3 2,580 38.8 77.0 1,046 Rural 17.6 18.7 1,952 21.6 54.1 639 Education No education 14.7 15.4 1,265 22.4 55.3 331 Primary 18.5 20.9 753 17.8 54.4 288 Secondary or higher 33.6 36.8 2,514 39.3 76.1 1,067 Total 25.8 28.2 4,532 32.3 68.3 1,685 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the 2 most common local misconceptions about AIDS transmission or prevention of the AIDS virus. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 2 For this table, the following responses are not considered a source for condoms: friends, family members, and home. The table shows that about one-quarter (26 percent) of young women and one-third (32 percent) of young men age 15-24 have comprehensive knowledge of AIDS. Knowledge of HIV and AIDS increases with age and is notably higher among urban residents (32 percent of young women and 39 percent of young men) than rural residents (18 percent and 22 percent, respectively). The proportion of youth with comprehensive knowledge is highest among those with a secondary education or higher (34 percent of young women and 39 percent of young men). Because of the important role that condoms play in combating the transmission of HIV, respondents were asked whether they know of a source of condoms. Only responses about formal sources were considered (i.e., sources other than friends or family members). As shown in Table 13.15, young men are more than twice as likely as young women to know where to obtain a condom (68 percent versus 28 HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 189 percent). Knowledge of a condom source increases with age. Knowledge is highest among young women and men who have never been married but have had sex (51 percent and 83 percent, respectively), those living in urban areas (35 percent and 77 percent, respectively), and those with a secondary education or higher (37 percent and 76 percent, respectively). 13.12.2 Age at First Sexual Intercourse among Youth Age at first sex is an important indicator of both exposure to the risk of pregnancy and exposure to STIs. Young people who initiate sex at an early age are considered to be at a higher risk of becoming pregnant or contracting an STI than young people who delay initiation of sexual activity. Consistent use of condoms can reduce such risks. Table 13.16 shows the proportion of young women and men age 15-24 who had sex before age 15 and before age 18. Eight percent of young women and 5 percent of young men had sex by age 15, and 32 percent of young women and 24 percent of young men had sex by age 18. Among young women, the proportion initiating sexual activity early is negligible among those who have not been married and higher among those who have been married. For example, 56 percent of ever-married young women had initiated sexual intercourse by age 18, as compared with just 7 percent of never-married young women. This pattern is reversed among men; those who have never been married are more likely to initiate sexual activity early than those who have been married. Sexual debut at an early age is more common among rural than urban young women: 12 percent of young women in rural areas had initiated sex by age 15, as compared with 5 percent of those in urban areas. Likewise, 45 percent of young women in rural areas had initiated sex by age 18, as compared with 23 percent of those in urban areas. Among young men, the urban-rural difference is insignificant. The likelihood of early sexual debut drops drastically among young women with a secondary education or higher. Among young men, the reverse pattern is observed: the likelihood of early sexual activity increases with increasing education. Table 13.16 Age at first sexual intercourse among young people Percentage of young women and young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and young men age 18-24 who had sexual intercourse before age 18, by background characteristics, The Gambia 2013 Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Background characteristic Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 5.7 2,407 na na 6.1 836 na na 15-17 5.7 1,323 na na 5.0 450 na na 18-19 5.7 1,084 27.8 1,084 7.4 386 28.6 386 20-24 10.1 2,125 34.3 2,125 3.0 849 22.2 849 20-22 9.7 1,337 34.3 1,337 3.3 556 24.6 556 23-24 10.9 788 34.3 788 2.5 293 17.6 293 Marital status Never married 1.0 2,646 6.9 1,555 4.6 1,624 24.6 1,174 Ever married 17.3 1,886 55.8 1,654 2.5 62 17.5 62 Knows condom source1 Yes 6.3 1,277 28.9 1,055 5.5 1,151 25.7 931 No 8.4 3,254 33.6 2,154 2.6 534 19.6 305 Residence Urban 4.9 2,580 23.2 1,882 4.9 1,046 23.3 803 Rural 11.6 1,952 44.7 1,326 4.1 639 26.0 432 Education No education 16.0 1,265 54.6 944 3.0 331 19.3 256 Primary 9.3 753 50.8 430 3.9 288 23.3 161 Secondary or higher 3.2 2,514 16.1 1,835 5.2 1,067 25.9 818 Total 7.8 4,532 32.1 3,209 4.6 1,685 24.2 1,236 na = Not available 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 190 • HIV and AIDS-Related Knowledge, Attitudes, and Behaviour 13.12.3 Premarital Sex The period between initiation of sexual intercourse and marriage is often a time of sexual experimentation. Table 13.17 presents information on premarital sexual intercourse and condom use among never-married youth age 15-24 in The Gambia. Ninety-one percent of never-married young women and 64 percent of never-married young men have never had sexual intercourse. Among never-married, sexually active young women and men, 28 percent and 59 percent, respectively, used a condom during their last sexual intercourse. Table 13.17 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, The Gambia 2013 Background characteristic Never married women age 15-24 Never married men age 15-24 Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married women Women who had sexual intercourse in the past 12 months Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married men Men who had sexual intercourse in the past 12 months Percentage who used a condom at last sexual intercourse Number of women Percentage who used a condom at last sexual intercourse Number of men Age 15-19 96.0 2.3 1,821 (28.3) 42 77.2 13.5 834 43.5 113 15-17 98.0 0.7 1,092 * 8 87.8 7.1 450 (35.2) 32 18-19 92.8 4.6 730 (28.5) 34 64.8 21.0 384 46.8 81 20-24 79.3 11.6 825 27.8 95 49.6 30.5 790 66.6 241 20-22 80.4 10.8 597 (32.1) 64 52.4 26.5 539 65.3 143 23-24 76.3 13.6 228 * 31 43.7 39.1 251 68.5 98 Knows condom source1 Yes 83.0 10.8 738 28.1 80 56.2 27.4 1,117 65.5 306 No 93.7 3.0 1,908 27.7 58 80.6 9.4 506 18.8 48 Residence Urban 90.2 6.0 1,756 33.8 105 61.9 22.7 1,023 66.1 232 Rural 91.8 3.7 891 (9.4) 33 67.0 20.3 601 46.1 122 Education No education 90.6 3.1 362 * 11 68.4 19.5 300 56.2 59 Primary 89.4 7.8 409 * 32 74.4 15.8 278 43.1 44 Secondary or higher 91.1 5.0 1,876 31.4 94 59.6 24.0 1,045 62.7 251 Total 90.8 5.2 2,646 28.0 137 63.8 21.8 1,624 59.2 354 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 13.12.4 Multiple Sexual Partners among Youth Less than 1 percent of young women and 2 percent of young men age 15-24 had two or more sexual partners during the 12 months preceding the survey (data not shown). The numbers of cases are too small to show these proportions by background characteristics. 13.12.5 Age Mixing in Sexual Relationships among Young Women Age 15-19 In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the spread of HIV and other STIs because older men are more likely to have been exposed to these diseases. Using preventive methods such as negotiating safer sex is more difficult when age differences are large. To examine age mixing in the 2013 GDHS, young women age 15-19 who had sex in the 12 months preceding the survey were asked whether their partner was younger, about the same age, or older than they were. If the partner was older, they were asked whether they thought he was less than 10 years older or 10 or more years older. HIV and AIDS-Related Knowledge, Attitudes, and Behaviour • 191 Table 13.18 shows that, among young women age 15-19 who had sexual intercourse in the 12 months preceding the survey, 65 percent had sex with a man 10 or more years older. Age mixing in sexual relationships is highest among young women age 15-17 (68 percent), those who have been married (70 percent), and those who know of a condom source (68 percent). There is little variation by urban-rural residence. Age mixing decreases steadily with increasing education. Sixty-nine percent of young women with no education had sexual intercourse with a man 10 or more years older in the past 12 months, as compared with 56 percent of those with a secondary education or higher. 13.12.6 Recent HIV Tests among Youth Table 13.19 shows the percentage of sexually active young women and men who were tested for HIV in the 12 months preceding the survey and received the test results, by selected background characteristics. Twenty-two percent of sexually active young women and 6 percent of sexually active young men age 15-24 were tested for HIV in the past 12 months and received the results. The percentage of sexually active young women who were tested for HIV in the past 12 months is highest among those age 23-24 (25 percent), those who have never been married (26 percent), those living in urban areas (27 percent), and those with a secondary education or higher (26 percent). Less pronounced differences are observed among young men. Table 13.19 Recent HIV tests among youth Among young women and young men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who were tested for HIV in the past 12 months and received the results of the last test, by background characteristics, The Gambia 2013 Women age 15-24 who have had sexual intercourse in the past 12 months: Men age 15-24 who have had sexual intercourse in the past 12 months: Background characteristic Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Age 15-19 21.0 533 4.3 113 15-17 21.5 185 (11.4) 32 18-19 20.7 348 1.4 81 20-24 23.0 1,181 6.9 295 20-22 21.3 679 3.2 159 23-24 25.3 502 11.3 135 Marital status Never married 26.1 137 5.9 354 Ever married 22.0 1,576 8.0 54 Knows condom source1 Yes 22.2 548 7.1 336 No 22.4 1,166 1.8 71 Residence Urban 26.6 795 6.1 253 Rural 18.7 919 6.3 154 Education No education 19.3 783 3.6 82 Primary 22.8 320 6.8 53 Secondary or higher 26.0 611 6.8 272 Total 22.4 1,714 6.2 407 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Table 13.18 Age mixing in sexual relationships among women and men age 15-19 Among women and men age 15-19 who had sexual intercourse in the past 12 months, percentage who had sexual intercourse with a partner who was 10 or more years older than themselves, by background characteristics, The Gambia 2013 Women age 15-19 who had sexual intercourse in the past 12 months Background characteristic Percentage who had sexual intercourse with a man 10+ years older Number of women Age 15-17 67.9 185 18-19 63.1 348 Marital status Never married (9.8) 42 Ever married 69.5 491 Knows condom source1 Yes 68.3 121 No 63.8 412 Residence Urban 66.1 212 Rural 63.9 321 Education No education 68.5 255 Primary 66.4 140 Secondary or higher 56.2 138 Total 64.8 533 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. HIV Prevalence • 193 HIV PREVALENCE 14 n The Gambia, much of the information on national HIV prevalence estimates is derived from sentinel surveillance at antenatal care clinics. Although surveillance data do not provide estimates of HIV prevalence for the general population, they do provide results specific to women attending antenatal clinics. As part of the 2013 GDHS, it was therefore decided to test a representative sample of women age 15-49 and men age 15-59 for HIV. For the first time, the 2013 GDHS provides direct estimates of HIV prevalence among the general adult female and male populations in The Gambia. HIV prevalence is disaggregated by various background characteristics, such as age, residence, Local Government Area (LGA), education, and wealth. In addition, HIV prevalence is analysed according to demographic characteristics and sexual behaviour to identify factors associated with the epidemic. Test results will be used to refine HIV prevalence estimates based on the sentinel surveillance system and allow better monitoring of the epidemic. The HIV prevalence estimates from the 2013 GDHS will also be used to provide data for future policy planning and programme interventions to prevent the spread of the disease. The HIV testing methodology is described in detail in Chapter 1. This chapter addresses the results of the testing and provides information on HIV testing coverage rates among eligible survey respondents. 14.1 COVERAGE RATES FOR HIV TESTING Table 14.1 shows the distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing outcome. Overall, 77 percent of the GDHS respondents who were eligible for testing were both interviewed and tested, and 2 percent were tested but not interviewed. Testing coverage rates are higher I Key Findings • Only 1.9 percent of adults age 15-49 in The Gambia are infected with HIV. • The HIV prevalence rate is 2.1 percent among women and 1.7 percent among men. • Among both women and men, HIV prevalence peaks at 5.9 percent in the 35-39 age group. • By residence, the HIV prevalence is 1.9 percent among urban respondents and 2.0 among rural respondents. • The HIV prevalence is lowest in Banjul (1.1 percent) and highest in Mansakonko (2.9 percent). • Only 0.3 percent of young people age 15-24 are infected with HIV. • A majority of respondents who are HIV positive have not been previously tested (67.4 percent) or have been tested but have not received the results of their last test (1.9 percent). • In 96.7 percent of the 1,193 cohabiting couples who were tested for HIV in the 2013 GDHS, both partners were HIV negative. In 0.8 percent of couples, both partners were HIV positive, and 2.5 percent of couples were discordant (that is, one partner was infected with HIV and the other was not). 194 • HIV Prevalence among women than among men (85 percent and 72 percent, respectively). Among all respondents eligible for testing, 8 percent refused to provide blood and 10 percent were absent at the time of blood collection. Table 14.1 Coverage of HIV testing by residence and Local Government Area Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to residence and Local Government Area (unweighted), The Gambia 2013 Testing status Total Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Residence and Local Government Area Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed WOMEN 15-49 Residence Urban 78.7 2.0 4.8 4.8 2.6 4.1 1.7 1.5 100.0 2,418 Rural 86.5 2.1 2.1 1.2 1.4 4.0 1.6 1.2 100.0 2,988 Local Government Area Banjul 80.0 1.6 4.2 5.0 2.3 3.3 1.7 1.9 100.0 575 Kanifing 72.6 2.1 4.8 6.5 3.6 5.7 2.4 2.3 100.0 861 Brikama 82.5 1.6 4.3 2.8 2.2 4.1 1.0 1.5 100.0 928 Mansakonko 91.3 1.9 2.7 1.3 0.4 1.9 0.0 0.6 100.0 527 Kerewan 89.5 4.8 1.2 0.6 0.9 2.6 0.3 0.3 100.0 778 Kuntaur 84.5 0.7 2.7 2.3 1.9 5.7 0.7 1.6 100.0 566 Janjanbureh 87.4 1.1 2.5 1.0 2.1 4.8 0.6 0.6 100.0 523 Basse 80.9 1.9 3.2 1.5 1.2 3.9 5.9 1.5 100.0 648 Total 83.0 2.1 3.3 2.8 1.9 4.0 1.6 1.3 100.0 5,406 MEN 15-59 Residence Urban 64.2 2.3 8.3 5.8 4.1 10.1 1.6 3.7 100.0 2,343 Rural 76.5 0.9 3.8 2.2 3.5 9.5 1.8 1.8 100.0 2,325 Local Government Area Banjul 65.5 1.8 8.8 4.8 2.8 7.6 2.0 6.6 100.0 603 Kanifing 61.0 3.1 7.8 6.4 4.6 11.7 2.1 3.3 100.0 779 Brikama 67.5 1.8 6.4 4.7 5.1 10.8 1.2 2.4 100.0 981 Mansakonko 85.4 0.7 4.7 2.7 0.2 5.0 0.2 1.0 100.0 403 Kerewan 83.6 1.6 2.3 1.8 1.6 6.9 0.4 1.9 100.0 568 Kuntaur 66.9 0.5 8.3 5.1 6.3 10.2 1.2 1.5 100.0 411 Janjanbureh 69.7 0.4 1.5 1.3 6.1 18.4 0.4 2.2 100.0 462 Basse 72.5 1.1 7.2 2.8 2.2 6.3 6.3 1.7 100.0 461 Total 15-59 70.3 1.6 6.1 4.0 3.8 9.8 1.7 2.8 100.0 4,668 TOTAL (WOMEN 15-49 AND MEN 15-59) Residence Urban 71.6 2.1 6.5 5.3 3.3 7.1 1.6 2.6 100.0 4,761 Rural 82.1 1.6 2.8 1.6 2.3 6.4 1.7 1.5 100.0 5,313 Local Government Area Banjul 72.6 1.7 6.5 4.9 2.5 5.5 1.9 4.3 100.0 1,178 Kanifing 67.1 2.6 6.2 6.5 4.1 8.5 2.3 2.8 100.0 1,640 Brikama 74.8 1.7 5.4 3.8 3.7 7.5 1.1 2.0 100.0 1,909 Mansakonko 88.7 1.4 3.5 1.9 0.3 3.2 0.1 0.8 100.0 930 Kerewan 87.0 3.4 1.6 1.1 1.2 4.4 0.3 1.0 100.0 1,346 Kuntaur 77.1 0.6 5.0 3.5 3.8 7.6 0.9 1.5 100.0 977 Janjanbureh 79.1 0.8 2.0 1.1 4.0 11.2 0.5 1.3 100.0 985 Basse 77.4 1.5 4.9 2.1 1.6 4.9 6.0 1.6 100.0 1,109 Total 77.1 1.8 4.6 3.3 2.8 6.7 1.6 2.0 100.0 10,074 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result (i.e., positive, negative, or indeterminate). Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. By residence, coverage of HIV testing is higher in rural areas (84 percent) than in urban areas (74 percent). Among LGAs, coverage rates are highest in Mansakonko and Kerewan (90 percent each) and lowest in Kanifing (70 percent). Table 14.2 shows coverage of HIV testing by background characteristics. Among women, coverage of HIV testing ranges from 80 percent for the 40-49 age groups to 87 percent among those age 15-19. Among men, testing coverage is 64 percent among men age 40-44, as compared with 75 percent HIV Prevalence • 195 among those age 15-19. There is little variation in testing coverage levels among women; in the case of men, coverage is lowest among those with no education (69 percent). Additional tables describing the relationship between participation in HIV testing and characteristics related to HIV risk are presented in Appendix A (see Tables A.7-A.10). Overall, the results in Tables A.7-A.10 do not show a systematic relationship between participation in testing and variables associated with a higher risk of HIV infection. Table 14.2 Coverage of HIV testing by selected background characteristics Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to selected background characteristics (unweighted), The Gambia 2013 Testing status Total Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Background characteristic Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed WOMEN 15-49 Age 15-19 85.1 1.6 3.4 2.1 1.8 2.8 1.9 1.3 100.0 1,247 20-24 83.8 1.6 3.0 2.4 2.1 4.4 1.4 1.3 100.0 1,108 25-29 81.9 2.0 3.4 2.7 1.9 5.3 1.8 0.9 100.0 928 30-34 83.4 2.4 2.9 3.7 1.9 3.0 1.5 1.1 100.0 789 35-39 81.4 3.4 4.1 2.1 1.5 4.8 1.0 1.7 100.0 585 40-44 82.4 2.1 2.1 4.6 2.1 3.5 1.4 1.9 100.0 432 45-49 78.2 1.9 4.1 3.8 2.2 5.7 1.9 2.2 100.0 317 Education No education 83.3 2.5 2.7 2.9 1.6 3.9 1.5 1.6 100.0 2,689 Primary 87.4 1.5 2.7 2.1 0.9 2.9 1.9 0.5 100.0 747 Secondary or higher 82.4 1.6 3.9 2.7 2.4 4.4 1.4 1.2 100.0 1,804 Wealth quintile Lowest 88.6 1.7 1.8 1.7 1.4 3.0 0.7 1.0 100.0 1,095 Second 87.1 2.3 1.3 0.7 1.4 4.3 1.7 1.3 100.0 1,223 Middle 82.9 2.3 3.4 2.3 1.9 4.2 1.9 1.1 100.0 965 Fourth 80.9 2.1 5.8 2.9 1.3 4.2 1.7 1.1 100.0 958 Highest 75.3 1.9 4.5 6.4 3.5 4.5 2.1 2.0 100.0 1,165 Total 83.0 2.1 3.3 2.8 1.9 4.0 1.6 1.3 100.0 5,406 MEN 15-59 Age 15-19 73.5 1.9 4.0 3.4 4.6 8.3 1.9 2.4 100.0 1,036 20-24 72.7 0.9 5.6 3.2 3.9 8.7 2.1 2.9 100.0 932 25-29 70.4 1.9 5.8 4.1 3.2 11.2 1.3 2.1 100.0 678 30-34 68.3 1.2 5.9 6.1 2.2 10.8 2.2 3.3 100.0 508 35-39 69.2 2.1 7.0 3.4 3.8 10.8 1.3 2.5 100.0 474 40-44 63.0 1.1 7.5 3.9 5.0 14.2 0.8 4.5 100.0 359 45-49 68.6 1.6 8.8 4.7 3.8 9.1 0.9 2.5 100.0 318 50-54 67.4 2.2 9.3 4.8 3.5 9.3 1.8 1.8 100.0 227 55-59 69.1 2.2 8.8 4.4 2.9 5.9 2.2 4.4 100.0 136 Education No education 67.1 1.7 5.7 4.3 4.1 12.2 1.4 3.5 100.0 1,813 Primary 73.8 1.4 7.0 2.4 3.3 7.6 2.1 2.4 100.0 630 Secondary or higher 73.0 1.7 5.3 4.2 3.5 8.5 1.6 2.2 100.0 1,931 Wealth quintile Lowest 78.9 1.3 3.9 2.4 2.4 7.8 0.8 2.6 100.0 875 Second 76.3 0.6 4.3 3.0 3.0 9.8 1.5 1.4 100.0 951 Middle 68.7 1.1 5.0 4.0 5.2 11.6 2.6 1.7 100.0 801 Fourth 65.7 2.8 7.8 4.8 3.8 9.9 1.2 3.9 100.0 963 Highest 63.4 1.9 8.6 5.4 4.5 10.1 2.3 3.8 100.0 1,078 Total 70.3 1.6 6.1 4.0 3.8 9.8 1.7 2.8 100.0 4,668 Note: Total includes 5 men for whom information on education is missing. 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result (i.e., positive, negative, or indeterminate). Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) non corresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 196 • HIV Prevalence 14.2 HIV PREVALENCE 14.2.1 HIV Prevalence by Age and Sex Table 14.3 shows the percentage of respondents age 15-49 who are infected with HIV. The overall HIV prevalence among all women and men tested in the 2013 GDHS is 1.9 percent. The HIV prevalence among women is 2.1 percent, as compared with 1.7 percent among men. In general, HIV prevalence increases with age among both women and men, peaking at 5.9 percent in the 35-39 age group. Table 14.3 HIV prevalence by age Among de facto women age 15-49 and men age 15-59 who were interviewed and tested, the percentage HIV positive, by age, The Gambia 2013 Women Men Total Age Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 0.4 943 0.3 818 0.4 1,761 20-24 0.3 859 0.0 827 0.1 1,686 25-29 2.5 746 0.6 581 1.7 1,327 30-34 2.5 613 3.9 407 3.1 1,020 35-39 5.9 414 5.9 367 5.9 781 40-44 4.9 299 3.2 251 4.1 550 45-49 3.4 213 2.7 200 3.1 413 50-59 na na 3.3 230 na na Total 15-49 2.1 4,089 1.7 3,450 1.9 7,539 Total 15-59 na na 1.8 3,680 na na na = Not applicable 14.2.2 HIV Prevalence by Socioeconomic Characteristics Table 14.4 shows the variation in HIV prevalence by various socioeconomic characteristics (religion, employment, residence, region, educational level, and wealth quintile). In the case of both women and men, HIV prevalence is somewhat higher among Christians than Muslims (3.8 percent versus 1.8 percent); in addition, it is higher among respondents who are employed than among those who are not employed (2.3 percent versus 1.3 percent). By LGA, HIV prevalence is highest in Mansakonko and Brikama (2.9 percent and 2.5 percent, respectively) and lowest in Banjul (1.1 percent). HIV prevalence decreases from 2.7 percent among respondents with no education to 1.2 percent among those with a secondary education or higher. Men and women in the lowest wealth quintile have the highest HIV prevalence (3.0 percent). HIV Prevalence • 197 Table 14.4 HIV prevalence by socioeconomic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by socioeconomic characteristics, The Gambia 2013 Women Men Total Background characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Religion Islam 2.0 3,936 1.6 3,307 1.8 7,242 Christianity 4.5 150 3.0 140 3.8 290 Employment (past 12 months ) Not employed 1.8 1,979 0.3 989 1.3 2,969 Employed 2.4 2,109 2.2 2,460 2.3 4,569 Residence Urban 2.4 2,291 1.3 2,150 1.9 4,441 Rural 1.8 1,798 2.3 1,300 2.0 3,098 Local Government Area Banjul 2.0 89 0.2 83 1.1 171 Kanifing 2.3 979 0.5 825 1.5 1,804 Brikama 2.6 1,362 2.4 1,403 2.5 2,765 Mansakonko 3.8 195 1.5 136 2.9 331 Kerewan 1.7 455 0.8 311 1.3 766 Kuntaur 1.4 216 1.3 138 1.4 353 Janjanbureh 2.8 291 1.3 231 2.1 521 Basse 0.2 503 3.0 323 1.3 826 Education No education 2.6 1,907 3.0 1,040 2.7 2,947 Primary 2.4 569 1.3 464 1.9 1,033 Secondary or higher 1.5 1,613 1.0 1,945 1.2 3,558 Wealth quintile Lowest 2.8 685 3.2 506 3.0 1,190 Second 1.5 804 1.4 602 1.5 1,406 Middle 2.8 703 2.8 549 2.8 1,252 Fourth 2.2 891 0.7 912 1.4 1,802 Highest 1.7 1,007 1.2 881 1.5 1,888 Total 15-49 2.1 4,089 1.7 3,450 1.9 7,539 50-59 na na 3.3 230 3.3 230 Total 15-59 na na 1.8 3,680 1.8 3,680 Note: Total includes 2 cases with no religion, 4 cases for whom information on type of religion is missing, and 1 case for whom information on current employment is missing. na = Not applicable 14.2.3 HIV Prevalence by Demographic Characteristics Table 14.5 shows HIV prevalence among women and men by marital status, type of union, number of times the respondent slept away from home in the 12 months before the survey, amount of time spent away from home in the past 12 months, and, among women, pregnancy status and use of antenatal care (ANC). Widowed respondents (13.3 percent), women in polygynous unions (3.3 percent), and men in non-polygynous unions (4.1 percent) are more likely than those in other subgroups to be HIV positive. HIV prevalence is higher among women and men who slept away from home five or more times in the past year (3.5 percent) and those who were away for more than one month (3.1 percent). Women who are not pregnant or not sure whether they are pregnant (2.2 percent) are more likely to be HIV positive than pregnant women (1.4 percent). In addition, HIV prevalence is higher among women who received ANC from a non-public sector provider in the three years preceding the survey (3.0 percent) than among those who received ANC from a public sector provider (1.8 percent) and those who did not receive any ANC for their most recent birth or did not have a birth in the last three years (2.3 percent). 198 • HIV Prevalence Table 14.5 HIV prevalence by demographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by demographic characteristics, The Gambia 2013 Women Men Total Demographic characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Never married 0.7 1,148 0.3 2,140 0.5 3,288 Ever had sexual intercourse 2.3 145 0.5 968 0.7 1,113 Never had sexual intercourse 0.5 1,003 0.2 1,173 0.3 2,175 Married/living together 2.4 2,725 3.7 1,271 2.8 3,996 Divorced or separated 2.6 154 (6.7) 37 3.4 191 Widowed 13.7 62 * 2 13.3 64 Type of union In polygynous union 3.3 1,028 1.8 216 3.0 1,244 In non-polygynous union 1.7 1,682 4.1 1,054 2.6 2,736 Not currently in union 1.5 1,364 0.5 2,179 0.9 3,543 Times slept away from home in past 12 months None 2.3 2,231 0.7 1,730 1.6 3,961 1-2 2.0 1,324 2.5 814 2.2 2,138 3-4 0.8 353 1.3 330 1.0 683 5+ 3.5 175 3.4 573 3.5 748 Time away in past 12 months Away for more than 1 month 2.8 655 3.5 602 3.1 1,257 Away for less than 1 month 1.4 1,197 2.1 1,114 1.7 2,311 Not away 2.3 2,232 0.7 1,730 1.6 3,962 Currently pregnant Pregnant 1.4 319 na na na na Not pregnant or not sure 2.2 3,770 na na na na ANC for last birth in the past 3 years ANC provided by the public sector 1.8 1,674 na na na na ANC provided by other than the public sector 3.0 109 na na na na No ANC/no birth in past 3 years 2.3 2,291 na na na na Total 15-49 2.1 4,089 1.7 3,450 1.9 7,539 50-59 na na 3.3 230 na na Total 15-59 na na 1.8 3,680 na na Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 15 cases for whom information on type of union is missing, 8 cases for whom information on times slept away from home in the past 12 months is missing, 9 cases for whom information on times away in past 12 months is missing, and 15 cases for whom information on ANC for last birth in the last 3 years is missing. na = Not applicable 14.2.4 HIV Prevalence by Sexual Behaviour Table 14.6 presents HIV prevalence rates among respondents who have ever had sexual intercourse by sexual behaviour indicators. In reviewing these results, one should note that responses to questions about sexual risk behaviour may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk. Among all respondents age 15-49 who had ever had sex and were tested for HIV, 2.5 percent are HIV positive (2.6 percent of women and 2.4 percent of men). In the general population, there is no strong relationship between age at first sexual intercourse and HIV prevalence. Among women, HIV prevalence decreases slightly as age at first sexual intercourse increases. Among men, there is no clear pattern in variations by age. However, those whose sexual debut was at age 16-17 are more likely to be HIV positive (4.7 percent) than other men. Caution should be used when interpreting HIV prevalence levels among women based on the number of sexual partners in the past 12 months because very few women report more than one partner. HIV prevalence was higher among women who had no sexual partners (3.6 percent) in the past 12 months than among those who had one partner (2.4 percent). HIV Prevalence • 199 Table 14.6 HIV prevalence by sexual behaviour Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by sexual behaviour characteristics, The Gambia 2013 Women Men Total Sexual behaviour characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sexual intercourse <16 3.0 905 0.6 271 2.5 1,177 16-17 2.5 605 4.7 306 3.3 911 18-19 2.4 587 2.6 452 2.5 1,039 20+ 2.0 746 2.2 1,159 2.1 1,906 Multiple sexual partners and partner concurrency in past 12 months 0 3.6 513 1.4 433 2.6 945 1 2.4 2,517 2.7 1,555 2.5 4,072 2+ * 10 2.2 274 2.1 284 Had concurrent partners1 * 0 1.8 187 1.8 188 None of the partners were concurrent * 9 3.1 87 2.8 96 Condom use at last sexual intercourse in past 12 months Used condom 3.1 82 0.7 496 1.0 578 Did not use condom 2.4 2,443 3.4 1,331 2.7 3,775 No sexual intercourse in last 12 months 3.6 513 1.3 436 2.5 949 Number of lifetime partners 1 1.7 2,445 2.9 846 2.0 3,291 2 7.0 457 2.0 571 4.2 1,028 3-4 5.4 109 3.0 478 3.4 587 5-9 * 16 1.1 239 1.3 255 10+ * 0 2.3 90 2.3 90 Paid for sexual intercourse in past 12 months Yes na na (6.8) 24 na na Used condom na na * 17 na na Did not use condom na na * 8 na na No/no sexual intercourse in last 12 months na na 2.4 2,241 na na Total 15-49 2.6 3,040 2.4 2,265 2.5 5,305 50-59 na na 3.3 229 na na Total 15-59 na na 2.5 2,494 2.5 2,494 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 272 cases for whom information on age at first sexual intercourse is missing, 4 cases for whom information on multiple sexual partners and partner concurrency in past 12 months is missing, 3 cases for whom information on condom use at last sexual intercourse in past 12 months is missing, and 54 cases for whom information on number of lifetime partners is missing. 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with 2 or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with 2 or more wives.) na = Not applicable Among men, HIV prevalence is higher among those with one partner in the past 12 months (2.7 percent) than among those who had no partners (1.4 percent) and those who had two or more partners (2.2 percent). HIV prevalence is lower among men who had concurrent partners (1.8 percent) than among those who did not (3.1 percent). Among women, those with two lifetime partners are most likely to be HIV positive (7 percent), followed by those with three to four lifetime partners (5.4 percent). Women with one lifetime partner are least likely to be HIV positive (1.7 percent). In the case of men, there is no clear relationship between HIV prevalence and number of lifetime partners. However, HIV prevalence is lowest among those with five to nine partners (1.1 percent). Table 14.6 also shows that there is no clear correlation between condom use during last sexual intercourse and HIV status. Among women, HIV prevalence is highest among those who did not have sexual intercourse in the past 12 months (3.6 percent), followed by those who used a condom (3.1 percent). In contrast, men who did not use a condom during their most recent sexual intercourse are more likely to be HIV positive (3.4 percent) than men who used a condom (0.7 percent) and those who had no sexual intercourse in the past 12 months (1.3 percent). 200 • HIV Prevalence In summary, the results presented in Table 14.6 do not demonstrate a consistent relationship between sexual risk behaviour and HIV prevalence. Additional analysis may be necessary to understand these relationships because they are often confounded by other factors that are associated with both behavioural measures and HIV prevalence such as age, marital status, and residence. In addition, because HIV prevalence rates are low overall, it may not be possible to parse differences in prevalence even when they are linked with behaviour. 14.3 HIV PREVALENCE AMONG YOUNG PEOPLE As specified in the United Nations General Assembly Special Session (UNGASS) on HIV and AIDS, young people in the 15-24 age range are an important group to monitor with respect to reductions in HIV incidence at the population level. Table 14.7 shows that HIV prevalence among youth age 15-24 is 0.3 percent (0.4 percent among young women and 0.2 percent among young men). Given the low overall HIV prevalence, there is little variation in prevalence by background characteristics. Table 14.7 HIV prevalence among young people by background characteristics Percentage HIV positive among women and men age 15-24 who were tested for HIV, by background characteristics, The Gambia 2013 Women Men Total Background characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 0.4 943 0.3 818 0.4 1,761 15-17 0.4 497 0.1 424 0.3 920 18-19 0.5 447 0.5 394 0.5 841 20-24 0.3 859 0.0 827 0.1 1,686 20-22 0.0 539 0.0 554 0.0 1,094 23-24 0.8 320 0.0 272 0.4 592 Marital status Never married 0.4 1,019 0.2 1,589 0.3 2,608 Ever had sex 0.0 97 0.0 585 0.0 681 Never had sex 0.4 923 0.3 1,004 0.3 1,927 Married/living together 0.2 741 0.0 53 0.2 795 Divorced/separated/widowed (2.5) 42 * 2 (2.4) 44 Currently pregnant Pregnant 0.7 129 na na na na Not pregnant or not sure 0.3 1,674 na na na na Residence Urban 0.3 1,029 0.0 1,029 0.2 2,058 Rural 0.4 774 0.4 616 0.4 1,389 Local Government Area Banjul 0.0 38 0.0 35 0.0 73 Kanifing 0.7 434 0.0 400 0.3 834 Brikama 0.0 597 0.3 681 0.2 1,278 Mansakonko 1.0 84 0.0 67 0.6 151 Kerewan 0.7 217 0.4 139 0.6 356 Kuntaur 0.6 87 0.0 57 0.3 144 Janjanbureh 0.7 137 0.0 115 0.4 253 Basse 0.0 207 0.0 151 0.0 358 Education No education 0.5 515 0.0 317 0.3 832 Primary 0.2 302 0.2 265 0.2 567 Secondary or higher 0.3 986 0.2 1,062 0.3 2,048 Wealth quintile Lowest 0.5 277 0.3 205 0.4 482 Second 0.1 354 0.7 304 0.4 659 Middle 0.5 300 0.0 280 0.3 580 Fourth 0.9 393 0.0 440 0.4 833 Highest 0.0 478 0.0 416 0.0 894 Total 15-24 0.4 1,803 0.2 1,644 0.3 3,447 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable HIV Prevalence • 201 The 2013 GDHS collected data on behaviours that correlate with sexually transmitted infection (STI) rates. Information on sexual behaviours is important in designing, targeting, and monitoring HIV prevention interventions for young adults. Three sexual behaviour characteristics that correlate with STI rates are number of sexual partners, age at first sexual intercourse, and condom use. It is important to note that responses about sexual behaviour are subject to reporting bias. Table 14.8 shows HIV prevalence among young people by sexual behaviour. Overall, 0.2 percent of respondents age 15-24 who have ever had sex and were tested in the 2013 GDHS are HIV positive. Because of the low HIV prevalence among youth age 15-24 who have ever had sex, there are no marked differences by background characteristics. Table 14.8 HIV prevalence among young people by sexual behaviour Percentage HIV positive among women and men age 15-24 who have ever had sex and were tested for HIV, by sexual behaviour, The Gambia 2013 Women Men Total Sexual behaviour characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Multiple sexual partners and partner concurrency in past 12 months 0 0.0 139 0.0 232 0.0 372 1 0.4 701 0.0 361 0.3 1,062 2+ * 2 (0.0) 41 (0.0) 43 Had concurrent partners1 * 0 * 13 * 13 None of the partners were concurrent * 2 (0.0) 27 (0.0) 29 Condom use at last sexual intercourse in past 12 months Used condom (0.0) 35 0.0 208 0.0 243 Did not use condom 0.4 668 0.0 194 0.3 862 No sexual intercourse in last 12 months 0.0 139 0.0 233 0.0 373 Total 15-24 0.3 843 0.0 635 0.2 1,478 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 1 case for whom information on multiple sexual partners and partner concurrency in past 12 months is missing and 1 case for whom information on condom use at last sexual intercourse in past 12 months is missing. 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with 2 or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with 2 or more wives.) 14.4 HIV PREVALENCE BY OTHER CHARACTERISTICS RELATED TO HIV RISK A strong link exists between sexually transmitted infections and sexual transmission of HIV. Many studies have demonstrated that STIs are a co-factor in HIV transmission. Management and treatment of STIs can play an important role in the reduction of HIV transmission. The 2013 GDHS asked respondents who had ever had sex if they had contracted a disease through sexual contact in the past 12 months or if they had any symptoms associated with STIs (an abnormal discharge from the vagina or penis or a genital sore or ulcer). Table 14.9 presents HIV prevalence by other characteristics related to HIV risk among women and men age 15-49 who have ever had sex. The table shows that women and men with a history of an STI are somewhat more likely to be HIV positive (3.2 percent and 2.8 percent, respectively) than those who have not had an STI or STI symptoms (2.5 percent and 2.4 percent, respectively). HIV prevalence is highest among respondents who had never been tested for HIV (2.9 percent) and lowest among those who had been tested but did not receive the results (1.6 percent). 202 • HIV Prevalence Table 14.9 HIV prevalence by other characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by whether they had an STI in the past 12 months and by prior testing for HIV, The Gambia 2013 Women Men Total Characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Sexually transmitted infection in past 12 months Had STI or STI symptoms 3.2 249 2.8 76 3.1 325 No STI, no symptoms 2.5 2,765 2.4 2,160 2.5 4,926 Prior HIV testing Ever tested 2.4 1,668 1.0 579 2.0 2,247 Received results 2.5 1,540 0.9 535 2.1 2,075 Did not receive results 1.4 128 (2.1) 45 1.6 173 Never tested 2.9 1,341 2.9 1,684 2.9 3,025 Total 15-49 2.6 3,040 2.4 2,265 2.5 5,305 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 54 cases for whom information on sexually transmitted infection in the past 12 months is missing and 33 cases for whom information on prior HIV testing is missing. Table 14.10 provides further information about the relationship between prior HIV testing and the actual HIV status of respondents. The results show that about three in ten individuals who are HIV positive (30.7 percent) have been tested previously and received the result of their last test (45.6 percent of women and 8.1 percent of men). A majority of HIV-positive respondents either have never been tested (67.4 percent) or have not received the results of their last test (1.9 percent) and therefore do not know that they can transmit HIV if they have unprotected sex. Table 14.10 Prior HIV testing by current HIV status Percent distribution of women and men age 15-49 who tested HIV positive and who tested HIV negative by HIV testing status prior to the survey, The Gambia 2013 Women Men Total HIV testing prior to the survey HIV positive HIV negative HIV positive HIV negative HIV positive HIV negative Previously tested Received result of last test 45.6 38.6 (8.1) 18.0 30.7 29.2 Did not receive result of last test 2.0 4.1 (1.6) 1.7 1.9 3.0 Not previously tested 52.4 56.4 (90.3) 80.2 67.4 67.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 87 4,002 57 3,393 144 7,395 Note: Figures in parentheses are based on 25-49 unweighted cases. 14.5 HIV PREVALENCE AMONG COUPLES A total of 1,193 cohabiting couples were tested for HIV in the 2013 GDHS. The results shown in Table 14.11 indicate that, among 96.7 percent of cohabiting couples, both partners tested negative for HIV. Both partners were HIV positive in 0.8 percent of cohabiting couples, while 2.5 percent of couples were discordant (i.e., one partner was infected and the other was not). In 1.6 percent of couples, the male partner was infected and the woman was not, while in 0.9 percent of couples, the woman was infected and the man was not. HIV Prevalence • 203 Table 14.11 HIV prevalence among couples Percent distribution of couples living in the same household, both of whom were tested for HIV, by HIV status, according to background characteristics, The Gambia 2013 Background characteristic Both HIV positive Man HIV positive, woman HIV negative Woman HIV positive, man HIV negative Both HIV negative Total Number Woman’s age 15-19 0.8 0.0 0.0 99.2 100.0 79 20-29 0.7 1.0 0.3 98.0 100.0 540 30-39 1.1 1.3 1.7 95.9 100.0 441 40-49 0.2 6.0 0.9 92.9 100.0 133 Man’s age 20-29 0.0 0.0 0.0 100.0 100.0 138 30-39 0.6 1.7 1.4 96.4 100.0 441 40-49 0.3 2.7 0.1 96.9 100.0 414 50-59 3.0 0.2 1.9 94.8 100.0 199 Age difference between partners Woman older * * * * 100.0 14 Same age/man older by 0-4 years 1.8 4.0 3.0 91.3 100.0 155 Man older by 5-9 years 0.0 0.8 0.4 98.8 100.0 421 Man older by 10-14 years 0.1 2.0 0.4 97.5 100.0 316 Man older by 15+ years 2.2 0.2 0.9 96.6 100.0 287 Type of union Non-polygynous 0.9 1.5 1.0 96.5 100.0 836 Polygynous 0.6 1.8 0.5 97.2 100.0 352 Multiple partners in past 12 months1 Both no 0.8 1.4 1.0 96.7 100.0 888 Man yes, woman no 0.7 2.1 0.4 96.8 100.0 300 Concurrent sexual partners in past 12 months2 Both no 0.9 1.4 1.0 96.7 100.0 936 Man yes, woman no 0.6 2.2 0.5 96.7 100.0 257 Residence Urban 0.9 1.1 1.2 96.8 100.0 564 Rural 0.7 2.1 0.6 96.7 100.0 629 Local Government Area Banjul 0.0 0.0 1.1 98.9 100.0 26 Kanifing 0.8 0.0 1.9 97.4 100.0 190 Brikama 1.5 2.1 1.1 95.3 100.0 424 Mansakonko 0.6 0.0 0.0 99.4 100.0 53 Kerewan 0.3 0.9 0.0 98.8 100.0 150 Kuntaur 0.7 1.2 0.9 97.1 100.0 88 Janjanbureh 0.7 2.3 0.9 96.1 100.0 89 Basse 0.0 3.3 0.0 96.7 100.0 174 Woman’s education No education 0.5 2.3 0.2 97.0 100.0 751 Primary 3.3 0.0 2.2 94.4 100.0 168 Secondary or higher 0.0 0.0 1.1 98.9 100.0 250 Man’s education No education 1.1 1.2 0.7 97.0 100.0 633 Primary 0.0 4.4 0.0 95.6 100.0 131 Secondary or higher 0.7 1.0 1.0 97.3 100.0 363 Wealth quintile Lowest 1.6 3.8 2.3 92.2 100.0 272 Second 0.0 0.8 0.0 99.2 100.0 257 Middle 0.0 1.9 0.0 98.1 100.0 180 Fourth 1.9 1.2 0.0 96.9 100.0 268 Highest 0.0 0.0 1.8 98.2 100.0 216 Total couples 0.8 1.6 0.9 96.7 100.0 1,193 Note: The table is based on couples for whom a valid test result (positive or negative) is available for both partners. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 5 cases for whom information on type of union is missing and 5 cases for whom information on multiple partners in the past 12 months is missing. 1 A respondent is considered to have had multiple sexual partners in the past 12 months if he or she had sexual intercourse with 2 or more people during this time period. (Respondents with multiple partners include polygynous men who had sexual intercourse with 2 or more wives.) 2 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with 2 or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with 2 or more wives.) Differences by background characteristics are small. The percentage of couples in which the man is HIV positive and the woman is HIV negative is higher in couples in which the female partner is age 40- 49 (6.0 percent), the partners are the same age or the man is older than the woman by four years or less (4.0 percent), and the man has a primary education (4.4 percent). Also, this percentage is highest among couples in the poorest households (3.8 percent). Women’s Empowerment and Demographic and Health Outcomes • 205 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 ender equality and women’s empowerment are key factors in development strategies that focus on poverty reduction and an improved standard of living for people in The Gambia. The government of The Gambia has placed gender equality and women’s empowerment as one of its top priorities in the national development agenda. The National Women’s Council and Women’s Bureau was established by the Council Act of 1980, and the first National Policy for the Advancement of Gambian Women (NPAGW 1999-2009) was formulated1. This policy provided a legitimate point of reference for addressing gender inequalities at all government levels and among all stakeholders. A review of the NPAGW in 2006, however, necessitated a policy shift from a women’s development perspective to a gender and women’s empowerment orientation with a rights-based approach. Thus, the revised National Gender and Women’s Empowerment Policy (2010-2020)1 aims to mainstream gender in all national and sectoral policies, programmes, plans, and budgets to achieve gender equity, equality, and women’s empowerment in the development process. This chapter presents information on factors that affect the status of women in society: employment, type of earnings, control over cash earnings, earnings relative to those of their husbands, and participation in decision making. It also defines two summary indices of empowerment derived from women’s responses. The indices are based on the number of household decisions in which the respondent participates and her agreement with reasons for which wife beating is justified. The ranking of women on these indices is then related to selected demographic and health outcomes, including contraceptive use, ideal family size, unmet need for family planning, and maternal and child health care. 1 Source: Women’s Bureau, Office of the Vice President and Ministry of Women’s Affairs, Banjul, The Gambia G Key Findings • About six in ten currently married women and almost all currently married men age 15-49 were employed in the 12 months preceding the survey. • Most women earn less than their husbands but make independent decisions about their own earnings. • Overall, 25 percent of women in The Gambia own a house, and 21 percent own land. • The majority of women participate in decisions about their own health care and visits to friends/family. However, men are more likely to make decisions about major household purchases. • A higher percentage of women than men (58 percent versus 33 percent) agree that wife beating is justified. • Women’s access to antenatal, delivery, and postnatal care from a health professional is lowest among those who agree with all five reasons justifying wife beating. • The likelihood of children surviving increases with improvements in women’s empowerment status. • Three-fourths (75 percent) of women who have heard of female genital circumcision are circumcised. • Among the overwhelming majority of women (85 percent), circumcision involved cutting and removal of flesh. 206 • Women’s Empowerment and Demographic and Health Outcomes 15.1 WOMEN’S AND MEN’S EMPLOYMENT Employment can be a source of empowerment for both women and men, especially if it puts them in control of income. In the 2013 GDHS, respondents were asked whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months preceding the survey. Women’s employment includes work in the home, on family farms, in family businesses, and in other informal sectors. It is important to be cautious when collecting data on women’s employment because some activities are not perceived by women themselves as employment and hence may not be reported as such. To avoid underestimating women’s employment, the 2013 GDHS asked women several questions to ascertain their employment status. First, they were asked “Aside from your own housework, have you done any work?” Women who answered no to this question were then asked the following: “As you know, some women take up jobs for which they are paid in cash or in kind. Others sell things, have a small business, or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?” Table 15.1 presents data on employment and cash earnings of currently married women and men who were employed in the 12 months preceding the survey. While almost all currently married men age 15-49 (98 percent) were employed at some time in the past 12 months, only six in ten currently married women (59 percent) were employed. Among those who were employed in the past 12 months, 63 percent of women and 82 percent of men were paid in cash only. Women are slightly more likely than men to take up jobs for which they are not paid (5 percent and 3 percent, respectively). The proportion of women employed increases with age, from 32 percent among those age 15-17 to 75-77 percent among those age 40-49. The proportion of men who were employed in the past 12 months is consistent at 96-98 percent in all age groups. Table 15.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, The Gambia 2013 Age Among currently married respondents: Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Total Number of women Percentage employed in past 12 months Number of respondents Cash only Cash and in-kind In-kind only Not paid WOMEN 15-19 31.7 573 44.9 38.5 6.7 8.9 100.0 182 20-24 44.0 1,237 59.7 32.1 3.4 4.8 100.0 545 25-29 58.7 1,528 65.2 27.5 2.6 4.6 100.0 897 30-34 61.4 1,319 65.6 26.8 2.1 5.4 100.0 810 35-39 69.4 966 65.4 26.2 2.5 5.4 100.0 670 40-44 76.9 673 66.3 27.6 1.6 4.3 100.0 517 45-49 75.1 496 61.3 31.9 1.5 4.9 100.0 373 Total 15-49 58.8 6,791 63.4 28.7 2.6 5.1 100.0 3,993 MEN 15-19 * 2 * * * * * 2 20-24 96.1 57 58.3 36.0 0.0 5.7 100.0 55 25-29 97.9 197 80.0 14.4 0.3 5.4 100.0 193 30-34 98.2 307 85.8 11.5 0.1 2.6 100.0 302 35-39 98.2 344 88.1 9.0 0.4 2.5 100.0 338 40-44 96.0 245 82.6 14.1 0.6 2.7 100.0 235 45-49 97.0 208 72.9 20.7 1.7 4.7 100.0 201 Total 15-49 97.5 1,360 81.8 14.2 0.5 3.4 100.0 1,326 50-59 91.2 233 82.0 14.3 0.9 2.5 100.0 213 Total 15-59 96.6 1,593 81.9 14.2 0.6 3.3 100.0 1,539 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Women’s Empowerment and Demographic and Health Outcomes • 207 15.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS Table 15.2.1 shows the percent distribution of currently married women who received cash earnings in the past 12 months by the person who controls their earnings and by their perception of the magnitude of their earnings relative to those of their husband. Overall, 80 percent of women reported that they mainly decide how their cash earnings are used, 11 percent indicated that the decision is made jointly with their husband, and almost 8 percent said that the allocation of their earnings is decided mainly by their husband. Five percent of women earn more than their husbands, while 84 percent report earning less. Three percent of women say that their husband has no cash earnings. Currently married women age 45-49 are more likely than women in other age groups to have sole control over their cash earnings. Also, women with no children are more likely than women with living children to mainly decide themselves how their earnings are spent. Sole decision making on earnings by women is slightly higher in rural than in urban areas (82 percent and 78 percent, respectively). However, joint decision making is more common in urban than rural areas (13 percent and 10 percent, respectively). By Local Government Area (LGA), married women in Janjanbureh are least likely to make decisions on how to use their own money (61 percent), and women in Basse are most likely to do so (94 percent). Joint decision making on how women’s cash earnings are spent is more common among married women with a secondary education or higher than among women with no education (16 percent and 10 percent, respectively). Older, urban, more educated, and wealthier women and those with five or more living children are more likely to report that their earnings exceed those of their husband. Table 15.2.2 shows the percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women age 15-49 whose husbands receive cash earnings by the person who decides how the husband’s earnings are used. The results indicate that a large majority of women and men report that the husband usually decides on how his cash earnings are spent (76 percent and 73 percent, respectively). Twenty-five percent of men and 17 percent of women report that these decisions are jointly made. Only 1 percent of men and 7 percent of women report that the wife is the main financial decision maker regarding the husband’s earnings. Eighty-seven percent of men age 20-24 say that they are the main decision maker with respect to how their income is spent, as compared with 78 percent of women in the same age group. Men with no children (82 percent), those in urban areas (74 percent) and Kerewan (86 percent), those with no education (76 percent), and those in the lowest wealth quintile (76 percent) are more likely than other men to decide alone on how their incomes are spent. Among women, those with no living children (78 percent), those in rural areas (82 percent) and Basse (92 percent), those with a primary or no education (79 percent each), and those in the lower three wealth quintiles (79-82 percent) are more likely than other women to report that their husband decides alone. 20 8 • W om en ’s E m po w er m en t a nd D em og ra ph ic a nd H ea lth O ut co m es Ta bl e 15 .2 .1 C on tro l o ve r w om en ’s c as h ea rn in gs a nd re la tiv e m ag ni tu de o f w om en ’s c as h ea rn in gs P er ce nt d is tri bu tio n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 w ho r ec ei ve d ca sh e ar ni ng s fo r em pl oy m en t i n th e 12 m on th s pr ec ed in g th e su rv ey , b y pe rs on w ho d ec id es h ow w ife ’s c as h ea rn in gs a re u se d an d by w he th er s he e ar ne d m or e or le ss th an h er h us ba nd , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic P er so n w ho d ec id es h ow th e w ife ’s c as h ea rn in gs a re u se d: W ife ’s c as h ea rn in gs c om pa re d w ith h us ba nd ’s c as h ea rn in gs : N um be r o f w om en M ai nl y w ife W ife a nd hu sb an d jo in tly M ai nl y hu sb an d M is si ng To ta l M or e Le ss A bo ut th e sa m e H us ba nd h as no e ar ni ng s D on ’t kn ow To ta l A ge 15 -1 9 79 .4 10 .0 8. 2 2. 0 10 0. 0 0. 0 90 .2 1. 2 0. 9 7. 7 10 0. 0 15 1 20 -2 4 78 .8 10 .3 10 .1 0. 4 10 0. 0 2. 5 87 .3 3. 7 3. 5 3. 0 10 0. 0 50 0 25 -2 9 79 .5 13 .0 6. 3 0. 7 10 0. 0 3. 2 88 .7 2. 6 1. 3 4. 1 10 0. 0 83 1 30 -3 4 78 .6 13 .5 7. 7 0. 2 10 0. 0 4. 5 85 .8 3. 2 3. 0 3. 5 10 0. 0 74 8 35 -3 9 79 .7 11 .3 7. 1 1. 9 10 0. 0 4. 5 82 .4 3. 8 4. 4 4. 8 10 0. 0 61 4 40 -4 4 82 .2 10 .7 6. 5 0. 6 10 0. 0 9. 2 78 .0 5. 0 4. 6 3. 2 10 0. 0 48 6 45 -4 9 85 .3 5. 9 8. 8 0. 0 10 0. 0 7. 7 74 .6 5. 1 7. 0 5. 6 10 0. 0 34 7 N um be r o f l iv in g ch ild re n 0 84 .1 9. 5 4. 7 1. 1 10 0. 0 3. 6 84 .6 1. 7 3. 5 6. 7 10 0. 0 27 0 1- 2 79 .3 12 .0 8. 3 0. 2 10 0. 0 3. 9 87 .2 3. 1 2. 6 3. 1 10 0. 0 1, 10 6 3- 4 79 .8 11 .4 7. 4 1. 2 10 0. 0 4. 2 84 .3 3. 7 3. 7 4. 0 10 0. 0 99 5 5+ 80 .4 11 .2 7. 7 0. 7 10 0. 0 5. 8 81 .4 4. 3 3. 9 4. 6 10 0. 0 1, 30 7 R es id en ce U rb an 78 .3 13 .1 7. 2 1. 2 10 0. 0 7. 3 79 .4 3. 7 4. 2 5. 3 10 0. 0 1, 65 4 R ur al 81 .6 9. 9 7. 9 0. 4 10 0. 0 2. 5 88 .1 3. 5 2. 8 3. 2 10 0. 0 2, 02 4 Lo ca l G ov er nm en t A re a B an ju l 76 .8 13 .1 8. 3 1. 1 10 0. 0 11 .1 77 .5 1. 1 3. 9 6. 4 10 0. 0 66 K an ifi ng 79 .8 11 .7 5. 9 2. 6 10 0. 0 7. 7 76 .0 3. 0 5. 9 7. 3 10 0. 0 62 6 B rik am a 77 .4 14 .3 7. 7 0. 3 10 0. 0 6. 7 81 .2 4. 5 3. 8 3. 7 10 0. 0 1, 21 9 M an sa ko nk o 75 .2 13 .5 10 .6 0. 5 10 0. 0 3. 3 83 .8 9. 6 1. 9 1. 4 10 0. 0 17 8 K er ew an 83 .6 9. 0 6. 5 0. 3 10 0. 0 2. 6 79 .8 3. 4 5. 6 8. 6 10 0. 0 40 5 K un ta ur 68 .0 15 .2 16 .2 0. 5 10 0. 0 1. 2 91 .6 1. 9 1. 2 4. 2 10 0. 0 21 6 Ja nj an bu re h 61 .0 17 .4 20 .3 1. 0 10 0. 0 3. 8 88 .5 5. 0 1. 0 1. 6 10 0. 0 23 4 B as se 94 .3 3. 8 1. 9 0. 1 10 0. 0 0. 8 95 .6 1. 4 1. 3 0. 9 10 0. 0 73 4 Ed uc at io n N o ed uc at io n 81 .0 9. 6 8. 6 0. 7 10 0. 0 3. 6 84 .5 3. 8 4. 1 4. 0 10 0. 0 2, 32 9 P rim ar y 81 .7 10 .9 5. 9 0. 9 10 0. 0 4. 2 88 .3 1. 9 1. 5 4. 2 10 0. 0 47 4 S ec on da ry o r h ig he r 76 .9 16 .4 5. 8 0. 7 10 0. 0 7. 7 81 .0 4. 1 2. 8 4. 4 10 0. 0 87 6 W ea lth q ui nt ile Lo w es t 78 .1 10 .7 10 .5 0. 3 10 0. 0 3. 4 85 .8 3. 5 3. 4 3. 9 10 0. 0 72 0 S ec on d 81 .8 11 .5 6. 3 0. 3 10 0. 0 3. 6 86 .1 4. 0 2. 5 3. 8 10 0. 0 83 2 M id dl e 82 .9 9. 9 6. 8 0. 4 10 0. 0 3. 8 87 .4 3. 5 2. 0 3. 3 10 0. 0 77 9 Fo ur th 79 .5 8. 6 10 .5 0. 9 10 0. 0 6. 2 82 .5 2. 6 4. 7 4. 1 10 0. 0 68 0 H ig he st 77 .7 16 .4 4. 0 1. 9 10 0. 0 6. 8 78 .1 4. 3 5. 0 5. 9 10 0. 0 66 8 To ta l 80 .1 11 .4 7. 6 0. 7 10 0. 0 4. 7 84 .2 3. 6 3. 4 4. 1 10 0. 0 3, 67 8 208 • Women’s Empowerment and Demographic and Health Outcomes W om en ’s E m po w er m en t a nd D em og ra ph ic a nd H ea lth O ut co m es • 2 09 Ta bl e 15 .2 .2 C on tro l o ve r m en ’s c as h ea rn in gs P er ce nt d is tri bu tio ns o f c ur re nt ly m ar rie d m en a ge 1 5- 49 w ho r ec ei ve c as h ea rn in gs a nd o f c ur re nt ly m ar rie d w om en a ge 1 5- 49 w ho se h us ba nd s re ce iv e ca sh e ar ni ng s, b y pe rs on w ho d ec id es ho w h us ba nd ’s c as h ea rn in gs a re u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T he G am bi a 20 13 B ac kg ro un d ch ar ac te ris tic M en W om en M ai nl y w ife H us ba nd a nd w ife jo in tly M ai nl y hu sb an d O th er M is si ng To ta l N um be r M ai nl y w ife H us ba nd a nd w ife jo in tly M ai nl y hu sb an d O th er M is si ng To ta l N um be r of m en A ge 15 -1 9 * * * * * 10 0. 0 2 3. 3 12 .7 83 .3 0. 5 0. 2 10 0. 0 54 7 20 -2 4 0. 0 10 .2 87 .1 1. 6 1. 1 10 0. 0 52 5. 4 16 .3 77 .8 0. 1 0. 4 10 0. 0 1, 19 8 25 -2 9 0. 3 27 .2 69 .6 1. 7 1. 2 10 0. 0 18 2 6. 0 16 .5 77 .2 0. 1 0. 1 10 0. 0 1, 50 5 30 -3 4 0. 5 24 .3 74 .3 0. 7 0. 3 10 0. 0 29 4 7. 2 18 .7 73 .9 0. 1 0. 1 10 0. 0 1, 27 5 35 -3 9 0. 8 20 .3 78 .2 0. 3 0. 4 10 0. 0 32 8 9. 6 19 .7 69 .9 0. 0 0. 7 10 0. 0 93 2 40 -4 4 1. 8 31 .6 66 .0 0. 0 0. 6 10 0. 0 22 7 6. 6 17 .7 75 .4 0. 0 0. 3 10 0. 0 63 9 45 -4 9 1. 9 25 .5 72 .1 0. 5 0. 0 10 0. 0 18 8 7. 5 13 .6 78 .4 0. 0 0. 5 10 0. 0 46 1 N um be r o f l iv in g ch ild re n 0 0. 3 16 .0 81 .5 0. 8 1. 4 10 0. 0 13 7 6. 2 15 .7 77 .9 0. 0 0. 1 10 0. 0 73 9 1- 2 0. 1 23 .7 74 .3 1. 3 0. 6 10 0. 0 46 2 6. 2 17 .3 75 .9 0. 2 0. 5 10 0. 0 2, 15 8 3- 4 3. 0 29 .8 66 .7 0. 0 0. 5 10 0. 0 30 9 8. 2 18 .0 73 .6 0. 1 0. 0 10 0. 0 1, 74 4 5+ 0. 6 24 .4 74 .8 0. 2 0. 0 10 0. 0 36 5 5. 6 16 .2 77 .8 0. 1 0. 4 10 0. 0 1, 91 7 R es id en ce U rb an 1. 4 24 .0 74 .1 0. 3 0. 2 10 0. 0 72 6 10 .3 18 .7 70 .5 0. 2 0. 3 10 0. 0 3, 25 3 R ur al 0. 4 25 .2 72 .5 1. 1 0. 8 10 0. 0 54 7 2. 9 15 .2 81 .5 0. 1 0. 3 10 0. 0 3, 30 3 Lo ca l G ov er nm en t A re a B an ju l 0. 6 20 .8 78 .6 0. 0 0. 0 10 0. 0 28 14 .6 22 .9 62 .1 0. 4 0. 0 10 0. 0 11 1 K an ifi ng 1. 5 27 .0 70 .5 0. 5 0. 6 10 0. 0 27 3 14 .6 21 .6 63 .2 0. 2 0. 4 10 0. 0 1, 20 5 B rik am a 1. 2 24 .5 73 .9 0. 0 0. 5 10 0. 0 48 4 7. 0 16 .9 75 .6 0. 1 0. 3 10 0. 0 2, 21 1 M an sa ko nk o 2. 3 19 .3 75 .5 2. 8 0. 0 10 0. 0 53 2. 8 21 .1 76 .0 0. 0 0. 1 10 0. 0 34 0 K er ew an 0. 0 13 .6 85 .6 0. 3 0. 5 10 0. 0 11 9 1. 8 9. 1 88 .5 0. 2 0. 4 10 0. 0 75 2 K un ta ur 0. 0 51 .5 45 .3 3. 1 0. 0 10 0. 0 69 1. 7 9. 4 88 .6 0. 1 0. 1 10 0. 0 42 3 Ja nj an bu re h 0. 5 29 .3 66 .3 3. 3 0. 5 10 0. 0 81 5. 1 39 .9 54 .8 0. 0 0. 3 10 0. 0 54 5 B as se 0. 5 17 .3 81 .4 0. 0 0. 9 10 0. 0 16 7 2. 7 5. 6 91 .5 0. 0 0. 2 10 0. 0 97 0 Ed uc at io n N o ed uc at io n 0. 4 23 .2 75 .6 0. 6 0. 2 10 0. 0 59 6 5. 8 14 .7 79 .2 0. 1 0. 3 10 0. 0 3, 96 4 P rim ar y 0. 3 23 .6 73 .3 2. 0 0. 9 10 0. 0 15 5 4. 7 16 .5 78 .6 0. 1 0. 1 10 0. 0 88 5 S ec on da ry o r h ig he r 1. 9 26 .3 71 .0 0. 2 0. 7 10 0. 0 52 2 9. 4 22 .5 67 .5 0. 1 0. 4 10 0. 0 1, 70 8 W ea lth q ui nt ile Lo w es t 0. 7 21 .8 75 .8 1. 2 0. 5 10 0. 0 23 0 3. 5 16 .8 79 .2 0. 1 0. 4 10 0. 0 1, 25 2 S ec on d 0. 6 28 .2 70 .4 0. 2 0. 7 10 0. 0 22 5 3. 2 16 .3 80 .2 0. 1 0. 2 10 0. 0 1, 35 0 M id dl e 0. 2 26 .3 71 .1 1. 6 0. 9 10 0. 0 22 8 4. 4 13 .8 81 .6 0. 0 0. 3 10 0. 0 1, 35 3 Fo ur th 1. 6 23 .6 74 .2 0. 4 0. 2 10 0. 0 31 8 9. 2 14 .0 76 .0 0. 2 0. 5 10 0. 0 1, 30 0 H ig he st 1. 5 23 .4 74 .8 0. 0 0. 3 10 0. 0 27 3 12 .7 24 .0 63 .2 0. 1 0. 1 10 0. 0 1, 30 3 To ta l 1 5- 49 1. 0 24 .5 73 .4 0. 6 0. 5 10 0. 0 1, 27 4 6. 6 17 .0 76 .1 0. 1 0. 3 10 0. 0 6, 55 7 50 -5 9 0. 1 22 .5 76 .7 0. 2 0. 4 10 0. 0 20 5 na na na na na na na To ta l 1 5- 59 0. 9 24 .3 73 .8 0. 6 0. 5 10 0. 0 1, 47 9 na na na na na na na N ot e: A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. na = N ot a pp lic ab le Women’s Empowerment and Demographic and Health Outcomes • 209 210 • Women’s Empowerment and Demographic and Health Outcomes Table 15.3 shows who controls the wife’s and husband’s earnings by the amount of the wife’s earnings relative to her husband’s. Among currently married women who earn more than their husband, 77 percent decide mainly by themselves and 16 percent decide jointly with their husbands on how their earnings are spent. Likewise, 15 percent of these women mainly decide how their husbands’ earnings are spent, and an additional 21 percent make these decisions jointly with their husbands. Eighty-two percent of women who earn less than their husbands decide mainly themselves on their own earnings. The percentage of women who mainly decide themselves on how to spend their earnings is lowest (45 percent) among those who earn the same as their husbands. On the other hand, women who earn the same as their husbands are more likely than other women to decide how to use their earnings jointly with their husbands (47 percent). Women whose husbands have no cash earnings or do not work are more likely than others to be the main decision makers regarding their own earnings. Table 15.3 Women’s control over their own earnings and over those of their husbands Percent distribution of currently married women age 15-49 with cash earnings in the last 12 months by person who decides how the wife’s cash earnings are used and percent distribution of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband’s cash earnings are used, according to the relation between wife’s and husband’s cash earnings, The Gambia 2013 Women’s earnings relative to husband’s earnings Person who decides how the wife’s cash earnings are used: Total Number of women Person who decides how the husband’s cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Missing Mainly wife Wife and husband jointly Mainly husband Missing More than husband 77.4 15.6 6.8 0.0 100.0 171 14.9 21.2 63.9 0.0 100.0 171 Less than husband 82.0 10.1 7.6 0.1 100.0 3,096 7.3 16.3 76.3 0.1 100.0 3,096 Same as husband 45.0 47.2 7.8 0.0 100.0 132 5.6 65.7 28.7 0.0 100.0 132 Husband has no cash earnings or did not work 83.2 9.5 6.7 0.5 100.0 126 na na na na na na Woman worked but has no cash earnings na na na na na na 8.3 11.1 78.4 1.9 100.0 304 Woman did not work na na na na na na 5.0 15.9 78.6 0.4 100.0 2,701 Don’t know/missing 73.3 2.1 9.2 15.0 100.0 152 7.5 15.2 76.2 0.2 100.0 152 Total1 80.1 11.4 7.6 0.7 100.0 3,678 6.6 17.0 76.1 0.3 100.0 6,557 na = Not applicable 1 Includes cases where a woman does not know whether she earned more or less than her husband 15.3 OWNERSHIP OF ASSETS Ownership and control of assets by women and men influence their individual participation in development processes at all levels. Lack of assets makes women vulnerable to various forms of violence and lessens their decision-making power in the household. Tradition and low economic status limit women’s ownership of productive assets such as land and housing. Ownership of assets confers additional economic value, status, and bargaining power. Table 15.4.1 shows the percent distribution of women age 15-49 by ownership of housing and land. Overall, 25 percent of women own a house and 21 percent own land. Seventeen percent of currently married women reported that they jointly own a house, and 15 percent jointly own land. Five percent and 4 percent, respectively, own a house alone and land alone. Ownership of a house or land increases with women’s age. Rural women are more likely than urban women to own a house (31 percent versus 20 percent). Women in the lowest wealth quintile are more likely to own a house (31 percent) than women in the other four wealth quintiles but less likely to own land (19 percent). Women’s Empowerment and Demographic and Health Outcomes • 211 Table 15.4.1 Ownership of assets: Women Percent distribution of women age 15-49 by ownership of housing and land, according to background characteristics, The Gambia 2013 Background characteristic Percentage who own a house: Total Percentage who own land: Total Number of women Alone Jointly Alone and jointly Percentage who do not own a house Alone Jointly Alone and jointly Percentage who do not own land Age 15-19 3.2 17.2 1.6 77.9 100.0 1.9 12.8 0.7 84.5 100.0 2,407 20-24 3.8 17.1 1.7 77.3 100.0 2.9 16.3 0.5 80.3 100.0 2,125 25-29 4.0 15.6 3.0 77.4 100.0 4.3 15.6 0.9 79.2 100.0 1,822 30-34 5.5 17.8 3.1 73.6 100.0 4.8 15.8 1.4 78.0 100.0 1,504 35-39 6.2 17.9 3.2 72.7 100.0 6.6 16.5 1.2 75.6 100.0 1,056 40-44 10.7 18.9 2.9 67.4 100.0 8.5 17.9 1.0 72.0 100.0 761 45-49 10.4 18.5 2.1 68.7 100.0 9.9 15.5 1.3 73.3 100.0 559 Residence Urban 4.5 13.7 1.7 80.1 100.0 4.7 14.6 0.8 79.9 100.0 5,730 Rural 5.8 21.7 3.3 69.0 100.0 3.9 16.3 1.1 78.5 100.0 4,503 Local Government Area Banjul 2.9 13.7 2.1 81.3 100.0 4.6 12.2 1.7 81.5 100.0 225 Kanifing 6.4 14.8 2.2 76.6 100.0 6.1 15.2 0.2 78.4 100.0 2,342 Brikama 4.3 15.4 1.7 78.5 100.0 5.1 16.1 1.1 77.6 100.0 3,550 Mansakonko 12.7 11.6 6.9 68.6 100.0 9.4 10.1 2.9 77.6 100.0 490 Kerewan 3.3 8.8 0.9 87.1 100.0 2.8 12.5 0.5 84.3 100.0 1,107 Kuntaur 0.9 39.4 1.5 58.2 100.0 0.9 16.4 0.6 82.0 100.0 526 Janjanbureh 13.2 6.4 6.5 73.7 100.0 3.4 12.8 1.5 81.9 100.0 739 Basse 0.6 34.4 2.2 62.7 100.0 0.5 19.9 0.8 78.6 100.0 1,254 Education No education 5.6 16.9 3.1 74.3 100.0 3.6 14.9 0.9 80.5 100.0 4,757 Primary 4.8 20.1 1.8 73.3 100.0 4.0 14.1 1.1 80.6 100.0 1,405 Secondary or higher 4.5 16.7 1.8 76.9 100.0 5.4 16.4 0.9 77.3 100.0 4,071 Wealth quintile Lowest 9.4 18.1 3.4 69.0 100.0 5.0 12.8 1.1 81.0 100.0 1,745 Second 5.6 18.6 3.6 71.9 100.0 3.6 15.1 1.1 79.9 100.0 1,882 Middle 1.8 19.7 2.5 75.9 100.0 2.4 15.0 1.0 81.6 100.0 1,927 Fourth 2.5 15.3 1.6 80.6 100.0 3.1 17.0 0.7 79.2 100.0 2,135 Highest 6.3 15.4 1.4 76.9 100.0 7.1 16.2 0.8 75.9 100.0 2,545 Total 5.1 17.2 2.4 75.2 100.0 4.4 15.4 0.9 79.3 100.0 10,233 Table 15.4.2 shows the percent distribution of men age 15-49 by ownership of housing and land. Overall, 35 percent of men own a house and 29 percent own land (both percentages are higher than those for women). Similar to women, the data for men show that ownership of a house or land increases with age. Men with no education are more likely to own a home than men with a secondary education or higher (41 percent and 33 percent, respectively), but there is no variation in land ownership by education. The likelihood of men owning a house decreases steadily with increasing wealth, while land ownership fluctuates and does not follow a clear pattern. 212 • Women’s Empowerment and Demographic and Health Outcomes Table 15.4.2 Ownership of assets; Men Percent distribution of men age 15-49 by ownership of housing and land, according to background characteristics, The Gambia 2013 Background characteristic Percentage who own a house: Alone Percentage who own land: Total Number of men Alone Jointly Alone and jointly Percentage who do not own a house Total Jointly Alone and jointly Percentage who do not own land Age 15-19 2.4 17.1 0.9 79.5 100.0 2.7 11.8 0.6 84.9 100.0 836 20-24 7.1 20.8 1.0 71.1 100.0 3.9 15.8 1.4 78.8 100.0 849 25-29 15.3 20.3 1.4 63.0 100.0 10.0 13.6 4.6 71.8 100.0 586 30-34 18.8 20.3 1.9 59.0 100.0 17.5 13.8 4.0 64.7 100.0 425 35-39 31.8 17.4 2.2 48.5 100.0 27.4 11.1 1.8 59.7 100.0 391 40-44 28.3 14.9 3.0 53.7 100.0 28.9 17.2 2.1 51.8 100.0 270 45-49 42.5 17.2 2.9 37.5 100.0 39.0 11.3 4.6 45.1 100.0 220 Residence Urban 8.9 15.9 0.8 74.4 100.0 11.9 12.1 1.1 74.9 100.0 2,228 Rural 25.7 23.6 2.7 48.1 100.0 14.5 15.9 4.4 65.2 100.0 1,349 Local Governmen t Area Banjul 5.7 9.0 0.9 84.3 100.0 11.5 3.7 0.9 83.8 100.0 85 Kanifing 6.0 16.3 0.7 77.0 100.0 11.2 13.1 0.5 75.2 100.0 858 Brikama 14.1 17.7 0.4 67.8 100.0 13.5 14.7 1.2 70.5 100.0 1,454 Mansakonko 34.9 34.8 0.0 30.3 100.0 11.4 30.6 1.4 56.6 100.0 141 Kerewan 22.7 20.0 6.2 51.0 100.0 12.2 14.3 11.4 62.1 100.0 323 Kuntaur 28.9 11.2 12.9 46.9 100.0 20.7 9.1 13.3 56.9 100.0 141 Janjanbureh 22.1 23.6 1.6 52.4 100.0 8.3 8.1 0.2 83.0 100.0 240 Basse 20.0 23.9 0.0 56.1 100.0 16.1 10.0 0.6 73.2 100.0 336 Education No education 23.7 14.9 2.2 59.1 100.0 15.2 9.6 4.5 70.7 100.0 1,090 Primary 12.7 20.0 1.5 65.8 100.0 10.3 14.8 1.1 73.9 100.0 493 Secondary or higher 11.2 20.6 1.2 67.0 100.0 12.2 15.4 1.5 70.8 100.0 1,994 Wealth quintile Lowest 28.6 22.5 3.0 45.9 100.0 15.4 16.0 2.5 66.0 100.0 517 Second 22.4 24.9 2.5 50.1 100.0 12.2 15.3 4.6 67.8 100.0 614 Middle 14.3 20.1 1.1 64.4 100.0 15.4 15.6 2.9 66.1 100.0 588 Fourth 10.5 15.6 0.7 73.3 100.0 10.6 11.7 1.1 76.6 100.0 940 Highest 8.3 14.9 1.2 75.4 100.0 12.5 11.6 1.6 74.2 100.0 919 Total 15-49 15.2 18.8 1.5 64.5 100.0 12.9 13.6 2.3 71.2 100.0 3,577 50-59 54.5 18.1 3.1 24.1 100.0 46.4 10.0 3.7 39.6 100.0 244 Total 15-59 17.7 18.7 1.6 61.9 100.0 15.0 13.3 2.4 69.2 100.0 3,821 15.4 WOMEN’S PARTICIPATION IN HOUSEHOLD DECISION MAKING The ability of women to make decisions that affect their personal circumstances is essential for their empowerment and serves as an important factor in national development. To assess women’s decision-making autonomy, the 2013 GDHS collected information on women’s participation in three types of decisions: their own health care, major household purchases, and visits to family or relatives. Women are considered to participate in decision making if they make decisions alone or jointly with their husband or someone else. Table 15.5 shows the percent distribution of currently married women and currently married men age 15-49 by the person who usually makes decisions about these various issues. Women report that most decisions are made jointly with the exception of decisions regarding major household purchases, which are more likely to be made by their husband (49 percent). About seven in ten women participate (alone or jointly) in making decisions regarding their own health care (72 percent) and visiting their family or relatives (71 percent). Men are more likely to say that they are the sole decision maker when it comes to their own health care (59 percent) and major household purchases (58 percent). Women’s Empowerment and Demographic and Health Outcomes • 213 Table 15.5 Participation in decision making Percent distribution of currently married women and currently married men age 15-49 by person who usually makes decisions about various issues, The Gambia 2013 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Total Number WOMEN Own health care 26.7 45.0 27.2 0.7 100.0 6,791 Major household purchases 6.5 42.4 49.4 1.0 100.0 6,791 Visits to her family or relatives 18.2 53.0 27.8 0.5 100.0 6,791 MEN Own health care 2.6 37.1 59.4 0.3 100.0 1,360 Major household purchases 3.4 37.1 58.1 0.9 100.0 1,360 Table 15.6 shows the percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband by background characteristics. Nearly four in ten women (39 percent) report taking part in all three decisions, while 16 percent have no say in any of the three decisions. Women’s participation in all three decisions increases with increasing age, parity, and education, and it generally increases with wealth. Women in Kuntaur are least likely to participate in all three decisions (16 percent), while women in Mansakonko and Janjanbureh are most likely to do so (51 percent each). Table 15.6 Women’s participation in decision making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, The Gambia 2013 Background characteristic Specific decisions All three decisions None of the three decisions Number of women Woman’s own health care Making major household purchases Visits to her family or relatives Age 15-19 62.8 39.0 61.7 31.3 25.3 573 20-24 67.9 47.3 68.6 37.4 19.0 1,237 25-29 68.2 47.3 70.5 36.7 18.9 1,528 30-34 73.6 52.9 71.2 41.5 15.0 1,319 35-39 76.9 50.2 74.8 42.1 12.3 966 40-44 78.7 53.2 77.4 43.6 10.8 673 45-49 78.3 50.4 75.6 43.0 11.8 496 Employment (last 12 months) Not employed 65.8 44.4 68.6 36.4 20.8 2,797 Employed for cash 76.8 52.8 73.9 42.0 12.6 3,678 Employed not for cash 66.8 44.6 62.8 32.7 22.0 307 Number of living children 0 66.5 43.9 67.9 35.1 19.7 771 1-2 71.0 48.6 69.6 38.5 17.3 2,212 3-4 72.1 50.4 72.6 40.2 15.5 1,818 5+ 74.4 49.9 73.0 40.7 15.1 1,990 Residence Urban 71.7 52.0 71.4 41.4 15.7 3,356 Rural 71.8 45.9 71.0 37.1 17.2 3,435 Local Government Area Banjul 67.7 50.1 70.8 37.7 15.6 114 Kanifing 74.2 54.4 75.8 44.8 13.4 1,258 Brikama 68.4 49.0 67.2 38.3 18.5 2,282 Mansakonko 68.4 60.9 78.8 51.4 15.7 344 Kerewan 72.4 34.2 61.2 22.6 19.9 801 Kuntaur 51.8 28.9 47.2 15.7 35.1 427 Janjanbureh 69.7 62.6 73.2 50.5 17.1 550 Basse 86.8 50.3 88.9 47.3 5.1 1,015 Education No education 71.0 45.2 70.7 37.2 17.9 4,125 Primary 72.4 49.1 72.4 39.2 14.7 912 Secondary or higher 73.3 57.6 71.8 43.9 13.9 1,754 Wealth quintile Lowest 71.8 49.4 69.3 40.9 18.9 1,303 Second 71.0 44.4 70.0 35.5 18.0 1,404 Middle 71.6 49.2 72.9 39.6 15.8 1,386 Fourth 70.0 45.9 71.5 34.7 15.3 1,344 Highest 74.4 55.9 72.2 45.6 14.3 1,354 Total 71.8 48.9 71.2 39.2 16.4 6,791 214 • Women’s Empowerment and Demographic and Health Outcomes Figure 15.1 shows the number of decisions in which currently married women participate. Fewer than four in ten women (39 percent) participate in all three decisions, 30 percent participate in two of the three decisions, 14 percent participate only in one decision, and 16 percent do not participate in any decisions. Figure 15.1 Number of decisions in which currently married women participate Married men’s participation in specific decisions is uniformly high and consistently above 90 percent regardless of background characteristic (data not shown). 15.5 ATTITUDES TOWARD WIFE BEATING Wife beating is a form of gender-based violence that degrades women’s humanity. It is also a violation of women’s human rights. Abuse by physical violence is one of the most common forms of abuse in many developing countries, including The Gambia. Acceptance of this practice reflects women’s low status and the perception that men are superior to women. In addition to negative physical health outcomes, this form of violence lowers a woman’s self-esteem and her image in society, leading to her disempowerment. Moreover, it is clear that all violence against women has serious consequences for their mental and physical well-being, including their reproductive and sexual health. Tables 15.7.1 and 15.7.2 show the percentages of women and men, respectively, who agree that a husband is justified in hitting or beating his wife in each of the following five situations: if the wife burns the food, argues with him, goes out without telling him, neglects the children, or refuses to have sexual intercourse with him. Agreement that wife beating is acceptable among a high proportion of women is an indication that women generally accept the right of a man to control his wife’s behaviour even by means of violence. If a low proportion of women agree that wife beating is acceptable, then the majority of women reject beliefs and behaviours that place them at a low status relative to men. Eleven percent of women report that a husband is justified in hitting or beating his wife if she burns the food, 24 percent if she argues with him, 42 percent if she goes out without telling him, 35 percent if she neglects the children, and 45 percent if she refuses to have sexual intercourse with him. Overall, 58 percent of women age 15-49 agree with at least one of specified reasons. The percentage of women who agree with at least one of the specified reasons increases with increasing parity. It is lowest among women who are not employed (53 percent) and highest among those 16 14 30 39 0 1 2 3 Number of decisions Percent of women GDHS 2013 Women’s Empowerment and Demographic and Health Outcomes • 215 who are employed but not for cash (67 percent). Currently married women are more likely to agree with at least one reason than are never-married women (63 percent and 50 percent, respectively). Women in rural areas are much more likely than urban women to believe that wife beating is justified for at least one of the specified reasons (73 percent and 47 percent, respectively). Agreement with wife beating for at least one of the specified reasons is highest in Basse (87 percent) and Kuntaur (82 percent) and lowest in Kanifing (42 percent). The percentage of women who believe that wife beating is justified for at least one of the specified reasons tends to decrease with increasing wealth. Table 15.7.1 Attitude toward wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, The Gambia 2013 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number of women Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 13.2 25.4 43.0 37.3 41.6 58.3 2,407 20-24 10.7 24.4 39.5 35.1 43.4 56.7 2,125 25-29 9.7 23.5 40.2 33.2 43.7 55.4 1,822 30-34 8.3 24.2 44.9 35.2 48.8 62.6 1,504 35-39 10.5 22.5 42.8 36.2 46.8 60.2 1,056 40-44 9.9 22.9 43.3 34.3 47.1 59.0 761 45-49 9.2 23.6 42.4 33.0 47.5 59.2 559 Employment (last 12 months) Not employed 8.8 20.2 36.4 30.4 39.7 52.8 5,109 Employed for cash 12.5 27.8 47.2 39.8 49.6 63.8 4,668 Employed not for cash 12.1 30.2 53.1 44.6 51.4 67.2 431 Number of living children 0 10.7 20.4 35.5 31.6 36.7 51.8 3,530 1-2 10.1 25.0 42.2 36.7 45.0 58.8 2,644 3-4 9.4 25.7 45.1 36.2 49.1 61.6 1,955 5+ 12.3 27.7 49.9 38.7 53.6 66.1 2,103 Marital status Never married 9.4 18.1 33.3 30.5 33.6 50.0 2,963 Married or living together 11.5 27.4 46.5 38.1 50.1 62.9 6,791 Divorced/separated/widowed 5.2 14.4 32.0 25.4 36.6 46.9 478 Residence Urban 4.8 13.8 29.7 23.4 33.1 47.1 5,730 Rural 18.0 37.2 57.7 50.4 59.5 72.7 4,503 Local Government Area Banjul 5.3 14.4 26.3 28.0 31.6 50.7 225 Kanifing 3.4 10.6 23.8 20.5 27.7 42.3 2,342 Brikama 7.6 17.3 34.8 27.5 38.4 52.5 3,550 Mansakonko 8.8 28.8 45.6 39.3 53.8 64.8 490 Kerewan 13.5 31.1 46.0 30.5 51.7 62.3 1,107 Kuntaur 17.6 34.9 68.6 62.9 68.0 81.7 526 Janjanbureh 16.3 32.4 53.6 43.4 51.9 65.2 739 Basse 25.3 52.7 76.3 72.4 72.8 86.9 1,254 Education No education 13.4 29.8 52.0 42.1 54.7 67.8 4,757 Primary 13.7 29.8 49.7 40.9 53.3 66.8 1,405 Secondary or higher 6.3 15.5 27.6 25.3 30.0 44.5 4,071 Wealth quintile Lowest 15.6 34.5 53.9 44.5 56.7 68.9 1,745 Second 16.2 34.0 53.6 44.2 55.1 68.7 1,882 Middle 15.0 29.8 55.5 46.4 56.3 70.4 1,927 Fourth 6.4 16.7 34.4 30.2 39.3 54.8 2,135 Highest 3.3 11.5 21.4 18.1 24.5 37.5 2,545 Total 10.6 24.1 42.0 35.3 44.7 58.4 10,233 Among men, 6 percent report that a husband is justified in hitting or beating his wife if she burns the food, 11 percent if she argues with him, 21 percent if she goes out without telling him, and 19 percent, each, if she neglects the children or if she refuses to have sexual intercourse with him Table 15.7.2. A lower proportion of men than women agree that a husband is justified in beating his wife for at least one of the specific reasons mentioned (33 percent versus 58 percent). Men age 15-19 (42 percent), those employed but not for cash (47 percent), those with no living children (36 percent), and those who have never been married (37 percent) are more likely than other groups to agree with at least one specified reason to justify wife beating. Similar to women, rural men are notably 216 • Women’s Empowerment and Demographic and Health Outcomes more likely than urban men to believe that wife beating is justified for at least one of the specified reasons (41 percent versus 28 percent). By LGA, more than half of men in Mansakonko (51 percent) and Janjanbureh (50 percent) believe that wife beating is justified for at least one of the specified reasons. Wealth is inversely associated with the percentage of men who agree with at least one of the specified reasons. Table 15.7.2 Attitude toward wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, The Gambia 2013 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number of men Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 11.8 17.2 30.6 25.2 25.4 41.9 836 20-24 6.5 11.4 21.9 19.7 21.5 35.7 849 25-29 4.7 10.9 18.3 17.0 15.5 30.8 586 30-34 3.8 8.0 16.2 16.7 17.4 30.0 425 35-39 3.0 5.8 12.9 11.6 13.6 22.6 391 40-44 3.9 8.7 14.7 14.5 12.3 23.0 270 45-49 2.4 9.9 17.1 19.6 19.8 31.5 220 Employment (last 12 months) Not employed 9.7 12.3 24.1 20.6 20.0 35.4 995 Employed for cash 4.3 9.8 17.8 16.8 18.2 30.3 2,298 Employed not for cash 10.7 20.7 35.3 30.5 25.7 47.4 278 Number of living children 0 7.9 13.2 24.2 20.9 21.4 36.3 2,282 1-2 3.6 7.9 12.9 12.7 14.0 25.8 558 3-4 4.6 6.4 14.3 17.0 17.8 26.0 336 5+ 2.3 9.7 18.1 17.9 16.2 30.3 400 Marital status Never married 8.1 13.6 24.7 21.5 22.0 37.2 2,177 Married or living together 3.5 7.9 14.7 14.8 15.1 26.6 1,360 Divorced/separated/widowed (3.9) (6.7) (17.2) (17.7) (16.1) (26.4) 40 Residence Urban 4.2 8.8 17.0 15.6 16.0 28.3 2,228 Rural 9.7 15.6 27.2 24.4 24.7 40.8 1,349 Local Government Area Banjul 3.0 5.0 9.6 11.9 11.5 21.4 85 Kanifing 4.1 7.2 15.2 14.4 14.3 25.8 858 Brikama 5.0 9.8 18.5 15.7 18.1 30.7 1,454 Mansakonko 16.5 29.3 41.9 33.1 31.1 51.1 141 Kerewan 9.9 12.8 26.8 19.0 25.8 43.1 323 Kuntaur 3.3 8.3 10.1 17.8 12.0 25.6 141 Janjanbureh 14.0 25.6 34.9 39.8 31.0 49.8 240 Basse 6.1 12.7 28.2 25.5 22.6 38.2 336 Education No education 4.7 12.0 24.6 19.9 23.4 35.2 1,090 Primary 10.2 16.6 27.9 23.0 26.4 41.9 493 Secondary or higher 6.2 9.7 17.0 17.4 15.3 29.7 1,994 Wealth quintile Lowest 10.6 17.0 25.2 25.0 25.5 42.8 517 Second 7.4 11.9 25.6 19.9 22.1 35.9 614 Middle 8.9 13.3 24.5 24.3 21.2 35.7 588 Fourth 4.6 11.6 20.4 18.7 19.3 33.5 940 Highest 3.1 6.3 13.3 11.6 12.8 23.5 919 Total 15-49 6.3 11.4 20.8 18.9 19.3 33.0 3,577 50-59 2.5 6.4 13.8 9.9 15.4 21.3 244 Total 15-59 6.0 11.0 20.4 18.3 19.0 32.3 3,821 Notes: Figures in parentheses are based on 25-49 unweighted cases. Total includes 6 cases for whom information on employment in the last 12 months is missing. 15.6 WOMEN’S EMPOWERMENT INDICATORS The two sets of empowerment indicators, namely women’s participation in making household decisions and their attitude toward wife beating, can be summarised in two separate indices. The first index shows the number of decisions (see Table 15.6 for the list of decisions) in which women participate alone Women’s Empowerment and Demographic and Health Outcomes • 217 or jointly with their husband or partner. This index ranges in value from 0 to 3 and relates positively to women’s empowerment. It reflects the degree of control that women are able to exercise in areas that affect their own lives and environments. The second index, which ranges in value from 0 to 5, is the total number of reasons (see Table 15.7.1 for the list of reasons) for which the respondent feels that a husband is justified in beating his wife. A lower score on this indicator is interpreted as reflecting a greater sense of entitlement and self-esteem and higher status. Table 15.8 shows the percentage of currently married women age 15-49 who participate in all decision making and the percentage who disagree with all of the reasons justifying wife beating by the value on each of the indicators of women’s empowerment. The table also shows how these two indices relate to each other. The proportion of women who disagree with all reasons for wife beating is highest among those who participate in making all three of the specified household decisions (39 percent) and lowest among those who do not participate in any of the decisions (30 percent). However, the percentage of women who participate in all five household decisions is highest among those who agree with all five reasons justifying wife beating (44 percent). Table 15.8 Indicators of women’s empowerment Percentage of currently married women age 15-49 who participate in all decision making and the percentage who disagree with all of the reasons justifying wife beating, by value on each of the indicators of women’s empowerment, The Gambia 2013 Empowerment indicator Percentage who participate in all decision making Percentage who disagree with all reasons justifying wife beating Number of women Number of decisions in which women participate1 0 na 29.7 1,117 1-2 na 37.9 3,011 3 na 39.4 2,663 Number of reasons for which wife beating is justified2 0 41.6 na 2,522 1-2 39.0 na 1,996 3-4 34.4 na 1,735 5 44.3 na 537 na = Not applicable 1 See Table 15.6 for the list of decisions. 2 See Table 15.7.1 for the list of reasons. 15.7 CURRENT USE OF CONTRACEPTION BY WOMEN’S EMPOWERMENT STATUS A woman’s desire and ability to control her fertility and her choice of contraceptive methods are affected by her status in the household and her own sense of empowerment. A woman who is unable to control other aspects of her life may be less able to make decisions regarding her fertility. She may also feel the need to choose contraceptive methods that are less obvious or do not need the approval or knowledge of her husband. Table 15.9 shows the percent distribution of currently married women age 15-49 by contraceptive method used. It also illustrates the relationship of each of the two indicators of women’s empowerment (number of decisions in which the woman participates and number of reasons that wife beating is justified) with current contraceptive method. Caution is advised when interpreting these numbers since the vast majority of women in The Gambia are not currently using any contraceptive method. Use of modern contraceptive methods tends to increase as women agree with fewer reasons justifying wife beating. There is no correlation with the number of decisions in which a woman participates. 218 • Women’s Empowerment and Demographic and Health Outcomes Table 15.9 Current use of contraception by women’s empowerment Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women’s status, The Gambia 2013 Empowerment indicator Any method Any modern method Modern methods Any traditional method Not currently using Total Number of women Female sterili- sation Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 9.3 8.3 1.0 6.8 0.6 1.0 90.7 100.0 1,117 1-2 8.6 7.6 0.5 6.4 0.6 1.1 91.4 100.0 3,011 3 9.2 8.5 0.5 7.5 0.5 0.6 90.8 100.0 2,663 Number of reasons for which wife beating is justified3 0 11.8 11.2 0.8 9.6 0.8 0.7 88.2 100.0 2,522 1-2 8.5 7.3 0.7 6.3 0.3 1.2 91.5 100.0 1,996 3-4 6.7 5.7 0.3 5.0 0.5 0.9 93.3 100.0 1,735 5 4.5 3.8 0.3 3.2 0.3 0.8 95.5 100.0 537 Total 9.0 8.1 0.6 6.9 0.6 0.9 91.0 100.0 6,791 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly, and lactational amenorrhoea method 2 See Table 15.6 for the list of decisions. 3 See Table 15.7.1 for the list of reasons. 15.8 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS As a woman becomes more empowered, she is more likely to have a say in the number (ideal family size) and spacing of children she desires. She therefore has more control over her own fertility. Women who have a desire to limit their births but who are not using family planning are defined as having an unmet need for family planning. Table 15.10 shows the mean ideal number of children for women age 15-49 and the percentage of currently married women with an unmet need of family planning by the two indicators of women’s empowerment. There is little correlation between a woman’s status and her mean ideal number of children. However, women who believe that wife beating is justified tend to want more children. For example, women who agree with all five reasons for wife beating have the highest mean ideal number of children (7.2), while women who do not believe that wife beating is ever justified have the lowest mean ideal family size (5.5). There is no clear relationship between the indices of woman’s status and unmet need for family planning. Table 15.10 Ideal number of children and unmet need for family planning by women’s empowerment Mean ideal number of children for women age 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women’s empowerment, The Gambia 2013 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of women For spacing For limiting Total Number of decisions in which women participate3 0 6.6 1,032 21.8 2.2 24.0 1,117 1-2 6.4 2,909 19.0 5.5 24.5 3,011 3 6.5 2,624 20.4 5.4 25.8 2,663 Number of reasons for which wife beating is justified4 0 5.5 4,197 19.5 5.1 24.7 2,522 1-2 6.1 2,868 19.8 5.0 24.8 1,996 3-4 6.6 2,191 20.8 4.5 25.3 1,735 5 7.2 677 20.2 5.2 25.4 537 Total 6.0 9,934 20.0 4.9 24.9 6,791 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.10 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 15.6 for the list of decisions. 4 See Table 15.7.1 for the list of reasons. Women’s Empowerment and Demographic and Health Outcomes • 219 15.9 WOMEN’S STATUS AND REPRODUCTIVE HEALTH CARE Women’s empowerment affects their ability to access reproductive health services. Higher levels of empowerment are likely to increase women’s ability to seek out and use health services to better meet their reproductive health goals, including safe motherhood. Table 15.11 shows the percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance, and postnatal care from skilled providers for their most recent birth, according to indicators of women’s empowerment. Because most women in The Gambia receive antenatal care from skilled providers, there are no major differences by empowerment indicators in receipt of ANC from a skilled provider (doctor, nurse, or midwife). The percentage of women receiving ANC from a skilled provider is lowest among those who participate in three decisions (83 percent) and those who agree with all five reasons for which wife beating is justified (75 percent). The number of reasons for which wife beating is justified is negatively associated with women’s access to delivery care from a skilled provider. Women who agree with all five reasons justifying wife beating are least likely to receive delivery care from a skilled provider (35 percent), and those who agree with none of the reasons are most likely to receive delivery care (68 percent). The proportion of women who received postnatal care from health personnel within the first two days after delivery increases from 64 percent among those who have no say in decision making to 82 percent among those who take part in making all three types of decisions. Similar to delivery care, women who agree with none of the reasons justifying wife beating are most likely to receive postnatal care from health personnel (81 percent), and those who agree with all five reasons are least likely to receive postnatal care (69 percent). Table 15.11 Reproductive health care by women's empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance, and postnatal care from health personnel for the most recent birth, by indicators of women's empowerment, The Gambia 2013 Empowerment indicator Percentage receiving antenatal care from a skilled provider1 Percentage receiving delivery care from a skilled provider1 Received postnatal care from health personnel within the first two days since delivery2 Number of women with a child born in the last five years Number of decisions in which women participate3 0 85.3 56.0 64.3 849 1-2 89.1 58.3 73.2 2,171 3 83.4 58.1 82.1 1,870 Number of reasons for which wife beating is justified4 0 84.5 67.9 80.6 1,919 1-2 88.4 59.2 74.3 1,547 3-4 89.5 54.5 70.6 1,406 5 75.4 34.5 68.9 434 Total 86.2 59.1 75.1 5,305 1 “Skilled provider” includes doctor, nurse, or midwife. 2 Includes women who received a postnatal checkup from a doctor, nurse, midwife, community health worker, or traditional birth attendant in the first 2 days after the birth. Includes women who gave birth in a health facility and those who did not give birth in a health facility. 3 Restricted to currently married women. See Table 15.6 for the list of decisions. 4 See Table 15.7.1 for the list of reasons. 15.10 DIFFERENTIALS IN INFANT AND CHILD MORTALITY BY WOMEN’S STATUS The ability of women to access information and make decisions and their ability to act effectively in their own interests or the interests of those who depend on them are essential aspects of empowerment. If 220 • Women’s Empowerment and Demographic and Health Outcomes women, the primary caretakers of children, are empowered, the health and survival of their infants will be enhanced. In fact, maternal empowerment fits into Mosley and Chen’s framework on child survival as an individual-level variable that affects child survival through proximate determinants (Mosley and Chen, 1984). Table 15.12 presents childhood mortality rates by the two indices of women’s status (participation in household decision making and attitudes toward wife beating). It shows that the likelihood of children surviving increases with improvements in women’s empowerment status. For instance, the infant mortality rate and under-5 mortality rate are 28 and 43 deaths per 1,000 live births, respectively, among children whose mothers believe that there is no justified reason for a husband to beat his wife. In contrast, among children whose mothers agree with all five reasons for wife beating, the infant mortality rate is 50 deaths per 1,000 live births and the under-5 mortality rate is 90 deaths per 1,000 live births. There is little difference in child mortality by number of decisions in which the mother participates. 15.11 FEMALE GENITAL CUTTING Female genital cutting (FGC), also known as female circumcision or female genital mutilation, is a common practice in many societies in Africa. Nearly universal in a few countries, it is practiced by various groups in at least 25 African nations, in Yemen, and in immigrant African populations in Europe and North America (Yoder, Abderrahim, and Zhuzhuni, 2004). In a few societies the procedure is routinely carried out when a girl is a few weeks or a few months old (e.g., Eritrea, Yemen), while in most others it occurs later in childhood or adolescence. In the case of the latter, FGC is typically part of a ritual initiation into womanhood that includes a period of seclusion and education about the rights and duties of a wife. The 2013 GDHS collected data on the practice of female circumcision from women age 15-49. This section discusses knowledge and prevalence of female circumcision and attitudes toward the practice. Among women who were circumcised, information about the type of circumcision, age at circumcision, and person who performed the circumcision was also collected. The terms FGC and female circumcision are used interchangeably in this section. 15.11.1 Knowledge of Female Genital Cutting Table 15.13 presents data on women’s knowledge of female circumcision. Almost all women in The Gambia (99 percent) have heard of the practice. There are no notable variations in knowledge of female circumcision by background characteristics. Table 15.12 Early childhood mortality rates by women’s status Infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by indicators of women’s empowerment, The Gambia 2013 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Number of decisions in which women participate1 0 41 26 65 1-2 36 25 61 3 44 21 64 Number of reasons for which wife beating is justified2 0 28 15 43 1-2 42 18 59 3-4 50 33 81 5 50 42 90 1 Restricted to currently married women. See Table 15.6 for the list of decisions. 2 See Table 15.7.1 for the list of reasons. Women’s Empowerment and Demographic and Health Outcomes • 221 Table 15.13 Knowledge of female circumcision Percentage of women age 15-49 who have heard of female circumcision, according to background characteristics, The Gambia 2013 Background characteristic Percentage of women who have heard of female circumcision Number of women Age 15-19 99.4 2,407 20-24 98.9 2,125 25-29 99.0 1,822 30-34 99.5 1,504 35-39 99.1 1,056 40-44 99.2 761 45-49 99.3 559 Religion Islam 99.3 9,793 Christianity 96.3 427 Residence Urban 99.4 5,730 Rural 98.9 4,503 Local Government Area Banjul 98.5 225 Kanifing 99.6 2,342 Brikama 99.4 3,550 Mansakonko 99.9 490 Kerewan 96.4 1,107 Kuntaur 99.9 526 Janjanbureh 99.3 739 Basse 99.8 1,254 Education No education 98.8 4,757 Primary 99.1 1,405 Secondary or higher 99.7 4,071 Wealth quintile Lowest 99.1 1,745 Second 98.6 1,882 Middle 99.6 1,927 Fourth 99.0 2,135 Highest 99.6 2,545 Total 99.2 10,233 Note: Total includes 6 cases with no religion and 6 cases for whom information on religion is missing. 15.11.2 Prevalence of Female Genital Cutting Table 15.14 shows the prevalence of female circumcision by background characteristics. The overall prevalence of FGC among women age 15-49 in The Gambia is 75 percent, slightly lower than 76 percent as reported in the 2010 MICS (GBoS, 2011). The practice of FGC varies little by age. It is higher among women in rural (79 percent) than in urban (72 percent) areas. The proportion of women who are circumcised is highest in Basse and Mansakonko (97 percent and 94 percent, respectively) and lowest in Banjul (47 percent). As noted, women who reported that they had been circumcised were asked about the type of circumcision. Table 15.14 indicates that among the overwhelming majority of women, circumcision involved cutting and removal of flesh (85 percent). Less than 1 percent of women reported that they were cut but that no flesh was removed. 222 • Women’s Empowerment and Demographic and Health Outcomes Table 15.14 Prevalence of female circumcision Percentage of women circumcised and the percent distribution of circumcised women by type of circumcision, according to background characteristics, The Gambia 2013 Percentage of women circumcised Number of women Type of circumcision Total Number of circumcised women Background characteristic Cut, no flesh removed Cut, flesh removed Don’t know/ missing Age 15-19 76.3 2,407 0.3 84.7 15.1 100.0 1,837 20-24 74.1 2,125 0.3 82.6 17.1 100.0 1,574 25-29 73.5 1,822 0.4 84.5 15.0 100.0 1,340 30-34 73.9 1,504 0.1 87.1 12.8 100.0 1,111 35-39 76.8 1,056 0.0 86.2 13.7 100.0 811 40-44 74.9 761 0.0 85.6 14.4 100.0 570 45-49 75.9 559 0.0 91.9 8.1 100.0 424 Religion Islam 77.3 9,793 0.2 85.2 14.6 100.0 7,568 Christianity 20.9 427 0.3 82.7 17.0 100.0 90 Residence Urban 71.6 5,730 0.3 84.0 15.7 100.0 4,104 Rural 79.1 4,503 0.1 86.6 13.3 100.0 3,564 Local Government Area Banjul 47.4 225 1.5 81.9 16.7 100.0 107 Kanifing 69.7 2,342 0.4 84.1 15.5 100.0 1,631 Brikama 77.6 3,550 0.1 88.9 11.0 100.0 2,757 Mansakonko 94.0 490 0.1 99.0 0.9 100.0 460 Kerewan 58.6 1,107 0.0 95.0 5.0 100.0 649 Kuntaur 57.1 526 0.3 89.0 10.7 100.0 300 Janjanbureh 74.7 739 0.6 82.4 17.0 100.0 552 Basse 96.7 1,254 0.0 68.4 31.6 100.0 1,212 Total 74.9 10,233 0.2 85.2 14.6 100.0 7,668 Note: Total includes 6 cases with no religion and 6 cases for whom information on religion is missing. Table 15.15 shows the percent distribution of women by age at circumcision. In The Gambia, female circumcision is done throughout childhood, with 55 percent of women reporting that they were circumcised before age 5. Another 28 percent of women were circumcised between age 5 and age 9, and 7 percent were circumcised between age 10 and 14. Table 15.15 Age at circumcision Percent distribution of circumcised women age 15-49 by age at circumcision, according to background characteristics, The Gambia 2013 Age at circumcision Total Number of circumcised women Background characteristic <51 5-9 10-14 15+ Don’t know/ missing Age 15-19 59.6 23.7 5.5 0.5 10.7 100.0 1,837 20-24 57.1 28.5 5.5 0.7 8.2 100.0 1,574 25-29 58.4 26.6 4.9 1.2 8.9 100.0 1,340 30-34 52.5 30.0 8.1 0.5 8.8 100.0 1,111 35-39 46.9 33.1 8.9 0.9 10.2 100.0 811 40-44 47.5 29.2 12.3 1.0 10.0 100.0 570 45-49 44.0 34.4 11.1 2.8 7.6 100.0 424 Religion Islam 54.8 28.2 6.8 0.8 9.3 100.0 7,568 Christianity 45.1 20.9 17.5 10.2 6.4 100.0 90 Residence Urban 49.5 30.0 8.3 1.1 11.1 100.0 4,104 Rural 60.8 25.9 5.3 0.7 7.3 100.0 3,564 Local Government Area Banjul 34.9 32.1 12.5 3.2 17.2 100.0 107 Kanifing 42.7 31.9 9.9 1.1 14.5 100.0 1,631 Brikama 53.7 31.0 7.6 1.3 6.4 100.0 2,757 Mansakonko 50.7 36.5 5.8 0.2 6.8 100.0 460 Kerewan 41.7 29.7 7.7 0.8 20.1 100.0 649 Kuntaur 51.7 29.7 4.1 0.6 14.0 100.0 300 Janjanbureh 57.1 24.7 4.1 0.1 14.0 100.0 552 Basse 83.3 13.3 3.0 0.2 0.2 100.0 1,212 Total 54.8 28.1 6.9 0.9 9.3 100.0 7,668 Note: Total includes 6 cases with no religion and 6 cases for whom information on religion is missing. 1 Includes women who reported that they were circumcised during infancy but did not provide a specific age Women’s Empowerment and Demographic and Health Outcomes • 223 The percentage of women who were circumcised before age 5 is highest among those age 15-19 (60 percent) and those who practice Islam (55 percent). Rural women (61 percent) are more likely than urban women (50 percent) to have been circumcised by age 5. By LGA, the proportion of women who were circumcised before age 5 is highest in Basse (83 percent) and lowest in Banjul (35 percent). Table 15.16 shows the person who performed the circumcision among circumcised women age 15-49. Almost all circumcisions (96 percent) were performed by traditional circumcisers. Traditional birth attendants performed only 1 percent of circumcisions, and medical practitioners performed less than 1 percent. 15.11.3 Attitudes Toward Female Genital Cutting Women who had heard of female circumcision were asked if they thought the practice should be continued or discontinued. Table 15.17 indicates that the majority of women who have heard of female circumcision (65 percent) believe that the practice should be continued; 33 percent believe that it should be discontinued. Table 15.17 Attitudes towards female genital cutting Percent distribution of all women who have heard of female circumcision by opinion on whether female genital cutting should be continued, according to selected background characteristics, The Gambia 2013 Women Background characteristic Continued Not continued Don’t know/ missing/depends Total Number of women Female circumcision status Circumcised 84.2 14.8 1.0 100.0 7,668 Not circumcised 5.4 91.3 3.2 100.0 2,462 Age 15-19 66.8 31.9 1.3 100.0 2,393 20-24 63.9 34.3 1.9 100.0 2,102 25-29 65.1 33.3 1.6 100.0 1,805 30-34 63.6 35.1 1.2 100.0 1,496 35-39 64.4 34.0 1.5 100.0 1,046 40-44 63.8 34.0 2.1 100.0 755 45-49 67.0 30.3 2.7 100.0 555 Religion Islam 67.0 31.4 1.6 100.0 9,728 Christianity 16.0 82.2 1.8 100.0 412 Residence Urban 61.3 37.0 1.7 100.0 5,697 Rural 69.7 28.8 1.5 100.0 4,455 Local Government Area Banjul 38.5 58.2 3.3 100.0 222 Kanifing 56.9 41.5 1.7 100.0 2,333 Brikama 69.4 29.2 1.4 100.0 3,530 Mansakonko 81.7 16.9 1.4 100.0 489 Kerewan 53.3 42.7 4.0 100.0 1,067 Kuntaur 40.8 58.1 1.1 100.0 525 Janjanbureh 57.0 42.1 0.9 100.0 734 Basse 90.5 9.0 0.6 100.0 1,252 Education No education 67.1 31.0 1.8 100.0 4,701 Primary 72.7 25.3 2.0 100.0 1,392 Secondary or higher 59.8 39.0 1.2 100.0 4,059 Wealth quintile Lowest 70.3 27.7 1.9 100.0 1,729 Second 67.9 30.6 1.4 100.0 1,856 Middle 71.8 26.6 1.6 100.0 1,918 Fourth 65.7 32.9 1.4 100.0 2,114 Highest 53.3 44.9 1.7 100.0 2,534 Total 15-49 65.0 33.4 1.6 100.0 10,152 Note: Total includes 5 cases for whom information on female circumcision status is missing, 6 cases with no religion, and 6 cases for whom information on religion is missing. Table 15.16 Person performing circumcision among circumcised women age 15-49 Percent distribution of circumcised women age 15-49 according to person performing the circumcision, The Gambia 2013 Background characteristic Women age 15-49 Person who performed the circumcision Traditional circumciser 95.7 Traditional birth attendant 1.2 Medical professional 0.3 Don’t know/missing 2.8 Total 100.0 Number of circumcised women 7,668 Note: The circumcision status of girls is reported by their mothers. 224 • Women’s Empowerment and Demographic and Health Outcomes As expected, the proportion of women who say that female circumcision should continue is much higher among circumcised women than among those who are not circumcised (84 percent versus 5 percent). Support for FGC is greater among rural women (70 percent) than urban women (61 percent). By LGA, the percentage of women who think that FGC should continue is highest in Basse (91 percent) and lowest in Banjul (39 percent). In general, support for continuation of FGC decreases with increasing education and wealth. Domestic Violence • 225 DOMESTIC VIOLENCE 16 ender-based violence is defined as any act that results in or is likely to result in physical, sexual, or psychological harm or suffering among women, including threats of such acts and coercion or arbitrary deprivations of liberty, whether occurring in public or in private life (United Nations, 1993; United Nations, 1995). One form of gender-based violence is domestic violence, also known as domestic abuse, spousal violence, family violence, or intimate partner violence. Domestic violence, broadly defined as a pattern of abusive behaviours by one or both partners in an intimate relationship, has many forms, including physical aggression (hitting, kicking, biting, shoving, restraining, slapping, or throwing objects) and threats, sexual and emotional abuse, controlling or domineering behaviours, intimidation, stalking, and passive or covert abuse (e.g., neglect or economic deprivation). Domestic violence continues to be a problem in The Gambia despite the ongoing efforts undertaken by the government of The Gambia and civil society organisations. Challenges include a culture where survivors suffer in silence, constrained factors such as fear of reprisals, unequal power relations, stigma, discrimination, and undue pressure from family and friends, especially if the perpetrator is a family member. As a result, most cases of violence against women, especially those occurring at home (e.g., wife beating, incest), go unreported. The Gambian government is committed to ending violence against women and girls. This is made clear in the passage of the Women’s Act of 2010 and the ratification of the Convention to Eliminate All Forms of Discrimination Against Women (CEDAW). The Gambia is a signatory to the Protocol on the African Charter on Human and People’s Rights, the Rights of Women in Africa, and the African Union’s Solemn Declaration on Gender Equality in Africa. The signing of these declarations and conventions demonstrates the government’s recognition of the need for addressing the problem of domestic violence in The Gambia. The Sexual Offence and Domestic Violence Bill, enacted by the National Assembly in 2013, addresses issues associated with violence and the socioeconomic empowerment of women. In the same vein, the 2013-2017 National Plans of Action for addressing gender-based violence and female genital mutilation/cutting has been developed and is being implemented. G Key Findings • Forty-one percent of women age 15-49 have experienced physical violence at least once since age 15, and 10 percent experienced physical violence within the 12 months prior to the survey. • Five percent of women age 15-49 report having experienced sexual violence at least once in their lifetime. • Overall, about one in four ever-married women (26 percent) report having experienced emotional, physical, or sexual violence from their spouse, and 12 percent report having experienced one or more of these forms of violence in the past 12 months. • Among ever-married women who had experienced spousal violence (physical or sexual) in the past 12 months, 24 percent reported experiencing physical injuries. • It is not common for women in The Gambia to seek assistance from any source for violence they have experienced. Only 38 percent of abused women sought help to stop the violence. 226 • Domestic Violence 16.1 VALID MEASURES OF DOMESTIC VIOLENCE Collection of valid, reliable, and ethical data on domestic violence involves particular challenges because what constitutes violence or abuse varies across cultures and individuals, and a culture of silence usually affects reporting of violence. Moreover, the sensitivity of the topic must be addressed. Assuring the safety of respondents and interviewers when asking about domestic violence in a familial setting, protecting women who disclose violence, and reducing the risk of double victimisation of respondents as they relive their experiences are all ethical concerns. Responses to these challenges in the 2013 GDHS are described below. 16.1.1 Use of Valid Measures of Violence In the 2013 GDHS, information was obtained from ever-married respondents on violence committed by their current and former spouses and by others. Information was collected from never- married respondents on violence committed by anyone. Since international research shows that intimate partner violence is one of the most common forms of violence against women, spousal violence was measured in more detail than violence committed by other perpetrators. These detailed measurements were made using a shortened and modified version of the Conflict Tactics Scale (Straus, 1990). Specifically, spousal physical violence by the husband for currently married women and the most recent husband for formerly married women was measured by asking all ever-married women the following set of questions. Does (did) your (last) husband/partner ever: (a) Push you, shake you, or throw something at you? (b) Slap you? (c) Twist your arm or pull your hair? (d) Punch you with his fist or with something that could hurt you? (e) Kick you, drag you, or beat you up? (f) Try to choke you or burn you on purpose? (g) Threaten or attack you with a knife, gun, or any other weapon? (h) Physically force you to have sexual intercourse with him when you did not want to? (i) Physically force you to perform any other sexual acts you did not want to? (j) Force you with threats or in any other way to perform sexual acts you did not want to? For every question that a woman answered “yes,” she was asked about the frequency of the act in the 12 months preceding the survey. A yes answer to one or more of items (a) to (g) above constitutes evidence of physical violence, and a yes answer to one or more of items (h) to (j) constitutes evidence of sexual violence. Similarly, emotional violence among ever-married women was measured with the following questions. Does (did) your (last) husband/partner ever: (a) Say or do something to humiliate you in front of others? (b) Threaten to hurt or harm you or someone close to you? (c) Insult you or make you feel bad about yourself? This approach of asking about specific acts to measure different forms of violence has the advantage of not being affected by different understandings of what constitutes a summary term such as violence. By including a wide range of acts, the approach has the additional advantage of giving the respondent multiple opportunities to disclose any experience of violence. Domestic Violence • 227 In addition to these questions, women were asked about physical violence from persons other than the current or most recent spouse. Respondents who answered this question in the affirmative were asked who committed the violence against them and the frequency of such violence during the 12 months preceding the survey. Although this approach to questioning is generally considered to be optimal, the possibility of underreporting of violence cannot be entirely ruled out in any survey, and this survey is no exception. 16.1.2 Ethical Considerations in the 2013 GDHS In recognition of the challenges in collecting data on violence, the interviewers in the 2013 GDHS were given special training. The training focused on how to ask sensitive questions, ensure privacy, and build rapport between interviewer and respondent. Rapport with the interviewer, confidentiality, and privacy are all keys to building respondents’ confidence so that they can safely share their experiences with the interviewer. Also, placement of the violence questions at the end of the questionnaire provided time for the interviewer to develop a certain degree of intimacy that should have further encouraged respondents to share their experiences of violence, if any. In addition, the following protections were built into the survey in keeping with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001): 1. Only one woman per household was administered the questions on violence to maintain confidentiality. The random selection of one woman was done through a simple selection procedure based on the Kish grid, which was built into the Household Questionnaire (Kish, 1965). 2. As a means of obtaining additional consent beyond the initial consent provided at the start of the interview, the respondent was informed that the questions could be sensitive and was reassured regarding the confidentiality of her responses. 3. The violence module was implemented only if privacy could be obtained. The interviewers were instructed to skip the module, thank the respondent, and end the interview if they could not maintain privacy. 4. A brochure that included information on domestic violence and contact information for service centres across the country was provided to all eligible respondents after the interview was completed, irrespective of whether or not they were selected for the module. This was done to safeguard against identifying the respondent selected for the module and to provide information to all respondents so that they could access the services and be informed about what to do in the event of domestic violence. 16.1.3 Sample for the Violence Module As mentioned above, in keeping with ethical requirements, only one woman per household was selected for the module. This restriction resulted in a total of 4,594 women being eligible for the module, of whom 4,525 were successfully interviewed. Twenty-seven eligible women were not interviewed because complete privacy could not be obtained, and there were 42 missing cases for which information was not collected due to other reasons. Specially constructed weights were used to adjust for the selection of only one woman per household and to ensure that the domestic violence sub-sample was nationally representative. 16.2 WOMEN EXPERIENCING PHYSICAL VIOLENCE Table 16.1 shows the percentage of women age 15-49 who have experienced physical violence since age 15 and the percentage who experienced violence during the 12 months preceding the survey. More than four in ten women (41 percent) have experienced physical violence since age 15. However, only 10 percent reported experiencing physical violence often (1 percent) or sometimes (8 percent) in the past 12 months. 228 • Domestic Violence Table 16.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who experienced violence during the 12 months preceding the survey, by background characteristics, The Gambia 2013 Percentage who have ever experienced physical violence since age 151 Percentage who experienced physical violence in the past 12 months Number of women Background characteristic Often Sometimes Often or sometimes2 Age 15-19 37.8 1.7 10.9 12.6 1,084 20-24 38.7 0.6 8.0 8.7 993 25-29 44.7 1.8 9.3 11.1 743 30-39 42.3 1.5 7.6 9.2 1,106 40-49 43.0 1.6 4.3 6.0 599 Religion Islam 40.5 1.4 8.0 9.4 4,342 Christianity 50.0 0.8 17.9 18.6 180 Residence Urban 40.9 1.9 8.6 10.5 2,516 Rural 41.0 0.8 8.1 8.9 2,009 Local Government Area Banjul 40.6 2.5 15.0 17.5 96 Kanifing 45.3 2.3 9.8 12.1 998 Brikama 43.2 1.5 9.2 10.7 1,577 Mansakonko 44.6 1.0 7.9 8.9 234 Kerewan 33.2 0.5 3.0 3.5 507 Kuntaur 31.4 0.4 7.8 8.2 231 Janjanbureh 47.8 1.1 7.0 8.0 322 Basse 32.2 0.9 8.4 9.3 559 Marital status Never married 40.9 1.3 10.8 12.1 1,288 Married/living together 40.3 1.4 7.1 8.5 3,018 Divorced/separated/widowed 49.2 1.9 11.8 13.7 219 Number of living children 0 39.9 1.2 10.4 11.6 1,571 1-2 39.1 1.0 7.3 8.4 1,223 3-4 44.8 2.8 7.8 10.6 809 5+ 41.8 1.0 6.7 7.8 923 Employment Employed for cash 44.3 1.5 8.0 9.5 2,093 Employed not for cash 36.7 4.4 8.7 13.1 175 Not employed 38.1 1.1 8.6 9.7 2,253 Education No education 38.1 1.3 5.9 7.2 2,146 Primary 41.9 1.3 10.1 11.4 644 Secondary or higher 44.0 1.6 10.7 12.3 1,734 Wealth quintile Lowest 42.1 1.0 8.4 9.4 773 Second 42.8 0.8 6.5 7.3 832 Middle 39.1 1.5 8.2 9.7 877 Fourth 38.8 2.0 9.3 11.4 941 Highest 41.9 1.6 9.0 10.6 1,102 Total 40.9 1.4 8.4 9.8 4,525 Note: Total includes 1 case with no religion, 2 cases for whom information on religion is missing, and 5 cases for whom information on employment is missing. 1 Includes violence in the past 12 months. For women who were married before age 15 and who reported physical violence by a spouse, the violence could have occurred before age 15. 2 Includes women for whom frequency in the past 12 months is not known The percentage of women who have experienced physical violence since age 15 varies by background characteristics. It is highest among women age 25-29 (45 percent), Christian women (50 percent), women in Janjanbureh (48 percent), women employed for cash (44 percent), and women with three to four children (45 percent). Forty-nine percent of women who are divorced, separated, or widowed have experienced physical violence since age 15, as compared with 40 percent of currently married women and 41 percent of never-married women. The percentage of women who have experienced physical violence since age 15 increases with increasing education, from 38 percent among those with no education to 44 percent among those with a secondary education or higher. There is no clear pattern according to wealth. Domestic Violence • 229 16.3 PERSONS COMMITTING PHYSICAL VIOLENCE Table 16.2 shows the perpetrators of physical violence, according to women’s marital status. Among ever-married women, the most commonly reported perpetrator of physical violence is their current husband or partner (42 percent), followed by their mother or stepmother (39 percent). Furthermore, 20 percent of ever- married women reported their father or stepfather as the perpetrator, and 18 percent reported a sister or brother. Among never-married women who have experienced physical violence since age 15, the most common perpetrators of violence are their mother or stepmother (56 percent), followed by their father or stepfather (28 percent) and sister or brother (21 percent). 16.4 EXPERIENCE OF SEXUAL VIOLENCE Table 16.3 shows the percentage of women who have ever experienced sexual violence and the percentage who experienced sexual violence in the past 12 months. Overall, 5 percent of women age 15-49 have ever experienced sexual violence, and 1 percent experienced such violence in the past 12 months. There are notable variations in the experience of sexual violence by age. Overall, younger women (age 15-19) are slightly less likely than older women to report having ever experienced sexual violence and having experienced sexual violence in the past 12 months. The percentage of women who have experienced sexual violence since age 15 ranges from 2 percent in Kerewan to 8 percent in Janjanbureh and Banjul. Four percent each of never-married women and those who are currently married or living together with a partner have experienced sexual violence, as compared with 12 percent of divorced, separated, or widowed women. The prevalence of sexual violence is somewhat lower among women with no children. Unemployed women are less likely than those who are employed to have experienced sexual violence since age 15. There are slight variations in the experience of sexual violence by education and wealth. Table 16.2 Persons committing physical violence Among women age 15-49 who have experienced physical violence since age 15, percentage who report specific persons who committed the violence, according to the respondent’s current marital status, The Gambia 2013 Person Marital status Total Ever married Never married Current husband/partner 42.0 na 30.1 Former husband/partner 12.6 na 9.0 Current boyfriend 0.3 0.6 0.3 Former boyfriend 1.4 1.4 1.4 Father/stepfather 19.5 27.7 21.8 Mother/stepmother 38.6 56.4 43.6 Sister/brother 17.5 20.5 18.3 Daughter/son 0.2 0.3 0.2 Other relative 6.0 11.8 7.7 Mother-in-law 0.2 na 0.1 Other in-law 0.3 na 0.3 Teacher 3.7 12.4 6.2 Other 2.1 2.8 2.3 Number of women who have experienced physical violence since age 15 1,326 526 1,852 Note: Women can report more than one person who committed the violence. na = Not applicable 230 • Domestic Violence Table 16.3 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence and percentage who experienced sexual violence in the 12 months preceding the survey, by background characteristics, The Gambia 2013 Percentage who have experienced sexual violence: Number of women Background characteristic Ever1 In the past 12 months Age 15-19 3.1 0.8 1,084 20-24 4.4 1.7 993 25-29 6.1 1.7 743 30-39 5.4 1.1 1,106 40-49 3.9 0.5 599 Religion Islam 4.5 1.2 4,342 Christianity 5.0 0.4 180 Residence Urban 4.5 1.1 2,516 Rural 4.7 1.3 2,009 Region Banjul 7.8 2.4 96 Kanifing 6.5 1.4 998 Brikama 4.3 1.1 1,577 Mansakonko 3.2 1.8 234 Kerewan 1.6 0.0 507 Kuntaur 4.3 1.8 231 Janjanbureh 8.0 2.3 322 Basse 2.5 0.6 559 Marital status Never married 4.3 1.4 1,288 Married or living together 4.2 1.1 3,018 Divorced/separated/widowed 11.5 1.1 219 Employment Employed for cash 5.6 1.1 2,093 Employed not for cash 6.1 4.3 175 Not employed 3.5 1.0 2,253 Number of living children 0 3.8 1.2 1,571 1-2 4.9 1.1 1,223 3-4 5.6 1.6 809 5+ 4.6 0.9 923 Education No education 3.9 0.7 2,146 Primary 3.8 1.5 644 Secondary or higher 5.7 1.6 1,734 Wealth quintile Lowest 4.1 1.3 773 Second 4.2 1.0 832 Middle 4.4 0.5 877 Fourth 6.0 2.1 941 Highest 4.0 0.9 1,102 Total 15-49 4.6 1.2 4,525 Note: Total includes 1 case with no religion, 2 cases for whom information on religion is missing, and 5 cases for whom information on employment is missing. 1 Includes violence in the past 12 months Domestic Violence • 231 16.5 PERSONS COMMITTING SEXUAL VIOLENCE Table 16.4 shows perpetrators of sexual violence among women who have ever experienced such violence. The most commonly reported perpetrators of sexual violence among ever-married women are their current (47 percent) and former (20 percent) husbands or partners. Additionally, 10 percent of women reported sexual violence from their current or former boyfriend. Among never-married women, the most commonly reported perpetrators of sexual violence are their current or former boyfriends (45 percent), followed by other relatives (22 percent) and strangers (18 percent). Table 16.4 Persons committing sexual violence Among women age 15-49 who have experienced sexual violence, percentage who report specific persons who committed the violence according to the respondent’s current marital status, The Gambia 2013 Marital status Total Person Ever married Never married Current husband/partner 47.1 * 34.4 Former husband/partner 19.8 * 14.4 Current/former boyfriend 10.1 (45.4) 19.6 Father/stepfather 1.0 (1.6) 1.2 Brother/stepbrother 1.8 (3.6) 2.3 Other relative 2.9 (22.2) 8.1 In-law 0.3 * 0.2 Own friend/acquaintance 6.4 (0.0) 4.7 Family friend 1.2 (2.4) 1.5 Teacher 1.1 (0.0) 0.8 Employer/someone at work 0.0 (0.0) 0.0 Police/soldier 0.0 (0.1) 0.0 Priest/religious leader 0.0 (0.0) 0.0 Stranger 6.8 (17.7) 9.7 Other 12.1 (7.0) 10.7 Missing 0.0 (0.0) 0.0 Number women who have experienced sexual violence 150 56 206 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Women can report more than one person who committed the violence. 16.6 AGE AT FIRST EXPERIENCE OF SEXUAL VIOLENCE The survey data show that among the 5 percent of women who have ever experienced sexual violence, the percentages who have experienced such violence by age are distributed equally at age 10, 12, 15, 18, and 22; 1 percent or less of women first experienced sexual violence at each of these ages (data not shown). 16.7 EXPERIENCE OF DIFFERENT FORMS OF VIOLENCE Table 16.5 presents information on the experience of various forms of violence among women age 15-49. Thirty-seven percent of women have experienced physical violence only, 1 percent have experienced sexual violence only, and 4 percent have experienced both physical and sexual violence. Overall, 42 percent of women reported that they have experienced Table 16.5 Experience of different forms of violence Percentage of women age 15-49 who have ever experienced different forms of violence by current age, The Gambia 2013 Age Physical violence only Sexual violence only Physical and sexual violence Physical or sexual violence Number of women 15-19 36.0 1.4 1.8 39.1 1,084 15-17 34.3 1.0 1.9 37.2 561 18-19 37.8 1.7 1.6 41.1 523 20-24 35.0 0.7 3.7 39.4 993 25-29 39.5 0.9 5.2 45.6 743 30-39 37.6 0.6 4.7 43.0 1,106 40-49 39.1 0.1 3.9 43.1 599 Total 37.2 0.8 3.8 41.7 4,525 232 • Domestic Violence either physical or sexual violence. In general, the percentage of women who have ever experienced physical or sexual violence increases slightly with age. 16.8 VIOLENCE DURING PREGNANCY Respondents who had ever been pregnant were asked specifically whether they had ever experienced physical violence while pregnant and, if so, who the perpetrators of the violence were. Table 16.6 shows that 4 percent of women have experienced physical violence during pregnancy. There is little variation in the experience of physical violence during pregnancy by most background characteristics. It tends to increase with age, rising from 2 percent among women age 15-19 to 6 percent among those age 25-39 and decreasing thereafter. The percentage of women who have experienced physical violence during pregnancy is highest among those who are divorced, separated, or widowed (12 percent); those who reside in Mansakonko (7 percent); and those with a primary education (9 percent). 16.9 MARITAL CONTROL BY HUSBAND Attempts by husbands to closely control and monitor their wives’ behaviour are known to be an important warning sign and correlate of violence in a relationship. A series of questions were included in the 2013 GDHS to elicit the degree of marital control exercised by husbands over wives. Controlling behaviours most often manifest themselves in terms of extreme possessiveness, jealousy, attempts to isolate the wife from her family and friends, and not trusting her with money. To determine the degree of marital control husbands exercise over their wives, ever-married women were asked whether their current or former husband exhibited each of the following controlling behaviours: (1) he is jealous or angry if she talks to other men, (2) he frequently accuses her of being unfaithful, (3) he does not permit meetings with female friends, (4) he tries to limit contact with her family, and (5) he insists on knowing where she is at all times. Because the concentration of such behaviours is more significant than the display of any single behaviour, the proportion of women whose husbands display at least three of the specified behaviours is highlighted. Table 16.7 presents the percentage of ever-married women whose husbands display each of the listed behaviours, by selected background characteristics. The main controlling behaviours reported by women were that their husband was jealous or angry if they talked to other men (38 percent) and insisted on knowing where they are at all times (30 percent). The next most common controlling behaviours were the husband not permitting them to meet their female friends (10 percent) and trying to limit their contact with family (7 percent). Table 16.6 Experience of violence during pregnancy Among women age 15-49 who have ever been pregnant, percentage who have ever experienced physical violence during pregnancy, by background characteristics, The Gambia 2013 Background characteristic Percentage who experienced violence during pregnancy Number of women who have ever been pregnant Age 15-19 2.4 219 20-24 3.3 643 25-29 6.0 623 30-39 5.0 1,059 40-49 3.2 583 Religion Islam 4.4 3,022 Christianity 3.5 103 Residence Urban 4.1 1,583 Rural 4.6 1,545 Local Government Area Banjul 5.7 63 Kanifing 4.7 600 Brikama 5.1 1,062 Mansakonko 6.8 178 Kerewan 2.5 367 Kuntaur 5.3 176 Janjanbureh 3.1 228 Basse 2.7 455 Marital status Never married 3.6 122 Married/living together 3.8 2,807 Divorced/separated/widowed 12.3 199 Number of living children 0 1.3 173 1-2 4.5 1,223 3-4 4.0 809 5+ 4.9 923 Education No education 3.3 1,874 Primary 9.0 434 Secondary or higher 4.1 820 Wealth quintile Lowest 4.7 591 Second 4.1 619 Middle 3.6 649 Fourth 4.7 643 Highest 4.5 627 Total 4.3 3,128 Note: Total includes 1 case with no religion and 2 cases for whom information on religion is missing. Domestic Violence • 233 Overall, 10 percent of ever-married women say that their husband displays three or more of the specified behaviours, while 49 percent say that he does not display any. Women living in Banjul (20 percent), formerly married women (26 percent), and those who are afraid of their husband or partner most of the time (24 percent) are substantially more likely than other subgroups to report that their husbands display three or more of the controlling behaviours. The percentage of women whose husbands display three or more controlling behaviours increases somewhat with increasing education. Table 16.7 Marital control exercised by husbands Percentage of ever-married women age 15-49 whose husbands/partners have ever demonstrated specific types of controlling behaviours, by background characteristics, The Gambia 2013 Percentage of women whose husband/partner: Number of ever- married women Background characteristic Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Displays 3 or more of the specific behaviours Displays none of the specific behaviours Age 15-19 34.8 3.7 7.3 4.9 23.3 6.9 55.4 287 20-24 45.4 5.5 9.2 7.2 29.2 9.7 44.5 624 25-29 40.1 7.7 15.2 8.9 33.4 12.2 45.2 645 30-39 36.2 8.3 10.1 6.2 31.1 11.0 50.0 1,084 40-49 34.7 3.9 7.2 7.7 26.1 6.6 51.8 597 Religion Islam 38.5 6.4 9.8 6.7 30.0 9.8 48.8 3,136 Christianity 32.4 8.5 20.7 19.3 15.2 8.4 49.1 99 Residence Urban 37.8 7.6 11.1 8.0 31.5 10.7 48.0 1,622 Rural 38.9 5.2 9.2 6.2 27.7 8.9 49.6 1,616 Local Government Area Banjul 39.3 6.6 19.2 14.1 39.1 19.5 45.6 62 Kanifing 41.1 9.7 13.0 11.5 35.7 13.0 43.3 585 Brikama 38.4 6.1 12.7 8.5 35.2 11.3 45.0 1,108 Mansakonko 36.9 7.7 14.9 10.5 38.3 14.8 45.0 183 Kerewan 15.5 3.0 3.9 1.1 23.4 3.7 69.1 391 Kuntaur 38.1 5.3 6.9 3.6 22.0 7.7 57.3 194 Janjanbureh 39.6 7.9 11.0 9.4 14.9 11.9 55.0 238 Basse 53.5 5.1 3.9 1.5 19.9 3.9 43.0 476 Marital status Married/living together 37.3 5.6 9.6 6.3 28.4 8.6 49.8 3,018 Divorced/separated/ widowed 53.0 17.3 18.3 18.8 46.1 25.9 35.0 219 Number of living children 0 37.9 4.9 10.3 9.1 26.0 7.6 50.2 401 1-2 41.0 6.6 10.6 8.3 32.3 11.9 45.8 1,111 3-4 39.8 7.3 10.4 5.6 30.9 9.7 48.6 802 5+ 34.0 6.1 9.4 6.1 26.7 8.3 52.0 923 Employment Employed for cash 39.7 7.7 10.4 8.1 32.9 10.9 45.5 1,810 Employed not for cash 36.9 7.2 11.0 5.3 19.9 10.3 58.7 132 Not employed 36.4 4.6 9.8 5.9 26.0 8.2 52.6 1,292 Education No education 34.1 5.0 7.6 5.0 25.4 7.2 53.9 1,952 Primary 42.7 6.9 11.3 6.8 30.7 12.3 45.6 448 Secondary or higher 45.8 9.5 15.5 12.2 38.7 14.5 38.8 838 Wealth quintile Lowest 36.1 6.7 10.5 6.9 27.1 10.4 51.8 619 Second 37.1 5.5 9.0 6.5 27.8 9.3 51.5 629 Middle 40.8 4.7 8.4 5.3 25.2 7.9 49.9 656 Fourth 41.0 7.3 10.7 6.0 31.6 9.9 44.6 671 Highest 36.6 7.8 12.2 10.9 35.9 11.4 46.6 662 Woman afraid of husband/partner Afraid most of the time 66.3 16.6 22.6 12.6 44.8 23.6 20.8 254 Sometimes afraid 47.4 5.3 9.1 5.5 32.8 9.7 39.5 1,034 Never afraid 29.8 5.5 9.1 7.3 25.8 7.9 57.4 1,928 Total 38.3 6.4 10.2 7.1 29.6 9.8 48.8 3,237 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 2 cases for whom information on religion is missing, 4 cases for whom information on employment is missing, and 22 cases for whom information on whether the woman is afraid of the husband/partner is missing. 234 • Domestic Violence 16.10 EXPERIENCE OF SPOUSAL VIOLENCE Different types of violence are not mutually exclusive, and women may report multiple forms of violence. Research suggests that physical violence in intimate relationships is often accompanied by psychological abuse and, in one-third to more than one-half of cases, by sexual abuse (Krug et al., 2002). Table 16.8 shows the percentage of ever-married women who have experienced various forms of violence by their spouse ever and in the 12 months preceding the survey. Note that respondents who are currently married reported on violence by their current spouse, and respondents who are widowed, divorced, or separated reported on violence by their most recent spouse. Table 16.8 Forms of spousal violence Percentage of ever-married women age 15-49 who have experienced various forms of violence ever or in the 12 months preceding the survey committed by their husband/partner, The Gambia 2013 Ever In the past 12 months Type of violence Often Sometimes Often or sometimes Spousal violence committed by current or most recent husband/partner Physical violence Any physical violence 19.6 1.4 5.5 6.9 Pushed her, shook her, or threw something at her 4.1 0.2 1.3 1.6 Slapped her 13.5 1.0 3.5 4.4 Twisted her arm or pulled her hair 2.9 0.2 1.0 1.2 Punched her with his fist or with something that could hurt her 2.8 0.2 0.7 0.9 Kicked her, dragged her, or beat her up 11.3 0.8 2.4 3.2 Tried to choke her or burn her on purpose 1.6 0.0 0.9 1.0 Threatened her or attacked her with a knife, gun, or other weapon 0.8 0.0 0.1 0.1 Sexual violence Any sexual violence 2.7 0.2 0.9 1.1 Physically forced her to have sexual intercourse with him when she did not want to 2.5 0.1 0.8 1.0 Physically forced her to perform any other sexual acts she did not want to 0.7 0.0 0.2 0.2 Forced her with threats or in any other way to perform sexual acts she did not want to 0.8 0.1 0.2 0.2 Emotional violence Any emotional violence 15.8 2.1 6.5 8.5 Said or did something to humiliate her in front of others 7.8 1.1 3.7 4.8 Threatened to hurt or harm her or someone she cared about 4.1 0.5 1.6 2.0 Insulted her or made her feel bad about herself 11.7 1.7 4.6 6.3 Any form of physical and/or sexual violence 20.1 1.5 5.8 7.3 Any form of emotional and/or physical and/or sexual violence 26.2 2.7 9.6 12.3 Spousal violence committed by any husband/partner Physical violence 21.3 na na 6.9 Sexual violence 3.0 na na 1.1 Physical and/or sexual violence 21.9 na na 7.3 Number of ever-married women 3,237 3,237 3,237 3,237 na = Not applicable One in five (20 percent) ever-married women reported having experienced physical violence committed by their current or most recent husband or partner, 3 percent reported sexual violence, and 16 percent reported emotional violence. Seven percent of women reported experiencing spousal physical violence in the past 12 months. With respect to specific types of abuse, the most common form of spousal physical violence is being slapped (14 percent), followed by being kicked, dragged, or beaten (11 percent). Overall, 26 percent of women have ever experienced emotional, physical, or sexual violence from their spouse, and 12 percent experienced one or more of these forms of violence in the past 12 months. Domestic Violence • 235 16.11 SPOUSAL VIOLENCE BY BACKGROUND CHARACTERISTICS Table 16.9 shows the percentage of ever-married women age 15-49 who have experienced spousal emotional, physical, or sexual violence by selected background characteristics. More than one in four women (26 percent) have experienced at least one form of spousal violence. The percentage of women who have ever experienced at least one form of spousal violence tends to increase with age and number of living children. The highest levels of spousal violence are found among women in Mansakonko (38 percent) and those who are divorced, separated, or widowed (46 percent). Table 16.9 Spousal violence by background characteristics Percentage of ever-married women age 15-49 who have ever experienced emotional, physical, or sexual violence committed by their husband/partner, by background characteristics, The Gambia 2013 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical, sexual, and emotional Physical or sexual Physical, sexual, or emotional Number of ever-married women Age 15-19 9.0 10.0 0.8 0.8 0.6 10.0 13.8 287 20-24 12.1 12.2 3.0 1.8 1.8 13.3 18.9 624 25-29 16.4 23.4 4.3 3.8 2.2 24.0 28.7 645 30-39 18.8 23.8 2.6 2.1 1.8 24.2 30.6 1,084 40-49 17.0 20.0 1.7 1.5 1.1 20.3 29.3 597 Religion Islam 15.6 19.6 2.7 2.2 1.7 20.1 26.2 3,136 Christianity 22.0 19.2 0.7 0.5 0.5 19.4 27.6 99 Residence Urban 16.5 17.0 2.4 2.0 1.7 17.5 24.5 1,622 Rural 15.1 22.2 2.9 2.4 1.6 22.7 28.0 1,616 Local Government Area Banjul 21.5 21.9 6.1 3.9 2.7 24.1 33.1 62 Kanifing 21.8 21.4 3.3 2.8 2.6 21.9 31.3 585 Brikama 15.0 17.2 2.4 1.7 1.1 17.9 24.1 1,108 Mansakonko 24.9 27.8 2.8 2.2 2.0 28.5 38.0 183 Kerewan 7.7 11.1 0.5 0.3 0.2 11.4 15.7 391 Kuntaur 10.1 27.2 2.9 2.9 0.3 27.3 30.4 194 Janjanbureh 18.9 19.9 6.1 5.7 5.3 20.2 27.6 238 Basse 13.6 23.1 2.1 1.7 1.4 23.6 25.8 476 Marital status Married/living together 14.5 18.3 2.3 1.8 1.2 18.9 24.8 3,018 Divorced/separated/widowed 34.3 36.5 7.5 7.4 7.4 36.5 46.2 219 Number of living children 0 6.6 9.2 1.6 1.1 1.1 9.7 12.1 401 1-2 17.1 17.8 3.3 2.7 2.5 18.5 24.3 1,111 3-4 17.6 23.0 3.2 2.5 1.2 23.7 30.7 802 5+ 16.7 23.1 2.0 1.7 1.2 23.3 30.8 923 Employment Employed for cash 16.9 23.3 3.3 2.6 2.0 24.0 29.9 1,810 Employed not for cash 19.6 25.2 2.4 2.4 1.0 25.2 32.4 132 Not employed 13.8 13.8 1.9 1.6 1.2 14.1 20.5 1,292 Education No education 14.6 20.1 2.1 1.9 1.1 20.3 26.0 1,952 Primary 18.0 21.7 2.7 1.9 1.4 22.5 30.0 448 Secondary or higher 17.5 17.2 4.1 3.0 3.0 18.2 24.8 838 Wealth quintile Lowest 17.3 24.6 2.9 2.4 1.6 25.1 31.6 619 Second 14.4 19.2 2.5 1.7 1.6 19.9 25.3 629 Middle 14.3 21.1 2.1 1.7 1.1 21.5 26.1 656 Fourth 13.8 18.2 4.0 3.2 2.2 18.9 23.2 671 Highest 19.3 15.2 1.9 1.7 1.7 15.3 25.2 662 Total 15.8 19.6 2.7 2.2 1.6 20.1 26.2 3,237 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 2 cases for whom religion is missing and 4 cases for whom information on employment is missing. 236 • Domestic Violence 16.12 SPOUSAL VIOLENCE BY HUSBAND’S CHARACTERISTICS AND WOMEN’S EMPOWERMENT INDICATORS Table 16.10 presents information on ever-married women age 15-49 who have experienced emotional, physical, or sexual violence committed by their spouse, according to spousal characteristics and empowerment indicators. Table 16.10 Spousal violence by husband’s characteristics and empowerment indicators Percentage of ever-married women age15-49 who have ever experienced emotional, physical, or sexual violence committed by their husband/partner, by husband’s characteristics and empowerment indicators, The Gambia 2013 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical, sexual, and emotional Physical or sexual Physical, sexual, or emotional Number of ever-married women Husband’s/partner’s education No education 14.1 19.8 2.3 1.9 1.3 20.3 25.6 1,814 Primary 17.9 24.8 5.7 5.6 3.6 24.8 31.0 207 Secondary 15.6 18.2 3.0 2.6 2.2 18.7 24.7 834 More than secondary 19.6 17.0 0.5 0.2 0.2 17.3 26.1 257 Don’t know/missing 30.9 21.7 4.9 2.1 1.9 24.5 38.4 126 Husband’s/partner’s alcohol consumption Does not drink 15.6 19.4 2.6 2.1 1.6 19.9 25.9 3,182 Drinks/never gets drunk * * * * * * * 3 Gets drunk sometimes (31.3) (35.1) (8.9) (3.4) (3.4) (40.7) (49.5) 28 Gets drunk very often * * * * * * * 14 Spousal education difference Husband better educated 15.0 16.4 1.7 1.3 0.7 16.8 23.4 942 Wife better educated 17.8 22.6 6.1 5.0 5.0 23.7 28.4 523 Both equally educated 17.2 16.4 1.4 1.4 0.2 16.4 25.6 164 Neither educated 13.6 20.4 2.0 1.7 1.1 20.7 25.9 1,444 Don’t know/missing 32.4 23.9 5.2 3.0 2.7 26.2 39.1 165 Spousal age difference1 Wife older (17.3) (20.8) (3.5) (3.5) (3.2) (20.8) (32.5) 30 Wife is same age (14.1) (21.1) (2.7) (0.0) (0.0) (23.8) (36.2) 30 Wife is 1-4 years younger 12.9 17.9 0.5 0.2 0.2 18.2 23.1 333 Wife is 5-9 years younger 15.2 17.0 2.7 2.0 1.8 17.7 24.9 836 Wife is 10+ years younger 14.5 19.0 2.5 2.0 1.2 19.5 24.9 1,715 Missing 12.3 18.4 0.5 0.5 0.0 18.4 22.1 75 Number of marital control behaviours displayed by husband/partner2 0 5.9 9.8 1.5 1.1 0.9 10.2 12.2 1,580 1-2 21.9 25.8 2.1 1.7 1.0 26.2 36.1 1,341 3-4 37.8 40.3 9.4 8.1 6.5 41.6 53.0 273 5 50.7 50.7 21.7 18.3 14.4 54.1 61.2 44 Number of decisions in which women participate3 0 12.1 17.4 2.8 2.3 0.6 17.8 23.2 495 1-2 14.1 19.8 2.4 1.6 1.1 20.5 25.6 1,373 3 15.9 17.1 2.0 1.7 1.6 17.4 24.6 1,151 Number of reasons for which wife beating is justified4 0 16.5 13.4 2.2 1.9 1.8 13.7 21.8 1,249 1-2 17.9 24.2 2.8 2.3 1.8 24.8 31.0 917 3-4 14.0 24.4 3.3 2.3 1.3 25.3 29.1 807 5 10.9 17.9 2.8 2.7 1.5 18.1 21.8 264 Woman’s father beat her mother Yes 29.1 29.2 7.2 5.9 4.1 30.4 40.6 300 No 13.9 17.8 2.2 1.7 1.3 18.2 24.3 2,555 Don’t know/missing 18.3 23.8 2.7 2.1 1.8 24.5 28.1 382 Woman afraid of husband/ partner Afraid most of the time 35.0 46.2 8.0 7.0 2.9 47.2 53.7 254 Sometimes afraid 19.5 28.2 3.6 3.3 2.9 28.5 34.9 1,034 Never afraid 11.4 11.4 1.4 0.8 0.8 12.0 18.0 1,928 Total 15.8 19.6 2.7 2.2 1.6 20.1 26.2 3,237 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 10 cases for whom information on husband’s/partner’s alcohol consumption is missing and 22 cases for whom information on whether the woman is afraid of her husband/partner is missing. 1 Includes only women who have been married only once 2 According to the wife’s report. See Table 16.7 for list of behaviours. 3 According to the wife’s report. See Table 15.6 for list of decisions. 4 According to the wife’s report. See Table 15.7.1 for list of reasons. Domestic Violence • 237 Women whose husbands have only a primary education (31 percent) and women who are better educated than their husbands (28 percent) are most likely to have experienced any of the three types of spousal violence. Among women whose husbands exhibit all five controlling behaviours, more than six in ten (61 percent) have experienced one or more forms of violence. In contrast, among women whose husbands display none of the five controlling behaviours, only 12 percent have experienced any form of spousal violence. Women whose father beat their mother are much more likely to experience any type of violence from their husband than women whose father did not beat their mother (41 percent and 24 percent, respectively). Finally, as expected, women who are often afraid of their husband are more likely to report experiencing any form of spousal violence than women who are never afraid of their husband (54 percent and 18 percent, respectively). 16.13 RECENT PHYSICAL OR SEXUAL VIOLENCE BY ANY HUSBAND OR PARTNER Table 16.11 shows the percentage of ever-married women who have experienced physical or sexual violence by any husband or partner in the past 12 months. Overall, 7 percent of women experienced either type of violence in the past 12 months. Women age 25-29 (11 percent), Christian women (9 percent), women living in rural areas (8 percent), and women living in Banjul (15 percent) are more likely than women in other groups to have experienced recent physical or sexual spousal violence. Women who are divorced, separated, or widowed are more likely than those who are currently married to have experienced physical or sexual violence by any husband or partner in the past 12 months (10 percent and 7 percent, respectively). Recent spousal violence is lowest among women who have no living children (4 percent), those who are not employed (6 percent), and those with no education (6 percent). Table 16.11 Physical or sexual violence in the past 12 months by any husband/partner Percentage of ever-married women who have experienced physical or sexual violence by any husband/partner in the past 12 months, by background characteristics, The Gambia 2013 Background characteristic Percentage of women who have experienced physical or sexual violence in the past 12 months from any husband/partner Number of ever- married women Age 15-19 5.0 287 20-24 6.6 624 25-29 10.6 645 30-39 8.0 1,084 40-49 4.3 597 Religion Islam 7.3 3,136 Christianity 9.2 99 Residence Urban 6.9 1,622 Rural 7.7 1,616 Local Government Area Banjul 15.1 62 Kanifing 7.1 585 Brikama 8.1 1,108 Mansakonko 8.4 183 Kerewan 1.7 391 Kuntaur 8.3 194 Janjanbureh 6.5 238 Basse 8.9 476 Marital status Married/living together 7.1 3,018 Divorced/separated/widowed 10.3 219 Number of living children 0 4.3 401 1-2 7.3 1,111 3-4 9.7 802 5+ 6.6 923 Employment Employed for cash 8.5 1,810 Employed not for cash 8.6 132 Not employed 5.6 1,292 Education No education 6.1 1,952 Primary 9.4 448 Secondary or higher 8.9 838 Wealth quintile Lowest 8.0 619 Second 5.9 629 Middle 8.2 656 Fourth 8.9 671 Highest 5.6 662 Woman afraid of husband/partner Afraid most of the time 22.4 254 Sometimes afraid 7.9 1,034 Never afraid 4.9 1,928 Total 7.3 3,237 Note: Any husband/partner includes all current, most recent, and former husbands/ partners. Total includes 7 cases for whom information on religion is missing, 4 cases for whom information on employment is missing, and 22 cases for whom information on whether the woman is afraid of her husband/partner is missing. 238 • Domestic Violence 16.14 EXPERIENCE OF SPOUSAL VIOLENCE BY DURATION OF MARRIAGE To obtain information on the onset of marital violence, the 2013 GDHS asked ever-married women how long after marriage the onset of spousal violence occurred, if ever. Table 16.12 shows that 81 percent of women have never experienced physical or sexual violence by their current or most recent husband. The onset of spousal violence tends to occur later in the marriage. Only 5 percent of women reported that spousal violence began within the first two years of marriage, while 17 percent reported that it began within the first 10 years of marriage. Table 16.12 Experience of spousal violence by duration of marriage Among currently married women age 15-49 who have been married only once, the percentage who first experienced physical or sexual violence committed by their current husband/partner by specific exact years since marriage, according to marital duration, The Gambia 2013 Percentage who first experienced spousal physical or sexual violence by exact marital duration: Percentage who have not experienced spousal sexual or physical violence Number of currently married women who have been married only once Duration of marriage Before marriage 2 years 5 years 10 years Years since marriage <2 0.1 na na na 93.3 349 2-4 0.0 6.7 na na 84.3 461 5-9 0.1 6.2 15.4 na 81.1 578 10+ 0.0 4.1 14.8 20.2 76.5 1,273 Total 0.1 5.3 13.8 17.1 81.1 2,662 na = Not applicable 16.15 PHYSICAL CONSEQUENCES OF SPOUSAL VIOLENCE In the 2013 GDHS, ever-married women were asked whether they had sustained some form of injury as a result of physical or sexual violence inflicted by their spouse. Among women who reported having ever experienced physical or sexual spousal violence, 15 percent suffered cuts, bruises, or aches; 6 percent had eye injuries, sprains, dislocations, or burns; and 3 percent had deep wounds, broken bones, broken teeth, or other serious injuries (Table 16.13). Table 16.13 Injuries to women due to spousal violence Percentage of ever-married women age 15-49 who have experienced specific types of spousal violence by types of injuries resulting from the violence, according to the type of violence and whether they experienced the violence ever and in the 12 months preceding the survey, The Gambia 2013 Type of violence Cuts, bruises, or aches Eye injuries, sprains, dislocations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of ever- married women who have ever experienced any physical or sexual violence Experienced physical violence1 Ever2 15.3 6.6 3.2 19.8 634 In the past 12 months 17.8 8.8 5.8 24.8 223 Experienced sexual violence Ever2 31.6 11.2 6.2 37.2 87 In the past 12 months (19.1) (12.2) (4.0) (23.9) 34 Experienced physical or sexual violence1 Ever2 14.9 6.4 3.1 19.4 650 In the past 12 months 16.9 8.4 5.4 23.5 236 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes women who reported violence only in response to a direct question on violence during pregnancy 2 Includes violence in the past 12 months Domestic Violence • 239 Among ever-married women who had experienced spousal violence (physical or sexual) in the past 12 months, 24 percent reported experiencing physical injuries. 16.16 WOMEN’S VIOLENCE AGAINST THEIR HUSBANDS In cases of domestic violence, either person (husband or wife) can be the perpetrator of violence. In the 2013 GDHS, ever-married women were asked about instances when they were the instigator of spousal violence. Specifically, they were asked whether they had initiated physical violence against their husband or partner when he was not already hitting or beating them. Table 16.14 shows the percentage of ever- married women age 15-49 who reported initiating physical violence against their spouse ever and in the 12 months prior to the survey. Overall, just over 1 percent of women reported that they had initiated physical violence against their husbands, and just below 1 percent had done so in the past 12 months. Women who have been physically abused by their husband ever and in the past 12 months (3 percent and 5 percent, respectively); women in Kanifing (4 percent); women who are divorced, separated, or widowed (3 percent); and women in the highest wealth quintile (3 percent) are somewhat more likely than other groups to commit physical violence against their husbands or partners. The percentage of women who have committed physical violence against their spouse is small and varies little by husbands’ characteristics (Table 16.15). It is worth noting that women’s violence against their spouse is substantial (12 percent) among those whose husbands display five or more controlling behaviours. Table 16.14 Women’s violence against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting them, ever and in the past 12 months, according to women’s own experience of spousal violence and background characteristics, The Gambia 2013 Percentage who have committed physical violence against their husband/partner Number of ever-married women Background characteristic Ever1 In the past 12 months Woman’s experience of spousal physical violence Ever1 3.4 2.1 634 In the past 12 months 5.0 4.5 223 Never 0.6 0.5 2,604 Age 15-19 0.0 0.0 287 20-24 0.5 0.4 624 25-29 0.7 0.6 645 30-39 2.1 1.6 1,084 40-49 1.3 0.1 597 Religion Islam 1.2 0.8 3,136 Christianity 1.1 0.8 99 Residence Urban 1.8 1.3 1,622 Rural 0.5 0.3 1,616 Local Government Area Banjul 1.6 0.6 62 Kanifing 4.0 3.0 585 Brikama 0.5 0.4 1,108 Mansakonko 0.1 0.1 183 Kerewan 0.8 0.3 391 Kuntaur 0.4 0.0 194 Janjanbureh 1.2 0.0 238 Basse 0.2 0.2 476 Marital status Married/living together 1.0 0.7 3,018 Divorced/separated/ widowed 3.4 1.4 219 Employment Employed for cash 0.8 0.5 1,810 Employed not for cash 1.6 1.1 132 Not employed 1.6 1.1 1,292 Number of living children 0 0.4 0.2 401 1-2 1.6 1.4 1,111 3-4 1.2 0.7 802 5+ 1.0 0.3 923 Wealth quintile Lowest 1.0 0.5 619 Second 0.4 0.0 629 Middle 0.4 0.4 656 Fourth 1.0 0.4 671 Highest 3.0 2.5 662 Total 1.2 0.8 3,237 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 2 cases for whom information on religion is missing and 4 cases for whom information on employment is missing. 1 Includes violence in the past 12 months 240 • Domestic Violence Table 16.15 Women's violence against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting her, ever and in the past 12 months, according their husband's characteristics, The Gambia 2013 Percentage who have committed physical violence against their husband/partner Background characteristic Ever1 In the past 12 months Number of ever- married women Husband’s/partner’s education No education 1.2 0.8 1,814 Primary 2.0 1.9 207 Secondary 1.2 0.7 810 More than secondary 0.6 0.3 281 DK/missing 0.1 0.0 126 Husband’s/partner’s alcohol consumption Does not drink 1.2 0.8 3,182 Drinks/never gets drunk * * 3 Gets drunk sometimes (3.9) (2.8) 28 Gets drunk very often * * 14 Spousal education difference Husband better educated 1.1 0.8 932 Wife better educated 1.3 0.9 532 Both equally educated 1.0 0.5 165 Neither educated 1.3 0.8 1,444 DK/missing 0.1 0.0 165 Spousal age difference2 Wife older (0.0) (0.0) 30 Wife is same age (0.0) (0.0) 30 Wife’s 1-4 years younger 0.6 0.3 333 Wife’s 5-9 years younger 1.9 1.5 836 Wife’s 10+ years younger 0.7 0.5 1,715 Missing 0.0 0.0 75 Number of marital control behaviors displayed by husband/partner3 0 0.5 0.2 1,580 1-2 1.6 1.2 1,341 3-4 1.3 1.1 273 5-6 11.8 5.9 44 Number of decisions in which women participate4 0 0.7 0.7 495 1-2 0.6 0.3 1,373 3 1.7 1.3 1,151 Number of reasons for which wife- beating is justified5 0 1.2 0.9 1,249 1-2 1.9 1.1 917 3-4 0.4 0.4 807 5 0.5 0.3 264 Woman's father beat her mother Yes 1.1 0.7 300 No 1.3 0.9 2,555 DK/Missing 0.5 0.0 382 Woman afraid of husband/partner Most of the time afraid 1.0 0.8 254 Sometimes afraid 2.1 1.6 1,034 Never afraid 0.6 0.3 1,928 Total 1.2 0.8 3,237 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 10 cases for whom information on husband’s/partner’s alcohol consumption is missing and 22 cases for whom information on whether the woman is afraid of her husband/partner is missing. 1 Includes in the past 12 months 2 Includes only women who have been married only once. 3 According to the wife’s report. See Table 16.7 for list of behaviors. 4 According to the wife’s report. See Table 15.6 for list of decisions. 5 According to the wife’s report. See Table 15.7 for list of decisions. Domestic Violence • 241 16.17 HELP-SEEKING BEHAVIOUR BY WOMEN WHO EXPERIENCE VIOLENCE Table 16.16 shows the percent distribution of women who have ever experienced physical or sexual violence committed by anyone, according to whether they sought help to stop the violence and, among those who did not seek help, whether or not they told anyone about the violence. Table 16.16 Help seeking to stop violence Percent distribution of women age 15-49 who have ever experienced physical or sexual violence by their help-seeking behaviour, according to type of violence and background characteristics, The Gambia 2013 Background characteristic Sought help to stop violence Never sought help but told someone Never sought help, never told anyone Missing/ don’t know Total Number of women who have ever experienced any physical or sexual violence Type of violence experienced Physical only 35.2 13.0 42.2 9.6 100.0 1,681 Sexual only (45.5) (6.9) (37.7) (10.0) 100.0 36 Physical and sexual 64.7 9.8 21.1 4.4 100.0 171 Age 15-19 29.8 17.6 40.5 12.2 100.0 424 20-24 40.0 12.9 37.0 10.1 100.0 391 25-29 38.9 13.1 40.7 7.3 100.0 339 30-39 41.9 6.6 45.5 6.0 100.0 476 40-49 40.6 14.2 34.0 11.2 100.0 258 Religion Islam 37.5 12.4 40.9 9.2 100.0 1,789 Christianity 48.6 15.4 27.2 8.8 100.0 96 Residence Urban 37.3 13.6 37.7 11.4 100.0 1,048 Rural 39.0 11.3 43.3 6.4 100.0 839 Region Banjul 34.1 16.0 40.2 9.6 100.0 40 Kanifing 36.8 10.9 40.4 11.9 100.0 459 Brikama 38.0 14.3 37.0 10.7 100.0 698 Mansakonko 39.9 16.2 41.9 2.0 100.0 106 Kerewan 45.3 6.4 41.1 7.2 100.0 169 Kuntaur 23.1 7.7 60.0 9.2 100.0 74 Janjanbureh 44.4 20.5 26.0 9.2 100.0 158 Basse 35.1 8.1 54.2 2.6 100.0 182 Marital status Never married 31.3 18.1 38.0 12.6 100.0 541 Married or living together 39.3 11.0 41.6 8.2 100.0 1,238 Divorced/separated/widowed 58.1 3.7 34.7 3.4 100.0 109 Number of living children 0 30.5 17.5 40.2 11.8 100.0 646 1-2 46.8 9.5 36.1 7.6 100.0 485 3-4 40.3 9.4 45.5 4.8 100.0 368 5+ 37.8 11.2 40.2 10.9 100.0 388 Employment Employed for cash 42.2 9.7 38.7 9.5 100.0 944 Employed not for cash 41.5 9.7 40.7 8.1 100.0 65 Not employed 33.6 15.7 41.8 9.0 100.0 874 Education No education 38.6 8.9 43.7 8.7 100.0 828 Primary 48.8 11.2 31.0 9.0 100.0 274 Secondary or higher 33.7 16.9 39.6 9.7 100.0 786 Wealth quintile Lowest 39.6 10.6 40.0 9.7 100.0 331 Second 37.3 7.5 46.5 8.8 100.0 367 Middle 41.2 16.2 37.2 5.4 100.0 346 Fourth 40.9 14.7 36.4 8.0 100.0 374 Highest 33.1 13.5 40.6 12.8 100.0 470 Total 38.1 12.6 40.2 9.2 100.0 1,887 Note: Women can report more than one source from which they sought help. Figures in parentheses are based on 25-49 unweighted cases. Total includes 1 case with no religion, 2 cases for whom information on religion is missing, and 4 cases for whom information on employment is missing. 242 • Domestic Violence Overall, only 38 percent of women sought help from any source to stop the violence. Forty percent never sought help and never told anyone, while 13 percent never sought help but told someone that they were victims of violence. Women who have experienced both physical and sexual violence are most likely to seek help (65 percent). By age, young women (15-19 years) are least likely to seek help (30 percent). Christian women (49 percent); those who are divorced, separated, or widowed (58 percent); those with one or two children (47 percent); those living in Kerewan (45 percent) and Janjanbureh (44 percent); and those with a primary education (49 percent) are more likely than other groups to seek help. 16.18 SOURCES OF HELP TO STOP VIOLENCE Table 16.17 shows the percentage of physically abused women who reported seeking help by the sources from which help was sought. Among women who experienced physical violence, the most common source of help is their own family (56 percent), followed by neighbours (28 percent), their husband or partner’s family (14 percent), and friends (8 percent). Women who experienced both physical and sexual violence also reported their family as the most common source of help (56 percent). Other sources included their husband or partner’s family (25 percent), friends (20 percent), and neighbours (17 percent). Table 16.17 Sources of help to stop the violence Percentage of women age 15-49 who have experienced physical or sexual violence and sought help by sources from which they sought help, according to the type of violence that women reported, The Gambia 2013 Type of violence experienced Total Person Physical only Sexual only Physical and sexual Own family 55.6 * 56.2 56.4 Husband/partner’s family 13.6 * 25.3 15.1 Husband/partner 1.0 * 0.0 0.8 Boyfriend 0.0 * 1.1 0.2 Friend 8.2 * 19.9 10.1 Neighbour 28.0 * 17.4 25.7 Religious leader 1.3 * 1.9 1.4 Police 3.7 * 1.0 3.2 Social work organisation 0.3 * 0.3 0.3 Other 0.6 * 0.5 0.5 Number of women who have experienced violence and sought help 592 16 110 719 Note: Women can report more than one source from which they sought help. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Adult and Maternal Mortality • 243 ADULT AND MATERNAL MORTALITY 17 dult and maternal mortality rates are key indicators of the health status of a population. In The Gambia, population and housing censuses are the main source of data on adult mortality. Adult mortality levels and trends over time have important implications for the country’s health and social programmes, especially with regard to the impact of noncommunicable diseases such as diabetes and hypertension on adult health and mortality. Census data show that adult mortality has been declining over time. This decline is a result of improvements in the socioeconomic status of the population, including increased availability of and accessibility to health facilities and services (particularly among children and pregnant and postpartum women), improved nutrition, increased access to safe drinking water, and improvements in other sanitary conditions. Estimation of mortality rates requires comprehensive and accurate reporting of adult deaths, including maternal deaths. The maternal mortality module included in the 2013 GDHS gathered the valuable information needed to determine maternal mortality. This chapter includes results based on sibling history data collected in the sibling survival module (commonly referred to as the maternal mortality module) of the 2013 GDHS Woman’s Questionnaire. In addition to adult mortality rates for five- year age groups, a summary measure (35q15) is included that represents the probability of dying between exact ages 15 and 50. The term maternal mortality used in this chapter corresponds to the term pregnancy-related mortality defined in the latest version of the International Classification of Diseases (ICD-10). The ICD-10 definition of a pregnancy-related death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death” (WHO, 2011). In keeping with this definition, the sibling survival module used in the DHS surveys measures only the timing of deaths and not the cause. The data collected in the GDHS questionnaire are based on information about deaths that occur during the two months following a birth rather than the 42 days following a birth. 17.1 ASSESSMENT OF DATA QUALITY To obtain a sibling history, the 2013 GDHS first asked each female respondent to list all children born to her biological mother, starting with the firstborn. The respondent was then asked whether each of these siblings was still alive. For living siblings, the interviewer asked the current age of each sibling. For deceased siblings, the age at death and the number of years since death were recorded. When a respondent could not provide precise information on age at death or years since death, approximate but quantitative answers were accepted. For sisters who died at age 12 or older, three questions were asked to determine whether the death was maternal: “Was [NAME] pregnant when she died?” and, if the response was A Key Findings • Adult mortality is slightly higher among men than women (2.4 male deaths and 2.3 female deaths per 1,000 population, respectively). • Between age 15 and age 50, approximately 99 women per 1,000 and 102 men per 1,000 are likely to die. • Maternal deaths account for 36 percent of all deaths among women age 15-49. The maternal mortality rate for the seven-year period preceding the survey was 0.77 maternal deaths per 1,000 woman-years of exposure. • The maternal mortality ratio was 433 maternal deaths per 100,000 live births for the seven-year period preceding the survey. 244 • Adult and Maternal Mortality negative, “Did she die during childbirth?” and, if not, “Did she die within two months after the end of a pregnancy or childbirth?” Table C.7 in Appendix C shows that, in the 2013 GDHS, a total of 55,064 siblings were recorded in the sibling histories. The survival status was not reported for 33 siblings (0.1 percent). Among surviving siblings, current age was not reported for 267 siblings (0.6 percent). For 98 percent of deceased siblings, both age at death (AD) and years since death (YSD) were reported. In 0.5 percent of cases, age at death and years since death were missing. The sex ratio of the enumerated siblings (the ratio of brothers to sisters multiplied by 100) is 104.4, which is within the range of the acceptable sex ratio at birth (Table C.8). 17.2 ESTIMATES OF ADULT MORTALITY One way to assess the quality of data used to estimate maternal mortality is to evaluate the plausibility and stability of adult mortality estimates. If the overall estimated rates of adult mortality are implausible, rates based on a subset of deaths—maternal mortality, in particular—are likely to have serious problems. Moreover, levels and trends in overall adult mortality have important implications for health and social welfare programmes in The Gambia, especially with regard to the potential impact of limited access to health care services, an inadequately qualified and skilled health work force, and the emergence of infectious and noncommunicable diseases. The direct estimation of adult mortality uses the reported ages at death and years since death of the respondents’ brothers and sisters. Mortality rates are calculated by dividing the number of deaths in each age group of women and men by the total person-years of exposure to the risk of dying in that age group during a specified period prior to the survey. To have a sufficiently large number of adult deaths to generate a robust estimate, the rates are calculated for the seven-year period preceding the survey (approximately 2006 to 2013). Nevertheless, age-specific mortality rates obtained in this manner are subject to considerable sampling variation. Table 17.1 Adult mortality rates Direct estimates of female and male mortality rates for the seven years preceding the survey, by five-year age groups, The Gambia 2013 Age Deaths Exposure years Mortality rate1 FEMALE 15-19 21 25,886 0.82 20-24 25 28,043 0.91 25-29 41 23,528 1.75 30-34 79 17,635 4.46 35-39 36 12,292 2.94 40-44 31 7,064 4.34 45-49 23 4,148 5.57 15-49 256 118,595 2.28a MALE 15-19 39 25,803 1.52 20-24 50 27,579 1.82 25-29 47 24,305 1.92 30-34 44 18,087 2.43 35-39 35 12,464 2.79 40-44 34 7,404 4.53 45-49 26 3,991 6.51 15-49 274 119,633 2.41a 1 Expressed per 1,000 population a Age-adjusted rate Table 17.1 shows age-specific mortality rates (ASMRs) among women and men age 15-49 for the seven-year period preceding the survey. Overall, the level of adult mortality is slightly higher among men (2.4 deaths per 1,000 population) than among women (2.3 deaths per 1,000 population). Age-specific mortality rates are higher for men than for women except in the 30-34 and 35-39 age groups, where the reverse is true. Adult and Maternal Mortality • 245 Generally, ASMRs show the expected increases with age among both women and men. The confidence intervals for many of the five-year mortality rates overlap and can be found in Appendix Table B.13. Table 17.2 shows the summary measure of the risk of dying between the exact ages of 15 and 50 (35q15). That is, 35q15 represents the risk of a 15-year-old person dying before age 50. According to the 2013 GDHS, 99 of 1,000 young women age 15 and 102 of 1,000 young men age 15 are likely to die before reaching age 50. The confidence limits for the 35q15 estimates can be found in Appendix Table B.13. 17.3 ESTIMATES OF MATERNAL MORTALITY In this survey, maternal deaths are defined as any deaths that occur during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy. Estimates of maternal mortality are therefore based solely on the timing of the death in relationship to the pregnancy.1 Maternal mortality in The Gambia and other developing countries can be estimated using two procedures: the indirect sisterhood method (Graham et al., 1989) or a direct estimation variant of the sisterhood method (Rutenberg and Sullivan, 1991). In this report, the direct estimation variant is used to estimate maternal mortality. Table 17.3 presents direct estimates of maternal mortality for the seven-year period preceding the survey. The maternal mortality rate among women age 15-49 is 0.77 maternal deaths per 1,000 woman- years of exposure. By five-year age groups, the maternal mortality rate is highest among women age 30-34 (1.96), followed by those age 45-49 (1.33). The confidence limits for maternal mortality rates can be found in Appendix Table B.13. Table 17.3 Maternal mortality Direct estimates of maternal mortality rates for the seven years preceding the survey, by five-year age groups, The Gambia 2013 Age Percentage of female deaths that are maternal Maternal deaths Exposure years Maternal mortality rate1 15-19 34.7 7 25,886 0.28 20-24 48.2 12 28,043 0.44 25-29 50.4 21 23,528 0.88 30-34 43.9 35 17,635 1.96 35-39 23.8 9 12,292 0.70 40-44 6.7 2 7,064 0.29 45-49 23.9 6 4,148 1.33 Total 15-49 35.5 91 118,595 0.77a General fertility rate (GFR)2 178a Maternal mortality ratio (MMR)3 433 CI: (299, 567) Lifetime risk of maternal death4 0.024 CI = Confidence interval 1 Expressed per 1,000 woman-years of exposure 2 Expressed per 1,000 women age 15-49 3 Expressed per 100,000 live births; calculated as the age-adjusted maternal mortality rate multiplied by 100 and divided by the age-adjusted general fertility rate 4 Calculated as 1-(1-MMR)TFR, where TFR represents the total fertility rate for the seven years preceding the survey a Age-adjusted rate 1 This time-dependent definition includes all deaths that occurred during pregnancy and two months after the pregnancy, even if the death was due to non-maternal causes. However, this definition is unlikely to result in overreporting of maternal deaths because most deaths among women during this two-month period are due to maternal causes. Table 17.2 Adult mortality probabilities The probability of dying between the ages of 15 and 50 among young women and men for the seven years preceding the survey, The Gambia 2013 Women Men Survey 35q151 35q151 2013 GDHS 99 102 1 The probability of dying between exact ages 15 and 50, expressed per 1,000 person-years of exposure 246 • Adult and Maternal Mortality In the 2013 GDHS, maternal deaths represent 36 percent of all deaths among women age 15-49. The percentage of female deaths that are maternal varies by age and ranges from 7 percent of all deaths among women age 40-44 to 50 percent of deaths among women age 25-29. The maternal mortality rate can be converted to a maternal mortality ratio (expressed as deaths per 100,000 live births) by dividing the total maternal mortality rate (0.77) by the general fertility rate of 178 that prevailed during the same time period and multiplying the result by 100,000. The resulting maternal mortality ratio is 433 deaths per 100,000 live births during the seven-year period preceding the survey. In other words, for every 1,000 live births in The Gambia during the seven years preceding the 2013 GDHS, about four women died during pregnancy, during childbirth, or within two months of childbirth. The lifetime risk of maternal death of 0.024 indicates that about 2 percent of women die during pregnancy, during childbirth, or within two months of childbirth. These figures should be viewed with caution because the number of female deaths occurring during pregnancy, at delivery, or within two months of delivery is small (91). 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Atlanta, Georgia, USA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. World Health Organization (WHO). 1998. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: WHO. World Health Organization (WHO). 2001. Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women. Geneva, Switzerland: WHO Department of Gender and Women’s Health. World Health Organization (WHO). 2005. Guiding Principles for Feeding Nonbreastfed Children 6-24 Months of Age. Geneva, Switzerland: WHO. World Health Organization (WHO) Multicentre Growth Reference Study Group. 2006. WHO child growth standards: Length/height-for-age, Weight-for-length, Weight-for-height and Body Mass Index-for-age: Methods and Development. 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Geneva, Switzerland/New York: WHO/UNICEF. http://www.wssinfo.org/fileadmin/user_upload/resources/JMP-report-2012-en.pdf. Windham, G.C., A. Eaton, and B. Hopkins. 1999. Evidence for an association between environmental tobacco smoke exposure and birth weight: A meta-analysis and new data. Paediatric and Perinatal Epidemiology 13: 35-37. Yoder, P. S., N. Abderrahim, and A. Zhuzhuni. 2004. Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis. DHS Comparative Report No 7. Calverton, Maryland, USA: ORC Macro. Appendix A • 251 SAMPLE DESIGN Appendix A A.1 INTRODUCTION The 2013 Gambia Demographic and Health Survey (GDHS) is the first DHS to be undertaken in The Gambia. The survey used a nationally representative sample of about 7,000 households. The main objectives of the 2013 GDHS survey were to provide up-to-date information on fertility and childhood mortality levels; fertility preferences; awareness, approval, and use of family planning methods; maternal and child health and nutrition; knowledge and attitudes toward HIV/AIDS and other sexually transmitted infections (STIs); HIV prevalence among the adult population age 15-49; anaemia prevalence among women; and anaemia and malaria prevalence among children age 6-59 months. All women age 15-49 who were usual members of the selected households or who spent the night in the selected households the day before the survey were eligible for the survey. The survey was expected to successfully interview about 11,300 women from this group. The goal was to produce representative results for the country as a whole, for the urban and the rural areas separately, and for each of the eight Local Government Areas (LGAs): two municipalities and six LGAs1. In addition to the survey of women, a survey of men was also conducted in a sub-sample of every other household selected for the women’s survey. All men age 15-59 who were usual members of the selected households or who spent the night in the selected households the day before the survey were eligible. The survey collected information on men’s basic demographic status; use of family planning methods; and knowledge and attitudes toward HIV/AIDS and other STIs. All women and men eligible for individual interviews in the sub-sample of men were also asked for consent for a dried blood spot (DBS) sample for HIV testing. A.2 SAMPLING FRAME The sampling frame used for the 2013 GDHS was the 2003 Gambia Population and Housing Census (Gambia Bureau of Statistics 2007). The sampling frame is a complete list of enumeration areas (EAs) across the country. An EA is a geographic area, consisting of a convenient number of households, which serves as a counting unit for the census. EAs have an average size of 64 households. The sampling frame contains information about the location, the administrative belongings, the type of residence, and the number of residential households and population of each EA. A sketch map, available for each EA, delimits its geographic boundaries. Administratively, Gambia is divided into two urban municipalities (Banjul and Kanifing) and six LGAs. In turn, each LGA is sub-divided into districts, and each district into settlements. An EA is a settlement, a group of small settlements, or a part of a large settlement. These units allow the country as to be easily separated into small geographical area units, each with an urban or rural designation. There are 39 districts, 1,923 settlements, and 2,475 EAs in The Gambia. Tables A.1 to A.3 show the distribution of the households, population, enumeration areas by LGA and urban-rural of residence. In The Gambia, 51 percent of the population lives in urban areas. More than half of the urban population lives in the two municipalities (Banjul and Kanifing). Urban population occupies 61percent of the households. 1 For the purposes of surveys and censuses, the two municipalities are considered Local Government Areas, resulting in a total of eight LGAs for the entire country. The tables in this report show only LGAs, which include Banjul and Kanifing. 252 • Appendix A Table A.1 Households Distribution of the households in the sampling frame by LGA and residence, Gambia 2013 LGA Number of households in frame Percentage of total households Percentage urban Urban Rural Total Banjul 6,903 0 6,903 4.4 100.0 Kanifing 49,227 0 49,227 31.1 100.0 Brikama 28,387 16,832 45,219 28.6 62.8 Mansakonko 2,040 6,429 8,469 5.4 24.1 Kerewan 4,554 13,745 18,299 11.6 24.9 Kuntaur 614 6,526 7,140 4.5 8.6 Janjanbureh 2,139 7,999 10,138 6.4 21.1 Basse 3,167 9,472 12,639 8.0 25.1 Gambia 97,031 61,003 158,034 100.0 61.4 * Source: 2003 Gambia population and housing census (GBoS, 2007) Table A.2 Population Distribution of the population in the sampling frame by LGA and residence, Gambia 2013 LGA Population in frame Percentage of total population Percentage urban Urban Rural Total Banjul 35,061 0 35,061 2.6 100.0 Kanifing 322,735 0 322,735 23.7 100.0 Brikama 235,798 153,796 389,594 28.6 60.5 Mansakonko 13,302 58,865 72,167 5.3 18.4 Kerewan 34,720 138,115 172,835 12.7 20.1 Kuntaur 5,040 73,451 78,491 5.8 6.4 Janjanbureh 16,836 90,376 107,212 7.9 15.7 Basse 23,729 158,857 182,586 13.4 13.0 Gambia 687,221 673,460 1,360,681 100.0 50.5 * Source: 2003 Gambia population and housing census (GBoS, 2007) Table A.3 Enumeration areas Distribution of the enumeration areas in the sampling frame by LGA and residence, Gambia 2013 LGA Number of enumeration areas in frame Average enumeration area size Urban Rural Total Urban Rural Total Banjul 92 0 92 75 0 75 Kanifing 634 0 634 78 0 78 Brikama 427 295 722 66 57 63 Mansakonko 33 122 155 62 53 55 Kerewan 66 256 322 69 54 57 Kuntaur 11 113 124 56 58 58 Janjanbureh 40 139 179 53 58 57 Basse 57 190 247 56 50 51 Gambia 1,360 1,115 2,475 71 55 64 * Source: 2003 Gambia population and housing census (GBoS, 2007) A.3 SAMPLE DESIGN AND IMPLEMENTATION The sample for the 2013 GDHS survey was a stratified sample selected in two stages from the sampling frame. Stratification was achieved by separating each LGA into urban and rural areas. In total, 14 sampling strata were created because Banjul and Kanifing are entirely urban. Samples were selected independently in each stratum by a two-stage selection process. Implicit stratification and proportional allocation was achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection, according to administrative units, and by using a probability proportional to size selection at the first stage of sampling. In the first stage, 281 EAs were selected with probability proportional to the EA size and with independent selection in each sampling stratum; the sample allocation is shown in Table A.4. The EA size is the number of residential households residing in the EA during the 2003 Population and Housing Census. After the selection of EAs and before the main survey, a household listing operation was carried Appendix A • 253 out in all selected EAs. The resulting lists of households served as the sampling frame for the selection of households in the second stage. If an EA was too large to be a DHS cluster (>200 households), the EA was segmented into smaller segments following specified guidelines, and one of the resulting segments was selected with probability proportional to size. The household listing was conducted only in the selected segment, and the listing of the segment was then used to help select the final household sample. So, a 2013 GDHS cluster was either an EA or a segment of an EA. In the second stage of selection, a fixed number of 25 households per cluster were selected with an equal probability systematic selection from the newly created household listing. The survey interviewers were asked to interview only the pre-selected households. To prevent bias, no replacements and no changes of the pre-selected households were allowed in the implementing stages. All women age 15-49 who were usual members of the selected households or who spent the night prior to the survey in the selected households were eligible for the female survey. A sub-sample of one in every two households selected for the women’s survey was selected for the men’s survey. All men age 15-59 who were usual members of the selected households or who spent the night prior to the survey in the selected households were eligible for the men’s survey. Table A.4 shows the sample allocation of clusters and the sample allocation of households by LGA and according to residence. The sample allocation of the expected number of completed interviews with women and men, by LGA and according to residence, is shown in Table A.5. In order that the survey precisions are comparable across LGAs, the sample allocation figures a power allocation among LGAs and between urban-rural residence within each LGA. This allocation guarantees at least 800 interviews of women per LGA to ensure that the estimates of demographic indicators such as total fertility rates (TFRs) and early childhood mortality rates (CMRs) have the acceptable precision. The capital city of Banjul was over-sampled to better capture its social, economic, and cultural diversity. With a fixed sample size of 25 households per cluster, a total of 281 clusters were selected. Of the selected clusters, 147 were in urban areas and 134 were in rural areas. The selected sample size was 7,025 households, 3,675 in urban areas and 3,350 in rural areas. This sample size was expected to result in about 11,280 completed interviews with women, 5,272 in urban areas and 6,008 in rural areas. The sample allocations were calculated based on findings from The Gambia 2005-06 MICS survey. The average number of women age 15-49 per household at the national level is 1.69. The range is from 1.2 women per household in Banjul to 2.7 in Basse. The estimated average number of men age 15-49 per household is 1.7 men (there was no male survey in the 2005-06 MICS). The household response rate was 98 percent in both urban and rural areas; the woman’s individual response rate was 97 percent in both urban and rural areas. Table A.4 Sample allocation of clusters and households Sample allocation of clusters and households by LGA, according to residence, Gambia 2013 LGA Allocation of clusters Allocation of households Urban Rural Total Urban Rural Total Banjul 43 0 43 1,075 0 1,075 Kanifing 46 0 46 1,150 0 1,150 Brikama 29 21 50 725 525 1,250 Mansakonko 7 23 30 175 575 750 Kerewan 10 31 41 250 775 1,025 Kuntaur 3 22 25 75 550 625 Janjanbureh 5 19 24 125 475 600 Basse 4 18 22 100 450 550 Gambia 147 134 281 3,675 3,350 7,025 254 • Appendix A Table A.5 Sample allocation of completed interviews with women and men Sample allocation of expected number of completed interviews with women and men by LGA, according to residence, Gambia 2013 LGA Women 15-49 Men 15-59* Urban Rural Total Urban Rural Total Banjul 1,261 0 1,261 652 0 652 Kanifing 1,681 0 1,681 869 0 869 Brikama 1,024 742 1,766 529 383 912 Mansakonko 275 900 1,175 141 464 605 Kerewan 345 1,073 1,418 179 555 734 Kuntaur 146 1,057 1,203 73 541 614 Janjanbureh 275 1,045 1,320 123 466 589 Basse 265 1,191 1,456 112 504 616 Gambia 5,272 6,008 11,280 2,678 2,913 5,591 *A survey of men was conducted in half of the households selected for the survey of women. An examination of response rates for the 2013 GDHS indicates that the survey was successfully implemented. In the interviewed households, 11,279 eligible women were identified for individual interviews. Complete interviews were conducted with 10,233 women, yielding a response rate of 91 percent. Similarly, a total of 4,668 eligible men were identified for individual interviews in the households selected for the male survey. Complete interviews were conducted with 3,821 men, yielding a response rate of 82 percent. Tables A.6 and A.7 present the interview response rates in the 2013 GDHS for women and men, respectively, both by urban and rural area and by LGA. Overall, the number of completed interviews is similar to the expected number for both women and men. Tables A.8 through A.11 present response rates for HIV testing by background characteristics. A pp en di x A • 2 55 Ta bl e A. 6 S am pl e im pl em en ta tio n: W om en P er ce nt d is tri bu tio n of h ou se ho ld s an d el ig ib le w om en b y re su lts o f t he h ou se ho ld a nd in di vi du al in te rv ie w s; a nd h ou se ho ld , e lig ib le w om en , a nd o ve ra ll w om en re sp on se ra te s, a cc or di ng to u rb an -r ur al re si de nc e an d LG A (u nw ei gh te d) , T he G am bi a 20 13 R es id en ce LG A To ta l R es ul t U rb an R ur al B an ju l K an ifi ng B rik am a M an sa ko nk o K er ew an K un ta ur Ja nj an bu re h B as se Se le ct ed h ou se ho ld s C om pl et ed (C ) 84 .5 93 .2 81 .0 86 .8 88 .7 92 .7 89 .3 93 .6 90 .5 93 .6 88 .7 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt a t ho m e (H P ) 0. 3 0. 0 0. 5 0. 0 0. 2 0. 0 0. 1 0. 2 0. 3 0. 0 0. 2 P os tp on ed (P ) 3. 2 2. 2 3. 3 2. 9 2. 2 3. 7 3. 1 1. 3 2. 8 1. 6 2. 7 R ef us ed (R ) 1. 1 0. 2 1. 0 1. 3 0. 8 0. 0 0. 3 0. 0 0. 3 0. 7 0. 6 D w el lin g no t f ou nd (D N F) 1. 6 0. 6 2. 4 0. 7 0. 9 0. 7 1. 3 0. 5 2. 3 0. 0 1. 1 H ou se ho ld a bs en t ( H A ) 3. 8 1. 0 4. 9 4. 0 2. 2 0. 5 1. 4 1. 8 1. 7 0. 7 2. 4 D w el lin g va ca nt /a dd re ss n ot a dw el lin g (D V ) 4. 5 2. 2 5. 4 3. 6 4. 2 1. 7 3. 5 2. 1 1. 3 2. 9 3. 4 D w el lin g de st ro ye d (D D ) 0. 4 0. 2 0. 7 0. 4 0. 2 0. 1 0. 2 0. 5 0. 3 0. 2 0. 3 O th er (O ) 0. 6 0. 4 0. 8 0. 3 0. 6 0. 5 0. 9 0. 2 0. 3 0. 2 0. 5 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed h ou se ho ld s 3, 66 1 3, 34 8 1, 07 5 1, 13 6 1, 25 0 75 0 1, 02 5 62 5 59 8 55 0 7, 00 9 H ou se ho ld re sp on se ra te (H R R )1 93 .2 96 .9 91 .9 94 .6 95 .6 95 .5 94 .9 98 .0 93 .9 97 .5 95 .0 El ig ib le w om en C om pl et ed (E W C ) 89 .2 92 .0 89 .0 85 .9 90 .4 95 .7 93 .3 91 .3 90 .1 92 .1 90 .7 N ot a t h om e (E W N H ) 6. 4 5. 4 5. 6 8. 5 6. 3 2. 2 4. 5 6. 5 7. 6 4. 5 5. 9 P os tp on ed (E W P ) 0. 1 0. 0 0. 1 0. 2 0. 1 0. 0 0. 0 0. 0 0. 0 0. 1 0. 1 R ef us ed (E W R ) 2. 2 0. 7 3. 0 3. 5 1. 1 0. 4 0. 7 0. 6 0. 4 0. 7 1. 4 P ar tly c om pl et ed (E W P C ) 0. 5 0. 2 0. 8 0. 6 0. 2 0. 2 0. 2 0. 2 0. 4 0. 1 0. 3 In ca pa ci ta te d (E W I) 0. 8 0. 9 0. 5 0. 7 1. 0 1. 0 0. 6 1. 1 0. 5 1. 5 0. 9 O th er (E W O ) 0. 8 0. 8 1. 0 0. 6 0. 9 0. 6 0. 7 0. 3 1. 1 1. 1 0. 8 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f w om en 5, 04 3 6, 23 6 1, 20 5 1, 75 3 2, 02 8 1, 08 8 1, 55 2 1, 13 8 1, 13 7 1, 37 8 11 ,2 79 E lig ib le w om en re sp on se ra te (E W R R )2 89 .2 92 .0 89 .0 85 .9 90 .4 95 .7 93 .3 91 .3 90 .1 92 .1 90 .7 O ve ra ll w om en re sp on se ra te (O R R )3 83 .1 89 .1 81 .8 81 .3 86 .4 91 .3 88 .6 89 .5 84 .6 89 .8 86 .2 1 U si ng th e nu m be r o f h ou se ho ld s fa llin g in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H R R ) i s ca lc ul at ed a s: 10 0 * C __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ C + H P + P + R + D N F 2 T he e lig ib le w om en re sp on se ra te (E W R R ) i s eq ui va le nt to th e pe rc en ta ge o f i nt er vi ew s co m pl et ed (E W C ) 3 T he o ve ra ll w om en re sp on se ra te (O W R R ) i s ca lc ul at ed a s: O W R R = H R R * E W R R /1 00 Appendix A • 255 25 6 • A pp en di x A Ta bl e A. 7 S am pl e im pl em en ta tio n: M en P er ce nt d is tri bu tio n of h ou se ho ld s an d el ig ib le m en b y re su lts o f th e ho us eh ol d an d in di vi du al i nt er vi ew s; a nd h ou se ho ld , el ig ib le m en , an d ov er al l m en r es po ns e ra te s, a cc or di ng t o ur ba n- ru ra l re si de nc e an d LG A (u nw ei gh te d) , T he G am bi a 20 13 R es id en ce LG A To ta l R es ul t U rb an R ur al B an ju l K an ifi ng B rik am a M an sa ko nk o K er ew an K un ta ur Ja nj an bu re h B as se Se le ct ed h ou se ho ld s C om pl et ed (C ) 84 .1 93 .5 79 .7 85 .7 89 .5 91 .4 91 .1 94 .7 89 .6 93 .6 88 .6 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt a t h om e (H P ) 0. 2 0. 0 0. 6 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 P os tp on ed (P ) 3. 4 2. 3 2. 5 3. 1 2. 8 4. 4 2. 4 1. 7 3. 8 1. 9 2. 9 R ef us ed (R ) 1. 3 0. 2 1. 4 1. 7 0. 8 0. 0 0. 2 0. 0 0. 7 0. 8 0. 8 D w el lin g no t f ou nd (D N F) 1. 5 0. 5 2. 5 0. 7 0. 3 0. 6 1. 0 0. 3 2. 4 0. 0 1. 0 H ou se ho ld a bs en t ( H A ) 4. 4 0. 8 6. 4 4. 2 2. 2 0. 8 1. 0 2. 0 2. 4 0. 4 2. 7 D w el lin g va ca nt /a dd re ss n ot a dw el lin g (D V ) 4. 2 2. 1 5. 4 4. 2 3. 7 2. 2 3. 0 0. 7 0. 3 3. 4 3. 2 D w el lin g de st ro ye d (D D ) 0. 4 0. 1 0. 6 0. 4 0. 0 0. 0 0. 4 0. 3 0. 3 0. 0 0. 3 O th er (O ) 0. 5 0. 4 1. 0 0. 0 0. 5 0. 6 0. 8 0. 3 0. 3 0. 0 0. 5 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed h ou se ho ld s 1, 75 7 1, 60 8 51 6 54 5 60 0 36 0 49 2 30 0 28 8 26 4 3, 36 5 H ou se ho ld re sp on se ra te (H R R )1 93 .0 96 .8 91 .9 94 .0 95 .6 94 .8 96 .1 97 .9 92 .8 97 .2 94 .9 El ig ib le m en C om pl et ed (E M C ) 78 .1 85 .6 79 .1 75 .5 80 .2 90 .6 87 .9 82 .7 77 .7 88 .1 81 .9 N ot a t h om e (E M N H ) 16 .8 10 .9 14 .8 18 .9 15 .6 4. 2 8. 8 15 .6 20 .3 7. 4 13 .9 P os tp on ed (E M P ) 0. 1 0. 1 0. 0 0. 1 0. 1 0. 2 0. 4 0. 0 0. 0 0. 0 0. 1 R ef us ed (E M R ) 2. 2 1. 2 2. 7 2. 6 2. 0 2. 2 0. 5 0. 0 0. 4 2. 0 1. 7 P ar tly c om pl et ed (E M P C ) 0. 6 0. 2 1. 0 0. 9 0. 3 0. 7 0. 0 0. 0 0. 0 0. 0 0. 4 In ca pa ci ta te d (E M I) 1. 2 1. 4 1. 0 1. 4 1. 0 1. 5 1. 8 1. 7 0. 9 1. 7 1. 3 O th er (E M O ) 0. 9 0. 6 1. 5 0. 6 0. 7 0. 5 0. 7 0. 0 0. 6 0. 9 0. 7 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f m en 2, 34 3 2, 32 5 60 3 77 9 98 1 40 3 56 8 41 1 46 2 46 1 4, 66 8 E lig ib le m en re sp on se ra te (E M R R )2 78 .1 85 .6 79 .1 75 .5 80 .2 90 .6 87 .9 82 .7 77 .7 88 .1 81 .9 O ve ra ll m en re sp on se ra te (O R R )3 72 .7 82 .9 72 .7 70 .9 76 .7 85 .9 84 .5 81 .0 72 .1 85 .6 77 .7 1 U si ng th e nu m be r o f h ou se ho ld s fa llin g in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H R R ) i s ca lc ul at ed a s: 10 0 * C __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ C + H P + P + R + D N F 2 T he e lig ib le m en re sp on se ra te (E M R R ) i s eq ui va le nt to th e pe rc en ta ge o f i nt er vi ew s co m pl et ed (E M C ) 3 T he o ve ra ll m en re sp on se ra te (O M R R ) i s ca lc ul at ed a s: O M R R = H R R * E M R R /1 00 256 • Appendix A Appendix A • 257 A.4 SAMPLE PROBABILITIES AND SAMPLING WEIGHTS Because of the nonproportional allocation of the sample across domains and urban-rural areas, and the differential response rates, sampling weights must be calculated using all analyses of the GDHS results to ensure that survey results are representative at both the national and domain level. The GDHS sample is a two-stage stratified cluster sample, so sampling weights are based on sampling probabilities calculated separately for each sampling stage and for each cluster where: P1hi: first-stage sampling probability of the ith cluster in stratum h P2hi: second-stage sampling probability within the ith cluster (households) The following describes the calculation of these probabilities: Let ah be the number of clusters selected in stratum h, Mhi the number of households according to the sampling frame in the ith cluster, and M hi the total number of households in the stratum. The probability of selecting the ith cluster in the 2013 LDHS sample is calculated as follows: M M a hi hih  Let hib be the proportion of households in the selected cluster compared with the total number of households in cluster i in stratum h if the cluster is segmented, otherwise 1=hib . Then the probability of selecting cluster i in the sample is: hi hi hih 1hi b M M a = P × Let hiL be the number of households listed in the household listing operation in cluster i in stratum h, and let hig be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster is calculated as follows: hi hi hi L gP =2 The overall selection probability of each household in cluster i of stratum h is therefore the product of the two stages of selection probabilities: hihihi PPP 21 ×= The design weight for each household in cluster i of stratum h is the inverse of its overall selection probability: hihi PW /1= Next, the design weight is adjusted for household non-response and individual non-response to get the sampling weights for households and for women and men, respectively. Non-response is adjusted at the sampling stratum level. For the household sampling weight, the household design weight is multiplied by the inverse of the household response rate, by stratum. For the women’s individual sampling weight, the household sampling weight is multiplied by the inverse of the women’s individual response rate, by stratum. For the men’s individual sampling weight, the household sampling weight for the male sub- sample is multiplied by the inverse of the men’s individual response rate, by stratum. After adjusting for non-response, the sampling weights are normalised to get the final standard weights that appear in the data 258 • Appendix A files. The normalisation process is done to obtain a total number of unweighted cases equal to the total number of weighted cases at the national level, for the total number of households, women, and men. Normalisation is done by multiplying the sampling weight by the estimated sampling fraction obtained from the survey for the household weight, the individual woman’s weight, and the individual man’s weight. The normalised weights are relative weights that are valid for estimating means, proportions, ratios, and rates, but they are not valid for estimating population totals or pooled data. The sampling weights for HIV testing are calculated in a similar way, but the normalisation of the HIV weights is done differently. The individual HIV testing weights are normalised at the national level for women and men together so that HIV prevalence estimates calculated for women and men together are valid. Table A.8 Coverage of HIV testing by social and demographic characteristics: Women Percent distribution of interviewed women age 15-49 by HIV testing status, according to social and demographic characteristics (unweighted), The Gambia 2013 Testing status Total Number Background characteristic DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Marital status Never married 90.6 4.5 2.9 2.1 100.0 1,323 Ever had sexual intercourse 93.3 3.6 2.4 0.6 100.0 165 Never had sexual intercourse 90.2 4.6 2.9 2.3 100.0 1,158 Married/living together 93.2 3.3 1.9 1.6 100.0 3,299 Divorced or separated 92.3 4.8 1.8 1.2 100.0 168 Widowed 92.2 3.1 0.0 4.7 100.0 64 Type of union In polygynous union 92.9 3.3 2.2 1.7 100.0 1,343 In non-polygynous union 93.4 3.3 1.7 1.6 100.0 1,940 Not currently in union 90.8 4.4 2.6 2.1 100.0 1,555 Missing 100.0 0.0 0.0 0.0 100.0 16 Ever had sexual intercourse Yes 93.3 3.3 1.9 1.6 100.0 3,647 No 89.9 4.7 2.9 2.5 100.0 1,201 Missing 100.0 0.0 0.0 0.0 100.0 6 Currently pregnant Pregnant 94.6 2.6 1.3 1.5 100.0 389 Not pregnant or not sure 92.3 3.7 2.2 1.8 100.0 4,465 Times slept away from home in past 12 months None 92.1 4.0 2.0 1.9 100.0 2,610 1-2 92.9 3.2 2.3 1.6 100.0 1,602 3-4 92.3 3.5 2.1 2.1 100.0 428 5+ 92.7 2.9 2.9 1.5 100.0 205 Missing 88.9 11.1 0.0 0.0 100.0 9 Time away in past 12 months Away for more than 1 month 92.2 3.9 2.6 1.3 100.0 797 Away for less than 1 month 93.3 2.8 2.1 1.8 100.0 1,433 No away 92.1 4.0 2.0 1.9 100.0 2,612 Missing 75.0 8.3 8.3 8.3 100.0 12 Religion Islam 92.7 3.6 2.0 1.7 100.0 4,713 Christianity 82.7 6.0 6.0 5.3 100.0 133 No religion 100.0 0.0 0.0 0.0 100.0 1 Missing 100.0 0.0 0.0 0.0 100.0 7 Total 92.4 3.6 2.1 1.8 100.0 4,854 1 Includes all dried blood samples tested at the lab and for which there is a result (i.e., positive, negative, or indeterminate). Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. Appendix A • 259 Table A.9 Coverage of HIV testing by social and demographic characteristics: Men Percent distribution of interviewed men 15-49[59] by HIV testing status, according to social and demographic characteristics (unweighted), The Gambia 2013 Testing status Total Number Characteristic DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Marital status Never married 86.9 6.0 4.8 2.3 100.0 2,102 Ever had sexual intercourse 88.8 5.5 4.5 1.2 100.0 910 Never had sexual intercourse 85.5 6.4 5.0 3.1 100.0 1,192 Married/living together 84.9 8.8 4.4 1.8 100.0 1,665 Divorced or separated 76.6 19.1 2.1 2.1 100.0 47 Widowed 71.4 14.3 14.3 0.0 100.0 7 Type of union In polygynous union 84.3 11.1 3.0 1.5 100.0 396 In nonpolygynous union 85.1 8.1 4.9 1.9 100.0 1,269 Not currently in union 86.6 6.3 4.8 2.3 100.0 2,156 Ever had sexual intercourse Yes 86.2 7.8 4.4 1.6 100.0 2,611 No 85.5 6.3 5.2 3.1 100.0 1,197 Missing 61.5 30.8 0.0 7.7 100.0 13 Times slept away from home in past 12 months None 85.7 7.8 4.7 1.9 100.0 1,862 1-2 86.0 6.9 4.1 3.1 100.0 948 3-4 87.3 4.1 6.3 2.3 100.0 394 5+ 85.6 9.2 4.2 1.0 100.0 612 Missing 80.0 20.0 0.0 0.0 100.0 5 Time away in past 12 months Away for more than 1 month 86.9 6.0 4.9 2.2 100.0 650 Away for less than 1 month 85.7 7.5 4.4 2.3 100.0 1,304 No away 85.7 7.8 4.7 1.9 100.0 1,862 Missing 80.0 20.0 0.0 0.0 100.0 5 Religion Islam 86.0 7.3 4.7 2.1 100.0 3,703 Christianity 81.4 12.4 3.5 2.7 100.0 113 No religion 100.0 0.0 0.0 0.0 100.0 3 Missing 100.0 0.0 0.0 0.0 100.0 2 Total 85.9 7.4 4.6 2.1 100.0 3,821 1 Includes all dried blood samples tested at the lab and for which there is a result (i.e., positive, negative, or indeterminate). Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 260 • Appendix A Table A.10 Coverage of HIV testing by sexual behaviour characteristics: Women Percent distribution of interviewed women age 15-49 who ever had sexual intercourse by HIV test status, according to sexual behaviour characteristics (unweighted), The Gambia 2013 Testing status Total Number Sexual behaviour characteristic DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Age at first sexual intercourse <16 94.5 2.6 1.4 1.5 100.0 1,129 16-17 94.6 2.3 1.6 1.5 100.0 746 18-19 94.2 3.4 1.2 1.2 100.0 669 20+ 90.4 5.0 2.7 2.0 100.0 863 Missing 90.8 3.8 3.8 1.7 100.0 240 Multiple sexual partners and partner concurrency in past 12 months 0 90.7 4.7 3.0 1.6 100.0 570 1 93.7 3.1 1.7 1.6 100.0 3,064 2+ 100.0 0.0 0.0 0.0 100.0 11 Had concurrent partners3 100.0 0.0 0.0 0.0 100.0 1 None of the partners were concurrent 100.0 0.0 0.0 0.0 100.0 10 Missing 100.0 0.0 0.0 0.0 100.0 2 Condom use at last sexual intercourse in past 12 months Used condom 88.5 5.3 3.5 2.7 100.0 113 Did not use condom 93.9 3.0 1.6 1.5 100.0 2,959 No sexual intercourse in last 12 months 90.7 4.7 3.0 1.6 100.0 572 Missing 100.0 0.0 0.0 0.0 100.0 3 Number of lifetime partners 1 93.3 3.4 1.8 1.6 100.0 2,967 2 93.0 3.0 2.3 1.7 100.0 531 3-4 95.6 1.8 1.8 0.9 100.0 114 5-9 87.5 6.3 6.3 0.0 100.0 16 10+ 0.0 0.0 0.0 100.0 100.0 1 Missing 88.9 11.1 0.0 0.0 100.0 18 Prior HIV testing Ever tested 93.6 2.7 2.0 1.7 100.0 1,884 Received results 93.6 2.8 1.8 1.8 100.0 1,702 Did not received results 94.0 2.2 3.3 0.5 100.0 182 Never tested 92.8 4.0 1.7 1.5 100.0 1,716 Missing 93.6 4.3 2.1 0.0 100.0 47 Total 93.3 3.3 1.9 1.6 100.0 3,647 1 Includes all dried blood samples tested at the lab and for which there is a result (i.e., positive, negative, or indeterminate). Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 3 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. Appendix A • 261 Table A.11 Coverage of HIV testing by sexual behaviour characteristics: Men Percent distribution of interviewed men age 15-59 who ever had sexual intercourse by HIV test status, according to sexual behaviour characteristics (unweighted), The Gambia 2013 Testing status Total Number Sexual behaviour characteristic DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing Age at first sexual intercourse <16 87.9 6.6 4.4 1.1 100.0 272 16-17 86.3 6.0 5.7 1.9 100.0 315 18-19 88.1 6.3 4.5 1.0 100.0 489 20+ 85.2 8.9 4.1 1.8 100.0 1,431 Missing 86.5 7.7 4.8 1.0 100.0 104 Multiple sexual partners and partner concurrency in past 12 months 0 89.4 5.2 4.1 1.4 100.0 444 1 85.5 7.9 4.8 1.8 100.0 1,741 2+ 85.9 9.8 3.3 1.0 100.0 418 Had concurrent partners2 85.1 9.7 4.2 1.0 100.0 288 None of the partners were concurrent 87.7 10.0 1.5 0.8 100.0 130 Missing 75.0 25.0 0.0 0.0 100.0 8 Condom use at last sexual intercourse in past 12 months Used condom 87.7 6.5 4.9 0.9 100.0 430 Did not use condom 85.1 8.7 4.4 1.8 100.0 1,727 No sexual intercourse in last 12 months 89.2 5.5 4.0 1.3 100.0 452 Missing 100.0 0.0 0.0 0.0 100.0 2 Paid for sexual intercourse in past 12 months Yes 96.8 3.2 0.0 0.0 100.0 31 Used condom 100.0 0.0 0.0 0.0 100.0 19 Did not use condom 91.7 8.3 0.0 0.0 100.0 12 No (No paid sexual intercourse/no sexual intercourse in last 12 months) 86.1 7.9 4.5 1.6 100.0 2,580 Number of lifetime partners 1 86.2 6.9 5.2 1.6 100.0 936 2 85.9 8.8 3.2 2.1 100.0 682 3-4 89.2 6.4 3.7 0.7 100.0 566 5-9 85.1 8.2 5.2 1.5 100.0 268 10+ 80.6 11.2 6.1 2.0 100.0 98 Missing 75.4 16.4 4.9 3.3 100.0 61 Prior HIV testing Ever tested 83.9 9.7 4.9 1.4 100.0 690 Received results 84.3 9.4 4.9 1.4 100.0 630 Did not received results 80.0 13.3 5.0 1.7 100.0 60 Never tested 87.0 7.1 4.2 1.6 100.0 1,920 Missing 100.0 0.0 0.0 0.0 100.0 1 Total 86.2 7.8 4.4 1.6 100.0 2,611 1 Includes all Dried Blood Samples (DBS) tested at the lab and for which there is a result (i.e., positive, negative, or indeterminate). Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes: 1) other results of blood collection (e.g., technical problem in the field), 2) lost specimens, 3) non corresponding bar codes, and 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 3 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. (Respondents with concurrent partners includes polygynous men who had overlapping sexual partnerships with two or more wives). Appendix B • 263 ESTIMATES OF SAMPLING ERRORS Appendix B he estimates from a sample survey are affected by two types of errors: nonsampling errors and sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions by either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2013 Gambia Demographic and Health Survey (GDHS) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2013 GDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability among all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. Sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2013 GDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulas. Sampling errors are computed in either ISSA or SAS, using programs developed by ICF International. These programs use the Taylor linearization method of variance estimation for survey estimates that are means, proportions, or ratios. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance:   = =        − − − == H h h h m i hi h h m zz m m x frvarrSE h 1 2 1 2 2 2 1 1)()( in which hihihi rxyz −= , and hhh rxyz −= T 264 • Appendix B where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulas. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2013 LDHS, there were 322 non-empty clusters. Hence, 322 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − =  in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 322 clusters, r(i) is the estimate computed from the reduced sample of 321 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, the design effect (DEFT) for each estimate is also calculated. The design effect is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error is due to the use of a more complex and less statistically efficient design. Relative standard errors and confidence limits for the estimates are also calculated. Sampling errors for the 2013 GDHS are calculated for selected variables considered to be of primary interest. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the eight Local Government Area (LGAs). For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 through B.12 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE) for each variable. The sampling errors for mortality rates are presented for the 5-year period preceding the survey for the whole country and for the 10-year period preceding the survey, by residence and region. The DEFT is considered undefined when the standard error considering a simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to childbearing. The confidence interval (e.g., as calculated for children ever born to women age 40-49) can be interpreted as follows: the overall average from the national sample is 6.186 and its standard error is 0.126. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the Appendix B • 265 sample estimate, i.e., 6.186±2×0.126. There is a high probability (95 percent) that the true average number of children ever born to all women age 40 to 49 is between 5.935 and 6.438. For the total sample, the value of the DEFT, averaged over all variables, is 1.80. This means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.80 over that in an equivalent simple random sample. Table B.1 List of selected variables for sampling errors, Gambia 2013 Variable Estimate Base population WOMEN Ownership of at least 1 insecticide treated net (ITN) Proportion Households Urban residence Proportion All women 15-49 Literacy Proportion All women 15-49 No education Proportion All women 15-49 Secondary education or higher Proportion All women 15-49 Never married/in union Proportion All women 15-49 Currently married/in union Proportion All women 15-49 Married before age 20 Proportion All women 20-49 Had sexual intercourse before age 18 Proportion All women 20-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women age 40-49 Mean All women 40-49 Know any contraceptive method Proportion Currently married women 15-49 Know a modern method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently using a traditional method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using male condoms Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using implants Proportion Currently married women 15-49 Currently using rhythm Proportion Currently married women 15-49 Used public sector source Proportion Current users of modern method Want no more children Proportion Currently married women 15-49 Want to delay next birth at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean All women 15-49 Mothers protected against tetanus for last birth Proportion Women with a live birth in last five years Had diarrhea in the past 2 weeks Proportion Children under 5 Treated with ORS Proportion Children under 5 with diarrhea in past 2 weeks Sought medical treatment for diarrhea Proportion Children under 5 with diarrhea in past 2 weeks Vaccination card seen Proportion Children 12-23 months Received BCG vaccination Proportion Children 12-23 months Received Pentavalent vaccination (3 doses) Proportion Children 12-23 months Received polio vaccination (3 doses) Proportion Children 12-23 months Received measles vaccination Proportion Children 12-23 months Received all vaccinations Proportion Children 12-23 months Height-for-age (-2SD) Proportion Children under 5 who are measured Weight-for-height (-2SD) Proportion Children under 5 who are measured Weight-for-age (-2SD) Proportion Children under 5 who are measured Body Mass Index (BMI) <18.5 Proportion All women 15-49 who were measured Had 2+ sexual partners in past 12 months Proportion All women 15-49 Condom use at last sex Proportion Women 15-49 with 2+ partners in past 12 months Abstinence among youth (never had sex) Proportion Never-married women 15-24 Sexually active in past 12 months among never-married youth Proportion Never-married women 15-24 Had an HIV test and received results in past 12 months Proportion All women 15-49 Accepting attitudes towards people with HIV Proportion All women who have heard of HIV/AIDS Total fertility rate (3 years) Rate Women-years of exposure to childbearing Neonatal mortality rate¹ Rate Children exposed to the risk of mortality Post-neonatal mortality rate¹ Rate Children exposed to the risk of mortality Infant mortality rate¹ Rate Children exposed to the risk of mortality Child mortality rate¹ Rate Children exposed to the risk of mortality Under-five mortality rate¹ Rate Children exposed to the risk of mortality HIV prevalence among all women 15-49 Proportion All interviewed women with DBS tested at the lab Continued… 266 • Appendix B Table B.1—Continued Variable Estimate Base population MEN Urban residence Proportion All men 15-49 Literacy Proportion All men 15-49 No education Proportion All men 15-49 Secondary education or higher Proportion All men 15-49 Never married/in union Proportion All men 15-49 Currently married/in union Proportion All men 15-49 Had sexual intercourse before age 18 Proportion All men 20-49 Know any contraceptive method Proportion Currently married men 15-49 Know a modern method Proportion Currently married men 15-49 Want no more children Proportion Currently married men 15-49 Want to delay next birth at least 2 years Proportion Currently married men 15-49 Ideal number of children Mean All men 15-49 Had 2+ sexual partners in past 12 months Proportion All men 15-49 Condom use at last sex Proportion Men 15-49 with 2+ partners in past 12 months Abstinence among youth (never had sex) Proportion Never-married men 15-24 Sexually active in past 12 months among never-married youth Proportion Never-married men 15-24 Paid for sexual intercourse in past 12 months Proportion All men 15-49 Had an HIV test and received results in past 12 months Proportion All men 15-49 Accepting attitudes towards people with HIV Proportion All men who have heard of HIV/AIDS HIV prevalence among all men 15-49 Proportion All interviewed men with DBS tested at the lab WOMEN AND MEN HIV prevalence among all women and men 15-49 Proportion All interviewed women and men with DBS tested at the lab 1 The mortality rates are calculated for 5 years and 10 years before the survey for the national sample and regional samples, respectively Appendix B • 267 Table B.2 Sampling errors: Total sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.560 0.017 10233 10233 3.514 0.031 0.525 0.594 No education 0.465 0.011 10233 10233 2.253 0.024 0.443 0.487 Secondary or higher education 0.398 0.011 10233 10233 2.347 0.029 0.375 0.421 Never married (never in union) 0.290 0.008 10233 10233 1.756 0.027 0.274 0.305 Currently married (in union) 0.664 0.008 10233 10233 1.811 0.013 0.647 0.681 Married before age 20 0.574 0.010 7770 7826 1.856 0.018 0.553 0.595 Had sexual intercourse before age 18 0.418 0.009 7770 7826 1.595 0.021 0.401 0.436 Currently pregnant 0.081 0.004 10233 10233 1.308 0.044 0.074 0.088 Children ever born 2.531 0.035 10233 10233 1.329 0.014 2.460 2.601 Children surviving 2.322 0.030 10233 10233 1.262 0.013 2.261 2.383 Children ever born to women age 40-49 6.014 0.105 1336 1320 1.489 0.017 5.805 6.224 Know any contraceptive method 0.963 0.006 6905 6791 2.741 0.006 0.950 0.975 Know a mordern method 0.958 0.007 6905 6791 2.799 0.007 0.945 0.972 Currently using any method 0.090 0.007 6905 6791 2.025 0.078 0.076 0.104 Currently using a modern method 0.081 0.006 6905 6791 1.974 0.080 0.068 0.094 Currently using pill 0.021 0.003 6905 6791 1.472 0.121 0.016 0.026 Currently using condoms 0.006 0.001 6905 6791 1.268 0.203 0.003 0.008 Currently using female sterilization 0.006 0.001 6905 6791 1.479 0.228 0.003 0.009 Currently using rythm 0.002 0.001 6905 6791 1.607 0.479 0.000 0.003 Used public sector source 0.601 0.035 630 666 1.800 0.059 0.531 0.672 Want no more children 0.158 0.007 6905 6791 1.661 0.046 0.144 0.173 Want to delay next birth at least 2 years 0.473 0.008 6905 6791 1.324 0.017 0.457 0.489 Ideal number of children 6.020 0.051 9902 9934 2.161 0.008 5.917 6.122 Mothers protected against tetanus for last birth 0.708 0.014 5385 5305 2.305 0.020 0.679 0.737 Had diarrhea in the last 2 weeks 0.174 0.009 7788 7586 2.017 0.053 0.155 0.192 Treated with ORS 0.592 0.017 1340 1318 1.228 0.030 0.557 0.627 Sought medical treatment for diarrhea 0.675 0.018 1340 1318 1.345 0.027 0.638 0.711 Vaccination card seen 0.902 0.012 1648 1660 1.543 0.013 0.878 0.925 Received BCG vaccination 0.989 0.004 1648 1660 1.452 0.004 0.981 0.996 Received DPT vaccination (3 doses) 0.877 0.011 1648 1660 1.401 0.013 0.854 0.900 Received polio vaccination (3 doses) 0.900 0.010 1648 1660 1.382 0.012 0.879 0.921 Received measles vaccination 0.878 0.019 1648 1660 2.273 0.021 0.841 0.916 Received all vaccinations 0.760 0.022 1648 1660 2.039 0.029 0.717 0.803 Height-for-age (-2SD) 0.245 0.011 3484 3372 1.320 0.045 0.223 0.267 Weight-for-height (-2SD) 0.115 0.009 3484 3372 1.620 0.082 0.096 0.133 Weight-for-age (-2SD) 0.162 0.010 3484 3372 1.422 0.061 0.143 0.182 Prevalence of anemia (Children 6-59 months) 0.728 0.012 3300 3238 1.530 0.017 0.703 0.753 Prevalence of anemia (women 15-49) 0.603 0.013 4478 4393 1.804 0.022 0.576 0.629 Body Mass Index (BMI) < 18.5 0.167 0.008 4062 4024 1.420 0.050 0.150 0.184 Had 2+ sexual partners in past 12 months 0.002 0.001 10233 10233 1.342 0.265 0.001 0.004 Abstinence among never-married youth (never had sex) 0.907 0.009 2569 2646 1.557 0.010 0.889 0.925 Sexually active in past 12 months among never-married youth 0.052 0.007 2569 2646 1.528 0.129 0.039 0.065 Had an HIV test and received results in past 12 months 0.139 0.005 10233 10233 1.536 0.038 0.128 0.149 Accepting attitudes towards people with HIV 0.052 0.005 10018 10066 2.297 0.098 0.041 0.062 Total fertility rate (3 years) 5.603 0.133 28544 28602 1.571 0.024 5.337 5.870 Neonatal mortality rate (last 0-4 years) 22.127 2.058 8097 7938 1.199 0.093 18.011 26.243 Post-neonatal mortality rate (last 0-4 years) 12.194 2.389 8043 7902 1.919 0.196 7.417 16.971 Infant mortality rate (last 0-4 years) 34.321 2.929 8104 7943 1.366 0.085 28.462 40.180 Child mortality rate (last 0-4 years) 19.946 2.621 7622 7510 1.535 0.131 14.704 25.187 Under-five mortality rate (last 0-4 years) 53.582 4.387 8163 8011 1.575 0.082 44.807 62.357 HIV prevalence (Women 15-49) 0.021 0.003 4487 4089 1.344 0.136 0.015 0.027 MEN Urban residence 0.623 0.019 3522 3577 2.337 0.031 0.585 0.661 No education 0.305 0.015 3522 3577 1.897 0.048 0.275 0.334 Secondary or higher education 0.558 0.016 3522 3577 1.923 0.029 0.525 0.590 Never married (never in union) 0.609 0.015 3522 3577 1.792 0.024 0.579 0.638 Currently married (in union) 0.380 0.015 3522 3577 1.823 0.039 0.350 0.410 Had sexual intercourse before age 18 0.157 0.012 2655 2741 1.673 0.075 0.133 0.180 Know any contraceptive method 0.989 0.003 1388 1360 1.198 0.003 0.983 0.996 Know a modern method 0.981 0.004 1388 1360 1.205 0.005 0.972 0.990 Want no more children 0.029 0.006 1388 1360 1.220 0.188 0.018 0.040 Want to delay next birth at least 2 years 0.575 0.019 1388 1360 1.445 0.033 0.536 0.613 Ideal number of children 7.669 0.148 3320 3405 1.545 0.019 7.373 7.964 Had 2+ sexual partners in past 12 months 0.082 0.005 3522 3577 1.167 0.066 0.072 0.093 Condom use at last sex 0.188 0.030 327 294 1.373 0.158 0.129 0.248 Abstinence among never-married youth (never had sex) 0.638 0.018 1593 1624 1.488 0.028 0.602 0.674 Sexually active in past 12 months among never-married youth 0.218 0.016 1593 1624 1.504 0.071 0.187 0.249 Paid for sexual intercourse in past 12 months 0.007 0.002 3522 3577 1.243 0.248 0.004 0.011 Had an HIV test and received results in past 12 months 0.072 0.006 3522 3577 1.490 0.090 0.059 0.085 Accepting attitudes towards people with HIV 0.103 0.013 3443 3505 2.577 0.130 0.076 0.129 HIV prevalence (Men 15-49) 0.017 0.004 3090 3493 1.677 0.232 0.009 0.024 HIV prevalence (Men 15-59) 0.018 0.004 3273 3670 1.615 0.211 0.010 0.025 WOMEN AND MEN HIV prevalence (Women and men 15-49) 0.019 0.002 7522 7539 1.467 0.121 0.014 0.024 268 • Appendix B Table B.3 Sampling errors: Urban sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 1.000 0.000 4498 5730 na 0.000 1.000 1.000 No education 0.341 0.013 4498 5730 1.780 0.037 0.315 0.366 Secondary or higher education 0.541 0.013 4498 5730 1.792 0.025 0.514 0.567 Never married (never in union) 0.355 0.012 4498 5730 1.666 0.034 0.331 0.378 Currently married (in union) 0.586 0.013 4498 5730 1.740 0.022 0.560 0.611 Married before age 20 0.470 0.014 3426 4409 1.681 0.031 0.441 0.499 Had sexual intercourse before age 18 0.341 0.011 3426 4409 1.388 0.033 0.318 0.363 Currently pregnant 0.066 0.005 4498 5730 1.245 0.070 0.057 0.075 Children ever born 2.119 0.047 4498 5730 1.304 0.022 2.025 2.212 Children surviving 1.974 0.042 4498 5730 1.251 0.021 1.890 2.057 Children ever born to women age 40-49 5.327 0.132 528 670 1.231 0.025 5.064 5.590 Know any contraceptive method 0.979 0.005 2509 3356 1.819 0.005 0.969 0.990 Know a mordern method 0.979 0.005 2509 3356 1.814 0.005 0.969 0.990 Currently using any method 0.130 0.011 2509 3356 1.678 0.087 0.108 0.153 Currently using a modern method 0.118 0.010 2509 3356 1.615 0.088 0.097 0.139 Currently using pill 0.035 0.005 2509 3356 1.269 0.134 0.025 0.044 Currently using condoms 0.009 0.002 2509 3356 1.123 0.235 0.005 0.013 Currently using female sterilization 0.008 0.003 2509 3356 1.434 0.325 0.003 0.013 Currently using rythm 0.003 0.002 2509 3356 1.347 0.468 0.000 0.006 Used public sector source 0.519 0.049 415 495 1.992 0.095 0.421 0.617 Want no more children 0.165 0.012 2509 3356 1.609 0.072 0.141 0.189 Want to delay next birth at least 2 years 0.460 0.012 2509 3356 1.190 0.026 0.437 0.484 Ideal number of children 5.494 0.064 4413 5626 1.959 0.012 5.367 5.621 Mothers protected against tetanus for last birth 0.673 0.020 1965 2643 1.944 0.030 0.632 0.713 Had diarrhea in the last 2 weeks 0.184 0.016 2657 3605 2.044 0.086 0.153 0.216 Treated with ORS 0.615 0.027 512 665 1.179 0.043 0.562 0.668 Sought medical treatment for diarrhea 0.659 0.030 512 665 1.349 0.045 0.600 0.719 Vaccination card seen 0.875 0.022 521 776 1.554 0.025 0.830 0.919 Received BCG vaccination 0.981 0.008 521 776 1.372 0.008 0.965 0.996 Received DPT vaccination (3 doses) 0.840 0.020 521 776 1.329 0.024 0.799 0.881 Received polio vaccination (3 doses) 0.871 0.019 521 776 1.333 0.022 0.833 0.909 Received measles vaccination 0.820 0.035 521 776 2.193 0.043 0.750 0.891 Received all vaccinations 0.671 0.040 521 776 2.023 0.060 0.591 0.750 Height-for-age (-2SD) 0.192 0.014 1084 1470 1.184 0.074 0.164 0.221 Weight-for-height (-2SD) 0.103 0.016 1084 1470 1.745 0.153 0.071 0.134 Weight-for-age (-2SD) 0.106 0.013 1084 1470 1.466 0.127 0.079 0.133 Prevalence of anemia (children 6-59 months) 0.667 0.023 1022 1433 1.649 0.035 0.621 0.714 Prevalence of anemia (women 15-49) 0.533 0.021 1887 2362 1.788 0.039 0.491 0.574 Body Mass Index (BMI) < 18.5 0.144 0.012 1773 2232 1.456 0.085 0.120 0.169 Had 2+ sexual partners in past 12 months 0.004 0.001 4498 5730 1.228 0.305 0.001 0.006 Abstinence among never-married youth (never had sex) 0.901 0.012 1449 1756 1.512 0.013 0.877 0.925 Sexually active in past 12 months among never-married youth 0.060 0.009 1449 1756 1.499 0.157 0.041 0.078 Had an HIV test and received results in past 12 months 0.145 0.007 4498 5730 1.306 0.047 0.131 0.159 Accepting attitudes towards people with HIV 0.062 0.008 4461 5691 2.256 0.132 0.046 0.078 Total fertility rate (3 years) 4.651 0.171 12611 16077 1.661 0.037 4.308 4.993 Neonatal mortality rate (last 0-9 years) 24.376 3.703 5051 6938 1.588 0.152 16.969 31.783 Post-neonatal mortality rate (last 0-9 years) 10.939 2.395 5044 6926 1.663 0.219 6.149 15.730 Infant mortality rate (last 0-9 years) 35.315 3.783 5053 6940 1.390 0.107 27.750 42.881 Child mortality rate (last 0-9 years) 18.557 2.859 4767 6555 1.540 0.154 12.838 24.276 Under-five mortality rate (last 0-9 years) 53.217 4.853 5070 6961 1.458 0.091 43.510 62.924 HIV prevalence (Women 15-49) 0.024 0.004 1903 2291 1.273 0.186 0.015 0.033 MEN Urban residence 1.000 0.000 1692 2228 na 0.000 1.000 1.000 No education 0.206 0.018 1692 2228 1.827 0.087 0.170 0.242 Secondary or higher education 0.674 0.020 1692 2228 1.752 0.030 0.634 0.714 Never married (never in union) 0.648 0.021 1692 2228 1.824 0.033 0.605 0.690 Currently married (in union) 0.340 0.022 1692 2228 1.870 0.063 0.297 0.383 Had sexual intercourse before age 18 0.159 0.016 1324 1758 1.631 0.103 0.126 0.192 Know any contraceptive method 0.993 0.004 580 758 1.226 0.004 0.985 1.002 Know a modern method 0.987 0.005 580 758 1.142 0.005 0.977 0.998 Want no more children 0.033 0.008 580 758 1.093 0.247 0.016 0.049 Want to delay next birth at least 2 years 0.577 0.028 580 758 1.342 0.048 0.522 0.632 Ideal number of children 6.633 0.174 1616 2147 1.541 0.026 6.285 6.980 Had 2+ sexual partners in past 12 months 0.066 0.007 1692 2228 1.132 0.104 0.052 0.080 Condom use at last sex 0.292 0.057 129 147 1.420 0.196 0.178 0.407 Abstinence among never-married youth (never had sex) 0.619 0.024 770 1023 1.348 0.038 0.572 0.666 Sexually active in past 12 months among never-married youth 0.227 0.021 770 1023 1.406 0.094 0.184 0.269 Paid for sexual intercourse in past 12 months 0.006 0.002 1692 2228 1.111 0.334 0.002 0.011 Had an HIV test and received results in past 12 months 0.084 0.010 1692 2228 1.415 0.113 0.065 0.103 Accepting attitudes towards people with HIV 0.127 0.020 1679 2210 2.430 0.156 0.087 0.166 HIV prevalence (Men 15-49) 0.013 0.005 1420 2171 1.603 0.375 0.003 0.022 HIV prevalence (Men 15-59) 0.015 0.005 1501 2268 1.498 0.318 0.005 0.024 WOMEN AND MEN HIV prevalence (Women and men 15-49) 0.019 0.003 3301 4441 1.269 0.161 0.013 0.025 Appendix B • 269 Table B.4 Sampling errors: Rural sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.000 0.000 5735 4503 na na 0.000 0.000 No education 0.623 0.016 5735 4503 2.510 0.026 0.591 0.655 Secondary or higher education 0.216 0.014 5735 4503 2.641 0.066 0.187 0.245 Never married (never in union) 0.207 0.009 5735 4503 1.652 0.043 0.189 0.225 Currently married (in union) 0.763 0.009 5735 4503 1.568 0.012 0.745 0.780 Married before age 20 0.709 0.011 4344 3417 1.666 0.016 0.686 0.732 Had sexual intercourse before age 18 0.519 0.012 4344 3417 1.549 0.023 0.495 0.542 Currently pregnant 0.100 0.005 5735 4503 1.277 0.051 0.090 0.110 Children ever born 3.055 0.049 5735 4503 1.294 0.016 2.956 3.154 Children surviving 2.765 0.042 5735 4503 1.214 0.015 2.682 2.849 Children ever born to women age 40-49 6.724 0.120 808 650 1.367 0.018 6.484 6.964 Know any contraceptive method 0.947 0.011 4396 3435 3.351 0.012 0.924 0.970 Know a mordern method 0.938 0.012 4396 3435 3.411 0.013 0.913 0.963 Currently using any method 0.050 0.005 4396 3435 1.608 0.106 0.039 0.061 Currently using a modern method 0.044 0.005 4396 3435 1.720 0.121 0.034 0.055 Currently using pill 0.007 0.002 4396 3435 1.176 0.204 0.004 0.011 Currently using condoms 0.002 0.001 4396 3435 1.080 0.342 0.001 0.004 Currently using female sterilization 0.004 0.001 4396 3435 1.236 0.278 0.002 0.007 Currently using rythm 0.000 0.000 4396 3435 na na 0.000 0.000 Used public sector source 0.840 0.033 215 171 1.297 0.039 0.775 0.905 Want no more children 0.152 0.008 4396 3435 1.566 0.056 0.135 0.169 Want to delay next birth at least 2 years 0.486 0.010 4396 3435 1.387 0.022 0.465 0.507 Ideal number of children 6.706 0.068 5489 4308 2.084 0.010 6.569 6.842 Mothers protected against tetanus for last birth 0.743 0.020 3420 2663 2.664 0.027 0.703 0.783 Had diarrhea in the last 2 weeks 0.164 0.010 5131 3981 1.836 0.062 0.144 0.184 Treated with ORS 0.568 0.023 828 653 1.265 0.041 0.522 0.615 Sought medical treatment for diarrhea 0.690 0.021 828 653 1.213 0.030 0.648 0.731 Vaccination card seen 0.925 0.009 1127 884 1.180 0.010 0.907 0.944 Received BCG vaccination 0.995 0.002 1127 884 1.144 0.002 0.991 1.000 Received DPT vaccination (3 doses) 0.909 0.011 1127 884 1.209 0.012 0.888 0.930 Received polio vaccination (3 doses) 0.925 0.010 1127 884 1.245 0.011 0.905 0.945 Received measles vaccination 0.929 0.010 1127 884 1.261 0.010 0.910 0.949 Received all vaccinations 0.839 0.014 1127 884 1.281 0.017 0.810 0.867 Height-for-age (-2SD) 0.285 0.014 2400 1902 1.359 0.050 0.257 0.314 Weight-for-height (-2SD) 0.124 0.011 2400 1902 1.544 0.090 0.102 0.146 Weight-for-age (-2SD) 0.206 0.012 2400 1902 1.275 0.056 0.183 0.229 Prevalence of anemia (children 6-59 months) 0.776 0.010 2278 1805 1.095 0.013 0.757 0.796 Prevalence of anemia (women 15-49) 0.684 0.015 2591 2030 1.588 0.021 0.655 0.713 Body Mass Index (BMI) < 18.5 0.195 0.011 2289 1792 1.278 0.054 0.174 0.216 Had 2+ sexual partners in past 12 months 0.001 0.001 5735 4503 1.181 0.473 0.000 0.002 Abstinence among never-married youth (never had sex) 0.918 0.012 1120 891 1.510 0.013 0.893 0.943 Sexually active in past 12 months among never-married youth 0.037 0.007 1120 891 1.297 0.199 0.022 0.051 Had an HIV test and received results in past 12 months 0.130 0.008 5735 4503 1.819 0.062 0.114 0.147 Accepting attitudes towards people with HIV 0.038 0.005 5557 4375 1.939 0.131 0.028 0.048 Total fertility rate (3 years) 6.805 0.139 15933 12525 1.390 0.020 6.527 7.083 Neonatal mortality rate (last 0-9 years) 29.010 2.291 9889 7731 1.204 0.079 24.427 33.593 Post-neonatal mortality rate (last 0-9 years) 14.896 1.822 9833 7686 1.358 0.122 11.253 18.539 Infant mortality rate (last 0-9 years) 43.906 3.111 9893 7734 1.292 0.071 37.684 50.129 Child mortality rate (last 0-9 years) 26.709 2.904 9387 7339 1.494 0.109 20.901 32.517 Under-five mortality rate (last 0-9 years) 69.443 4.711 9936 7771 1.542 0.068 60.020 78.865 HIV prevalence (Women 15-49) 0.018 0.003 2584 1798 1.286 0.188 0.011 0.025 MEN Urban residence 0.000 0.000 1830 1349 na na 0.000 0.000 No education 0.468 0.024 1830 1349 2.075 0.052 0.419 0.516 Secondary or higher education 0.366 0.025 1830 1349 2.236 0.069 0.315 0.416 Never married (never in union) 0.544 0.014 1830 1349 1.229 0.026 0.515 0.573 Currently married (in union) 0.446 0.014 1830 1349 1.223 0.032 0.418 0.475 Had sexual intercourse before age 18 0.152 0.015 1331 983 1.509 0.098 0.122 0.181 Know any contraceptive method 0.984 0.005 808 602 1.215 0.005 0.974 0.995 Know a modern method 0.973 0.007 808 602 1.280 0.008 0.958 0.987 Want no more children 0.025 0.007 808 602 1.357 0.297 0.010 0.040 Want to delay next birth at least 2 years 0.571 0.026 808 602 1.483 0.045 0.520 0.623 Ideal number of children 9.437 0.187 1704 1258 1.190 0.020 9.062 9.811 Had 2+ sexual partners in past 12 months 0.109 0.009 1830 1349 1.218 0.081 0.092 0.127 Condom use at last sex 0.084 0.023 198 147 1.146 0.270 0.039 0.130 Abstinence among never-married youth (never had sex) 0.670 0.027 823 601 1.654 0.041 0.616 0.724 Sexually active in past 12 months among never-married youth 0.203 0.022 823 601 1.552 0.108 0.159 0.246 Paid for sexual intercourse in past 12 months 0.008 0.003 1830 1349 1.422 0.369 0.002 0.014 Had an HIV test and received results in past 12 months 0.051 0.008 1830 1349 1.503 0.151 0.036 0.067 Accepting attitudes towards people with HIV 0.062 0.013 1764 1295 2.181 0.202 0.037 0.087 HIV prevalence (Men 15-49) 0.023 0.007 1670 1322 1.787 0.284 0.010 0.036 HIV prevalence (Men 15-59) 0.022 0.006 1772 1402 1.766 0.277 0.010 0.035 WOMEN AND MEN HIV prevalence (Women and men 15-49) 0.020 0.004 4221 3098 1.707 0.185 0.013 0.027 270 • Appendix B Table B.5 Sampling errors: Banjul sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 1.000 0.000 1073 225 na 0.000 1.000 1.000 No education 0.257 0.016 1073 225 1.168 0.061 0.226 0.288 Secondary or higher education 0.626 0.019 1073 225 1.304 0.031 0.587 0.665 Never married (never in union) 0.409 0.015 1073 225 1.024 0.038 0.378 0.440 Currently married (in union) 0.506 0.018 1073 225 1.201 0.036 0.469 0.542 Married before age 20 0.378 0.020 845 177 1.228 0.054 0.337 0.419 Had sexual intercourse before age 18 0.258 0.022 845 177 1.470 0.086 0.214 0.303 Currently pregnant 0.058 0.008 1073 225 1.072 0.132 0.043 0.073 Children ever born 1.851 0.059 1073 225 0.901 0.032 1.732 1.969 Children surviving 1.733 0.054 1073 225 0.882 0.031 1.626 1.841 Children ever born to women age 40-49 4.286 0.256 134 27 1.162 0.060 3.775 4.798 Know any contraceptive method 0.968 0.011 535 114 1.475 0.012 0.945 0.990 Know a mordern method 0.966 0.011 535 114 1.464 0.012 0.943 0.989 Currently using any method 0.211 0.019 535 114 1.053 0.088 0.174 0.248 Currently using a modern method 0.207 0.018 535 114 1.048 0.089 0.170 0.244 Currently using pill 0.081 0.013 535 114 1.090 0.159 0.055 0.106 Currently using condoms 0.006 0.004 535 114 1.156 0.645 0.000 0.014 Currently using female sterilization 0.008 0.004 535 114 1.060 0.513 0.000 0.016 Currently using rythm 0.004 0.003 535 114 1.003 0.686 0.000 0.009 Used public sector source 0.647 0.047 147 31 1.197 0.073 0.552 0.742 Want no more children 0.236 0.019 535 114 1.043 0.081 0.198 0.274 Want to delay next birth at least 2 years 0.380 0.022 535 114 1.058 0.059 0.335 0.424 Ideal number of children 4.492 0.080 1044 219 1.427 0.018 4.331 4.653 Mothers protected against tetanus for last birth 0.658 0.028 437 93 1.230 0.042 0.602 0.714 Had diarrhea in the last 2 weeks 0.260 0.027 567 121 1.404 0.104 0.206 0.314 Treated with ORS 0.605 0.045 145 31 1.076 0.074 0.516 0.694 Sought medical treatment for diarrhea 0.635 0.055 145 31 1.293 0.086 0.526 0.744 Vaccination card seen 0.759 0.048 103 21 1.113 0.064 0.662 0.856 Received BCG vaccination 0.937 0.025 103 21 0.998 0.026 0.888 0.986 Received DPT vaccination (3 doses) 0.761 0.051 103 21 1.174 0.067 0.659 0.863 Received polio vaccination (3 doses) 0.762 0.054 103 21 1.235 0.070 0.655 0.869 Received measles vaccination 0.818 0.045 103 21 1.154 0.055 0.728 0.909 Received all vaccinations 0.588 0.057 103 21 1.132 0.097 0.474 0.702 Height-for-age (-2SD) 0.122 0.021 214 47 0.881 0.172 0.080 0.164 Weight-for-height (-2SD) 0.092 0.027 214 47 1.282 0.296 0.037 0.147 Weight-for-age (-2SD) 0.122 0.026 214 47 1.144 0.211 0.070 0.173 Prevalence of anemia (children 6-59 months) 0.613 0.033 189 41 0.917 0.053 0.548 0.678 Prevalence of anemia (women 15-49) 0.527 0.030 458 96 1.303 0.058 0.466 0.587 Body Mass Index (BMI) < 18.5 0.120 0.015 429 90 0.939 0.123 0.090 0.149 Had 2+ sexual partners in past 12 months 0.004 0.002 1073 225 1.065 0.498 0.000 0.008 Abstinence among never-married youth (never had sex) 0.897 0.020 354 74 1.246 0.023 0.856 0.937 Sexually active in past 12 months among never-married youth 0.048 0.010 354 74 0.906 0.214 0.028 0.069 Had an HIV test and received results in past 12 months 0.172 0.016 1073 225 1.347 0.090 0.141 0.203 Accepting attitudes towards people with HIV 0.135 0.018 1062 223 1.724 0.134 0.098 0.171 Total fertility rate (3 years) 3.895 0.188 3028 635 1.117 0.048 3.520 4.271 Neonatal mortality rate (last 0-9 years) 26.683 5.238 1065 228 0.956 0.196 16.206 37.160 Post-neonatal mortality rate (last 0-9 years) 8.210 2.539 1067 229 0.939 0.309 3.132 13.289 Infant mortality rate (last 0-9 years) 34.893 6.419 1065 228 1.086 0.184 22.056 47.731 Child mortality rate (last 0-9 years) 21.181 6.226 1009 216 1.253 0.294 8.728 33.634 Under-five mortality rate (last 0-9 years) 55.335 8.421 1068 229 1.145 0.152 38.494 72.177 HIV prevalence (Women 15-49) 0.020 0.007 460 89 1.153 0.381 0.005 0.034 MEN Urban residence 1.000 0.000 411 85 na 0.000 1.000 1.000 No education 0.206 0.025 411 85 1.270 0.123 0.155 0.257 Secondary or higher education 0.660 0.031 411 85 1.324 0.047 0.598 0.722 Never married (never in union) 0.621 0.030 411 85 1.235 0.048 0.562 0.680 Currently married (in union) 0.351 0.030 411 85 1.267 0.085 0.291 0.411 Had sexual intercourse before age 18 0.192 0.020 331 69 0.931 0.105 0.152 0.233 Know any contraceptive method 0.976 0.013 139 30 1.030 0.014 0.950 1.003 Know a modern method 0.972 0.014 139 30 0.986 0.014 0.944 1.000 Want no more children 0.065 0.027 139 30 1.291 0.417 0.011 0.120 Want to delay next birth at least 2 years 0.573 0.042 139 30 1.006 0.074 0.488 0.658 Ideal number of children 5.871 0.297 382 77 1.349 0.051 5.278 6.465 Had 2+ sexual partners in past 12 months 0.091 0.017 411 85 1.227 0.192 0.056 0.126 Condom use at last sex 0.482 0.087 41 8 1.093 0.180 0.308 0.655 Abstinence among never-married youth (never had sex) 0.475 0.040 167 33 1.040 0.085 0.394 0.555 Sexually active in past 12 months among never-married youth 0.336 0.043 167 33 1.160 0.127 0.250 0.421 Paid for sexual intercourse in past 12 months 0.021 0.007 411 85 1.050 0.356 0.006 0.036 Had an HIV test and received results in past 12 months 0.102 0.019 411 85 1.254 0.184 0.064 0.139 Accepting attitudes towards people with HIV 0.114 0.023 407 84 1.440 0.199 0.069 0.160 HIV prevalence (Men 15-49) 0.002 0.002 356 86 0.871 1.005 0.000 0.006 HIV prevalence (Men 15-59) 0.006 0.003 395 95 0.898 0.606 0.000 0.012 WOMEN AND MEN HIV prevalence (Women and men 15-49) 0.011 0.004 805 171 1.068 0.355 0.003 0.019 Appendix B • 271 Table B.6 Sampling errors: Kanifing sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 1.000 0.000 1506 2342 na 0.000 1.000 1.000 No education 0.315 0.016 1506 2342 1.347 0.051 0.282 0.347 Secondary or higher education 0.578 0.017 1506 2342 1.325 0.029 0.544 0.612 Never married (never in union) 0.397 0.012 1506 2342 0.987 0.031 0.372 0.422 Currently married (in union) 0.537 0.014 1506 2342 1.053 0.025 0.510 0.564 Married before age 20 0.418 0.016 1155 1826 1.089 0.038 0.387 0.450 Had sexual intercourse before age 18 0.321 0.018 1155 1826 1.301 0.056 0.285 0.357 Currently pregnant 0.059 0.007 1506 2342 1.144 0.118 0.045 0.072 Children ever born 1.880 0.054 1506 2342 0.924 0.029 1.772 1.987 Children surviving 1.760 0.053 1506 2342 0.976 0.030 1.654 1.865 Children ever born to women age 40-49 5.074 0.212 163 250 1.119 0.042 4.649 5.499 Know any contraceptive method 0.978 0.007 786 1258 1.265 0.007 0.964 0.991 Know a mordern method 0.978 0.007 786 1258 1.265 0.007 0.964 0.991 Currently using any method 0.146 0.014 786 1258 1.143 0.099 0.118 0.175 Currently using a modern method 0.134 0.014 786 1258 1.182 0.107 0.105 0.163 Currently using pill 0.042 0.009 786 1258 1.277 0.219 0.023 0.060 Currently using condoms 0.011 0.004 786 1258 0.980 0.332 0.004 0.018 Currently using female sterilization 0.006 0.003 786 1258 0.948 0.440 0.001 0.011 Currently using rythm 0.004 0.003 786 1258 1.189 0.659 0.000 0.010 Used public sector source 0.330 0.034 138 222 0.845 0.103 0.262 0.398 Want no more children 0.177 0.014 786 1258 1.010 0.078 0.150 0.205 Want to delay next birth at least 2 years 0.439 0.017 786 1258 0.968 0.039 0.405 0.474 Ideal number of children 5.118 0.074 1487 2314 1.400 0.014 4.969 5.266 Mothers protected against tetanus for last birth 0.678 0.032 613 982 1.671 0.046 0.615 0.741 Had diarrhea in the last 2 weeks 0.223 0.025 816 1317 1.635 0.110 0.174 0.272 Treated with ORS 0.572 0.042 174 293 1.091 0.073 0.488 0.655 Sought medical treatment for diarrhea 0.648 0.042 174 293 1.162 0.065 0.564 0.732 Vaccination card seen 0.830 0.046 139 240 1.407 0.055 0.739 0.922 Received BCG vaccination 0.951 0.023 139 240 1.323 0.024 0.905 0.998 Received DPT vaccination (3 doses) 0.827 0.033 139 240 1.026 0.040 0.760 0.893 Received polio vaccination (3 doses) 0.834 0.033 139 240 1.018 0.039 0.768 0.899 Received measles vaccination 0.843 0.032 139 240 1.020 0.038 0.779 0.907 Received all vaccinations 0.709 0.036 139 240 0.945 0.051 0.637 0.781 Height-for-age (-2SD) 0.233 0.023 321 499 0.918 0.098 0.187 0.278 Weight-for-height (-2SD) 0.113 0.025 321 499 1.398 0.224 0.062 0.163 Weight-for-age (-2SD) 0.117 0.020 321 499 1.108 0.171 0.077 0.157 Prevalence of anemia (children 6-59 months) 0.631 0.028 305 482 0.997 0.044 0.575 0.686 Prevalence of anemia (women 15-49) 0.505 0.031 616 976 1.567 0.062 0.442 0.567 Body Mass Index (BMI) < 18.5 0.109 0.014 591 930 1.072 0.125 0.082 0.137 Had 2+ sexual partners in past 12 months 0.006 0.002 1506 2342 1.035 0.333 0.002 0.011 Abstinence among never-married youth (never had sex) 0.882 0.019 521 785 1.317 0.021 0.844 0.919 Sexually active in past 12 months among never-married youth 0.070 0.015 521 785 1.320 0.212 0.040 0.099 Had an HIV test and received results in past 12 months 0.146 0.009 1506 2342 1.024 0.064 0.127 0.164 Accepting attitudes towards people with HIV 0.079 0.012 1492 2319 1.758 0.155 0.055 0.104 Total fertility rate (3 years) 3.960 0.205 4225 6593 1.248 0.052 3.550 4.371 Neonatal mortality rate (last 0-9 years) 24.455 4.493 1572 2536 1.032 0.184 15.469 33.442 Post-neonatal mortality rate (last 0-9 years) 7.182 2.140 1567 2523 1.009 0.298 2.902 11.461 Infant mortality rate (last 0-9 years) 31.637 4.707 1572 2536 0.990 0.149 22.222 41.051 Child mortality rate (last 0-9 years) 20.933 4.385 1493 2408 1.205 0.209 12.163 29.704 Under-five mortality rate (last 0-9 years) 51.908 6.858 1578 2544 1.187 0.132 38.191 65.624 HIV prevalence (Women 15-49) 0.023 0.007 625 979 1.078 0.280 0.010 0.036 MEN Urban residence 1.000 0.000 553 858 na 0.000 1.000 1.000 No education 0.186 0.022 553 858 1.358 0.121 0.141 0.231 Secondary or higher education 0.718 0.026 553 858 1.344 0.036 0.666 0.769 Never married (never in union) 0.651 0.026 553 858 1.286 0.040 0.599 0.704 Currently married (in union) 0.333 0.027 553 858 1.343 0.081 0.279 0.387 Had sexual intercourse before age 18 0.184 0.028 444 696 1.533 0.154 0.127 0.240 Know any contraceptive method 0.985 0.011 185 286 1.195 0.011 0.963 1.006 Know a modern method 0.973 0.013 185 286 1.104 0.014 0.946 0.999 Want no more children 0.051 0.017 185 286 1.021 0.326 0.018 0.084 Want to delay next birth at least 2 years 0.512 0.039 185 286 1.057 0.076 0.434 0.590 Ideal number of children 6.061 0.225 528 820 1.259 0.037 5.612 6.510 Had 2+ sexual partners in past 12 months 0.079 0.009 553 858 0.753 0.109 0.062 0.097 Condom use at last sex 0.359 0.085 42 68 1.126 0.236 0.190 0.529 Abstinence among never-married youth (never had sex) 0.590 0.039 256 394 1.255 0.066 0.512 0.667 Sexually active in past 12 months among never-married youth 0.256 0.029 256 394 1.049 0.112 0.199 0.314 Paid for sexual intercourse in past 12 months 0.014 0.005 553 858 1.070 0.379 0.003 0.025 Had an HIV test and received results in past 12 months 0.119 0.014 553 858 1.021 0.118 0.091 0.148 Accepting attitudes towards people with HIV 0.111 0.020 550 853 1.464 0.177 0.071 0.150 HIV prevalence (Men 15-49) 0.005 0.003 454 836 0.894 0.587 0.000 0.011 HIV prevalence (Men 15-59) 0.007 0.003 475 872 0.876 0.497 0.000 0.013 WOMEN AND MEN HIV prevalence (Women and men 15-49) 0.015 0.004 1073 1804 1.098 0.272 0.007 0.023 272 • Appendix B Table B.7 Sampling errors: Brikama sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.727 0.028 1833 3550 2.725 0.039 0.670 0.784 No education 0.369 0.018 1833 3550 1.617 0.049 0.332 0.405 Secondary or higher education 0.484 0.020 1833 3550 1.674 0.040 0.445 0.524 Never married (never in union) 0.310 0.017 1833 3550 1.614 0.056 0.275 0.345 Currently married (in union) 0.643 0.019 1833 3550 1.676 0.029 0.605 0.680 Married before age 20 0.537 0.023 1407 2729 1.721 0.043 0.491 0.583 Had sexual intercourse before age 18 0.377 0.017 1407 2729 1.306 0.045 0.343 0.410 Currently pregnant 0.077 0.006 1833 3550 0.980 0.079 0.065 0.089 Children ever born 2.508 0.073 1833 3550 1.188 0.029 2.361 2.655 Children surviving 2.303 0.065 1833 3550 1.141 0.028 2.174 2.432 Children ever born to women age 40-49 5.890 0.209 250 477 1.334 0.036 5.471 6.308 Know any contraceptive method 0.985 0.007 1188 2282 1.906 0.007 0.972 0.999 Know a mordern method 0.985 0.007 1188 2282 1.906 0.007 0.972 0.999 Currently using any method 0.111 0.016 1188 2282 1.741 0.143 0.079 0.143 Currently using a modern method 0.099 0.015 1188 2282 1.674 0.147 0.070 0.128 Currently using pill 0.025 0.005 1188 2282 1.070 0.195 0.015 0.034 Currently using condoms 0.006 0.002 1188 2282 1.070 0.389 0.001 0.011 Currently using female sterilization 0.010 0.004 1188 2282 1.259 0.357 0.003 0.018 Currently using rythm 0.002 0.002 1188 2282 1.390 0.956 0.000 0.005 Used public sector source 0.695 0.068 126 271 1.629 0.097 0.560 0.830 Want no more children 0.170 0.017 1188 2282 1.520 0.098 0.137 0.203 Want to delay next birth at least 2 years 0.459 0.014 1188 2282 0.966 0.030 0.431 0.487 Ideal number of children 5.917 0.097 1798 3472 1.784 0.016 5.724 6.110 Mothers protected against tetanus for last birth 0.696 0.027 949 1820 1.783 0.038 0.642 0.749 Had diarrhea in the last 2 weeks 0.190 0.019 1363 2566 1.684 0.101 0.152 0.229 Treated with ORS 0.623 0.034 281 488 1.038 0.054 0.555 0.690 Sought medical treatment for diarrhea 0.688 0.034 281 488 1.093 0.049 0.620 0.756 Vaccination card seen 0.895 0.022 304 599 1.233 0.025 0.851 0.940 Received BCG vaccination 0.995 0.004 304 599 0.907 0.004 0.988 1.002 Received DPT vaccination (3 doses) 0.857 0.024 304 599 1.194 0.028 0.810 0.905 Received polio vaccination (3 doses) 0.905 0.021 304 599 1.206 0.023 0.864 0.947 Received measles vaccination 0.829 0.045 304 599 2.081 0.054 0.739 0.919 Received all vaccinations 0.695 0.051 304 599 1.932 0.074 0.592 0.798 Height-for-age (-2SD) 0.178 0.017 626 1140 0.999 0.098 0.143 0.213 Weight-for-height (-2SD) 0.090 0.017 626 1140 1.327 0.189 0.056 0.124 Weight-for-age (-2SD) 0.102 0.016 626 1140 1.146 0.152 0.071 0.134 Prevalence of anemia (children 6-59 months) 0.677 0.028 612 1127 1.392 0.042 0.620 0.733 Prevalence of anemia (women 15-49) 0.563 0.027 758 1451 1.505 0.048 0.509 0.618 Body Mass Index (BMI) < 18.5 0.165 0.019 692 1346 1.382 0.118 0.126 0.204 Had 2+ sexual partners in past 12 months 0.002 0.001 1833 3550 1.139 0.584 0.000 0.004 Abstinence among never-married youth (never had sex) 0.892 0.018 505 978 1.296 0.020 0.856 0.928 Sexually active in past 12 months among never-married youth 0.061 0.013 505 978 1.218 0.212 0.035 0.088 Had an HIV test and received results in past 12 months 0.155 0.010 1833 3550 1.200 0.066 0.134 0.175 Accepting attitudes towards people with HIV 0.060 0.011 1822 3531 2.032 0.189 0.037 0.082 Total fertility rate (3 years) 5.567 0.220 5161 9968 1.397 0.039 5.128 6.007 Neonatal mortality rate (last 0-9 years) 26.926 4.760 2662 5052 1.367 0.177 17.406 36.447 Post-neonatal mortality rate (last 0-9 years) 16.526 3.531 2660 5052 1.346 0.214 9.464 23.587 Infant mortality rate (last 0-9 years) 43.452 5.101 2665 5056 1.152 0.117 33.250 53.654 Child mortality rate (last 0-9 years) 18.486 3.728 2519 4768 1.359 0.202 11.031 25.941 Under-five mortality rate (last 0-9 years) 61.135 5.963 2675 5074 1.127 0.098 49.209 73.061 HIV prevalence (Women 15-49) 0.026 0.007 766 1362 1.149 0.256 0.013 0.039 MEN Urban residence 0.750 0.030 742 1454 1.877 0.040 0.690 0.810 No education 0.226 0.025 742 1454 1.650 0.112 0.175 0.276 Secondary or higher education 0.637 0.027 742 1454 1.528 0.042 0.583 0.691 Never married (never in union) 0.640 0.029 742 1454 1.615 0.045 0.582 0.697 Currently married (in union) 0.349 0.029 742 1454 1.644 0.083 0.292 0.407 Had sexual intercourse before age 18 0.161 0.021 549 1101 1.316 0.129 0.119 0.202 Know any contraceptive method 1.000 0.000 262 508 na 0.000 1.000 1.000 Know a modern method 0.997 0.003 262 508 0.867 0.003 0.991 1.003 Want no more children 0.025 0.010 262 508 0.976 0.374 0.006 0.045 Want to delay next birth at least 2 years 0.608 0.036 262 508 1.202 0.060 0.535 0.680 Ideal number of children 7.110 0.236 715 1406 1.301 0.033 6.639 7.581 Had 2+ sexual partners in past 12 months 0.057 0.010 742 1454 1.156 0.173 0.037 0.076 Condom use at last sex 0.170 0.063 45 82 1.103 0.368 0.045 0.295 Abstinence among never-married youth (never had sex) 0.634 0.031 355 683 1.220 0.049 0.571 0.696 Sexually active in past 12 months among never-married youth 0.205 0.029 355 683 1.356 0.142 0.147 0.264 Paid for sexual intercourse in past 12 months 0.002 0.001 742 1454 0.760 0.570 0.000 0.005 Had an HIV test and received results in past 12 months 0.060 0.012 742 1454 1.339 0.196 0.036 0.083 Accepting attitudes towards people with HIV 0.131 0.029 729 1429 2.299 0.221 0.073 0.188 HIV prevalence (Men 15-49) 0.024 0.008 631 1410 1.320 0.337 0.008 0.040 HIV prevalence (Men 15-59) 0.025 0.008 660 1479 1.255 0.304 0.010 0.040 WOMEN AND MEN HIV prevalence (Women and men 15-49) 0.025 0.005 1392 2765 1.211 0.204 0.015 0.035 Appendix B • 273 Table B.8 Sampling errors: Mansakonko sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.178 0.016 1041 490 1.385 0.092 0.145 0.211 No education 0.514 0.029 1041 490 1.894 0.057 0.455 0.573 Secondary or higher education 0.309 0.025 1041 490 1.751 0.081 0.259 0.359 Never married (never in union) 0.242 0.017 1041 490 1.308 0.072 0.207 0.276 Currently married (in union) 0.704 0.016 1041 490 1.125 0.023 0.672 0.735 Married before age 20 0.709 0.031 777 370 1.916 0.044 0.647 0.772 Had sexual intercourse before age 18 0.507 0.033 777 370 1.851 0.066 0.440 0.574 Currently pregnant 0.091 0.008 1041 490 0.943 0.093 0.074 0.107 Children ever born 3.044 0.146 1041 490 1.539 0.048 2.753 3.336 Children surviving 2.753 0.128 1041 490 1.520 0.047 2.496 3.010 Children ever born to women age 40-49 6.992 0.383 142 68 1.540 0.055 6.227 7.757 Know any contraceptive method 0.955 0.030 726 344 3.802 0.031 0.896 1.014 Know a mordern method 0.951 0.030 726 344 3.673 0.031 0.892 1.010 Currently using any method 0.080 0.012 726 344 1.200 0.152 0.056 0.104 Currently using a modern method 0.070 0.012 726 344 1.279 0.173 0.046 0.095 Currently using pill 0.006 0.003 726 344 1.129 0.520 0.000 0.013 Currently using condoms 0.013 0.004 726 344 1.047 0.339 0.004 0.022 Currently using female sterilization 0.007 0.005 726 344 1.525 0.684 0.000 0.016 Currently using rythm 0.004 0.003 726 344 1.179 0.702 0.000 0.009 Used public sector source 0.723 0.069 57 28 1.147 0.095 0.586 0.861 Want no more children 0.132 0.013 726 344 1.064 0.101 0.105 0.159 Want to delay next birth at least 2 years 0.482 0.014 726 344 0.741 0.028 0.455 0.510 Ideal number of children 7.077 0.131 1032 485 1.652 0.019 6.815 7.340 Mothers protected against tetanus for last birth 0.874 0.016 558 265 1.100 0.018 0.843 0.905 Had diarrhea in the last 2 weeks 0.144 0.016 813 385 1.247 0.112 0.112 0.176 Treated with ORS 0.579 0.060 117 55 1.249 0.104 0.458 0.700 Sought medical treatment for diarrhea 0.684 0.069 117 55 1.477 0.102 0.545 0.823 Vaccination card seen 0.920 0.020 167 80 0.964 0.022 0.879 0.960 Received BCG vaccination 0.992 0.007 167 80 1.102 0.007 0.978 1.007 Received DPT vaccination (3 doses) 0.945 0.018 167 80 1.001 0.019 0.910 0.980 Received polio vaccination (3 doses) 0.922 0.024 167 80 1.162 0.026 0.874 0.971 Received measles vaccination 0.924 0.025 167 80 1.209 0.027 0.875 0.974 Received all vaccinations 0.855 0.040 167 80 1.479 0.047 0.775 0.936 Height-for-age (-2SD) 0.273 0.021 427 211 0.917 0.079 0.231 0.316 Weight-for-height (-2SD) 0.105 0.018 427 211 1.145 0.169 0.070 0.141 Weight-for-age (-2SD) 0.185 0.016 427 211 0.747 0.084 0.153 0.216 Prevalence of anemia (children 6-59 months) 0.792 0.025 379 186 1.240 0.031 0.742 0.841 Prevalence of anemia (women 15-49) 0.671 0.027 478 221 1.239 0.040 0.618 0.725 Body Mass Index (BMI) < 18.5 0.215 0.023 427 197 1.123 0.105 0.170 0.260 Had 2+ sexual partners in past 12 months 0.002 0.001 1041 490 0.949 0.717 0.000 0.004 Abstinence among never-married youth (never had sex) 0.941 0.017 249 113 1.137 0.018 0.907 0.975 Sexually active in past 12 months among never-married youth 0.027 0.012 249 113 1.140 0.438 0.003 0.050 Had an HIV test and received results in past 12 months 0.095 0.016 1041 490 1.750 0.168 0.063 0.127 Accepting attitudes towards people with HIV 0.082 0.011 1029 484 1.233 0.129 0.061 0.103 Total fertility rate (3 years) 5.986 0.318 2882 1360 1.270 0.053 5.350 6.621 Neonatal mortality rate (last 0-9 years) 29.714 4.304 1605 763 0.932 0.145 21.107 38.322 Post-neonatal mortality rate (last 0-9 years) 12.523 4.561 1590 756 1.486 0.364 3.401 21.646 Infant mortality rate (last 0-9 years) 42.238 6.529 1606 764 1.126 0.155 29.180 55.296 Child mortality rate (last 0-9 years) 21.721 3.638 1545 736 0.951 0.167 14.445 28.998 Under-five mortality rate (last 0-9 years) 63.042 7.288 1611 766 1.101 0.116 48.465 77.618 HIV prevalence (Women 15-49) 0.038 0.009 481 195 1.075 0.247 0.019 0.057 MEN Urban residence 0.184 0.023 339 141 1.079 0.124 0.139 0.230 No education 0.288 0.036 339 141 1.467 0.126 0.216 0.360 Secondary or higher education 0.507 0.040 339 141 1.486 0.080 0.427 0.588 Never married (never in union) 0.583 0.032 339 141 1.176 0.054 0.519 0.646 Currently married (in union) 0.417 0.032 339 141 1.176 0.076 0.354 0.481 Had sexual intercourse before age 18 0.163 0.020 237 98 0.819 0.121 0.124 0.202 Know any contraceptive method 0.979 0.020 139 59 1.614 0.020 0.940 1.019 Know a modern method 0.945 0.039 139 59 1.996 0.041 0.867 1.023 Want no more children 0.022 0.012 139 59 0.952 0.539 0.000 0.046 Want to delay next birth at least 2 years 0.646 0.047 139 59 1.165 0.074 0.551 0.741 Ideal number of children 10.821 0.544 319 133 1.277 0.050 9.733 11.909 Had 2+ sexual partners in past 12 months 0.101 0.021 339 141 1.249 0.203 0.060 0.142 Condom use at last sex 0.145 0.053 34 14 0.866 0.365 0.039 0.250 Abstinence among never-married youth (never had sex) 0.640 0.048 162 67 1.272 0.075 0.543 0.736 Sexually active in past 12 months among never-married youth 0.266 0.049 162 67 1.403 0.184 0.168 0.364 Paid for sexual intercourse in past 12 months 0.002 0.002 339 141 0.860 0.987 0.000 0.007 Had an HIV test and received results in past 12 months 0.042 0.010 339 141 0.942 0.245 0.021 0.063 Accepting attitudes towards people with HIV 0.051 0.021 336 139 1.713 0.403 0.010 0.093 HIV prevalence (Men 15-49) 0.015 0.010 327 138 1.413 0.635 0.000 0.034 HIV prevalence (Men 15-59) 0.016 0.009 344 145 1.334 0.558 0.000 0.035 WOMEN AND MEN HIV prevalence (Women and men 15-49) 0.029 0.007 802 331 1.269 0.261 0.014 0.044 274 • Appendix B Table B.9 Sampling errors: Kerewan sample, Gambia 2013 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.191 0.025 1448 1107 2.441 0.132 0.140 0.242 No education 0.600 0.040 1448 1107 3.126 0.067 0.519 0.681 Secondary or higher education 0.262 0.032 1448 1107 2.737 0.121 0.199 0.325 Never married (never in union) 0.243 0.017 1448 1107 1.528 0.071 0.209 0.278 Currently married (in union) 0.724 0.020 1448 1107 1.682 0.027 0.684 0.763 Married before age 20 0.678 0.018 1068 824 1.266 0.027 0.642 0.714 Had sexual intercourse before age 18 0.525 0.022 1068 824 1.454 0.042 0.481 0.569 Currently pregnant 0.088 0.010 1448 1107 1.365 0.116 0.068 0.108 Children ever born 2.954 0.090 1448 1107 1.122 0.030 2.775 3.133 Children surviving 2.720 0.078 1448 1107 1.078 0.029 2.563 2.876 Children ever born to women age 40-49 6.945 0.270 210 165 1.434 0.039 6.405 7.485 Know any contraceptive method 0.958 0.011 1044 801 1.720 0.011 0.936 0.979 Know a mordern method 0.932 0.021 1044 801 2.679 0.022 0.890 0.974 Currently using any method 0.071 0.013 1044 801 1.650 0.185 0.045 0.097 Currently using a modern method 0.064 0.013 1044 801 1.681 0.199 0.039 0.090 Currently using pill 0.008 0.003 1044 801 1.131 0.379 0.002 0.015 Currently using condoms 0.003 0.002 1044 801 1.024 0.589 0.000 0.006 Currently using female sterilization 0.006 0.002 1044 801 0.934 0.366 0.002 0.011 Currently using rythm 0.000 0.000 1044 801 na na 0.000 0.000 Used public sector source 0.932 0.033 71 55 1.085 0.035 0.866 0.997 Want no more children 0.169 0.012 1044 801 1.008 0.069 0.146 0.193 Want to delay next birth at least 2 years 0.429 0.024 1044 801 1.591 0.057 0.380 0.478 Ideal number of children 6.381 0.113 1256 957 1.694 0.018 6.154 6.608 Mothers protected against tetanus for last birth 0.723 0.032 775 589 1.968 0.044 0.659 0.787 Had diarrhea in the last 2 weeks 0.129 0.014 1163 890 1.310 0.106 0.102 0.156 Treated with ORS 0.639 0.030 144 115 0.751 0.048 0.578 0.699 Sought medical treatment for diarrhea 0.736 0.051 144 115 1.370 0.069 0.634 0.838 Vaccination card seen 0.926 0.018 270 214 1.113 0.019 0.891 0.961 Received BCG vaccination 0.994 0.006 270 214 1.213 0.006 0.983 1.005 Received DPT vaccination (3 doses) 0.883 0.022 270 214 1.122 0.025 0.839 0.927 Received polio vaccination (3 doses) 0.892 0.022 270 214 1.169 0.025 0.847 0.936 Received measles vaccination 0.933 0.018 270 214 1.158 0.019 0.897 0.969 Received all vaccinations 0.789 0.030 270 214 1.216 0.038 0.728 0.849 Height-for-age (-2SD) 0.249 0.025 543 420 1.170 0.102 0.198 0.300 Weight-for-height (-2SD) 0.095 0.014 543 420 1.036 0.151 0.066 0.124 Weight-for-age (-2SD) 0.159 0.021 543 420 1.163 0.130 0.118 0.200 Prevalence of anemia (children 6-59 months) 0.733 0.020 555 432 1.056 0.027 0.693 0.773 Prevalence of anemia (women 15-49) 0.596 0.033 685 517 1.728 0.055 0.530 0.661 Body Mass Index (BMI) < 18.5 0.214 0.018 616 465 1.111 0.086 0.177 0.251 Had 2+ sexual partners in past 12 months 0.000 0.000 1448 1107 na na 0.000 0.000 Abstinence among never-married youth (never had sex) 0.965 0.009 343 257 0.922 0.009 0.947 0.983 Sexually active in past 12 months among never-married youth 0.021 0.007 343 257 0.915 0.334 0.007 0.036 Had an HIV test and received results in past 12 months 0.140 0.010 1448 1107 1.128 0.073 0.120 0.161 Accepting attitudes towards people with HIV 0.012 0.003 1425 1088 1.208 0.295 0.005 0.019 Total fertility rate (3 years) 6.283 0.290 4037 3096 1.405 0.046 5.703 6.863 Neonatal mortality rate (last 0-9 years) 25.925 4.809 2278 1731 1.230 0.186 16.307 35.544 Post-neonatal mortality rate (last 0-9 years) 9.020 2.472 2255 1714 1.122 0.274 4.076 13.964 Infant mortality rate (last 0-9 years) 34.945 5.618 2278 1731 1.240 0.161 23.708 46.182 Child mortality rate (last 0-9 years) 18.011 3.434 2157 1651 1.151 0.191 11.143 24.879 Under-five mortality rate (last 0-9 years) 52.327 7.219 2286 1737 1.330 0.138 37.890 66.764 HIV prevalence (Women 15-49) 0.017 0.006 696 455 1.134 0.324 0.006 0.029 MEN Urban residence 0.226 0.035 455 323 1.763 0.153 0.157 0.296 No education 0.394 0.066 455 323 2.869 0.168 0.261 0.526 Secondary or higher education 0.436 0.054 455 323 2.296 0.123 0.328 0.543 Never married (never in union) 0.553 0.033 455 323 1.397 0.059 0.488 0.618 Currently married (in union) 0.444 0.032 455 323 1.391 0.073 0.379 0.509 Had sexual intercourse before age 18 0.139 0.028 339 242 1.502 0.204 0.082 0.195 Know any contraceptive method 0.992 0.007 199 143 1.175 0.007 0.978 1.007 Know a modern method 0.974 0.013 199 143 1.155 0.013 0.948 1.000 Wa